Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

The effect of journal impact factor, reporting conflicts, and reporting funding sources, on standardized effect sizes in back pain trials: a systematic review and meta-regression

BACKGROUND

Low back pain is a common and costly health complaint for which there are several moderately effective treatments. In some fields there is evidence that funder and financial conflicts are associated with trial outcomes. It is not clear whether effect sizes in back pain trials relate to journal impact factor, reporting conflicts of interest, or reporting funding.

METHODS

We performed a systematic review of English-language papers reporting randomised controlled trials of treatments for non-specific low back pain, published between 2006-2012. We modelled the relationship using 5-year journal impact factor, and categories of reported of conflicts of interest, and categories of reported funding (reported none and reported some, compared to not reporting these) using meta-regression, adjusting for sample size, and publication year. We also considered whether impact factor could be predicted by the direction of outcome, or trial sample size.

RESULTS

We could abstract data to calculate effect size in 99 of 146 trials that met our inclusion criteria. Effect size is not associated with impact factor, reporting of funding source, or reporting of conflicts of interest. However, explicitly reporting 'no trial funding' is strongly associated with larger absolute values of effect size (adjusted β=1.02 (95 % CI 0.44 to 1.59), P=0.001). Impact factor increases by 0.008 (0.004 to 0.012) per unit increase in trial sample size (P<0.001), but does not differ by reported direction of the LBP trial outcome (P=0.270).

CONCLUSIONS

The absence of associations between effect size and impact factor, reporting sources of funding, and conflicts of interest reflects positively on research and publisher conduct in the field. Strong evidence of a large association between absolute magnitude of effect size and explicit reporting of 'no funding' suggests authors of unfunded trials are likely to report larger effect sizes, notwithstanding direction. This could relate in part to quality, resources, and/or how pragmatic a trial is.

Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial

BACKGROUND

Management of chronic neck pain may benefit from additional active self-care-oriented approaches.

OBJECTIVE

To evaluate clinical effectiveness of Alexander Technique lessons or acupuncture versus usual care for persons with chronic, nonspecific neck pain.

DESIGN

Three-group randomized, controlled trial. (Current Controlled Trials: ISRCTN15186354).

SETTING

U.K. primary care.

PARTICIPANTS

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.

INTERVENTION

12 acupuncture sessions or 20 one-to-one Alexander lessons (both 600 minutes total) plus usual care versus usual care alone.

MEASUREMENTS

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).

RESULTS

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.

LIMITATION

Practitioners belonged to the 2 main U.K.-based professional associations, which may limit generalizability of the findings.

CONCLUSION

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.

Disease Prevention and Health Promotion: How Integrative Medicine Fits

As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. The fields of preventive medicine and public health share the objectives of promoting general health, preventing disease, and applying epidemiologic techniques to these goals. This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine principles and practices with preventive medicine in the context of these levels of prevention, acknowledging the relative deficiency of research on the effectiveness of practice-based integrative care. One goal of integrative medicine is to make the widest array of appropriate options available to patients, ultimately blurring the boundaries between conventional and complementary medicine. Both disciplines should be subject to rigorous scientific inquiry so that interventions that are efficacious and effective are systematically distinguished from those that are not. Furthermore, principles of preventive medicine can be infused into prevalent practices in complementary and integrative medicine, promoting public health in the context of more responsible practices. The case is made that an integrative preventive approach involves the responsible use of science with responsiveness to the needs of patients that persist when conclusive data are exhausted, providing a framework to make clinical decisions among integrative therapies.

The evidence base for managing older persons with low back pain

It has been suggested that older persons are less likely to receive optimal care for pain, and a recent population study suggested that management of low back pain (LBP) in primary care differed with older age. Low back pain is the most commonly reported regional pain syndrome, and the objective of the current review was to determine the evidence base for managing LBP in older persons; specifically, to ascertain if randomized controlled trials provide information on the effectiveness of two common non-pharmacological treatments (manual therapy, physical activity/exercise) for LBP amongst older patients. We examine data from trials which contributed to the United Kingdom National Institute for Health and Clinical Excellence (NICE) guidelines on the management of LBP and determine whether the trials had upper age restrictions, their justification and whether any age-specific analyses had been conducted. The present survey included 21 studies of manual therapy and 71 of physical activity/exercise. Many studies had an upper age limit of ≤ 60 years (24% manual therapy, 44% physical activity/exercise) or 61-70 years (33%, 41%) but few gave a rationale for imposing an upper age limit in the trial eligibility criteria (2 out of 17 studies of manual therapy, 4 out of 68 studies of physical activity/exercise). Only 14% of studies of manual therapy and 1% of physical activity/exercise studies provided an age-specific analysis. Upper age limits in back pain trials of manual therapy and physical activity/exercise are common but a justification for these is rarely given. Almost no studies have reported whether effectiveness differs by age.

Integrative treatment for low back pain: An exploratory systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Low back pain (LBP) is a common musculoskeletal condition often treated using integrative medicine (IM). Most reviews have focused on a single complementary and alternative medicine (CAM) therapy for LBP rather than evaluating wider integrative approaches. This exploratory systematic review aimed to identify randomized controlled trials (RCTs) and provide evidence on the effectiveness, cost effectiveness and adverse effects of integrative treatment for LBP.

METHODS

A literature search was conducted in 12 English and Chinese databases. RCTs evaluating an integrative treatment for musculoskeletal related LBP were included. Reporting, methodological quality and relevant clinical characteristics were assessed and appraised. Metaanalyses were performed for outcomes where trials were sufficiently homogenous.

RESULTS

Fifty-six RCTs were identified evaluating integrative treatment for LBP. Although reporting and methodological qualities were poor, meta-analysis showed a favourable effect for integrative treatment over conventional and CAM treatment for back pain and function at 3 months or less follow-up. Two trials investigated costs, reporting £ 5332 per quality adjusted life years with 6 Alexander technique lessons plus exercise at 12 months follow-up; and an increased total costs of $244 when giving an additional up to 15 sessions of CAM package of care at 12 weeks. Sixteen trials mentioned safety; no severe adverse effects were reported.

CONCLUSION

Integrative treatment that combines CAM with conventional therapies appeared to have beneficial effects on pain and function. However, evidence is limited due to heterogeneity, the relatively small numbers available for subgroup analyses and the low methodological quality of the included trials. Identification of studies of true IM was not possible due to lack of reporting of the intervention details (registration No. CRD42013003916).

Using an internet intervention to support self-management of low back pain in primary care: protocol for a randomised controlled feasibility trial (SupportBack)

INTRODUCTION

Low back pain (LBP) is a prevalent and costly condition. The majority of patients experiencing LBP are managed in primary care, where first-line care recommendations consist of advice to self-manage and remain active. Internet interventions present a potential means of providing patients with tailored self-management advice and evidence-based support for increasing physical activity.

