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Management of chronic neck pain may benefit from additional active self-care–oriented approaches.
To evaluate clinical effectiveness of Alexander Technique lessons or acupuncture versus usual care for persons with chronic, nonspecific neck pain.
Three-group randomized, controlled trial. (Current Controlled Trials: ISRCTN15186354)
U.K. primary care.
Persons with neck pain lasting at least 3 months, a score of at least 28% on the Northwick Park Questionnaire (NPQ) for neck pain and associated disability, and no serious underlying pathology.
12 acupuncture sessions or 20 one-to-one Alexander lessons (both 600 minutes total) plus usual care versus usual care alone.
NPQ score (primary outcome) at 0, 3, 6, and 12 months (primary end point) and Chronic Pain Self-Efficacy Scale score, quality of life, and adverse events (secondary outcomes).
517 patients were recruited, and the median duration of neck pain was 6 years. Mean attendance was 10 acupuncture sessions and 14 Alexander lessons. Between-group reductions in NPQ score at 12 months versus usual care were 3.92 percentage points for acupuncture (95% CI, 0.97 to 6.87 percentage points) (P = 0.009) and 3.79 percentage points for Alexander lessons (CI, 0.91 to 6.66 percentage points) (P = 0.010). The 12-month reductions in NPQ score from baseline were 32% for acupuncture and 31% for Alexander lessons. Participant self-efficacy improved for both interventions versus usual care at 6 months (P < 0.001) and was significantly associated (P < 0.001) with 12-month NPQ score reductions (acupuncture, 3.34 percentage points [CI, 2.31 to 4.38 percentage points]; Alexander lessons, 3.33 percentage points [CI, 2.22 to 4.44 percentage points]). No reported serious adverse events were considered probably or definitely related to either intervention.
Practitioners belonged to the 2 main U.K.-based professional associations, which may limit generalizability of the findings.
Acupuncture sessions and Alexander Technique lessons both led to significant reductions in neck pain and associated disability compared with usual care at 12 months. Enhanced self-efficacy may partially explain why longer-term benefits were sustained.
Primary Funding Source:
Arthritis Research UK.
Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck pain: estimates from the Global Burden of Disease 2010 Study. Ann Rheum Dis. 2014;73:1309-15. [PMID: 24482302] doi:10.1136/annrheumdis-2013-204431 CrossrefMedlineGoogle Scholar
Jull G, Sterling M, Falla D, Treleaven J, O'Leary S. Whiplash, Headache and Neck Pain. Edinburgh, United Kingdom: Churchill Livingston; 2008. Google Scholar
Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med. 2001;9:2-11. [PMID: 11264963] CrossrefMedlineGoogle Scholar
Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008:1-23. [PMID: 19361005] MedlineGoogle Scholar
MacPherson H, Thomas K. Self-help advice as a process integral to traditional acupuncture care: implications for trial design. Complement Ther Med. 2008;16:101-6. [PMID: 18514912] doi:10.1016/j.ctim.2008.02.010 CrossrefMedlineGoogle Scholar
Robinson N, Lorenc A, Ding W, Jia J, Bovey M, Wang XM. Exploring practice characteristics and research priorities of practitioners of traditional acupuncture in China and the EU-A survey. J Ethnopharmacol. 2012;140:604-13. [PMID: 22338645] doi:10.1016/j.jep.2012.01.052 CrossrefMedlineGoogle Scholar
Evans M, Paterson C, Wye L, Chapman R, Robinson J, Norton R, et al. Lifestyle and self-care advice within traditional acupuncture consultations: a qualitative observational study nested in a co-operative inquiry. J Altern Complement Med. 2011;17:519-29. [PMID: 21649518] doi:10.1089/acm.2010.0749 CrossrefMedlineGoogle Scholar
Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ. 2006;333:623. [PMID: 16980316] CrossrefMedlineGoogle Scholar
- 9. National Institute for Health and Care Excellence. Low back pain: early management of persistent non-specific low back pain. London: National Institute for Health and Care Excellence; 2009:4-25. Accessed at www.nice.org.uk/cg88 on 8 September 2015. Google Scholar
