A controlled trial including an economic analysis found that lessons in the Alexander Technique (AT), an individualised approach aimed at improving posture and musculoskeletal use, gave better long-term outcomes in patients with chronic back pain than massage or prescribed exercise. A short AT course was likely to be cost-effective on usual criteria, and a short AT course plus exercise prescription was even more effective and cost-effective.
Chronic back pain is a major healthcare problem, with few interventions proven to give good long-term relief. Massage can give good short-term relief, and there is evidence that targeted exercise regimes can be helpful. Limited evidence shows that the AT may be effective short-term, however it is designed to have long-term effects: this trial aimed to determine whether AT, massage, or either combined with prescribed exercise were effective after one year in patients with chronic or recurrent back pain. The study included a cost-effectiveness element by design.
Participants were recruited from 64 general practices in the South-West of England: all had chronic back pain and were randomised to one of eight treatment groups: normal care (control), 6 massage sessions, 6 AT sessions, or 24 AT sessions, then each with prescribed exercise. There were two primary outcomes – disability, according to a standard measurement (the Roland-Morris disability questionnaire; a 0 to 24 points scale), and number of days pain in the previous four weeks. Based on previous work, a change of between 1.5 and 2.5 was considered to be clinically significant in this patient population. A number of secondary outcomes were also measured. Outcomes were assessed at baseline, then at three months and one year.
The economic evaluation was carried out at 12 months, and was conducted from the perspectives of the NHS, participants, and society. Included costs were those to the NHS, personal costs to participants, and time off work and unpaid activities. NHS costs included the intervention, primary care contacts, outpatient appointments, inpatient hospital stays, and medication. The cost effectiveness analysis compared cost to the NHS with the primary disability outcome questionnaire, the number of days in pain, and the QALY gain.
Initially, 18,342 patients were invited to participate. Of these, 4,803 responded, and 1,027 were potentially eligible for the study; 810 were screened, and of these 579 were eligible and randomised (compared to a required study size of 536 according to power calculations). Further contact with a sample of non-responders to the original invitation found that most would have been ineligible for the study. Most dropouts were in the early stages - 469 (81%) completed the study questionnaires at three months, and 463 (80%) at 12 months. Completion rates were similar across most of the eight study groups (71% to 84%, lowest for exercise only).
At one year, both exercise and AT remained effective, however massage showed no long-term effect. Compared to the control disability score of 8.1, the score for massage was –0.58 (95% CI –1.94 to 0.77), AT six lessons –1.40 (–2.77 to –0.03), AT 24 lessons –3.4 (–4.76 to –2.03), and exercise alone –1.29 (–2.25 to –0.34).
Adding exercise to 24 AT sessions had limited additional value (disability score compared to control –4.14; –6.13 to –2.31), however exercise plus 6 AT sessions gave 72% of the effect of 24 lessons alone (score vs. control –2.98; –4.88 to –1.07).
The costs for the interventions ranged from £30 for exercise prescription to £596 for 24 lessons in AT plus exercise. Additional health services costs ranged from £50 for 24 lessons in Alexander technique to £124 for exercise. Total costs for all groups ranged from £54.46 for the control group to £661.18 for 24 AT sessions plus exercise.
Incremental cost-effectiveness analysis found that exercise was the most cost-effective single therapy (£61 per point on disability score, £9 per additional pain-free day, £2,847 per QALY gain), compared to 6 sessions AT (£113, £13, £5,889), and massage (£448, £26, £34,473). For the two-stage therapies, exercise plus 6 AT sessions became most cost-effective (£64 per point on disability score, £43 per additional pain-free day, £5,332 per QALY gain) - 24 sessions AT was counted as a two-stage intervention (£145, £56, £20,993).
The authors conclude that one-to-one AT lessons have long-term benefits for chronic back pain. A short (six lessons) course of AT plus targeted prescribed exercise is almost as effective as 24 lessons of AT, and nearly as cost-effective as exercise alone.
[Editor’s note: the trial results were originally published in August, however the BMJ has now published the economic evaluation and re-presents the original study with these.]