Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Interpreting clinically meaningful change versus statistical significance
- Steven M McPhail, Queensland, Australia 4102 (21 August 2008)
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Evidence on the effect of Alexander Technique
- RJ Nash (22 August 2008)
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Treatment for low back pain--who does best?
- Brian J Sweetman (22 August 2008)
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Are Scientific Standards Being Maintained by the BMJ & MRC?
- Tim Germon (24 August 2008)
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No-one ever mentions mattesses!
- Lesley A M Evans (24 August 2008)
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Sub-grouping, an important issue to be considered
- Gydhia Zuhair AL-CHALABY (25 August 2008)
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"Are scientific standards being maintained..."
- Dyfan A Lewis (26 August 2008)
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Are Scientific Standards Being Maintained by the BMJ & MRC?
- Giles T Smith (27 August 2008)
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Decompress the spine
- Roderic S MacDonald (27 August 2008)
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BMA members requested investigation of the Alexander Technique in 1937
- Jean M. Fischer (28 August 2008)
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Re: Are Scientific Standards Being Maintained by the BMJ & MRC?
- Timothy W Cacciatore (28 August 2008)
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Comparison of group means
- Jennifer E. Bolton (29 August 2008)
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difference in approach
- Dirk Verelst (16 September 2008)
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Prejudice against alternative therapies
- Shamil Haroon (19 December 2008)
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A trial subject's perspective
- Peter Lewis (2 March 2009)
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Steven M McPhail, Research Officer Princess Alexandra Hospital, Queensland, Australia 4102
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The investigators should be congratulated on the factorial design employed in this study allowing for clinically relevant comparisons to be made. I would like to primarily draw attention to the issue of clinically meaningful change in relation to one of the conclusions described in this investigation. The authors have commented that the six sessions of massage were much less effective at one year than three months but that the benefits of six lessons on Alexander technique were retained at one year. However, amongst the group who received the six lessons in Alexander technique alone, the primary outcome (Roland disability score) was reported to have only improved by 1.44 points after 12 months (Table 5). This is notably less than the value reported in the sample size calculation regarded by experts as clinically meaningful change (2.5 points) and slightly less than the lower limit of the range which the investigators considered could be clinically important (1.5 - 2.5 points). A discrete value for minimal clinically important difference in the primary outcomes, derived from recommended approaches,(1) would have been helpful in the interpretation of these results in terms of whether they were clinically important as opposed to statistically significant (i.e. unlikely to be due to random chance). It is also noteworthy that a more detailed description of the exercise prescription intervention would have been valuable given that there are various approaches to exercise for patients suffering from chronic low back pain.(2) However, this investigation is informative and offers the best evidence to date for Alexander technique lessons in the treatment of chronic low back pain; for this the authors should be commended. (1) de Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM. Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change. Health Qual Life Outcomes 2006;4:54. (2) Hodges PW. Core stability exercise in chronic low back pain. Orthop Clin North Am 2003;34(2):245-54. Competing interests: None declared |
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RJ Nash, Lead Spinal Extended Scope Practitioner Wexham Park Hospital SL2 4HL
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I am intrigued by the claim that The Alexander Technique can 'decompress the spine' as stated twice in the Introduction. Is there any evidence that this actually occurs? It is quite a strong suggestion to make to patients who are receiving this treatment Competing interests: None declared |
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Brian J Sweetman, Consultant Rheumatologist SA6 6NL
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Is it not awful? Yet another major back pain study fails to include enough base line detail to help show which patients responded to each of the particular treatments. This time it was the Alexander technique, exercises and massage study (1) that suffered. However this is a failure common to nearly all such studies during the last couple of decades. When such studies have “failed”, there have occasionally been some rueful comments that future studies will need such base line clinical observations. This means distinctive features of impairment and not just questionnaires about the non-specific resulting disability, psychological consequences and handicap. But there is hope. A few studies have indeed included such details (2,3). Subgroups of patients were identified who did relatively well, and it is likely that the features that selected for success would hopefully work for the many other forms of treatment that need to be reviewed for efficacy. How many more decades do we have to wait for such improvements in study design to be adopted as a matter of routine? Brian J Sweetman Competing interests: None declared. 1 Little R, Lewith G, Webley F, Evans M, Beattie A, Middleton K et al. Randomised controlled trial of Alexander technique lessons, exercises, and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008; 337: 438- 41. 2 Childs J, Fritz J, Flynn T, et al. Validation of a clinical prediction rule to identify patients with low back pain likely to benefit from spinal manipulation. Ann Intern Med 2004; 140: 920-8. 3 Sweetman BJ. Low back pain; some real answers. 2005. tfm publishing, Harley, SY5 6LX, UK. Competing interests: None declared |