- 10. National Institute for Health and Care Excellence. Headaches: diagnosis and management of headaches in young people and adults. NICE guideline CG150. London: National Institute for Health and Care Excellence; 2012. Accessed at http://guidance.nice.org.uk/CG150 on 20 November 2014. Google Scholar
Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN. Acupuncture for patients with chronic neck pain. Pain. 2006;125:98-106. [PMID: 16781068] CrossrefMedlineGoogle Scholar
Woodman JP, Moore NR. Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review. Int J Clin Pract. 2012;66:98-112. [PMID: 22171910] doi:10.1111/j.1742-1241.2011.02817.x CrossrefMedlineGoogle Scholar
Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K, et al. Randomised controlled trial of Alexander Technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ. 2008;337:a884. [PMID: 18713809] doi:10.1136/bmj.a884 CrossrefMedlineGoogle Scholar
Cacciatore TW, Gurfinkel VS, Horak FB, Cordo PJ, Ames KE. Increased dynamic regulation of postural tone through Alexander Technique training. Hum Mov Sci. 2011;30:74-89. [PMID: 21185100] doi:10.1016/j.humov.2010.10.002 CrossrefMedlineGoogle Scholar
Cacciatore TW, Gurfinkel VS, Horak FB, Day BL. Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique. Gait Posture. 2011;34:496-501. [PMID: 21782443] doi:10.1016/j.gaitpost.2011.06.026 CrossrefMedlineGoogle Scholar
Cacciatore TW, Horak FB, Henry SM. Improvement in automatic postural coordination following Alexander Technique lessons in a person with low back pain. Phys Ther. 2005;85:565-78. [PMID: 15921477] CrossrefMedlineGoogle Scholar
Cacciatore TW, Mian OS, Peters A, Day BL. Neuromechanical interference of posture on movement: evidence from Alexander Technique teachers rising from a chair. J Neurophysiol. 2014;112:719-29. [PMID: 25085609] doi:10.1152/jn.00617.2013 CrossrefMedlineGoogle Scholar
Salter GC, Roman M, Bland MJ, MacPherson H. Acupuncture for chronic neck pain: a pilot for a randomised controlled trial. BMC Musculoskelet Disord. 2006;7:99. [PMID: 17156464] CrossrefMedlineGoogle Scholar
MacPherson H, Tilbrook HE, Richmond SJ, Atkin K, Ballard K, Bland M, et al. Alexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS): study protocol for a randomised controlled trial. Trials. 2013;14:209. [PMID: 23841901] doi:10.1186/1745-6215-14-209 CrossrefMedlineGoogle Scholar
Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank AO. The Northwick Park Neck Pain Questionnaire, devised to measure neck pain and disability. Br J Rheumatol. 1994;33:469-74. [PMID: 8173853] CrossrefMedlineGoogle Scholar
Moffett JK, Jackson DA, Gardiner ED, Torgerson DJ, Coulton S, Eaton S, et al. Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management. Rheumatology (Oxford). 2006;45:1514-21. [PMID: 17062645] CrossrefMedlineGoogle Scholar
- 22. Skills for Health. CNH3 Deliver Alexander Technique Teaching. Bristol, United Kingdom: Skills for Health; 2010. Accessed at https://tools.skillsforhealth.org.uk/competence/show/pdf/id/2800 on 8 September 2015. Google Scholar
Anderson KO, Dowds BN, Pelletz RE, Edwards WT, Peeters-Asdourian C. Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain. Pain. 1995;63:77-84. [PMID: 8577493] CrossrefMedlineGoogle Scholar
Dziedzic K, Hill J, Lewis M, Sim J, Daniels J, Hay EM. Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics. Arthritis Rheum. 2005;53:214-22. [PMID: 15818640] CrossrefMedlineGoogle Scholar
Sim J, Jordan K, Lewis M, Hill J, Hay EM, Dziedzic K. Sensitivity to change and internal consistency of the Northwick Park Neck Pain Questionnaire and derivation of a minimal clinically important difference. Clin J Pain. 2006;22:820-6. [PMID: 17057565] CrossrefMedlineGoogle Scholar
White IR, Kalaitzaki E, Thompson SG. Allowing for missing outcome data and incomplete uptake of randomised interventions, with application to an Internet-based alcohol trial. Stat Med. 2011;30:3192-207. [PMID: 21948462] doi:10.1002/sim.4360 CrossrefMedlineGoogle Scholar
Hewitt CE, Torgerson DJ, Miles JN. Is there another way to take account of noncompliance in randomized controlled trials? CMAJ. 2006;175:347. [PMID: 16908892] CrossrefMedlineGoogle Scholar