METHODS/ANALYSIS

This protocol describes a single-blind, randomised controlled feasibility trial of an internet intervention developed to support the self-management of LBP in primary care. Patients are being randomised to 1 of 3 groups receiving either usual primary care, usual primary care with the addition of an internet intervention or an internet intervention with physiotherapist telephone support. Patients are followed up at 3 months. Primary outcomes are the feasibility of (1) the trial design/methods, (2) the delivery of the internet intervention and (3) the provision of telephone support by physiotherapists. Secondary outcomes will include exploratory analysis of estimates and variation in clinical outcomes of pain and disability, in order to inform a future main trial.

ETHICS/DISSEMINATION

This feasibility trial has undergone ethical scrutiny and been approved by the National Health Service (NHS) Research Ethics Committee, REC Reference 13/SC/0202. The feasibility findings will be disseminated to the research community through presentations at conferences and publication in peer review journals. Broader dissemination will come following a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN 31034004.

Efficacy of a trunk orthosis with joints providing resistive force on low-back load in elderly persons during static standing

Purpose

Postural alignment of elderly people becomes poor due to aging, possibly leading to low-back pain and spinal deformity. Although there are several interventions for treating these conditions, no previous study has reported the effectiveness of a spinal orthosis or lumbosacral orthosis (LSO) in healthy elderly people without specific spinal deformity. We therefore developed a trunk orthosis to decrease low-back muscle activity while training good postural alignment through resistive force provided by joints with springs (here, called the ORF, which stands for orthosis with joints providing resistive force) as a preventive method against abnormal posture and low-back pain in healthy elderly persons.

Patients and methods

Fifteen community-dwelling elderly men participated in this study. Participants stood freely for 10 seconds in a laboratory setting under three conditions: without an orthosis, with the ORF, and with an LSO. The Damen corset LSO was selected as it is frequently prescribed for patients with low-back pain. Postural alignment during static standing was recorded using a three-dimensional motion capture system employing infrared cameras. Two force plates were used to record center of pressure. Electromyograms were obtained for bilateral erector spinae (ES), left internal abdominal oblique, and right gluteus medius muscles.

Results

Pelvis forward tilt angle tended to increase while wearing the ORF and decrease while wearing the LSO, but these results were not significant compared to no orthosis. Thorax extension angle and thorax angle on pelvis coordinate system significantly increased while wearing the ORF compared to the other two conditions. ES activity significantly decreased while wearing the ORF compared to the other two conditions. Internal oblique activity was significantly smaller while wearing the LSO than with no orthosis. Center of pressure did not significantly differ among the conditions.

Conclusion

The ORF significantly improved trunk alignment and decreased ES activity in healthy elderly subjects during static standing.

Massage for low-back pain

BACKGROUND

Low-back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. It is experienced by 70% to 80% of adults at some time in their lives. Massage therapy has the potential to minimize pain and speed return to normal function.

OBJECTIVES

To assess the effects of massage therapy for people with non-specific LBP.

SEARCH METHODS

We searched PubMed to August 2014, and the following databases to July 2014: MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Index to Chiropractic Literature, and Proquest Dissertation Abstracts. We also checked reference lists. There were no language restrictions used.

SELECTION CRITERIA

We included only randomized controlled trials of adults with non-specific LBP classified as acute, sub-acute or chronic. Massage was defined as soft-tissue manipulation using the hands or a mechanical device. We grouped the comparison groups into two types: inactive controls (sham therapy, waiting list, or no treatment), and active controls (manipulation, mobilization, TENS, acupuncture, traction, relaxation, physical therapy, exercises or self-care education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures and followed CBN guidelines. Two independent authors performed article selection, data extraction and critical appraisal.

MAIN RESULTS

In total we included 25 trials (3096 participants) in this review update. The majority was funded by not-for-profit organizations. One trial included participants with acute LBP, and the remaining trials included people with sub-acute or chronic LBP (CLBP). In three trials massage was done with a mechanical device, and the remaining trials used only the hands. The most common type of bias in these studies was performance and measurement bias because it is difficult to blind participants, massage therapists and the measuring outcomes. We judged the quality of the evidence to be "low" to "very low", and the main reasons for downgrading the evidence were risk of bias and imprecision. There was no suggestion of publication bias. For acute LBP, massage was found to be better than inactive controls for pain ((SMD -1.24, 95% CI -1.85 to -0.64; participants = 51; studies = 1)) in the short-term, but not for function ((SMD -0.50, 95% CI -1.06 to 0.06; participants = 51; studies = 1)). For sub-acute and chronic LBP, massage was better than inactive controls for pain ((SMD -0.75, 95% CI -0.90 to -0.60; participants = 761; studies = 7)) and function (SMD -0.72, 95% CI -1.05 to -0.39; 725 participants; 6 studies; ) in the short-term, but not in the long-term; however, when compared to active controls, massage was better for pain, both in the short ((SMD -0.37, 95% CI -0.62 to -0.13; participants = 964; studies = 12)) and long-term follow-up ((SMD -0.40, 95% CI -0.80 to -0.01; participants = 757; studies = 5)), but no differences were found for function (both in the short and long-term). There were no reports of serious adverse events in any of these trials. Increased pain intensity was the most common adverse event reported in 1.5% to 25% of the participants.

AUTHORS' CONCLUSIONS

We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up. There were only minor adverse effects with massage.

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

Background

Randomised controlled trial evidence indicates that Alexander Technique is clinically and cost effective for chronic back pain. The aim of this mixed methods evaluation was to explore the role and perceived impact of Alexander Technique lessons in the naturalistic setting of an acute hospital Pain Management Clinic in England.

Methods

To capture changes in health status and resource use amongst service users, 43 service users were administered three widely used questionnaires (Brief Pain Inventory, MYMOP and Client Service Resource Inventory) at three time points: baseline, six weeks and three months after baseline. We also carried out 27 telephone interviews with service users and seven face-to-face interviews with pain clinic staff and Alexander Technique teachers. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically.

Results

Those taking Alexander Technique lessons reported small improvements in health outcomes, and condition-related costs fell. However, due to the non-randomised, uncontrolled nature of the study design, changes cannot be attributed to the Alexander Technique lessons. Service users stated that their relationship to pain and pain management had changed, especially those who were more committed to practising the techniques regularly. These changes may explain the reported reduction in pain-related service use and the corresponding lower associated costs.

