MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

The aim of this study was to evaluate clinical effectiveness of Alexander Technique lessons or acupuncture versus usual care for persons with chronic, nonspecific neck pain.

Patients 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 were randomised to receive 12 acupuncture sessions or 20 one-to-one Alexander lessons (both 600 minutes total) plus usual care versus usual care alone. The NPQ score 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) served as outcome measures. 517 patients were recruited. Their 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.

The authors drew the following conclusions: 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.

Where to begin? There is much to be criticised about this study!

For starters, the conclusions are factually wrong. They should read “acupuncture sessions plus usual care and Alexander Technique lessons plus usual care 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.

On this blog, we have repeatedly discussed the ‘A+B versus B’ study design and the fact that it cannot provide information about cause and effect because it fails to control for placebo effects and the extra attention, time and empathy (for instance here and here). I suspect that this is the reason why it is so very popular in alternative medicine. It can make ineffective therapies appear to be effective.

Another point is a more clinical concern. Neck pain is not a disease, it is a symptom. In medicine we should, whenever possible, try to treat the cause of the underlying condition and not the symptom. Acupuncture is at best a symptomatic treatment. Usual care is often not very effective because we normally fail to see the cause of neck pain. In my view, alternative treatments should either be tested against placebo or sham interventions or against optimal care.

What is optimal care for nonspecific neck pain? As its causes are often unclear and usually multifactorial, the optimal treatment needs to be multifactorial (one could also call it holistic) as well. The causes often range from poor ergometric conditions at work to muscular tension, stress, psychological problems etc. Thus optimal care would be a team work tailor-made for each patient possibly including physiotherapists, pain specialists, clinical psychologists, orthopaedic surgeons etc.

My points here are:

  • neither acupuncture nor Alexander technique take account of this complexity,
  • they claim to be holistic but, in fact, this turns out to be merely a good sales-slogan,
  • usual care is usually no good,
  • if pragmatic trials using the ‘A+B versus B’ design make any sense at all, they should employ not usual care but optimal care for the control group.

In the end, we are left with a study that looks fairly rigorous at first sight, but that really tells us next to nothing (except that dedicating 600 minutes to patients in pain is not without effect). I am truly surprised that a top journal like the Annals of Internal Medicine decided to publish it.

22 Responses to Nonspecific neck pain: Alexander technique or acupuncture? Probably neither!

  • A 4% improvement on top of 28% from “usual care” does not sound clinically significant when there is no control for placebo effects. Patients voting with their feet and giving up on Alexander technique loots significant – averaged only 14 sessions.
    What was their “usual care”? Good physiotherapy would be a starting point for me.

    • The Alexander Technique is something you learn and learn to apply in everyday activity. It is not a therapy. The people choosing not to attend lessons could have been wanting a quick fix. The number of drop-outs is higher in the beginning. As many as 25% of participants had only 5 lessons or less and half of these didn’t even turn up for the first lesson.

      The trial result is nevertheless disappointing in regards to Alexander Technique and neck pain, and we have to take it into account when describing the possible influence on health from learning the Alexander Technique.

      Halvard Heggdal
      Alexander Technique teacher

      • if the claim is that it effectively treats neck pain, then – in my book – one might be forgiven for calling it a therapy.

        • You are right that in regard to health claims and research on health effects the Alexander Technique must be treated like a therapy in line with any other intervention.

          When I said the technique is not a therapy I was refering to the lessons offered trial participants. In lessons, a person is treated like a pupil, not as a patient. People in pain are generally more focused on getting rid of the pain than on learning a new skill. I suggest that this may be a reason for the high initial number of drop-outs.

      • Halvard Heggdal said:

        we have to take it into account when describing the possible influence on health from learning the Alexander Technique.

        How will you do that?

        • That is very easy. I will not claim that the Alexander Technique can reduce neck pain to any significant degree.

          Halvard Heggdal
          Alexander Technique teacher

          • no, it’s not that easy. the claim is being made for alexander technique – therefore it is fair to call it a therapy.#
            what you personally believe or do is not relevant in this context.

          • To clarify:
            I interpreted the question from Alan Henness to be specifically what I myself would do to take into account the results from this trial when describing the Alexander Technique. My answer was that I will not claim that the Alexander Technique can reduce neck pain to any significant degree. In this connection it is irrelevant whether the Alexander Technique is regarded as a therapy or not, my answer would be the same.

          • Are you saying that there is other evidence that AT can reduce neck pain to some degree? If so, can you cite it?

          • “Are you saying that there is other evidence that AT can reduce neck pain to some degree? If so, can you cite it?”

            No, I’m saying the opposite. If Ernst is correct and we should dismiss this latest trial, then there is no evidence that AT can reduce neck pain. Because of this, I’m NOT going to say that the Alexander Technique can reduce neck pain.

            Am I clear?

          • Halvard Heggdal

            Thanks for the clatification : it was your use of the phrase “to any significant degree” that led me to believe you were implying that there was other evidence.

    • “Good physiotherapy would be a starting point for me”, is an oxymoronic statement. Where are the peer review articles to validate physiotherapy? They may state a type of care e.g. manipulation, mobilisation, TENS etc., but because Physiotherapy is such a broad waste basket of a profession, then it should not be treated as a modality in itself.

  • ”Edzard on Thursday 12 November 2015 at 06:32
    nothing that special about it – some aspects of physiotherapy are the same”

    There is nothing special about the Alexander Technique, but it is different from any physiotherapy approach that I know of. The Alexander Technique is a skill. It is a way of thinking that I can use in my daily activities. For instance I can use it while practicing the violin in order to avoid unecessary or unwanted tensions.
    I’m sure physiotherapy can also improve quality of movement, but the means are certainly very different. I can’t imagine how I could use physiotherapy while I’m actually playing.

    Halvard Heggdal
    Alexander Tecnique teacher

    • I don’t think I’ve ever found myself in disagreement with Edzard Ernst before. Still…
      Having had many AT lessons some years ago, and undergone a lot of physiotherapy for various sports injuries, broken bones etc., I would agree that Alexander Technique and physiotherapy have virtually nothing in common.

      I would summarise Alexander Technique as a way of using the body in as efficient and stress-free way as possible. It is a way of thinking, and it requires a lot physical self-awareness. One really useful thing I learned in my lessons is how unreliable my physical/spatial feedback was, and how little I was actually aware of my posture and muscular tension.

      Maybe Alexander Technique should be called Physical Awareness Technique. And its use is preventative rather than curative. I suppose it might be better compared to yoga than physiotherapy, but even that would be inaccurate.

  • Some might find it odd that the magazine What Doctors Don’t Tell You say this about that very same study:

    Acupuncture and Alexander Technique both better for chronic neck pain

    Acupuncture and the Alexander Technique—which helps to improve posture—are both more successful at reducing chronic neck pain than standard treatment, a new study has found.

    They both achieved a “clinically significant” greater reduction in pain than standard care, which may include painkillers and exercise, when they were tested on a group of more than 500 patients who had been suffering from general neck pain for at least three months.

    Both therapies had achieved a 30 per cent reduction in pain and disability, whereas standard care had resulted in a 23 per cent reduction, after a year.

    Others my not find it odd at all…

  • A serious matter has come to my attention in relation with this trial. It is summarised in a ‘letter to the editor’ which has, I think, been published in the journal but is also available here https://docs.google.com/document/d/1M_KNDBeSh4WVvWyz4nobpon4-LYGNNOlG-dXChChUTo/edit?pli=1
    One wonders whether this does not render the study fraudulent.

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