McLean SM, KlaberMoffett JA, Sharp DM, Gardiner E. A randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial). Man Ther. 2013;18:199-205. [PMID: 23085116] doi:10.1016/j.math.2012.09.005 CrossrefMedlineGoogle Scholar
Klaber Moffett JA, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin A, et al. Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference. BMJ. 2005;330:75. [PMID: 15585539] CrossrefMedlineGoogle Scholar
Vernon H, Humphreys BK. Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews. Eura Medicophys. 2007;43:91-118. [PMID: 17369783] MedlineGoogle Scholar
Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al; COG. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther. 2010;15:315-33. [PMID: 20510644] doi:10.1016/j.math.2010.04.002 CrossrefMedlineGoogle Scholar
Bertozzi L, Gardenghi I, Turoni F, Villafañe JH, Capra F, Guccione AA, et al. Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Phys Ther. 2013;93:1026-36. [PMID: 23559524] doi:10.2522/ptj.20120412 CrossrefMedlineGoogle Scholar
Furlan AD, Yazdi F, Tsertsvadze A, Gross A, VanTulder M, Santaguida L, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012;2012:953139. [PMID: 22203884] doi:10.1155/2012/953139 CrossrefMedlineGoogle Scholar
Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E, Cameron ID, et al; Cervical Overview Group. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2006:CD004870. [PMID: 16856065] MedlineGoogle Scholar
Lauche R, Schuth M, Schwickert M, Lüdtke R, Musial F, Michalsen A, et al. Efficacy of the Alexander Technique in treating chronic non-specific neck pain: a randomized controlled trial. Clin Rehabil. 2015. [PMID: 25834276] MedlineGoogle Scholar
Miller J, Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010;15:334-54. [PMID: 20593537] CrossrefMedlineGoogle Scholar
- 37. Tsakitzidis G, Remmen R, Peremans L, Van Royen P, Duchesnes C, Paulus D, et al. Non-specific neck pain: diagnosis and treatment. KCE reports 119C. Brussels, Belgium: Belgian Health Care Knowledge Centre; 2009. Accessed at https://kce.fgov.be/sites/default/files/page_documents/d20091027356.pdf on 8 September 2015. Google Scholar
McClean S, Brilleman S, Wye L. What is the perceived impact of Alexander Technique lessons on health status, costs and pain management in the real life setting of an English hospital? The results of a mixed methods evaluation of an Alexander Technique service for those with chronic back pain. BMC Health Serv Res. 2015;15:293. [PMID: 26215122] doi:10.1186/s12913-015-0966-1 CrossrefMedlineGoogle Scholar
Ferrari R, Russell AS. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol. 2003;17:57-70. [PMID: 12659821] CrossrefMedlineGoogle Scholar
Hurwitz EL, Goldstein MS, Morgenstern H, Chiang LM. The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: results from the UCLA Neck Pain Study. Disabil Rehabil. 2006;28:1319-29. [PMID: 17083180] CrossrefMedlineGoogle Scholar
Haldeman S, Carroll LJ, Cassidy JD. The empowerment of people with neck pain: introduction. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009;32:S10-6. [PMID: 19251058] doi:10.1016/j.jmpt.2008.11.006 CrossrefMedlineGoogle Scholar
Andersson S, Andersson S, Sundberg T, Sundberg T, Johansson E, Johansson E, et al. Patients' experiences and perceptions of integrative care for back and neck pain. Altern Ther Health Med. 2012;18:25-32. [PMID: 22875559] MedlineGoogle Scholar
Ballard K. Ideomotor principle – was Alexander correct?. In: Rennie C, Shoop T, Thapen K, eds. Connected Perspectives – The Alexander Technique in Context. London: HITE; 2015. Google Scholar
Filevich E, Kühn S, Haggard P. Intentional inhibition in human action: the power of 'no'. Neurosci Biobehav Rev. 2012;36:1107-18. [PMID: 22305996] doi:10.1016/j.neubiorev.2012.01.006 CrossrefMedlineGoogle Scholar
MacPherson H, Altman DG, Hammerschlag R, Youping L, Taixiang W, White A, et al; STRICTA Revision Group.. Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement. PLoS Med. 2010;7:e1000261. [PMID: 20543992] doi:10.1371/journal.pmed.1000261 CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
From University of York, York, and Society of Teachers of the Alexander Technique and British Acupuncture Council, London, United Kingdom.