Conclusions

Alexander Technique lessons may be used as another approach to pain management. The findings suggests that Alexander Technique lessons can help improve self-efficacy for those who are sufficiently motivated, which in turn may have an impact on service utilisation levels.

Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review

QUESTION

Is massage therapy effective for people with musculoskeletal disorders compared to any other treatment or no treatment?

DESIGN

Systematic review of randomised clinical trials.

PARTICIPANTS

People with musculoskeletal disorders.

INTERVENTIONS

Massage therapy (manual manipulation of the soft tissues) as a stand-alone intervention.

OUTCOME

The primary outcomes were pain and function.

RESULTS

The 26 eligible randomised trials involved 2565 participants. The mean sample size was 95 participants (range 16 to 579) per study; 10 studies were considered to be at low risk of bias. Overall, low-to-moderate-level evidence indicated that massage reduces pain in the short term compared to no treatment in people with shoulder pain and osteoarthritis of the knee, but not in those with low back pain or neck pain. Furthermore, low-to-moderate-level evidence indicated that massage improves function in the short term compared to no treatment in people with low back pain, knee arthritis or shoulder pain. Low-to-very-low-level evidence from single studies indicated no clear benefits of massage over acupuncture, joint mobilisation, manipulation or relaxation therapy in people with fibromyalgia, low back pain and general musculoskeletal pain.

CONCLUSIONS

Massage therapy, as a stand-alone treatment, reduces pain and improves function compared to no treatment in some musculoskeletal conditions. When massage is compared to another active treatment, no clear benefit was evident.

Teachers of the Alexander Technique in the UK and the people who take their lessons: A national cross-sectional survey

OBJECTIVES

Given the rising profile of the Alexander Technique in the UK, there is a need for a comprehensive description of its teachers and of those who currently take lessons. In a national survey of Alexander teachers, we set out to address this information gap.

DESIGN

A cross-sectional survey of 871 UK members of three main Alexander Technique teachers' professional associations was conducted. A questionnaire requested information about their professional background, teaching practice and methods, and about the people who attend lessons and their reasons for seeking help.

RESULTS

With an overall response rate of 61%, 534 teachers responded; 74% were female with median age of 58 years, 60% had a higher education qualification, and 95% were self-employed, many with additional non-Alexander paid employment. The majority (87%) offered lessons on their own premises or in a privately rented room, and 19% provided home visits; both individual and group lessons were provided. People who took lessons were predominantly female (66%) with a median age of 48 years, and 91% paid for their lessons privately. Nearly two-thirds (62%) began lessons for reasons related to musculoskeletal conditions, including back symptoms, posture, neck pain, and shoulder pain. Other reasons were general (18%, including well-being), performance-related (10%, including voice-, music-, and sport-related), psychological (5%) and neurological (3%). We estimate that Alexander teachers in the UK provide approximately 400,000 lessons per year.

CONCLUSIONS

This study provides an overview of Alexander Technique teaching in the UK today and data that may be useful when planning future research.

The preparatory set: a novel approach to understanding stress, trauma, and the bodymind therapies

Basic to all motile life is a differential approach/avoid response to perceived features of environment. The stages of response are initial reflexive noticing and orienting to the stimulus, preparation, and execution of response. Preparation involves a coordination of many aspects of the organism: muscle tone, posture, breathing, autonomic functions, motivational/emotional state, attentional orientation, and expectations. The organism organizes itself in relation to the challenge. We propose to call this the "preparatory set" (PS). We suggest that the concept of the PS can offer a more nuanced and flexible perspective on the stress response than do current theories. We also hypothesize that the mechanisms of body-mind therapeutic and educational systems (BTES) can be understood through the PS framework. We suggest that the BTES, including meditative movement, meditation, somatic education, and the body-oriented psychotherapies, are approaches that use interventions on the PS to remedy stress and trauma. We discuss how the PS can be adaptive or maladaptive, how BTES interventions may restore adaptive PS, and how these concepts offer a broader and more flexible view of the phenomena of stress and trauma. We offer supportive evidence for our hypotheses, and suggest directions for future research. We believe that the PS framework will point to ways of improving the management of stress and trauma, and that it will suggest directions of research into the mechanisms of action of BTES.

Lighten Up: Specific Postural Instructions Affect Axial Rigidity and Step Initiation in Patients With Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) is associated with stooped postural alignment, increased postural sway, and reduced mobility. The Alexander Technique (AT) is a mindfulness-based approach to improving posture and mobility by reducing muscular interference while maintaining upward intentions. Evidence suggests that AT can reduce disability associated with PD, but a mechanism for this effect has not yet been established.

OBJECTIVE

We investigated whether AT-based instructions reduce axial rigidity and increase upright postural alignment, and whether these instructions have different effects on postural alignment, axial rigidity, postural sway, and mobility than effort-based instructions regarding posture.

METHOD

Twenty subjects with PD practiced 2 sets of instructions and then attempted to implement both approaches (as well as a relaxed control condition) during quiet standing and step initiation. The "Lighten Up" instructions relied on AT principles of reducing excess tension while encouraging length. The "Pull Up" instructions relied on popular concepts of effortful posture correction. We measured kinematics, resistance to axial rotation, and ground reaction forces.

RESULTS

Both sets of experimental instructions led to increases in upright postural alignment relative to the control condition. Only the Lighten Up instructions led to reduced postural sway, reduced axial postural tone, greater modifiability of tone, and a smoother center of pressure trajectory during step initiation, possibly indicating greater movement efficiency.

CONCLUSION

Mindful movement approaches such as AT may benefit balance and mobility in subjects with PD by acutely facilitating increased upright postural alignment while decreasing rigidity.

Effects of Alexander Technique training experience on gait behavior in older adults

Heightened fall risk, potentially caused by aging-related changes in gait, is a serious health issue faced by older adults. The Alexander Technique is thought to improve balance and motor function; however, the technique's effect on gait has not been studied. The purpose of this study was to examine the effect of Alexander Technique training in older adults on the temporospatial characteristics of gait and medio-lateral center of mass displacement during fast and comfortably paced over-ground walking. Six licensed Alexander Technique teachers and seven controls between the ages of 60 and 75 years of age participated in the study. Alexander Technique teachers exhibited a reduction in medio-lateral center of mass displacement during fast paced walking compared to comfortably paced walking that was not present in controls. Due to this difference Alexander Technique teachers displayed a smaller medio-lateral Center of Mass displacement compared to controls during fast paced walking. Alexander Technique teachers also demonstrated significantly smaller stride width and lower gait timing variability compared to controls. These findings, which suggest superior control of dynamic stability during gait and potentially reduced fall risk in Alexander Technique teachers, warrant further study.

Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review

Considerable amount of money spent in health care is used for treatments of lifestyle related, chronic health conditions, which come from behaviors that contribute to morbidity and mortality of the population. Back and neck pain are two of the most common musculoskeletal problems in modern society that have significant cost in health care. Yoga, as a branch of complementary alternative medicine, has emerged and is showing to be an effective treatment against nonspecific spinal pain. Recent studies have shown positive outcome of yoga in general on reducing pain and functional disability of the spine. The objective of this study is to conduct a systematic review of the existing research within Iyengar yoga method and its effectiveness on relieving back and neck pain (defined as spinal pain). Database research form the following sources (Cochrane library, NCBI PubMed, the Clinical Trial Registry of the Indian Council of Medical Research, Google Scholar, EMBASE, CINAHL, and PsychINFO) demonstrated inclusion and exclusion criteria that selected only Iyengar yoga interventions, which in turn, identified six randomized control trials dedicated to compare the effectiveness of yoga for back and neck pain versus other care. The difference between the groups on the postintervention pain or functional disability intensity assessment was, in all six studies, favoring the yoga group, which projected a decrease in back and neck pain. Overall six studies with 570 patients showed, that Iyengar yoga is an effective means for both back and neck pain in comparison to control groups. This systematic review found strong evidence for short-term effectiveness, but little evidence for long-term effectiveness of yoga for chronic spine pain in the patient-centered outcomes.

The Alexander Technique and musicians: a systematic review of controlled trials

BACKGROUND

Musculoskeletal disorders, stress and performance anxiety are common in musicians. Therefore, some use the Alexander Technique (AT), a psycho-physical method that helps to release unnecessary muscle tension and re-educates non-beneficial movement patterns through intentional inhibition of unwanted habitual behaviours. According to a recent review AT sessions may be effective for chronic back pain. This review aimed to evaluate the evidence for the effectiveness of AT sessions on musicians' performance, anxiety, respiratory function and posture.

METHODS

The following electronic databases were searched up to February 2014 for relevant publications: PUBMED, Google Scholar, CINAHL, EMBASE, AMED, PsycINFO and RILM. The search criteria were "Alexander Technique" AND "music*". References were searched, and experts and societies of AT or musicians' medicine contacted for further publications.

RESULTS

237 citations were assessed. 12 studies were included for further analysis, 5 of which were randomised controlled trials (RCTs), 5 controlled but not randomised (CTs), and 2 mixed methods studies. Main outcome measures in RCTs and CTs were music performance, respiratory function, performance anxiety, body use and posture. Music performance was judged by external experts and found to be improved by AT in 1 of 3 RCTs; in 1 RCT comparing neurofeedback (NF) to AT, only NF caused improvements. Respiratory function was investigated in 2 RCTs, but not improved by AT training. Performance anxiety was mostly assessed by questionnaires and decreased by AT in 2 of 2 RCTs and in 2 of 2 CTs.

CONCLUSIONS

A variety of outcome measures has been used to investigate the effectiveness of AT sessions in musicians. Evidence from RCTs and CTs suggests that AT sessions may improve performance anxiety in musicians. Effects on music performance, respiratory function and posture yet remain inconclusive. Future trials with well-established study designs are warranted to further and more reliably explore the potential of AT in the interest of musicians.

A time for action: Opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries

Musculoskeletal (MSK) conditions cause an enormous global burden, and this is dramatically increasing in developing countries, particularly due to rapidly ageing populations and increasing obesity. Many of the global non-communicable disease (NCD) initiatives need to expand beyond the traditional 'top four' NCD groups by incorporating MSK diseases. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid doubling of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of 'development effectiveness' are met; strengthening leadership and commitment; building the research, information and evidence base; and reducing the incidence and disability of MSK conditions through better prevention. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.

Can the Alexander Technique improve balance and mobility in older adults with visual impairments? A randomized controlled trial

Objective:

To investigate the impact of Alexander Technique lessons on balance and mobility in older adults with visual impairments.

Design:

Randomized assessor blinded controlled trial with intervention and usual care control groups.

Setting:

Participants’ homes.

Subjects:

A total of 120 community-dwellers aged 50+ with visual impairments.

Intervention:

Twelve weeks of Alexander lessons and usual care.

Main outcome measures:

Short Physical Performance Battery items were primary outcomes at 3 months and secondary outcomes at 12 months. Additional secondary outcomes were postural sway, maximal balance range and falls over 12 months.

Results:

Between-group differences in primary outcomes were not significant. The intervention group reduced postural sway on a firm surface with eyes open at 3 months after adjusting for baseline values (–29.59 mm, 95%CI −49.52 to −9.67, P < 0.01). Planned sub-group analyses indicated a greater intervention effect among past multiple-fallers (2+) than non-multiple fallers for gait speed ( P = 0.02) and step length ( P < 0.01) at 3 months and chair stand at 12 months ( P < 0.01). There was a non-significant reduction in falls rate (IRR = 0.64, 95%CI 0.34 to 1.15, P = 0.13) and injurious falls (IRR = 0.61, 95% CI 0.28 to 1.30, P = 0.20) in the intervention group compared to the control group.

Conclusion:

The intervention did not have a significant impact on the primary outcomes but benefits for the intervention group in postural sway, trends towards fewer falls and injurious falls and improved mobility among past multiple-fallers suggest further investigation of the Alexander Technique is warranted.

Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To evaluate the quality, conduct, and reporting of subgroup analyses performed in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain (NSLBP).

SUMMARY OF BACKGROUND DATA

Randomized controlled trials of therapist-delivered interventions for NSLBP to date have, at best, shown small to moderate positive effects. Identifying subgroups is an important research priority. This review evaluates the quality, conduct, and reporting of subgroup analyses performed in the NSLBP literature.

METHODS

Multiple electronic databases were searched for randomized controlled trials of therapist-delivered interventions for NSLBP. Of the identified articles, only articles reporting subgroup analyses (confirmatory or exploratory) were included in the final review. Methodological criteria were used to evaluate the quality of subgroup analyses. The quality of conduct and reporting was also evaluated.

RESULTS

Thirty-nine articles were included in the final review. Of these, only 3 (8%) tested hypotheses about moderators (confirmatory findings), 18 (46%) generated hypotheses about moderators to inform future research (exploratory findings), and 18 (46%) provided insufficient findings. The appropriate statistical test for interaction was performed in 27 of the articles, of which 10 reported results from interaction tests, 4 incorrectly reported results within individual subgroups, and the remaining articles reported either P values or nothing at all.

CONCLUSION

Subgroup analyses performed in NSLBP trials have been severely underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting. Using current approaches, few definitive trials of subgrouping in back pain are very likely to be performed. There is a need to develop new approaches to subgroup identification in back pain research.

