By Mercy Kagoda, MD
Dr. Kagoda reports no financial relationships relevant to this field of study.
Summary Point
- Compared to usual care, both acupuncture and Alexander Technique lessons were associated with statistically and clinically significant decreases in chronic neck pain and increased ability to acquire lifelong skills that decreased neck pain.
SYNOPSIS: Alexander Technique lessons or acupuncture sessions for people with chronic neck pain led to greater decreases in neck pain and disability and a more significant increase in self-efficacy than normal care at 12 months.
SOURCE: MacPherson H, Tilbrook H, Richmond S, et al. Alexander Technique lessons or acupuncture sessions for persons with chronic neck pain. A randomized trial. Ann Intern Med 2015;163:653-662.
Chronic neck pain is a significant public health challenge with consequences that include decreased personal well-being, increased healthcare utilization, missed days at work, and loss of productivity.1,2 Many people suffering from neck pain obtain care from complementary medical practices such as acupuncture and Alexander Technique lessons. The clinical effectiveness of these practices has only been marginally studied, with this study being the first to have a usual care group and 12-month follow-up. Prior reviews suggest that Alexander Technique improves balance, decreases general pain, and improves posture.3 MacPherson et al reviewed outcomes of patients with chronic neck pain at 1 year after random assignment to Alexander Technique or acupuncture in addition to usual care vs. usual care alone. This is not a comparison between Alexander Technique and acupuncture, but rather an assessment of Alexander Technique plus usual care to usual care alone or acupuncture plus usual care to usual care alone.
This study was carried out in the United Kingdom with a predominantly white British population. Study participants were identified through their general practitioners. Inclusion criteria included: age > 18 years, neck pain for a minimum of three months, recent contact with their primary care physician/general practitioner in the past 2 years, Northwick Park Questionnaire (NPQ) score of more than 27%, which signified neck pain affecting activities of daily living. Exclusion criteria included severe underlying pathology, pregnancy, currently receiving acupuncture, or prior attendance of Alexander Technique lessons in the previous two years. A total of 577 study participants were randomly assigned to one of three groups: acupuncture plus usual care (n = 173), Alexander Technique plus usual care (n = 172), or usual care alone (n = 172). Study participants were mostly female (69%) and white British (90%). (See Table 1.) Randomization allowed the study designers to control for selection bias, improving the methodology.
Table 1: Baseline Characteristics of Study Participants (n = 517) |
|||
|
Characteristic |
Acupuncture (n = 173) |
Alexander Technique (n = 172) |
Usual Care (n = 17) |
|
Mean age ± SD |
52.0 ± 13.8 |
53.6 ± 14.6 |
53.9 ± 13.0 |
|
Females (n) |
119 |
120 |
118 |
|
White |
158 |
151 |
152 |
|
Mean NPQ score baseline ± SD |
39.64 ± 9.71 |
39.38 ± 11.91 |
40.46 ± 11.60 |
|
Median duration of neck pain (range) |
60 (5-600) |
60 (6-540) |
96 (5-600) |
Participants assigned to the acupuncture group were presented with the opportunity to attend twelve 50-minute sessions for a total of 600 minutes in addition to the usual care. Acupuncture was one on one, and also included lifestyle advice such as engaging in exercise, relaxing, eating healthy foods, and resting. Advice by acupuncturists also included the use of magnets and herbs. Participants assigned to the Alexander Technique group were presented with the opportunity to attend twenty 30-minute sessions for a total of 600 minutes in addition to the usual care. Alexander Technique was one on one, and also included hands on and verbal guidance. Alexander Technique is a method of self-care that involves unlearning harmful habits of physical movement to optimize activities of daily living, such as walking, sitting, standing, and speaking, with the goals of maintaining balance and preventing pain. The technique also develops self and spatial awareness through quieting the mind and learning new ways of physical movement that enliven the musculature of the back and spinal cord while allowing the head to be freely poised. The Alexander Technique is based on three key principles. First, to remain pain free there needs to be a dynamically maintained axis and proper head poise. Second, muscle tension from negative emotional or physical reactions to everyday living affect how the axis is dynamically maintained, leading to decreased mobility and pain. Third, restoring balance of the body axis can be achieved by relearning new habits that allow for a dynamically maintained axis and head poise. During the Alexander Technique lessons, participants were shown how to maintain body awareness to maintain the dynamic axis, which allowed them to engage in activities with more thoughtfulness and hence prevent injuries.
The instructors for acupuncture or Alexander Technique lessons were part of a larger governing body for the respective practices, which suggests that the sessions offered were standardized.
Usual care for neck pain entailed prescribed pain medications and physical therapy. Prescribed pain medications were used by 43% of all study participants between 0 to 6 months after enrolling in the study. Six months prior to enrolling in the study, 59% of participants used neck pain-specific medications.
Prior to the start of the study, the expectations and preferences for acupuncture, Alexander Technique, or usual care were measured. Each randomized group included about the same number of people, with varying expectations and preferences for the options of care.
All sessions were delivered within five months. Alexander Technique lessons were offered twice a week and then every two weeks. The acupuncture sessions were once per week initially and then every two weeks. The primary outcome measure was the NPQ score measured at baseline, three months, six months, and 12 months. Secondary outcome measures included pain level text messages and self-efficacy score.
