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Dynamic Chiropractic Canada – May 1, 2009, Vol. 02, Issue 03
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ATEAM for Chronic Low Back Pain

By Shawn Thistle, DC, BKin (hons), CSCS

The Study

Title: "Randomised Controlled Trial of Alexander Technique Lessons, Exercise and Massage (ATEAM) for Chronic and Recurrent Back Pain."
Authors: Little P, et al.
Author Affiliation(s): Primary Care Group, Community Clinical Sciences Division, Southampton University (U.K.)
Publication: British Medical Journal, 2008;337:a884


Few interventions have substantial evidence to support their use in the treatment of chronic low back pain (CLBP). Function has been shown to improve moderately with combined spinal manipulation and physiotherapy-supervised exercise programs. It has also been demonstrated that individual or group classes consisting of spinal stabilization and strengthening exercises can be of some benefit. The Alexander technique offers an individualized approach to help patients develop skills to recognize, understand and manage the poor habits that affect their posture and influence their back pain.

A small body of literature suggests that the Alexander technique can positively affect postural tone and dynamic adaptability to changes in load and position.1-3 The goal of the technique is to reduce back pain by limiting muscle spasm, strengthening postural muscles, decompressing the spine, and improving coordination and flexibility (for more information visit

The purpose of this factorial randomized trial was to compare the effectiveness of the Alexander technique, massage therapy and physician advice to undertake exercise in conjunction with behavioral counseling in a patient population (n=579) with chronic and recurrent LBP. This was the first randomized trial published on this technique, and had an accompanying paper published as a cost-analysis.4

Study Methods

Sixty-four general practices were recruited in England, from which 152 therapists agreed to participate. Each practice contacted a random selection of those who had attended their clinics with back pain in the previous five years, resulting in a study population of 579 patients.

Inclusion criteria included the following: between 18-65 years of age; presentation in primary care with low back pain more than three months previously  (to exclude first episodes); currently scoring 4 or more on the Roland-Morris disability scale; and current pain for three or more weeks (to exclude recurrence of short duration). Exclusion criteria included previous experience with Alexander technique; perceived inability to walk 100 m (indicating a difficulty with exercise); and other standard exclusions - nerve root pain, serious disease indicators, psychosis, etc.

Subjects were randomized to one of four treatment groups (each intervention was applied with or without general exercise prescription from a GP, resulting in eight possible allocations): normal care (n=144), six massage therapy treatments (n=147), six lessons of Alexander technique (n=144) or 24 lessons of Alexander technique (n=144). All outcomes were measured at baseline, three months and 12 months. The primary outcomes were the Roland-Morris Disability Questionnaire and number of days in pain.

Pertinent Results

Of the 579 subjects who entered the study, 469 (81 percent) completed questionnaires at three months, while 80 percent completed them at 12 months. The responders at 12 months were more likely to have left full-time education later, and to be self-employed or homemakers. (Note: Including education and employment in the final analysis did not alter the results of this study.) 

  • The patients had an average of 243 days of pain in the previous year, representing a chronic population (79 percent reported more than 90 days of pain).
  • Overall, little change occurred in the Roland-Morris (RM) scores in the control group.
  • At three months, significant improvements for all interventions (including massage) were noted compared to the control group for days in pain and RM scores
  • In the group receiving 24 Alexander lessons, the effect at 12 months was greater than the effect at three months (42 percent reduction in RM score; 86 percent reduction in days with pain at 12 months).
  • The effect of only six Alexander lessons was maintained at 12 months: 17 percent reduction in RM scores and 48 percent reduction in days with pain.
  • Positive effects were noted after 24 Alexander lessons relative to all outcomes, while similar but only slightly smaller improvements were seen with six lessons followed by exercise.
  • Comparing six lessons of Alexander technique and six massage treatments, similar outcomes were noted at three months, but the results of the six Alexander lessons lasted through the 12-month point, while the massage benefits did not.
  • Overall adherence was good - 91 percent in the massage group, 94 percent in the group receiving six Alexander lessons and 81 percent in the group receiving 24 Alexander lessons.
  • Combining exercise with 24 Alexander lessons did not improve outcomes as much as the addition of exercise to six Alexander lessons; in fact, the combination of only six lessons with exercise was as effective (approximately 72 percent) at one year as 24 lessons alone.
  • Only one adverse reaction was noted in a massage patient, while none was reported in any other intervention.

Conclusions and Practical Applications

In this study, exercises and lessons in the Alexander technique improved pain and disability levels at one year in a very chronic LBP patient sample, while massage only demonstrated comparable short-term benefits. One-on-one lessons from registered Alexander teachers can have positive long-term benefits for chronic LBP patients. As this was a large, multi-center, multi-therapist trial, the results are not likely due to the superior skills of a few clinicians. 

Study Critique

This study involved numerous treatment centers, teachers and therapists using a pragmatic treatment approach.  The patient sample was also large for this type of study. The patients included were generally very chronic in nature, reporting a high number of pain days. These patients are traditionally difficult to treat, so any quality studies with favorable outcomes should be viewed as influential and important. This study used simple and validated outcomes, achieved good adherence to treatments, and applied appropriate controls during the statistical analysis. 

Additional References

  1. Cacciatore T, et al. 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 July, 2007:18.
  2. Cacciatore T, Horak F, Henry S. Improvement in automatic postural coordination following Alexander technique lessons in a person with low back pain. Physical Therapy, 2005;85:565-578.
  3. Gurfinkel V, et al. Postural muscle tone in the body axis of healthy humans. Journal of Neurophysiology, 2006;96:2678-2687.
  4. Hollinghurst S, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation. BMJ, 2008;337:a2656. doi: 10.1136/bmj.a2656.

Dr. Shawn Thistle is founder and president of the Research Review Service (, from which all content for this and other articles by Dr. Thistle is derived. Research Review Service posts approximately 60 reviews like this each year and currently has a database of more than 250 reviews. Dr. Thistle graduated from the Canadian Memorial Chiropractic College, where he has been a faculty member since 2004. He holds an honours degree in kinesiology (McMaster) and a certificate in contemporary medical acupuncture. He is also fully ART-certified and is a certified strength and conditioning specialist. Dr. Thistle practices full time at Shape Health and Wellness Centre in Toronto.

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