Changes in pain intensity and health related quality of life with Iyengar yoga in nonspecific chronic low back pain: A randomized controlled study

BACKGROUND

Nonspecific chronic low back (nCLBP) pain is prevalent among adult population and often leads to functional limitations, psychological symptoms, lower quality of life (QOL), and higher healthcare costs. The purpose of this study was to determine the efficacy of Iyengar yoga therapy on pain intensity and health related quality of life (HRQOL) with nCLBP.

AIM OF THE STUDY

To compare the effect of Iyengar yoga therapy and conventional exercise therapy on pain intensity and HRQOL in nonspecific chronic low back pain.

MATERIALS AND METHODS

Experimental study with random sampling technique.

SUBJECTS/INTERVENTION

Sixty subjects who fulfilled the selection criteria were randomly assigned to Iyengar yoga (yoga group, n = 30) and control group (exercise group, n = 30). Participants completed low back pain evaluation form and HRQOL-4 questionnaire before their intervention and again 4 weeks and 6 month later. Yoga group underwent 29 yogic postures training and exercise group had undergone general exercise program for 4 weeks.

STATISTICS

Repeated measures analysis of variance (ANOVA) was used to analyze group differences over time, while controlling for baseline differences.

RESULTS

Patients in both groups experienced significant reduction in pain and improvement in HRQOL. In visual analogue scale (VAS) yoga group showed reduction of 72.81% (P = 0.001) as compared to exercise group 42.50% (P = 0.001). In HRQOL, yoga group showed reduction of 86.99% (P = 0.001) as compared to exercise group 67.66% (P = 0.001).

CONCLUSION

These results suggest that Iyengar yoga provides better improvement in pain reduction and improvement in HRQOL in nonspecific chronic back pain than general exercise.

Compliance effects in a randomised controlled trial of yoga for chronic low back pain: a methodological study

STUDY DESIGN

Methodological study nested within a multicentre randomised controlled trial (RCT) of yoga plus usual general practitioner (GP) care vs usual GP care for chronic low back pain.

OBJECTIVE

To explore the treatment effects of non-compliance using three approaches in an RCT evaluating yoga for low back pain.

SUMMARY OF BACKGROUND DATA

A large multicentre RCT using intention-to-treat (ITT) analysis found that participants with chronic low back pain who were offered a 12-week progressive programme of yoga plus usual GP care had better back function than those offered usual GP care alone. However, ITT analysis can underestimate the effect of treatment in those who comply with treatment. As such, the data were analysed using other approaches to assess the problem of non-compliance. The main outcome measure was the self-reported Roland Morris Disability Questionnaire (RMDQ).

METHODS

Complier average causal effect (CACE) analysis, per-protocol analysis and on-treatment analysis were conducted on the data of participants who were fully compliant, predefined as attendance of at least three of the first six sessions and at least three other sessions. The analysis was repeated for participants who had attended at least one yoga session (i.e. any compliance), which included participants who were fully compliant. Each approach was described, including strengths and weaknesses, and the results of the different approaches were compared with those of the ITT analysis.

RESULTS

For the participants who were fully compliant (n=93, 60%), a larger beneficial treatment effect was seen using CACE analysis compared with per-protocol, on-treatment and ITT analyses at 3 and 12 months. The difference in mean change in RMDQ score between randomised groups was -3.30 [95% confidence interval (CI) -4.90 to -1.70, P<0.001] at 3 months and -2.23 (95% CI -3.93 to -0.53, P=0.010) at 12 months for CACE analysis, -3.12 (95% CI -4.26 to -1.98, P<0.001) at 3 months and -2.11 (95% CI -3.33 to -0.89, P=0.001) at 12 months for per-protocol analysis, and -2.91 (95% CI -4.06 to -1.76, P<0.001) at 3 months and -2.10 (95% CI -3.31 to -0.89, P=0.001) at 12 months for on-treatment analysis. For the participants who demonstrated any compliance (n=133, 85%), the results were generally consistent with the fully compliant group at 3 months, but the treatment effect was smaller. The difference in mean change in RMDQ score between randomised groups was -2.45 (95% CI -3.67 to -1.24) for CACE analysis, -2.30 (95% CI -3.43 to 1.17) for per-protocol analysis and -2.15 (95% CI -3.25 to -1.06) for on-treatment analysis, which was slightly less than that for ITT analysis. In contrast, at 12 months, per-protocol and on-treatment analyses showed a larger treatment effect compared with CACE and ITT analyses: per protocol analysis -1.86 (95% CI -3.02 to -0.71), on-treatment analysis -1.99 (95% CI -3.13 to -0.86) and CACE analysis -1.67 (95% CI -2.95 to -0.40).

CONCLUSION

ITT analysis estimated a slightly smaller treatment effect in participants who complied with treatment. When examining compliance, CACE analysis is more rigorous than per-protocol and on-treatment analyses. Using CACE analysis, the treatment effect was larger in participants who complied with treatment compared with participants who were allocated to treatment, and the difference between ITT and CACE analyses for the fully compliant group at 3 months was small but clinically important. Per-protocol and on-treatment analyses may produce unreliable estimates when the effect of treatment is small.

INTERNATIONAL STANDARD RANDOMISED TRIAL NUMBER REGISTER

ISRCTN 81079604.

Alexander Technique Lessons, Acupuncture Sessions or usual care for patients with chronic neck pain (ATLAS): study protocol for a randomised controlled trial

BACKGROUND

Chronic neck pain is a common condition in the adult population. More research is needed to evaluate interventions aiming to facilitate beneficial long-term change. We propose to evaluate the effect of Alexander Technique lessons and acupuncture in a rigorously conducted pragmatic trial with an embedded qualitative study.

METHODS/DESIGN

We will recruit 500 patients who have been diagnosed with neck pain in primary care, who have continued to experience neck pain for at least three months with 28% minimum cut-off score on the Northwick Park Neck Pain Questionnaire (NPQ). We will exclude patients with serious underlying pathology, prior cervical spine surgery, history of psychosis, rheumatoid arthritis, ankylosing spondylitis, osteoporosis, haemophilia, cancer, HIV or hepatitis, or with alcohol or drug dependency currently or in the last 12 months, or actively pursuing compensation or with pending litigation.The York Trials Unit will randomly allocate participants using a secure computer-based system. We will use block randomisation with allocation to each intervention arm being unambiguously concealed from anyone who might subvert the randomisation process.Participants will be randomised in equal proportions to Alexander Technique lessons, acupuncture or usual care alone. Twenty 30-minute Alexander Technique lessons will be provided by teachers registered with the Society of Teachers of the Alexander Technique and twelve 50-minute sessions of acupuncture will be provided by acupuncturists registered with the British Acupuncture Council. All participants will continue to receive usual GP care.The primary outcome will be the NPQ at 12 months, with the secondary time point at 6 months, and an area-under-curve analysis will include 3, 6 and 12 month time-points. Adverse events will be documented. Potential intervention effect modifiers and mediators to be explored include: self-efficacy, stress management, and the incorporation of practitioner advice about self-care and lifestyle. Qualitative material will be used to address issues of safety, acceptability and factors that impact on longer term outcomes.

