Original Research3 November 2015
A Randomized Trial
    Author, Article, and Disclosure Information


    This article has been corrected. The original version (PDF) is appended to this article as a Supplement.


    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.


    • 1. Hoy DMarch LWoolf ABlyth FBrooks PSmith Eet alThe global burden of neck pain: estimates from the Global Burden of Disease 2010 Study. Ann Rheum Dis2014;73:1309-15. [PMID: 24482302] doi:10.1136/annrheumdis-2013-204431 CrossrefMedlineGoogle Scholar
    • 2. Jull GSterling MFalla DTreleaven JO'Leary SWhiplash, Headache and Neck Pain. Edinburgh, United Kingdom: Churchill Livingston; 2008. Google Scholar
    • 3. Thomas KJNicholl JPColeman PUse and expenditure on complementary medicine in England: a population based survey. Complement Ther Med2001;9:2-11. [PMID: 11264963] CrossrefMedlineGoogle Scholar
    • 4. Barnes PMBloom BNahin RLComplementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report2008:1-23. [PMID: 19361005] MedlineGoogle Scholar
    • 5. MacPherson HThomas KSelf-help advice as a process integral to traditional acupuncture care: implications for trial design. Complement Ther Med2008;16:101-6. [PMID: 18514912] doi:10.1016/j.ctim.2008.02.010 CrossrefMedlineGoogle Scholar
    • 6. Robinson NLorenc ADing WJia JBovey MWang XMExploring practice characteristics and research priorities of practitioners of traditional acupuncture in China and the EU-A survey. J Ethnopharmacol2012;140:604-13. [PMID: 22338645] doi:10.1016/j.jep.2012.01.052 CrossrefMedlineGoogle Scholar
    • 7. Evans MPaterson CWye LChapman RRobinson JNorton Ret alLifestyle and self-care advice within traditional acupuncture consultations: a qualitative observational study nested in a co-operative inquiry. J Altern Complement Med2011;17:519-29. [PMID: 21649518] doi:10.1089/acm.2010.0749 CrossrefMedlineGoogle Scholar
    • 8. Thomas KJMacPherson HThorpe LBrazier JFitter MCampbell MJet alRandomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ2006;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
    • 11. Witt CMJena SBrinkhaus BLiecker BWegscheider KWillich SNAcupuncture for patients with chronic neck pain. Pain2006;125:98-106. [PMID: 16781068] CrossrefMedlineGoogle Scholar
    • 12. Woodman JPMoore NREvidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review. Int J Clin Pract2012;66:98-112. [PMID: 22171910] doi:10.1111/j.1742-1241.2011.02817.x CrossrefMedlineGoogle Scholar
    • 13. Little PLewith GWebley FEvans MBeattie AMiddleton Ket alRandomised controlled trial of Alexander Technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ2008;337:a884. [PMID: 18713809] doi:10.1136/bmj.a884 CrossrefMedlineGoogle Scholar
    • 14. Cacciatore TWGurfinkel VSHorak FBCordo PJAmes KEIncreased dynamic regulation of postural tone through Alexander Technique training. Hum Mov Sci2011;30:74-89. [PMID: 21185100] doi:10.1016/j.humov.2010.10.002 CrossrefMedlineGoogle Scholar
    • 15. Cacciatore TWGurfinkel VSHorak FBDay BLProlonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique. Gait Posture2011;34:496-501. [PMID: 21782443] doi:10.1016/j.gaitpost.2011.06.026 CrossrefMedlineGoogle Scholar
    • 16. Cacciatore TWHorak FBHenry SMImprovement in automatic postural coordination following Alexander Technique lessons in a person with low back pain. Phys Ther2005;85:565-78. [PMID: 15921477] CrossrefMedlineGoogle Scholar
    • 17. Cacciatore TWMian OSPeters ADay BLNeuromechanical interference of posture on movement: evidence from Alexander Technique teachers rising from a chair. J Neurophysiol2014;112:719-29. [PMID: 25085609] doi:10.1152/jn.00617.2013 CrossrefMedlineGoogle Scholar
    • 18. Salter GCRoman MBland MJMacPherson HAcupuncture for chronic neck pain: a pilot for a randomised controlled trial. BMC Musculoskelet Disord2006;7:99. [PMID: 17156464] CrossrefMedlineGoogle Scholar
    • 19. MacPherson HTilbrook HERichmond SJAtkin KBallard KBland Met alAlexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS): study protocol for a randomised controlled trial. Trials2013;14:209. [PMID: 23841901] doi:10.1186/1745-6215-14-209 CrossrefMedlineGoogle Scholar
    • 20. Leak AMCooper JDyer SWilliams KATurner-Stokes LFrank AOThe Northwick Park Neck Pain Questionnaire, devised to measure neck pain and disability. Br J Rheumatol1994;33:469-74. [PMID: 8173853] CrossrefMedlineGoogle Scholar
    • 21. Moffett JKJackson DAGardiner EDTorgerson DJCoulton SEaton Set alRandomized 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
    • 23. Anderson KODowds BNPelletz REEdwards WTPeeters-Asdourian CDevelopment and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain. Pain1995;63:77-84. [PMID: 8577493] CrossrefMedlineGoogle Scholar
