Back pain treatments once again featured on the cover of the BMJ in August this year. The high profile was attributable to a large randomised controlled trial of lessons in the Alexander Technique (AT), exercise and massage in patients with chronic low back pain.
The AT lessons offered patients one-to-one tuition with a trained AT teacher. AT involves learning to recognise, understand and correct poor postural habits and neuromuscular coordination. The study recruited 579 patients from 64 general practices. Patients were selected randomly from practice registers if they had consulted in the preceding 5 years with back pain. It is important to appreciate that these patients were not recruited prospectively and were not actively seeking treatment for their back pain at the time of the study. Patients were randomised to control (‘usual care’), massage, 6 sessions of AT or 24 sessions of AT. Half of each group were further randomised to receive an exercise prescription from a doctor and behavioural counselling from a nurse. Follow-up rates were good with 81% of subjects completing a questionnaire at 3 months and 80% at 12 months from baseline. Primary outcome measures were the number of days per month in pain and the Roland Morris disability score. Quality of life was also measured by SF-36. 1
Subjects reported an average of 243 days of back pain in the year preceding the study. Little change occurred in the control group during the study period. There was significant improvement in outcome measures in all three intervention groups at 3 months. The effect of 24 lessons of AT increased at 12 months, whereas the effect of massage declined. The benefit of 6 lessons of AT was maintained at 12 months. Exercise prescription added to 24 lessons of AT did not lead to significant improvements over AT alone. Exercise prescription added to 6 lessons of AT improved outcome measures to 72% of that achieved by 24 lessons alone. An accompanying editorial
welcomed the findings, particularly because the benefits of the AT lessons were maintained or improved over the longer term – 12 months. Evidence from systematic reviews for other treatments for chronic back pain is strong for exercise prescription, especially if the exercise programme is individually designed and supervised, and for intensive multidisciplinary programmes. Evidence is moderately strong for behavioural therapy, back schools and spinal manipulation. However the benefits of these interventions have usually been demonstrated over the short term; evidence of longer-term benefits is lacking. 2
So what can the jobbing GP take from all this? Combining the findings of systematic reviews and currently available guidelines, exercise therapy (supervised to ensure adherence), cognitive-behavioural therapy, educational interventions and multidisciplinary interventions based on a biopsychosocial model of back pain have most to offer. Spinal manipulation, massage, acupuncture and back school may also be beneficial in the short term. Invasive interventions and passive treatments with ultrasound, short-wave diathermy and lumbar supports showed no evidence of effectiveness and cannot be recommended.