DISCUSSION

This study will provide robust evidence on whether there are significant clinical benefits to patients, economic benefits demonstrating value for money, and sufficient levels of acceptability and safety.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15186354.

Comparing Once- versus Twice-Weekly Yoga Classes for Chronic Low Back Pain in Predominantly Low Income Minorities: A Randomized Dosing Trial

Background. Previous studies have demonstrated that once-weekly yoga classes are effective for chronic low back pain (cLBP) in white adults with high socioeconomic status. The comparative effectiveness of twice-weekly classes and generalizability to racially diverse low income populations are unknown. Methods. We conducted a 12-week randomized, parallel-group, dosing trial for 95 adults recruited from an urban safety-net hospital and five community health centers comparing once-weekly (n = 49) versus twice-weekly (n = 46) standardized yoga classes supplemented by home practice. Primary outcomes were change from baseline to 12 weeks in pain (11-point scale) and back-related function (23-point modified Roland-Morris Disability Questionnaire). Results. 82% of participants were nonwhite; 77% had annual household incomes <$40,000. The sample's baseline mean pain intensity [6.9 (SD 1.6)] and function [13.7 (SD 5.0)] reflected moderate to severe back pain and impairment. Pain and back-related function improved within both groups (P < 0.001). However, there were no differences between once-weekly and twice-weekly groups for pain reduction [-2.1 (95% CI -2.9, -1.3) versus -2.4 (95% CI -3.1, -1.8), P = 0.62] or back-related function [-5.1 (95% CI -7.0, -3.2) versus -4.9 (95% CI -6.5, -3.3), P = 0.83]. Conclusions. Twelve weeks of once-weekly or twice-weekly yoga classes were similarly effective for predominantly low income minority adults with moderate to severe chronic low back pain. This trial is registered with ClinicalTrials.gov NCT01761617.

Self-reported interoceptive awareness in primary care patients with past or current low back pain

Background

Mind–body interactions play a major role in the prognosis of chronic pain, and mind–body therapies such as meditation, yoga, Tai Chi, and Feldenkrais presumably provide benefits for pain patients. The Multidimensional Assessment of Interoceptive Awareness (MAIA) scales, designed to measure key aspects of mind–body interaction, were developed and validated with individuals practicing mind–body therapies, but have never been used in pain patients.

Methods

We administered the MAIA to primary care patients with past or current low back pain and explored differences in the performance of the MAIA scales between this and the original validation sample. We compared scale means, exploratory item cluster and confirmatory factor analyses, scale–scale correlations, and internal-consistency reliability between the two samples and explored correlations with validity measures.

Results

Responses were analyzed from 435 patients, of whom 40% reported current pain. Cross-sectional comparison between the two groups showed marked differences in eight aspects of interoceptive awareness. Factor and cluster analyses generally confirmed the conceptual model with its eight dimensions in a pain population. Correlations with validity measures were in the expected direction. Internal-consistency reliability was good for six of eight MAIA scales. We provided specific suggestions for their further development.

Conclusion

Self-reported aspects of interoceptive awareness differ between primary care patients with past or current low back pain and mind–body trained individuals, suggesting further research is warranted on the question whether mind–body therapies can alter interoceptive attentional styles with pain. The MAIA may be useful in assessing changes in aspects of interoceptive awareness and in exploring the mechanism of action in trials of mind–body interventions in pain patients.

Common medical problems of instrumental athletes

The fields of sports medicine and performing arts medicine have begun recent initiatives to collaborate more closely and to share information pertinent to the treatment of athletes and performing artists. This article provides a review of the common musculoskeletal and neurological problems encountered among performing artists who play instruments. Approaches to history, examination, diagnosis, and treatment are offered, based on literature reviews, expert opinion, and the authors' own experiences in a musician's clinic. Treatments focus on conservative management within a multidisciplinary framework, and indications are given for appropriate surgical referral. Providers are encouraged to build an understanding of the unique issues affecting instrumental athletes.

Are the Current Complementary and Alternative Therapies Available for the Treatment of Low Back Pain and Chronic Fatigue Syndrome Reliable Clinically? A Review of the Literature

Low back pain and chronic fatigue syndrome are major work-related disablers affecting millions around the globe today. This article assesses the clinical reliability of complementary and alternative therapies in the treatment of low back pain and chronic fatigue syndrome using the existing accessible literature. Multiple bibliographic databases that include medical, general health care, and natural medicine literature were searched for relevant terms and conclusions. The authors examined all abstracts obtained through the search and reviewed the full text of the relevant articles along with the additional supporting articles that resulted from the search. It is observed from the literature that most of the complementary and alternative treatments available today are clinically reliable for the treatment of low back pain, as significantly evidenced. However, not many studies support the clinical reliability of the use of complementary and alternative therapies in the treatment of chronic fatigue syndrome.

A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation

STUDY DESIGN

Multicentered randomized controlled trial with quality of life and resource use data collected.

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness of yoga intervention plus usual care compared with usual care alone for chronic or recurrent low back pain.

SUMMARY OF BACKGROUND DATA

Yoga has been shown as an effective intervention for treating chronic or recurrent low back pain. However, there is little evidence on its cost-effectiveness. The data are extracted from a pragmatic, multicentered, randomized controlled trial that has been conducted to evaluate the effectiveness and cost-effectiveness of a 12-week progressive program of yoga plus usual care in patients with chronic or recurrent low back pain.

METHODS

With this trial data, a cost-effectiveness analysis during the time period of 12 months from both perspectives of the UK National Health Service and the societal is presented. Main outcome measure is an incremental cost per quality-adjusted life-year (QALY).

RESULTS

From the perspective of the U.K. National Health Service, yoga intervention yields an incremental cost-effectiveness ratio of £13,606 per QALY. Given a willingness to pay for an additional QALY of £20,000, the probability of yoga intervention being cost-effective is 72%. From the perspective of the society, yoga intervention is a dominant treatment compared with usual care alone. This result is surrounded by fewer uncertainties-the probability of yoga being cost-effective reaches 95% at a willingness to pay for an additional QALY of £20,000. Sensitive analyses suggest the same results that yoga intervention is likely to be cost-effective in both perspectives.

