Back pain is a common condition managed in primary care and one of the commonest causes of disability in Western societies.1 2 As yet few interventions have been proved to substantially help patients with chronic back pain in the longer term.
Supervised exercise classes—mainly strengthening and stabilising exercises—probably have moderate benefit for chronic pain.3 4 5 6 7 A trial of advice from a doctor to take aerobic exercise showed short term benefit for acute pain,8 but the evidence of longer term benefit for chronic or recurrent pain and for exercise “prescriptions” is lacking.9
Lessons in the Alexander technique offer an individualised approach designed to develop lifelong skills for self care that help people recognise, understand, and avoid poor habits affecting postural tone and neuromuscular coordination. Lessons involve continuous personalised assessment of the individual patterns of habitual musculoskeletal use when stationary and in movement; paying particular attention to release of unwanted head, neck, and spinal muscle tension, guided by verbal instruction and hand contact, allowing decompression of the spine; help and feedback from hand contact and verbal instruction to improve musculoskeletal use when stationary and in movement; and spending time between lessons practising and applying the technique (also see appendix on bmj.com).
The Alexander technique is thus distinct from manipulation,10 back schools,11 and conventional physiotherapy.12 The practice and theory of the technique, in conjunction with preliminary findings of changes in postural tone and its dynamic adaptability to changes in load and position,13 14 15 support the hypothesis that the technique could potentially reduce back pain by limiting muscle spasm, strengthening postural muscles, improving coordination and flexibility, and decompressing the spine. A small trial, not fully reported, showed promising short term results for back pain.16 We are not aware of a trial reporting long term results.
Systematic reviews and a recent trial highlighted the importance of research to assess the effectiveness of holistic therapeutic massage17 18 19; we particularly wanted to assess massage as it provides no long term educational element, in contrast with lessons in the Alexander technique.
We determined the effectiveness of six or 24 lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (using an exercise prescription) with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.