søndag 8. juni 2014

Neck pain trial negative

In my article on the Eyebody Method I said that as more and more research is being done on the Alexander Technique, we have to be prepared for negative results. Now the negative results are already here. The conclusion in a recent trial on the Efficacy of Alexander Technique in the Treatment of Chronic Non-Specific Neck Pain  was that: "Five sessions of AT were no better than a heat pack application for relieving chronic non-specific neck pain. Therefore it cannot be recommended as routine intervention at this time."

The trial
This was a randomised controlled trial with 3 parallel groups. 72 patients were randomly allocated to either 5 weekly sessions of AT, heat pack application or guided imagery. The primary outcome measure at week 5 was neck pain intensity. Secondary outcomes included neck disability, quality of life, satisfaction and safety.
There was no significant difference in neck pain intensity when AT was compared to heat pack application, but AT did better than guided imagery. 
AT scored better than the other two interventions on physical quality of life. The patients in the AT group also experienced increased body awareness and control, relaxing or stimulating effects and mood changes after the sessions.
Adverse events were reported and included slightly increased pain and muscle soreness.

One should be careful of drawing any conclusions from a single trial, but it does give material for some considerations.

Five lessons
The result backs up the fact reiterated by Alexander teachers that the technique is not a quick fix. In the Alexander tradition there are numerous anecdotes about immediate relief from neck or back pain from a single lesson. We can probably say that these stories represents the exception and not the rule.

In this trial the participants received 5 AT lessons. This a small number. 20 to 30 lessons are often recommended for learning the Alexander Technique. In the ATEAM trial on Alexander Technique and back pain, the group receiving 24 AT lessons had the most positive results.

Would 20 lessons of AT have given a more positive result on neck pain intensity? We don't know yet. Another randomised controlled trial is under way that will compare Alexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS). The patients in the AT group will receive twenty 30 minutes lessons.

The reason for testing a short series of only five AT lessons could be to compare it to treatments used in normal health care in terms of cost-effectiveness. It could well be that other methods are both more effective and cost effective under those terms, not the least in regard to the time scale.

Five weeks
The abstract of the neck pain trial has a nice definition of the Alexander Technique as: "an educational method aiming at increased sensory awareness and kinaesthetic control to modify postural and movement patterns." It could be said, however, that the trial does not test the AT as an educational method. It does not test the outcome of the process of learning the technique, only the immediate effects of having lessons.

In the ATEAM trial one group of patients received 6 lessons of AT and another group 6 sessions of massage. Both groups showed a small effect after three months. After 12 months there was significant difference:
"That six sessions of massage were much less effective at one year than at three months whereas six lessons in the Alexander technique retained effectiveness at one year shows that the long term benefit of Alexander technique lessons is unlikely to result from non-specific placebo effects of attention and touch".

In other words: It is possible that the patients in the AT group learnt something useful in only six lessons that increased their sensory awareness and kinaesthetic control, and that this had a positive long term effect on their level of back pain.

The trial on AT and neck pain has an outcome measure after only five weeks. Would there still have been an effect after three months? If so, it would have indicated that it is possible to learn from only five lessons sufficiently for there to be an impact on health, albeit this effect could well be so small that it would not be clinically significant. A three month outcome measure would also have made it possible to compare this trial with some aspects of the ATLAS trial under way.

If there had been no detectable effect at three months one could question the whole idea of having only five lessons, and one might have to see the results from six lessons in the ATEAM trial in a different light.

Guided imagery
The Alexander Technique is a process which includes what we call "giving directions". Directions can in some instances have similarities with mental imagery. In the trial, sessions in guided imagery turned out to be inferior to Alexander Technique or heat pack treatment in reducing neck pain intensity.

It is my impression from teaching the Alexander Technique to people in pain that they are in particular need of the hands-on guidance during the learning process. If I was to speculate I would suggest that the difference between the effects of AT and mental imagery could be due to improvements in body control and movement patterns through the use of hands-on guidance.

In the ATEAM trial, by comparing AT and massage it was found that "the long term benefit of Alexander technique lessons is unlikely to result from non-specific placebo effects of attention and touch".
In the neck pain trial it is not possible to say whether the positive effect from Alexander Technique lessons stems from learning the technique or is the "non-specific placebo effects" of the use of touch. This is yet another reason why outcome measurement on a later date would have been useful. The short time scale of the neck pain trial makes the educational aspects of the Alexander Technique more or less irrelevant. They could in fact just as well have substituted massage therapy for the Alexander Technique.

The immediate effects of lessons in the technique may give an indication on the successfulness of the lessons, and maybe give some indication of possible long term benefits. But the immediate effects of the lesson are subordinate to the goal which is for the pupil to learn the Alexander Technique and to learn to apply it in his or her daily activities. This learning process involves changes in quality of movement which in turn may give health benefits. The Alexander Technique is thought to have a health effect indirectly, by improving general functioning. The higher score in secondary outcomes like quality of life and increased body awareness and control could be an example of this.

Adverse events
In the ATEAM trial the only adverse events reported were from a patient receiving massage, none from the 288 patients receiving a total of 2400 lessons in the Alexander Technique. In the neck pain trial adverse events were reported to be slightly increased pain and muscle soreness.

The difference in adverse events between the two trials could have multiple explanations.
It could be due to the difference in nature of neck and back problems, the neck being more movable and thereby more prone to be subject to non-habitual movements causing soreness. It could be that the Alexander Technique teachers in the ATEAM trial indeed were very careful, and that this showed in the reduction in pain, the absence of adverse events, and a reduction in disability score that might have been higher if the habitual movement patterns of the patients had been more challenged.

Or, it could be that the occurrence of adverse events from Alexander Technique lessons in the ATEAM trial is underreported. Knowing that some adverse effects like temporarily increased pain and muscle soreness is not unheard of, I would think that the adverse events in the ATEAM trial indeed is underreported. It is very likely that there must have been some experience of temporarily increased pain and muscle soreness given such a high number of lessons, and especially within a group of people already experiencing back pain.

Negative conclusions
The Alexander Technique not performing any better than heat packs after five weeks is disappointing. I don't expect many Alexander teachers to report on this trial. Some may even try to dismiss it. A negative result, however, does not mean that the trial is not useful. As I have tried to show there are a lot of things to learn from this trial. A negative result gives us indications about the limits of the Alexander Technique. It is obvious that there must be limits to the technique's effect on health. We need to know what those limits are. Negative results are necessary to find this out.

Usefulness of a scientific research does not depend on whether the outcomes are positive of negative. Instead, the usefulness depend on the quality of the research. Having only the abstract available from this trial I'm in no position to consider its quality. 
The trial was published in The Journal of Alternative and Complementary Medicine, a scientific journal which quackwatch labels as fundamentally flawed.
One of the trial authors is working at NAFKAM, the The National Research Center in Complementary and Alternative Medicine in Norway. The centre has been criticised for publishing research of poor quality (newspaper article in Norwegian).

Edzard Ernst wrote about this trial on his blog . He commended the authors of the trial for their cautious conclusion. The trial being published in a journal with low reputation means we should be a little sceptical. But the main outcome being negative I think there is reason to believe the results. After all, the primary outcome only confirms what we Alexander Technique teachers have been saying all along: the technique is not a quick fix. If anybody with neck pain comes for lessons and expect to be much better after only five lessons and five weeks they could probably do just as well by trying some heat packs.

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