Alexander technique and Supervised Physiotherapy Exercises in back paiN (ASPEN): a four-group randomised feasibility trial

NIHR Journals Library; 2014 October

Little P, Stuart B, Stokes M, Nicholls C, Roberts L, Preece S, Cacciatore T, Brown S, Lewith G, Geraghty A, Yardley L, O’Reilly G, Chalk C, Sharp D, Smith P



ASPEN (Alexander technique and Supervised Physiotherapy Exercises in back paiN) was a small study designed to assess the feasibility of a full trial; it was led by Dr Paul Little who was the principal investigator on the ATEAM trial. One of the main aims of the study was to explore whether Alexander lessons can be successfully combined with supervised physiotherapy exercises for people with chronic back pain. It concluded that a full trial will be feasible and that the interventions studied may provide clinically important benefits. As such it is broadly supportive of the ATEAM findings.


The full results are available as a 106-page report that can be downloaded here:



BACKGROUND: The Alexander technique probably helps back pain but it is unclear whether or not it can be combined with physiotherapy exercise classes, how many lessons are needed and what mechanisms might be involved.

OBJECTIVES: To undertake a feasibility trial of the Alexander technique and supervised exercise classes and perform exploratory biomechanical and neuromuscular physiological marker analyses to better understand mediators of recovery.

DESIGN: Feasibility parallel-group randomised controlled trial.

SETTING: General practices in southern England.

PARTICIPANTS: Patients with recurrent back pain (at least 3 weeks’ duration of a current episode).

INTERVENTIONS: Participants were allocated by an external 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 the Roland–Morris Disability Questionnaire (RMDQ), days in pain, the Von Korff pain and disability scale, overall improvement, fear of activity, enablement, the Oswestry Disability Index and the Aberdeen pain and function scale. Laboratory-based markers were axial muscle tone and flexibility, electrical activity, muscle tone and mechanical properties of elasticity and stiffness, trunk strength, and proprioception.

RESULTS: In total, 83 patients consented, 69 were randomised and 56 (81%) were followed up at 6 months. Most patients had long-standing pain (median > 300 days of pain). The RMDQ and other instruments were sensitive to change and the preliminary evidence suggests that the Aberdeen scale could be a useful measure. Study procedures were feasible and three methods of recruitment were successfully piloted. At 6 months the control group had changed little (RMDQ 1 point lower than at baseline) and, compared with the control 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 −6.5 to 0.8; combined Alexander technique + exercise classes −2.50, 9% CI −6.20 to 1.19]. Novel biomechanical variables strongly associated with RMDQ score at 6 months were muscle tone (0.94 increase in RMDQ per unit increase in Hz, 95% CI 0.48 to 1.40; p p p 

CONCLUSIONS: The trial is feasible and the interventions may provide clinically important benefits. Exploratory analysis suggests that muscle tone, elasticity and proprioception are strongly associated with improved RMDQ score and are likely to be modified by the interventions.

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