Developed at the Northwick Park Hospital in Middlesex, England, the NPQ includes nine questions. Each question has five options with a score from 0 to 4; the higher the score, the worse the disability/pain. The score is calculated by cumulative points/36 if 9 questions are answered or /32 if only first 8 questions are answered x 100. The maximum cumulative score is 36 and the minimum score is zero. The items that are rated include: pain intensity; pain and sleeping; pins, needles, or numbness in arms at night; duration of symptoms; pain with carrying; pain while reading and watching TV; working/housework; social activities; driving; and comparison of neck pain on the day the questionnaire was last taken.5
The study used various statistical analyses including repeated measures, mixed model, and linear regression. The difference in NPQ score between acupuncture and usual care and Alexander Technique and usual care was statistically significant at all three time points (P < 0.05). (See Tables 2 and 3.) Self-efficacy improved with both techniques more than in usual care and was measured using the Chronic Pain Self-Efficacy Scale. This scale measures how well people can manage their pain and the degree to which pain interferes with activities of daily living.
Table 2: Attendance at Sessions |
|||
|
Intervention |
Acupuncture |
Alexander Technique |
Usual Care |
|
Mean attendance |
10/12 sessions |
14/20 sessions |
N/A |
|
% attended all sessions |
72% |
60% |
N/A |
|
% attended no sessions |
6% |
12% |
N/A |
|
Completion of 12 months follow-up |
87% |
85% |
85% |
Table 3: Differences in Mean Adjusted NPQ Scores at 3, 6, and 12 Months |
|||
|
3 months NPQ (95% CI) |
6 months NPQ (95% CI) |
12 months NPQ (95% CI) |
|
|
Acupuncture |
37.23 (30.35-44.1) |
35.35 (28.73-41.96) |
37.07 (30.35-43.79) |
|
Usual care |
43.46 (35.40-51.5) |
40.90 (32.94-48.97) |
40.99 (33.01-48.96) |
|
Alexander Technique |
38.62 (31.62-45.6) |
32.65 (25.92-39.38) |
33.39 (26.73-40.05) |
|
Usual care |
42.22 (34.07-50.4) |
37.64 (29.58-45.69) |
37.18 (29.16-45.19) |
Another strength of the study was the long-term follow up at one year. At one year, there was still a significant clinical and statistical decrease in the NPQ score for both acupuncture and Alexander Technique lessons. During the trial, there were 80 adverse events in 73 people, 30 of which were classified as serious and 50 of which were non-serious. None of the serious adverse events were considered "probably or definitely" related to the relevant intervention, but Alexander Technique lessons "possibly" caused pain, muscle spasms, and knee injury; acupuncture "possibly" caused bruising, swelling, numbness, muscle spasms, pain, and respiratory problems; and usual care "possibly" caused pain, incapacity, and complications after surgery.
COMMENTARY
The findings in this study showed that acupuncture and Alexander Technique lessons were associated with statistically and clinically significant decreases in chronic neck pain, increased ability to manage pain, and decreased negative effect of pain.
The benefits compare favorably with physical therapy. Overall, the therapies were safe, with increased pain and muscle spasms the most commonly reported adverse effects. During the acute phase, it would be prudent to follow allopathic convention of limiting activity and using pain-relieving medications. Acupuncture may be used during the acute phase in addition to pain-relieving medication. Alexander Technique lessons may then be used after the acute phase to mediate the conditions that caused neck pain by relearning new ways of thinking and moving. Cost will be an issue for some patients as average costs range from $50-100 for acupuncture and $40-70 for Alexander Technique lessons. Out-of-pocket costs can easily reach $1,000.
The main strength of this study was that it randomized participants to intervention and usual care. Some studies in this field do not randomize participants nor do they have a “usual care” group for comparison. Since there were varying degrees of expectations and skepticism about benefits of any of the treatments in all the treatment groups, the techniques may be suggested to all patients. However, it may be that the patients who would benefit most from either acupuncture or Alexander Technique lessons are those most likely to be interested in building self-efficacy. The authors did not address the complex relationship between self-efficacy and the placebo effect: Is self-efficacy a measure of the placebo effect, mutually exclusive from placebo, or perhaps a combination of the two?
The statistical analysis used was appropriate for the study. Repeated measures mixed model was a better choice than the traditional fixed repeated measures. In repeated measures, the same subject also acts as the control; in this study, the baseline NPQ was compared with the NPQ at three, six, and 12 months. With the mixed model, the researchers were able to report both the within-group change and also the between-group change. In addition, a mixed model has the advantage of keeping all other data points of a participant, even if one data point is missing. For example, if a participant did not turn in the NPQ at three months, in the mixed model that data point would be removed; however, the remaining data points would be kept. In the traditional model, even one missing point would lead to dropping that subject and thus losing out on all other points. The authors did not mention how many subjects had all the data points available.
In summary, the study design was robust and provides strong evidence on the clinical value of adding acupuncture or Alexander Technique lessons to the usual care of people with chronic neck pain.
REFERENCES
- Fejer R, Kwik KO, Hartvigsen J. The prevalence of neck pain in the world population: A systematic critical review of the literature. Eur Spine J 2006;15:834-848.
- Côté P, Cassidy JD, Carroll L. The treatment of neck and low back pain: Who seeks care? Who goes where? Med Care 2001;39:956-967.
- Woodmnan JP, Moore NR. Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: A Systematic review. Int J Clin Pract 2012;66:98-112.
- MacPherson H, Tilbrook H, Richmond S. et al. Alexander Technique lessons or acupuncture sessions for persons with chronic neck pain. A randomized trial. Ann Intern Med 2015;163:653-662.
- Physio-pedia. The Northwick Park Questionnaire Available at: www.physio-pedia.com/The_Northwick_Park_Questionnaire. Accessed Feb. 2, 2016.
Alexander Technique lessons or acupuncture sessions for people with chronic neck pain led to greater decreases in neck pain and disability and a more significant increase in self-efficacy than normal care at 12 months.
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