Alexander technique and Supervised Physiotherapy Exercises in back paiN

106 Pages·2014·20.71 MB·English

by  Little P

EFFICACY AND MECHANISM EVALUATION
VOLUME 1 ISSUE 2 OCTOBER 2014
ISSN 2050-4365
Alexander technique and Supervised Physiotherapy
Exercises in back paiN (ASPEN): a four-group
randomised feasibility trial
Paul Little, Beth Stuart, Maria Stokes, Carolyn Nicholls, Lisa Roberts,
Stephen Preece, Tim Cacciatore, Simon Brown, George Lewith,
Adam Geraghty, Lucy Yardley, Gilly O’Reilly, Caroline Chalk,
Debbie Sharp and Peter Smith
DOI 10.3310/eme01020

Alexander technique and Supervised
Physiotherapy Exercises in back paiN
(ASPEN): a four-group randomised
feasibility trial
Paul Little,1* Beth Stuart,1 Maria Stokes,2
Carolyn Nicholls,3 Lisa Roberts,2 Stephen Preece,4
Tim Cacciatore,5 Simon Brown,2 George Lewith,1
’
Adam Geraghty,1 Lucy Yardley,6 Gilly O Reilly,1
Caroline Chalk,7 Debbie Sharp8 and Peter Smith9
1Primary Care and Population Sciences Group, University of Southampton,
Southampton, UK
2Faculty of Health Sciences, University of Southampton, Southampton, UK
3Brighton Alexander Technique College, Brighton, UK
4School of Health Sciences, University of Salford, Salford, UK
5Institute of Neurology, University College London, London, UK
6School of Psychology, University of Southampton, Southampton, UK
7Bristol Alexander School, Bristol, UK
8Centre for Academic Primary Care, University of Bristol, Bristol, UK
9Southampton Statistical Sciences Research Institute, University of Southampton,
Southampton, UK
*Corresponding author
Declared competing interests of authors: PaulLittle iseditor-in-chief of theProgramme Grants for
Applied Research journal.
Published October 2014
DOI: 10.3310/eme01020
This reportshould be referenced as follows:
Little P, Stuart B, StokesM, Nicholls C, Roberts L, Preece S,et al. Alexander technique and
Supervised Physiotherapy Exercises in back paiN (ASPEN): afour-group randomised feasibility trial.
Efficacy Mech Eval 2014;1(2).