Note: Dr. MacPherson (the manuscript's guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgment: The authors thank the participants, Alexander teachers, acupuncturists, and general medical practitioners; David Laverack and Anthony Murray, their patient representatives; Elaine Hay, Debbie Sharp, and David Geddes, their collaborators; Matthew Bailey, Sue Collins, Ben Elliot, Pauline Holloway, Dionysios Pallas, Lucy Revell, and Val Wadsworth from the ATLAS research team; and Cindy Cooper (Chair), Sarah Brown, and Gareth Jones, who were members of the independent steering group.
Financial Support: The trial was sponsored by the University of York. This research was funded by clinical studies grant 19702 from Arthritis Research UK.
Disclosures: Drs. MacPherson and Lansdown report that they are members of the British Acupuncture Council. Drs. Woodman and Ballard report that they are members of the Society of Teachers of the Alexander Technique. Dr. Atkin reports a grant from Arthritis Research UK during the conduct of the study. Dr. Eldred reports a grant from Arthritis Research UK during the conduct of the study. Dr. Hewitt reports a grant from Arthritis Research UK during the conduct of the study. Dr. Torgerson reports a Programme Grant from the National Institute for Health Research during the conduct of the study. Dr. Watt reports a grant from Arthritis Research UK during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0667.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol: Available in reference 19. Statistical code and data set: Relevant anonymized patient-level data are available from Dr. MacPherson (e-mail, hugh.
Corresponding Author: Hugh MacPherson, BSc, PhD, Department of Health Sciences, University of York, York YO10 5DD, United Kingdom; e-mail, hugh.
Current Author Addresses: Drs. MacPherson, Atkin, Bland, Eldred, Essex, Hewitt, Torgerson, Wenham, and Watt; Ms. Tilbrook; Ms. Hopton; Ms. Keding; Ms. Lansdown; and Mr. Parrott: Department of Health Sciences, University of York, York YO10 5DD, United Kingdom.
Dr. Richmond: Sydera Research Associates, 34 Shipman Road, Market Weighton, York YO43 3RB, United Kingdom.
Drs. Woodman and Ballard: Society of Teachers of the Alexander Technique, Grove Business Park, Unit 48, 560-568 High Road, London N17 9TA, United Kingdom.
Author Contributions: Conception and design: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, K. Atkin, M. Bland, H. Lansdown, S. Parrott, D. Torgerson, I. Watt.
Analysis and interpretation of the data: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, K. Atkin, M. Bland, H. Essex, C. Hewitt, A. Keding, H. Lansdown, S. Parrott, D. Torgerson, I. Watt.
Drafting of the article: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, K. Atkin, J. Eldred, H. Essex, S. Parrott, D. Torgerson, I. Watt.
Critical revision of the article for important intellectual content: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, C. Hewitt, H. Lansdown, S. Parrott, D. Torgerson, I. Watt.
Final approval of the article: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, K. Atkin, M. Bland, J. Eldred, H. Essex, C. Hewitt, A. Hopton, A. Keding, H. Lansdown, S. Parrott, D. Torgerson, A. Wenham, I. Watt.
Provision of study materials or patients: H. MacPherson, J. Woodman, K. Ballard.
Statistical expertise: M. Bland, H. Essex, C. Hewitt, A. Keding.
Obtaining of funding: H. MacPherson, S. Richmond, J. Woodman, K. Ballard, K. Atkin, M. Bland, A. Hopton, S. Parrott, D. Torgerson, I. Watt.
Administrative, technical, or logistic support: H. MacPherson, H. Tilbrook, S. Richmond, J. Woodman, K. Ballard, J. Eldred, A. Hopton, D. Torgerson, I. Watt.
Collection and assembly of data: H. MacPherson, H. Tilbrook, S. Richmond, A. Wenham.