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Tim Germon, Consultant Spinal Neurosurgeon, Dept Neurosurgery, Derriford Hospital, Plymouth, PL6 8DH
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Dear Sir, Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain (BMJ 2008;337:a884) I read with interest the article by Little et al. The authors have examined the effect of the Alexander technique on chronic low back pain. However, it appears to lack scientific credibility. The first and most fundamental question is, why should the Alexander technique help chronic low back pain? No rationale to explain why the Alexander technique might help chronic back pain is provided. In the introduction three references are quoted to support the hypothesis that the Alexander technique could potentially reduce back pain by,” limiting muscle spasm, strengthening postural muscles, improving coordination and flexibility, and decompressing the spine”. One of the quoted studies describes the maintenance of postural tone in the neck trunk and hips of a healthy human adults.1 Any link to the cause of back pain and the potential for the Alexander technique to treat such pain is purely hypothetical. The second article is merely a case report which does not stand scrutiny in supporting the underlying hypothesis that the Alexander technique might help chronic back pain and the third reference I was unable to find.2,3 If it could be demonstrated that The Alexander technique were effective in making the changes claimed we would then require evidence that the patients enrolled in the trial were suffering from back pain as a result of “muscle spasm, weakness from muscles, or poor coordination and flexibility and a compressed spine? If this were the case these variables should be defined and measured and changes should be related to outcome. The specific criticisms of this paper are set in a background of a more general problem. The constant management of low back pain as a diagnosis rather than a symptom. Until this is addressed it is difficult to see how real progress in understanding the conditions which lead to low back pain will be better understood. From the data presented, I am concerned that the MRC has used precious research funding to support this study and that the BMJ has published it. In the meantime this paper has already been and no doubt continue to be used in marketing the Alexander technique. Yours sincerely, Tim Germon
1. Cacciatore T, Horak F, Henry S. Improvement in automatic postural coordination following Alexander technique lessons in a person with low back pain. Phys Ther 2005;85:565-78.[Abstract/Free Full Text] 2. Gurfinkel V, Cacciatore T, Cordo P, Horak F, Nutt J, Skoss R. Postural muscle tone in the body axis of healthy humans. J Neurophysiol 2006;96:2678-87. 3. Cacciatore T, Gurfinkel V, Horak F, Cordo P, Ames K. Alteration of muscle tone through conscious intervention: increased adaptability of axial and proximal tone through the Alexander technique. Proceedings of the International Society for Posture and Gait Research , Vermont, USA, 14 -18 Jul 2007;18. Competing interests: None declared |
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Lesley A M Evans, Retired Consultant Geriatrician Retired (Woodpeckers, Bossington Lane, Porlock TA24 8HD)
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It was interesting to read that exercise and the Alexander technique can help chronic low back pain. Until last year I had continuous right sacro-iliac pain for 17 years, following a car crash. It was made worse by manipulation, and the only time I was free of pain was when staying in an old Welsh farmhouse on holiday and sleeping in a very soft mattress on an ancient bed! I decided to try a memory foam mattress, having failed to find any other which helped despite considerable expense on new mattresses. For the past 18 months, to my joy, I have had almost no pain at all, which has transformed my life. Hill walking, using two poles, also helps, but flat walking makes it much worse, and avoiding lifting heavy weights is important. But by far the most important thing for me has been the soft, yielding mattress. No-one ever seems to mention the importance of your bed, and indeed tourist boards seem to encourage hotels and guest houses to provide firm beds, which always reduce me to misery and severe pain after one night. It seems obvious that as our spines are not rigid, but curved, we need a mattress which moulds itself to our body shape. My back pain was partly responsible for my taking early retirement. I was told once that it was all in my mind - but now I know it is purely physical, and the cure is physical too. I agree that exercise is very important, and I walk many miles a week, but this is only part of the answer, and I would like to see someone doing some good research on memory foam mattresses. Yours sincerely, Lesley A M Evans MSc MRCP Competing interests: None declared |
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Gydhia Zuhair AL-CHALABY, F1 doctor pre-registration doctor
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Chronic back pain is a substantial health problem, it affects up to 80% of adult population and accounts for considerable healthcare and socioeconomic cost. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific back pain indicate limited long-term effectiveness for most commonly applied iterventions and approaches. Alexander technique lessons might give new hope for patients with chronic and recurrent back pain, but there is an important issue that needs to be addressed thoroughly before reaching the final conclusion about its effectiveness as a new method of treatment and that is "sub-grouping" of the patients involved in that study. In my opinion, patients presentations and responses to treatment will always vary and require personalisation of care. It is important to consider if these variations need to be interpreted as indicating distinctly different mechanisms underlying the disorder. Futhermore, ther is little evidence to endorse that method of treatment for chronic back pain, as most treatments provide only small short-term changes and there is scant evidence that this form of treatment is superior to another. In conclusion, more details should be given about sub-grouping in order to prove the effectiveness of Alexander technique lessons as new line of managment of chronic and recurrent back pain. Dr.Gydhia Zuhair Al-Chalaby.