Efficacy and Mechanism Evaluation
ISSN2050-4365(Print)
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DOI:10.3310/eme01020 EFFICACYANDMECHANISMEVALUATION2014 VOL.1 NO.2
Abstract
Alexander technique and Supervised Physiotherapy
Exercises in back paiN (ASPEN): a four-group randomised
feasibility trial
Paul Little,1* Beth Stuart,1 Maria Stokes,2 Carolyn Nicholls,3
Lisa Roberts,2 Stephen Preece,4 Tim Cacciatore,5 Simon Brown,2
George Lewith,1 Adam Geraghty,1 Lucy Yardley,6 Gilly O’Reilly,1
Caroline Chalk,7 Debbie Sharp8 and Peter Smith9
1Primary Careand Population Sciences Group, University ofSouthampton, Southampton, UK
2Faculty of Health Sciences, University of Southampton, Southampton, UK
3Brighton Alexander Technique College, Brighton, UK
4School ofHealth Sciences, University of Salford, Salford, UK
5Institute of Neurology, University College London, London, UK
6School ofPsychology, University ofSouthampton, Southampton, UK
7Bristol Alexander School, Bristol, UK
8Centre forAcademic Primary Care, University of Bristol, Bristol, UK
9Southampton Statistical Sciences Research Institute, University ofSouthampton,
Southampton, UK
*Corresponding author [email protected]
Background: The Alexander technique probably helps back painbut itis unclearwhether or notit canbe
combined with physiotherapy exercise classes, howmany lessons areneededand what mechanisms might
be involved.
Objectives: To undertake afeasibility trial of the Alexander technique and supervised exercise classes and
perform exploratory biomechanical andneuromuscular physiological marker analysesto better understand
mediators of recovery.
Design: Feasibility parallel-group randomised controlled trial.
Setting: General practices in southern England.
Participants: Patients with recurrent back pain (atleast 3weeks’ duration of acurrent episode).
Interventions: Participants were allocated by anexternal randomisation line to four groups: (1) normal
care, (2) 10 Alexander technique lessons, (3) 12 physiotherapy exercise classes, (4) Alexander technique
lessons plus exercise classes.
Main outcome measures:The feasibility outcomes were recruitment, acceptability and follow-up.
The clinical outcomes were theRoland–Morris Disability Questionnaire (RMDQ), days in pain, theVon Korff
pain anddisability scale, overall improvement, fear of activity, enablement, the Oswestry Disability Index
and theAberdeen painand function scale. Laboratory-based markers were axial muscle toneand flexibility,
electrical activity, muscle toneand mechanical properties of elasticity andstiffness, trunk strength,
and proprioception.
©Queen’sPrinterandControllerofHMSO2014.ThisworkwasproducedbyLittleetal.underthetermsofacommissioningcontractissuedbytheSecretaryofStateforHealth.
Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournalsprovidedthat v
suitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbeaddressedto:NIHR
JournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonSciencePark,Southampton
SO167NS,UK.
ABSTRACT
Results: Intotal, 83 patients consented, 69 were randomised and56 (81%) were followed up at
6 months.Most patients had long-standing pain (median >300 days of pain). TheRMDQ and other
instruments were sensitive to changeand thepreliminary evidence suggests that the Aberdeen scale could
be auseful measure. Study procedures were feasible and three methods of recruitment were successfully
piloted. At 6months the control grouphad changed little (RMDQ1point lower than at baseline) and,
compared with thecontrol group, clinically important improvements in RMDQ were seen in all groups,
albeit not significant [Alexander technique −3.0, 95% confidence interval (CI) −6.7 to 0.8]; exercise classes
−2.9, 95% CI −6.5to 0.8; combined Alexander technique+exercise classes −2.50, 9%CI −6.20 to 1.19].
Novel biomechanical variables strongly associated with RMDQ scoreat 6months were muscle tone
(0.94 increase in RMDQ per unit increase in Hz, 95% CI 0.48 to 1.40; p<0.0001), lumbar proprioception
(1.48 increase in RMDQ per degree, 95% CI 0.83 to 2.12;p<0.0001) and muscle elasticity (−4.86
increase in RMDQ perunit log decrement, 95% CI −0.01 to −9.72;p<0.05). At 3months the Alexander
technique improved proprioception and exercise classes improved trunk extension strength. At 6months
the Alexander technique improved thetiming of multifidus muscle onset and theactive straight leg raise
test and exercise classes improved multifidus muscle thickness and theability to contract. The combined
effects of theAlexander technique and exercise classes were improvements in muscle tone,elasticity
and thickness and contractile ability. These observations provide possible links between intervention,
proprioception, muscle tone and elasticity and outcome. Interms of harms, one patient fell in the
exercise classgroup.
Conclusions: The trial is feasible and theinterventions may provide clinically important benefits.
Exploratory analysis suggests that muscle tone, elasticity and proprioception are strongly associated with
improved RMDQ score and arelikely to be modified by theinterventions.
Trial registration: Current Controlled Trials ISRCTN51496752.
Funding: This project was funded bythe Medical Research Council throughthe Efficacy and Mechanism
Evaluation Board.
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NIHRJournalsLibrary www.journalslibrary.nihr.ac.uk
DOI:10.3310/eme01020 EFFICACYANDMECHANISMEVALUATION2014 VOL.1 NO.2
Contents
List oftables ix
List offigures xi
List ofabbreviations xiii
PlainEnglish summary xv
Scientific summary xvii
Chapter 1Introduction 1
Existing research 1
Physiotherapy exercises 1
Alexander technique 1
Mechanism and biomechanical/physiological markers of improvement 2
Alexander technique 2
Physiotherapy exercises 2
Risks andbenefits 3
Rationalefor the full trial 3
Chapter 2Research objectives 5
Chapter 3Methods 7
Research design 7
Changes or additions to the protocol since application 7
Study population 7
Planned interventions and proposed trial groups 8
Normal care 9
Outcome measures (at 3and 6months) 9
Assessment andfollow-up 11
Proposed sample size 11
Statistical analysis 12
Ethical arrangements 13
Research governance 13
Patient andpublic involvement 13
Chapter 4Results 15
Feasibility of recruitment 15
Invited recruitment for patient attending within thelast 5years 15
Opportunistic recruitment in surgery 15
Invited recruitment based on attendance in theprevious week 15
Feasibility of randomisation 16
Feasibility of intervention lessons 18
Logistical issues 18
Feasibility of delivering the intervention: compliance with attending intervention classes 18
©Queen’sPrinterandControllerofHMSO2014.ThisworkwasproducedbyLittleetal.underthetermsofacommissioningcontractissuedbytheSecretaryofStateforHealth.
Thisissuemaybefreelyreproducedforthepurposesofprivateresearchandstudyandextracts(orindeed,thefullreport)maybeincludedinprofessionaljournalsprovidedthat vii
suitableacknowledgementismadeandthereproductionisnotassociatedwithanyformofadvertising.Applicationsforcommercialreproductionshouldbeaddressedto:NIHR
JournalsLibrary,NationalInstituteforHealthResearch,Evaluation,TrialsandStudiesCoordinatingCentre,AlphaHouse,UniversityofSouthamptonSciencePark,Southampton
SO167NS,UK.
CONTENTS
Feasibility of retention 19
Feasibility of laboratory-based biomechanical andneuromuscular physiological measures 19
Sensitivity to change 20
Clinical outcome measures 20
Change in laboratory-based measures 20
Exploratory analysesof effectiveness 20
Main clinical results 20
‘Dose response’: rating of painand function by participants at Alexander technique
lessons and exercise classes 26
Exploratory analysesof intermediate markers (laboratory-based tests) 28
Understanding key issues in thetrial: qualitative substudy 30
Feedbackfrom Alexander technique teachers 32
Chapter 5Discussion 33
Strengths and limitations 33
Feasibility outcomes 33
Feasibility of laboratory biomechanical tests 34
Clinical outcomes 34
Effects of the interventions onlaboratory measures at 3 months’ follow-up 35
Effects of the interventions onlaboratory measures at 6 months’ follow-up 35
Mechanisms of treatment effects during recovery 35
Sensitivity and predictive valueof assessment tools for later studies 36
Chapter 6Conclusion 39
Recommendations for afuturetrial 39
Acknowledgements 41
References 43
Appendix 1Alexander technique lessons and physiotherapy exercise classes 47
Appendix 2Laboratory measures 63
Appendix 3Qualitative study 73
Appendix 4Comments fromteachers fed backto Carolyn Nicholls 79
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