    • 24. Dziedzic KHill JLewis MSim JDaniels JHay EMEffectiveness 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 Rheum2005;53:214-22. [PMID: 15818640] CrossrefMedlineGoogle Scholar
    • 25. Sim JJordan KLewis MHill JHay EMDziedzic KSensitivity to change and internal consistency of the Northwick Park Neck Pain Questionnaire and derivation of a minimal clinically important difference. Clin J Pain2006;22:820-6. [PMID: 17057565] CrossrefMedlineGoogle Scholar
    • 26. White IRKalaitzaki EThompson SGAllowing for missing outcome data and incomplete uptake of randomised interventions, with application to an Internet-based alcohol trial. Stat Med2011;30:3192-207. [PMID: 21948462] doi:10.1002/sim.4360 CrossrefMedlineGoogle Scholar
    • 27. Hewitt CETorgerson DJMiles JNIs there another way to take account of noncompliance in randomized controlled trials? CMAJ2006;175:347. [PMID: 16908892] CrossrefMedlineGoogle Scholar
    • 28. McLean SMKlaberMoffett JASharp DMGardiner EA randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial). Man Ther2013;18:199-205. [PMID: 23085116] doi:10.1016/j.math.2012.09.005 CrossrefMedlineGoogle Scholar
    • 29. Klaber Moffett JAJackson DARichmond SHahn SCoulton SFarrin Aet alRandomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference. BMJ2005;330:75. [PMID: 15585539] CrossrefMedlineGoogle Scholar
    • 30. Vernon HHumphreys BKManual therapy for neck pain: an overview of randomized clinical trials and systematic reviews. Eura Medicophys2007;43:91-118. [PMID: 17369783] MedlineGoogle Scholar
    • 31. Gross AMiller JD'Sylva JBurnie SJGoldsmith CHGraham Net alCOGManipulation or mobilisation for neck pain: a Cochrane Review. Man Ther2010;15:315-33. [PMID: 20510644] doi:10.1016/j.math.2010.04.002 CrossrefMedlineGoogle Scholar
    • 32. Bertozzi LGardenghi ITuroni FVillafañe JHCapra FGuccione AAet alEffect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Phys Ther2013;93:1026-36. [PMID: 23559524] doi:10.2522/ptj.20120412 CrossrefMedlineGoogle Scholar
    • 33. Furlan ADYazdi FTsertsvadze AGross AVanTulder MSantaguida Let alA 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 Med2012;2012:953139. [PMID: 22203884] doi:10.1155/2012/953139 CrossrefMedlineGoogle Scholar
    • 34. Trinh KVGraham NGross ARGoldsmith CHWang ECameron IDet alCervical Overview GroupAcupuncture for neck disorders. Cochrane Database Syst Rev2006:CD004870. [PMID: 16856065] MedlineGoogle Scholar
    • 35. Lauche RSchuth MSchwickert MLüdtke RMusial FMichalsen Aet alEfficacy of the Alexander Technique in treating chronic non-specific neck pain: a randomized controlled trial. Clin Rehabil2015. [PMID: 25834276] MedlineGoogle Scholar
    • 36. Miller JGross AD'Sylva JBurnie SJGoldsmith CHGraham Net alManual therapy and exercise for neck pain: a systematic review. Man Ther2010;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
    • 38. McClean SBrilleman SWye LWhat 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 Res2015;15:293. [PMID: 26215122] doi:10.1186/s12913-015-0966-1 CrossrefMedlineGoogle Scholar
    • 39. Ferrari RRussell ASRegional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol2003;17:57-70. [PMID: 12659821] CrossrefMedlineGoogle Scholar
    • 40. Hurwitz ELGoldstein MSMorgenstern HChiang LMThe impact of psychosocial factors on neck pain and disability outcomes among primary care patients: results from the UCLA Neck Pain Study. Disabil Rehabil2006;28:1319-29. [PMID: 17083180] CrossrefMedlineGoogle Scholar
    • 41. Haldeman SCarroll LJCassidy JDThe 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 Ther2009;32:S10-6. [PMID: 19251058] doi:10.1016/j.jmpt.2008.11.006 CrossrefMedlineGoogle Scholar
    • 42. Andersson SAndersson SSundberg TSundberg TJohansson EJohansson Eet alPatients' experiences and perceptions of integrative care for back and neck pain. Altern Ther Health Med2012;18:25-32. [PMID: 22875559] MedlineGoogle Scholar
    • 43. Ballard KIdeomotor principle – was Alexander correct?. In: Rennie C, Shoop T, Thapen K, eds. Connected Perspectives – The Alexander Technique in Context. London: HITE; 2015. Google Scholar
    • 44. Filevich EKühn SHaggard PIntentional inhibition in human action: the power of 'no'. Neurosci Biobehav Rev2012;36:1107-18. [PMID: 22305996] doi:10.1016/j.neubiorev.2012.01.006 CrossrefMedlineGoogle Scholar
    • 45. MacPherson HAltman DGHammerschlag RYouping LTaixiang WWhite Aet alSTRICTA Revision Group.Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement. PLoS Med2010;7:e1000261. [PMID: 20543992] doi:10.1371/journal.pmed.1000261 CrossrefMedlineGoogle Scholar