Annals of Internal Medicine 2015;163:653-62
MacPherson H, Tilbrook H, Richmond S, Woodman J, Ballard K, Atkin K, Bland M, Eldred J, Essex H, Hewitt C, Hopton A, Keding A, Lansdown H, Parrott S, Torgerson D, Wenham A, Watt I
Background: Chronic neck pain is a difficult condition to manage and additional approaches are needed, particularly ones that have a strong self-care basis. The Alexander Technique is, by its very nature, a self-care method. Acupuncture can include a self-care aspect as acupuncturists often provide dietary and lifestyle advice. The ATLAS trial evaluated the effectiveness of Alexander Technique lessons or acupuncture, each compared with usual care alone, for people with chronic neck pain.
Methods: ATLAS (Alexander Technique Lessons or Acupuncture Sessions for people with chronic neck pain) was a large clinical trial involving people with neck pain that had lasted at least 3 months and who scored above a certain threshold on the Northwick Park neck pain questionnaire (NPQ) – the NPQ is a self-report questionnaire that gives a measure of the degree of neck pain and associated disability that the person is experiencing. People were invited to participate in the trial via their GPs. The selected participants had neck pain of the most common type, which is called 'non-specific'; patients whose neck pain was caused by complex medical conditions were excluded. The trial took place in four cities in the North of England.
Participants were randomly allocated to one of three groups: Alexander Technique lessons plus continued usual GP-led care, acupuncture sessions plus continued usual GP-led care, or usual GP-led care alone. Participants in the Alexander group were offered 20 lessons, each lasting 30 minutes (total time for the 20 lessons was 600 minutes overall). Participants in the acupuncture group were offered 12 acupuncture sessions, each lasting 50 minutes (total time for the 12 sessions was also 600 minutes overall). All Alexander lessons were one-to-one and provided by teachers registered with the Society of Teachers of the Alexander Technique (STAT). All acupuncture sessions were provided one-to-one by practitioners registered with the British Acupuncture Council (BAcC).
The participants completed the NPQ questionnaire at the study start and at later intervals (3 months, 6 months and 1 year) with the 1 year finding being the main result. The trial also evaluated the degree to which participants felt able to manage their pain ('self-efficacy'), and their quality of life. Monitoring was carried out to identify any possible safety issues.
Findings: A total of 517 people with chronic non-specific neck pain participated in the trial. The average (median) duration of prior neck pain was 6 years. On average, participants in the Alexander group attended 14 of the 20 lessons offered. In the acupuncture group, participants attended an average of 10 of the 12 acupuncture sessions offered. For both the Alexander and acupuncture groups, there were long-term improvements in pain and associated disability that were statistically significantly greater than those observed in the group who received usual care alone (as shown by the change in NPQ scores over 1 year). Furthermore, these improvements from study start to 1 year later were large enough to be considered clinically relevant for both the Alexander lesson and the acupuncture group. Overall, participants experienced nearly a third less pain and associated disability at the end of the trial than at the start (a 31% reduction for the Alexander group and 32% for the acupuncture group).
Self-efficacy improved in both the Alexander and the acupuncture groups compared with the usual care alone group, and this improvement was associated with a better outcome in terms of pain and associated disability at 1 year. Improvement was also seen in the mental health of both Alexander and acupuncture groups at 1 year, as revealed by a self-report quality-of-life questionnaire. No safety issues related to Alexander lessons or acupuncture were identified in the trial.
Limitations of the trial: As all the participating Alexander teachers and acupuncturists belonged to STAT or BAcC, respectively, it is not known whether the study findings apply to practitioners registered with other organisations.
Conclusions: Both Alexander Technique lessons and acupuncture sessions led to statistically significant and clinically relevant reductions in neck pain and associated disability, compared with usual care alone, at 1 year. The sustained, long-term benefit is likely to be due, in part, to the participants' gain in self-efficacy resulting from the Alexander lessons or the acupuncture sessions.
Funding source: Arthritis Research UK.
The study protocol has also been published:
MacPherson H, Tilbrook HE, Richmond SJ, Atkin K, Ballard K, Bland M, Eldred J, Essex HN, Hopton A, Lansdown H, Muhammad U, Parrott S, Torgerson D, Wenham A, Woodman J, Watt I. Alexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS): study protocol for a randomised controlled trial. Trials. 2013 Jul 10;14:209.
BACKGROUND: Management of chronic neck pain may benefit from additional active self-care–oriented approaches.
OBJECTIVE: To evaluate clinical effectiveness of Alexander Technique lessons or acupuncture versus usual care for persons with chronic, nonspecific neck pain.
DESIGN: Three-group randomized, controlled trial. (Current Controlled Trials: ISRCTN15186354)
SETTING: U.K. primary care.
PARTICIPANTS: Persons with neck pain lasting at least 3 months, a score of at least 28% on the Northwick Park Questionnaire (NPQ) for neck pain and associated disability, and no serious underlying pathology.
INTERVENTION: 12 acupuncture sessions or 20 one-to-one Alexander lessons (both 600 minutes total) plus usual care versus usual care alone.
MEASUREMENTS: NPQ score (primary outcome) at 3, 6, and 12 months (primary end point) and Chronic Pain Self-Efficacy Scale score, quality of life, and adverse events (secondary outcomes).
RESULTS: 517 patients were recruited, and the median duration of neck pain was 6 years. Mean attendance was 10 acupuncture sessions and 14 Alexander lessons. Between-group reductions in NPQ score at 12 months versus usual care were 3.92 percentage points for acupuncture (95% CI, 0.97 to 6.87 percentage points) (P = 0.009) and 3.79 percentage points for Alexander lessons (CI, 0.91 to 6.66 percentage points) (P = 0.010). The 12-
month reductions in NPQ score from baseline were 32% for acupuncture and 31% for Alexander lessons. Participant self-efficacy improved for both interventions versus usual care at 6 months (P
month NPQ score reductions (acupuncture, 3.34 percentage points [CI, 2.31 to 4.38 percentage points]; Alexander lessons, 3.33 percentage points [CI, 2.22 to 4.44 percentage points]). No reported serious adverse events were considered probably or definitely related to either intervention.
LIMITATION: Practitioners belonged to the 2 main U.K.-based professional associations, which may limit generalizability of the findings.
CONCLUSION: Acupuncture sessions and Alexander Technique lessons both led to significant reductions in neck pain and associated disability compared with usual care at 12 months. Enhanced self-efficacy may partially explain why longer-term benefits were sustained.
PRIMARY FUNDING SOURCE: Arthritis Research UK.