Competing interests: None declared |
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Dyfan A Lewis, specialist in general & family medicine Nacka 131 47 Sweden
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Tim Germon's rapid response is intriguing. An evidence-based and consistent explanatory mechanism for the effect of the Alexander Technique is a secondary question. A legitimate response to this interesting article would be to endeavour to repeat or fail to repeat the results in the article and then to postulate explanatory hypotheses and ultimately to find or fail to find patho-physiological evidence to support those hypotheses. The BMJ would hopefully have published Alexander Fleming's theoretically inappropriate report on the bactericidal effect of penicillinium mould even before he was able to elucidate the laktam ring's exact mechanism of damaging the bacterial wall. Competing interests: None declared |
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Giles T Smith, Alexander technique teacher Private, NG9 1DW
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I am surprised that Mr Germon feels that the scientific validity of the research is brought into question due to a perceived lack of explanation in the paper of why the technique should help a condition such as recurrent back pain. Surely these are two separate issues? The principle hypothesis upon which the technique rests is that the way one uses oneself affects ones functioning (a simplified but less accurate way of saying this would be the way one moves affects ones functioning). That there are better and worse ways for a human to move seems such a reasonable hypothesis from a mechanical viewpoint as to be axiomatic. The question is to what extent can use influence functioning either positively or negatively, and to what extent can a given intervention bring about change in use and a corresponding but indirect change in functioning. This approach appears inconsistent with the “management of low back pain as a diagnosis rather than a symptom”. Alexander proposed what he believed to constitute good use, a technique for bringing about that use in oneself, and methods for teaching that technique to others. Is it not scientific to assess the effectiveness of such a technique based upon statistical outcomes? The scientific approach is to discard that which has been shown to be false, rather than to exclude that which is as yet untested. Mr Germon appears to propose that more detailed research would need to be carried out for scientific standards to be maintained, yet he is concerned that the MRC has already used “precious research funding” on this subject. This seems to suggest an underlying prejudice against the possibility that the technique could be based on a valid hypothesis, and that is surely not scientific. Competing interests: Alexander technique teacher |
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Roderic S MacDonald, Musculoskeletal Physician Ealing PCT, W5
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R J Nash asks for evidence that the improved use of one's self, taught by Alexander's followers can decompress the spine. Obviously intradiscal pressure data could be obtained to test this assertion and, following the interest that this trial should provoke, probably will. However at a slightly lower level of evidence, the rational inference, it should be easy to conceptualise the effect of excess activation of the erector spinae muscles while standing, a common postural fault foisted on the young when told to "Stand up straight, chest out, shoulders back.". Pulling roughly parallel with the spine and usually capable of generating a force equivalent to ten times body weight, the inappropriate activation of these muscles cannot fail to compress the spine. How wise our children are that they usually flout this advice. How much better they might fare if instead we taught them according to the principles of Alexander to achieve balance in the body with efficient employment of their muscles. This would be attempting the primary prevention that the trial's achievement suggests is there for the asking. What is Physical Education for if not this ? Congratulations to those involved in this long-needed trial. Our declared interest is that, while not attempting to replicate Alexander's teaching technique, a significant part of the courses taught by our Institute directly derive from the continuing relevance of his century-old principles which are worthy of study by any doctor attempting to manage musculoskeletal pain and disability. Dr Roderic MacDonald, President, British Institute of Musculoskeletal Medicine. Competing interests: None declared |
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Jean M. Fischer, Teacher Pimlico SW1
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Thank you for publishing the results of this trial. Between 1923 and 1951 the BMJ published some 30 articles and letters, most of them by BMA members, testifying to the efficacy of lessons in the Alexander Technique. One of the letters, published 29 May 1937, was signed by 19 BMA doctors and surgeons. They reported that patients they had sent for lessons had greatly benefited and urged the medical community to investigate the Alexander Technique. How fitting that 70 years later the BMJ should publish the results of such an investigation. Competing interests: Teacher of the Alexander Technique |
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Timothy W Cacciatore, Research Associate Institute of Neurology, University College London, WC1N 3BG
