A feature on the National Public Radio (NPR) website proclaimed an alternative therapy known as “The Alexander Technique” to be “highly effective” in the treatment of chronic back pain. But what does “highly effective” mean in real world terms—for a condition considered resistant to effective treatment?
Does the Alexander Technique—which educates patients on posture, movement and neuromuscular coordination—find strong support in multiple clinical trials? Is the therapy more effective than common evidence-based treatments for chronic back pain? Is it cost-effective? Unfortunately, the NPR story never provided answers to any of these questions.
Instead, it examined the value of this therapy through the prism of two individuals heavily invested in its success: (1) a jazz trumpeter attempting to use the Alexander Technique to work through his chronic back symptoms; and (2) a therapist who makes a living teaching these methods.
The article included brief comments from the British researcher who led a clinical trial showing the Alexander Technique to be superior to six sessions of massage and an uNPRoven exercise program. But the journalist highlighted only the most positive results from this study, and none of its potential limitations—of which there are several. (See BackLetter, 2008). And the writer didn’t seek out dispassionate commentary from any independent experts, much to the article’s detriment.
So what might those experts have said about the Alexander Technique? They might have pointed out that the Alexander approach to chronic low back pain has been examined in only a single randomized clinical trial. To be persuasive, these results would need to be confirmed in other clinical settings. Though they are promising and warrant further investigation, it isn’t clear if these findings represent a breakthrough, a further option for individuals with low back pain, or a false hope.
At present there is no evidence that the Alexander Technique is more effective than other common evidence-based treatments for chronic low back pain—from manual therapies to structured exercise programs to multidisciplinary rehabilitation. A recent systematic review performed for the British National Health Service concluded that all of these may be viable options for chronic back pain—but that none stood out as superior. (See NICE, 2009). So calling the Alexander Technique “highly effective” may be a bit of a reach.
In addition, the cost-effectiveness of this approach remains very much up in the air. In the clinical trial cited above, the Alexander Technique (which involved either six or 24 visits with a therapist) proved less cost-effective than a simple exercise program. (See NICE, 2009)
So should individuals with chronic or recurrent back pain consider the Alexander Technique as a treatment option? That would be a reasonable response. However, they should opt for this treatment approach only after taking a balanced look at both its potential strengths and its weaknesses—a process this article didn’t facilitate.
References:
BackLetter, The Alexander Technique for low back pain: the hazards of over-interpreting a single clinical trial, 2008; 23(9): 97-106.
NICE (National Institute for Health and Clinical Excellence), Early management of persistent, nonspecific low back pain, May, 2009; see http://www.nice.org.uk/nicemedia/live/11887/44334/44334.pdf
Back pain is a common human symptom that affects approximately half of the general population of the United States every year. Roughly 5-10% of those who experience back pain go on to develop chronic symptoms lasting more than three to six months. (See Lawrence RC, 2008). These individuals exact a huge toll in terms of medical costs, work loss, and long-term disability claims.
There are more than 200 hundred treatments for chronic back pain in the clinical marketplace. However, few if any have been proven to improve the long-term natural history of this condition. While some therapies show promise over the short to medium term, they generally have a modest impact on pain and function.
So the identification of more effective treatment approaches for chronic back pain remains a major public health priority.
Reference:
Lawrence RC, Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, part II, Arthritis & Rheumatism, 2008; 58(1): 26-35.
The article did not discuss the costs of Alexander Therapy. The clinical trial mentioned in the article involved up to 24 sessions with an Alexander therapist, so this treatment can be expensive.
A systematic review conducted for the British National Health Service found instruction in the Alexander Technique to be significantly less cost-effective than a simple exercise program (See Nice, 2009; p. 97). So costs are an issue with this therapy and they should have been discussed in the article.
The article provided skeletal information on only one of two primary outcome measures in the study, the one that cast the Alexander Technique in the most positive light. The article noted that subjects who had 24 lessons in the Alexander Technique went from 21 days of pain to 3 days of pain without ever mentioning what this means in real life terms. This statistic referred to the number of days in the last month during which the study subjects experienced any back pain. Without information on back pain intensity, or disability attributed to back pain, this statistic is difficult to interpret. So this article did not adequately frame this benefit.
The results of this study are not easy for journalists to characterize or present—given the way the study was conducted and reported. The journalist did a better job of attempting to quantify the benefit of the Alexander Technique than she did in evaluating the quality of the evidence.
3. The article did not discuss harms or adverse events. The study did not report any adverse events related to Alexander Therapy. Individuals interested in this this treatment approach might find this information useful, since several other common therapies for chronic back pain—from
acupuncture to manual therapies to invasive treatments—do cause adverse events and complications.
The journalist did not adequately characterize the quality of evidence supporting the Alexander Technique. The evidence supporting the Alexander Technique is thin. It comes from a single clinical trial with some distinct methodological limitations.
For instance, the study compared up to 24 sessions of Alexander Therapy with only six sessions of massage. The exercise program employed in this study has never been adequately tested in a clinical trial. Given the way the study subjects were selected, it is not clear if this technique can be applied in usual clinical practice with the same results.
And the article did not mention that the Alexander Technique has never been compared to other standard treatments for chronic back pain in clinical trials.
So pending further research, it is not clear if this constitutes a treatment advance or merely one more option that provides a modest benefit.
There is no significant disease mongering in this article. Chronic low back pain is a common problem for which there are limited effective treatments.
The article did not include commentary from an independent expert source—to its detriment. Independent commentary might have allowed readers to come to a much better understanding of the potential benefits of the Alexander Technique, and the level of evidence supporting it. The journalist did not provide any information on potential conflicts-of-interest.
The article mentioned that the jazz trumpeter featured in the piece had failed to improve after trying massage, chiropractic, and powerful painkillers. The implication in the article is that this treatment worked where other treatments didn’t. However, the article did not discuss the benefits and risks of other potentially effective treatments for low back pain—or how instruction in the Alexander Technique might fit into the larger universe of treatment choices.
In a major oversight, the article didn’t mention that instruction in the Alexander Technique is not widely available in the United States. And that insurance companies in the U.S. generally do not provide reimbursement for this therapy.
The article makes it clear that the Alexander Technique dates back to the 19th century.
The article did not appear to rely on a press release.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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