CONCLUSION

On the basis of this trial, 12 weekly group classes of specialized yoga are likely to be a cost-effective intervention for treating patients with chronic or recurrent low back pain.

Modifying patterns of movement in people with low back pain -does it help? A systematic review

BACKGROUND

Physiotherapy for people with low back pain frequently includes assessment and modification of lumbo-pelvic movement. Interventions commonly aim to restore normal movement and thereby reduce pain and improve activity limitation. The objective of this systematic review was to investigate: (i) the effect of movement-based interventions on movement patterns (muscle activation, lumbo-pelvic kinematics or postural patterns) of people with low back pain (LBP), and (ii) the relationship between changes in movement patterns and subsequent changes in pain and activity limitation.

METHODS

MEDLINE, Cochrane Central, EMBASE, AMI, CINAHL, Scopus, AMED, ISI Web of Science were searched from inception until January 2012. Randomised controlled trials or controlled clinical trials of people with LBP were eligible for inclusion. The intervention must have been designed to influence (i) muscle activity patterns, (ii) lumbo-pelvic kinematic patterns or (iii) postural patterns, and included measurement of such deficits before and after treatment, to allow determination of the success of the intervention on the lumbo-pelvic movement. Twelve trials (25% of retrieved studies) met the inclusion criteria. Two reviewers independently identified, assessed and extracted data. The PEDro scale was used to assess method quality. Intervention effects were described using standardised differences between group means and 95% confidence intervals.

RESULTS

The included trials showed inconsistent, mostly small to moderate intervention effects on targeted movement patterns. There was considerable heterogeneity in trial design, intervention type and outcome measures. A relationship between changes to movement patterns and improvements in pain or activity limitation was observed in one of six studies on muscle activation patterns, one of four studies that examined the flexion relaxation response pattern and in two of three studies that assessed lumbo-pelvic kinematics or postural characteristics.

CONCLUSIONS

Movement-based interventions were infrequently effective for changing observable movement patterns. A relationship between changes in movement patterns and improvement in pain or activity limitation was also infrequently observed. No independent studies confirm any observed relationships. Challenges for future research include defining best methods for measuring (i) movement aberrations, (ii) improvements in movements, and (iii) the relationship between changes in how people move and associated changes in other health indicators such as activity limitation.

Exercise and Auricular Acupuncture for Chronic Low-back Pain: A Feasibility Randomized-controlled Trial

OBJECTIVES

To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP).

METHODS

Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) "Exercise Alone (E)"-12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) "Exercise and AA (EAA)"-12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire.

RESULTS

Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, -15.3,-5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, -11.4,-1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants.

DISCUSSION

Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

Group cognitive behavioural interventions for low back pain in primary care: extended follow-up of the Back Skills Training Trial (ISRCTN54717854)

Group cognitive behavioural intervention (CBI) is effective in reducing low back pain and disability over a 12-month period, in comparison to best practice advice in primary care. The aim was to study the effects of this CBI beyond 12 months. We undertook an extended follow-up of our original randomised, controlled trial of a group CBI and best practice advice in primary care, in comparison to best practice advice alone. Participants were mailed a questionnaire including measures of disability, pain, health services resource use, and health-related quality of life. The time of extended follow-up ranged between 20 and 50 months (mean 34 months). Fifty-six percent (395 of 701) of the original cohort provided extended follow-up. Those who responded were older and had less disability and pain at baseline than did the original trial cohort. After 12 months, the improvements in pain and disability observed with CBI were sustained. For disability measures, the treatment difference in favour of CBI persisted (mean difference 1.3 Roland and Morris Disability Questionnaire points, 95% confidence interval 0.27 to 2.26; 5.5 Modified von Korff Scale disability points, 95% confidence interval 0.27 to 10.64). There was no between-group difference in Modified von Korff Scale pain outcomes. The results suggest that the effects of a group CBI are maintained up to an average of 34 months. Although pain improves in response to best practice advice, longer-term recovery of disability remains substantially less.

Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review

BACKGROUND

Complementary medicine and alternative approaches to chronic and intractable health conditions are increasingly being used, and require critical evaluation.

OBJECTIVE

The aim of this review was to systematically evaluate available evidence for the effectiveness and safety of instruction in the Alexander Technique in health-related conditions.

METHODS

PUBMED, EMBASE, PSYCHINFO, ISI Web-of-Knowledge, AMED, CINHAL-plus, Cochrane library and Evidence-based Medicine Reviews were searched to July 2011. Inclusion criteria were prospective studies evaluating Alexander Technique instruction (individual lessons or group delivery) as an intervention for any medical indication/health-related condition. Studies were categorised and data extracted on study population, randomisation method, nature of intervention and control, practitioner characteristics, validity and reliability of outcome measures, completeness of follow-up and statistical analyses.

RESULTS

  Of 271 publications identified, 18 were selected: three randomised, controlled trials (RCTs), two controlled non-randomised studies, eight non-controlled studies, four qualitative analyses and one health economic analysis. One well-designed, well-conducted RCT demonstrated that, compared with usual GP care, Alexander Technique lessons led to significant long-term reductions in back pain and incapacity caused by chronic back pain. The results were broadly supported by a smaller, earlier RCT in chronic back pain. The third RCT, a small, well-designed, well-conducted study in individuals with Parkinson's disease, showed a sustained increased ability to carry out everyday activities following Alexander lessons, compared with usual care. The 15 non-RCT studies are also reviewed.

CONCLUSIONS

Strong evidence exists for the effectiveness of Alexander Technique lessons for chronic back pain and moderate evidence in Parkinson's-associated disability. Preliminary evidence suggests that Alexander Technique lessons may lead to improvements in balance skills in the elderly, in general chronic pain, posture, respiratory function and stuttering, but there is insufficient evidence to support recommendations in these areas.

A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain

Background. Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain. Data Sources. Records without language restriction from various databases up to February 2010. Data Extraction. The efficacy outcomes of interest were pain intensity and disability. Data Synthesis. Reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature. Conclusions. CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.

The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice.

SUMMARY OF BACKGROUND DATA

Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care.

METHODS

A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization.

RESULTS

Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences.

CONCLUSION

In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.

Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique

The Alexander Technique (AT) is used to improve postural and movement coordination and has been reported to be clinically beneficial, however its effect on movement coordination is not well-characterized. In this study we examined the sit-to-stand (STS) movement by comparing coordination (phasing, weight-shift and spinal movement) between AT teachers (n=15) and matched control subjects (n=14). We found AT teachers had a longer weight-shift (p<0.001) and shorter momentum transfer phase (p=0.01), than control subjects. AT teachers also increased vertical foot force monotonically, rather than unweighting the feet prior to seat-off, suggesting they generate less forward momentum with hip flexors. The prolonged weight-shift of AT teachers occurred over a greater range of trunk inclination, such that their weight shifted continuously onto the feet while bringing the body mass forward. Finally, AT teachers had greatly reduced spinal bending during STS (cervical, p<0.001; thoracic, p<0.001; lumbar, p<0.05). We hypothesize that the low hip joint stiffness and adaptive axial postural tone previously reported in AT teachers underlies this novel "continuous" STS strategy by facilitating eccentric contractions during weight-shift.

A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial

BACKGROUND

Few studies have evaluated the effectiveness of massage for chronic low back pain.

OBJECTIVE

To compare the effectiveness of 2 types of massage and usual care for chronic back pain.

DESIGN

Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384)

SETTING

An integrated health care delivery system in the Seattle area.

PATIENTS

401 persons 20 to 65 years of age with nonspecific chronic low back pain.

INTERVENTION

Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133).

MEASUREMENTS

Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful.

RESULTS

The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small.

LIMITATION

Participants were not blinded to treatment.

CONCLUSION

Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.

PRIMARY FUNDING SOURCE

National Center for Complementary and Alternative Medicine.

Body Awareness: a phenomenological inquiry into the common ground of mind-body therapies

Enhancing body awareness has been described as a key element or a mechanism of action for therapeutic approaches often categorized as mind-body approaches, such as yoga, TaiChi, Body-Oriented Psychotherapy, Body Awareness Therapy, mindfulness based therapies/meditation, Feldenkrais, Alexander Method, Breath Therapy and others with reported benefits for a variety of health conditions. To better understand the conceptualization of body awareness in mind-body therapies, leading practitioners and teaching faculty of these approaches were invited as well as their patients to participate in focus groups. The qualitative analysis of these focus groups with representative practitioners of body awareness practices, and the perspectives of their patients, elucidated the common ground of their understanding of body awareness. For them body awareness is an inseparable aspect of embodied self awareness realized in action and interaction with the environment and world. It is the awareness of embodiment as an innate tendency of our organism for emergent self-organization and wholeness. The process that patients undergo in these therapies was seen as a progression towards greater unity between body and self, very similar to the conceptualization of embodiment as dialectic of body and self described by some philosophers as being experienced in distinct developmental levels.

Educating with the hands: working on the body/self in Alexander Technique

Traditionally, forms of body work such as Alexander Technique have been excluded from mainstream biomedicine and healthcare, despite attempts by practitioners to have the work accepted within the medical community. Using data from a UK-based study of Alexander Technique which combined participant observation, interviews with 17 teachers and pupils, and analysis of historical texts, this article examines the relationship of the Alexander Technique to the field of healthcare, looking at its embodied practices, and contrasting these with the discourses in which it is framed. Applying Foucault's concept of 'techniques of the self', the article examines Alexander Technique's physical practices as a form of embodied knowledge, and goes on to look at its use of particular ideas about nature and evolution as guiding authorities, its emphasis on holism through its conception of the 'self', and how it has been positioned in relation to biomedical approaches. The article argues that while the embodied practice of Alexander Technique has much to offer to mainstream healthcare, the discourses and knowledge systems in which it is embedded make it unlikely to receive mainstream medical acceptance.

Increased dynamic regulation of postural tone through Alexander Technique training

Gurfinkel and colleagues (2006) recently found that healthy adults dynamically modulate postural muscle tone in the body axis during anti-gravity postural maintenance and that this modulation is inversely correlated with axial stiffness. Our objective in the present study was to investigate whether dynamic modulation of axial postural tone can change through training. We examined whether teachers of the Alexander Technique (AT), who undergo "long-term" (3-year) training, have greater modulation of axial postural tone than matched control subjects. In addition, we performed a longitudinal study on the effect of "short-term" (10-week) AT training on the axial postural tone of individuals with low back pain (LBP), since short term AT training has previously been shown to reduce LBP. Axial postural tone was quantified by measuring the resistance of the neck, trunk and hips to small (±10°), slow (1°/s) torsional rotation during stance. Modulation of tone was determined by the torsional resistance to rotation (peak-to-peak, phase-advance, and variability of torque) and axial muscle activity (EMG). Peak-to-peak torque was lower (∼50%), while phase-advance and cycle-to-cycle variability were enhanced for AT teachers compared to matched control subjects at all levels of the axis. In addition, LBP subjects decreased trunk and hip stiffness following short-term AT training compared to a control intervention. While changes in static levels of postural tone may have contributed to the reduced stiffness observed with the AT, our results suggest that dynamic modulation of postural tone can be enhanced through long-term training in the AT, which may constitute an important direction for therapeutic intervention.

Cost-effectiveness of general practice care for low back pain: a systematic review

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.

The diagnosis and management of common non-specific back pain - a clinical review

The assessment and management of common non-specific back pain that is associated with considerable personal morbidity and cost to society is reviewed and set in a bio-psycho-social context.

How usual is usual care in pragmatic intervention studies in primary care? An overview of recent trials

BACKGROUND

Because pragmatic trials are performed to determine if an intervention can improve current practice, they often have a control group receiving 'usual care'. The behaviour of caregivers and patients in this control group should be influenced by the actions of researchers as little as possible. Guidelines for describing the composition and management of a usual care control group are lacking.

AIM

To explore the variety of approaches to the usual care concept in pragmatic trials, and evaluate the influence of the study design on the behaviour of caregivers and patients in a usual care control group.

DESIGN OF STUDY

Review of 73 pragmatic trials in primary care with a usual care control group published between January 2005 and December 2009 in the British Medical Journal, the British Journal of General Practice, and Family Practice. Outcome measures were: description of the factors influencing caregiver and patients in a usual care control group related to an individual randomised design versus cluster randomisation.

RESULTS

In total, 38 individually randomised trials and 35 cluster randomised trials were included. In most trials, caregivers had the freedom to treat control patients according to their own insight; in two studies, treatment options were restricted. Although possible influences on the behaviour of control caregivers and control patients were more often identified in individually randomised trials, these influences were also present in cluster randomised trials. The description of instructions and information provided to the control group was often insufficient, which made evaluation of the trials difficult.

CONCLUSION

Researchers in primary care medicine should carefully consider the design of a usual care control group, especially with regard to minimising the risk of study-induced behavioural change. It is recommended that an adequate description of the information is provided to control caregivers and control patients. A proposal is made for an extension to the CONSORT statement that requires authors to specify details of the usual care control group.