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The abstract (1) referenced by Little et al is freely available from the International Society for Posture and Gait Research at the following link: http://ispgr.org/conferences/vermont-2007/abstracts-online/index.html While this report is preliminary, abstracts for this meeting are reviewed and competitive. Briefly we observed significant reductions in axial and proximal stiffness during standing in subjects with chronic idiopathic low back pain following a course in Alexander Technique lessons. This lower stiffness resulted from increased adaptation of postural tone to imposed torsional length changes though modulation of tonic muscle activity. While the causes of such back pain are poorly understood, these results are consistent with decreased loading of the spine and related tissues, which could plausibly underlie pain reduction. Pending peer review, we hope that a full description of this work will soon be forthcoming. In the meantime, Little et al have cited our 2006 J. Neurophysiology paper (2) that details the methodology used to assess axial proximal stiffness and the adaptivity of muscle tone. Little et al also cite our case report (3), which quantitatively describes changes in postural behaviour of a subject with chronic back pain through a course of Alexander Technique lessons. The observations in this subject were also consistent with reduced spinal stiffness. One of the primary purposes of a case report is to generate hypotheses. We suggest the observations in this report can be used for this purpose. 1. Cacciatore T, Gurfinkel V, Horak F, Cordo P, Ames K. Alteration of muscle tone through conscious intervention: increased adaptability of axial and proximal tone through the Alexander technique. Proceedings of the International Society for Posture and Gait Research , Vermont, USA, 14 -18 Jul 2007;18. 2. Gurfinkel V, Cacciatore T, Cordo P, Horak F, Nutt J, Skoss R. Postural muscle tone in the body axis of healthy humans. J Neurophysiol 2006;96:2678-87. 3. Cacciatore T, Horak F, Henry S. Improvement in automatic postural coordination following Alexander technique lessons in a person with low back pain. Phys Ther 2005;85:565-78. Competing interests: None declared |
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Jennifer E. Bolton, Director of Research Anglo-European College of Chiropractic, Bournemouth BH5 2DF
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In response to the continuing clamour for more evidence into CAM interventions, Little et al. have published an RCT into the efficacy of the Alexander technique. No doubt the critics will pour over this RCT and the issues of blinding, adherence and therapist effect will be discussed ad nauseam. This RCT randomised patients to no less than 8 groups, measured a plethora of outcomes, and reported findings in terms of statistical differences between group mean values. Unfortunately what is not clear from this study is exactly what the benefits are for the individual patient, and whether some patients are more likely to benefit than others. I suggest that until we spend our precious resources on research that can easily be translated into practice, and readily understood by clinicians and patients, we run the risk of becoming hidebound to the demands of those who can see no further than the holy grail of the RCT. Professor Jennifer Bolton
Competing interests: None declared |
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Dirk Verelst, MD Nijmegen Trombosedienst
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The difficulty some Medically trained professionals experience in understanding how the Alexander Technique might possibly remedy chronic back pain is in my opinion due to the fact that the preventive approach is one that is lacking in common Medical practice. Remember prevention is either primary (no complaints, health promotion), secondary (complaints disappear) or tertiary (palliative approach). This is very different from treating mere symptoms or doing away with the suffering with the help of medication. I know I've had to readapt my point of view on how health problems arise when I first started studying the Alexander Technique, and I am often confronted with the inabilty of colleagues to reason along different lines when I try to axplain why AT lessons can be beneficial. Surely putting aside the outcome of a study because one's understanding is (still) lacking in comprehending the mechanisms is not the shortest way in acquiring more knowledge on the subject. If the problem were easy to understand one would have known it already. A teacher training course takes three years, during which the pupil acquires an understanding in functioning of the human apparatus that is not taught in Medical school/University. Dr. Dirk Verelst (MD, Alexander Teacher) Competing interests: Teacher Alexander Technique |
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Shamil Haroon, SHO Christchurch Public Hospital, New Zealand
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The rapid responses to Little et al's study while addressing legitimate concerns also appear to be clouded by the age-long prejudice by the medical field to alternative therapies. A lack of scientific evidence for the physiological basis of treatment is, as commented by other readers, not unique to the Alexander Technique, nor is it relevant to the actual efficacy of treatment. Furthermore a relatively safe treatment for chronic back pain should be welcomed by clinicians as much as by patients who may consequently save years of treatment with NSAIDs with their associated side-effects. I trust the BMJ will not be discouraged from pursuing this subject. Competing interests: None declared |
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Peter Lewis, retired Home BA2 2BB
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I was a subject on the A-TEAM trial. My tardy response is because I was told that subjects would be informed of the study results. To date this has not happened, I only found this paper when a friend mentioned it to me. In Table 5, which gives the one year results, SF-36, “quality of life mental” shows no effect. This seems to have been overlooked. It is desirable to reduce days of back pain, but until this is zero there is the constant reminder of the underlying problem. Is it not this continual worry of exacerbation that is wearing, reduces activity levels and leads to the low mental state? The authors say that they used primary outcome measures that have been well validated. Were the subjects used in the validation specifically asked what outcome they would value most following therapy? I would think not. Certainly the subjects in the ATEAM trial were not asked. It is surprising that the authors do not distinguish bewteen what they want to measure and what patients might want them to measure. Why do they think that patients would value an “improvement” on their scales? The validation or otherwise of the wrong measure is irrelevant. As a patient, for me, the take home message for this study is that none of the therapies cures back pain, therefore, they are not worth bothering with. Competing interests: None declared |
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