Friday, August 9, 2013

Scientific Research in the AT, Part 1

Before we apply the theory of the body-self neuromatirx to the Alexander Technique, I think it is important to review the scientific evidence for efficacy.

This is of course, of prime importance to the medical provider.  As stated in the introduction, a theoretical understanding for the mechanism of action may be interesting to the provider, but it should have little, if any, role in deciding to recommend an intervention to a chronic back pain sufferer.  Again, the decision should be based on:

-the need VS safety (interventions with even small risk should not be considered in the treatment of male pattern baldness.  Alternatively, high risks may be acceptable for life threatening problems)
-cost
-availability
-scientific evidence to support it's efficacy.

In FM Alexanders time, medical care providers made decisions primarily based on the expert opinions.  Today, however, we have scientific research.  In todays evidence based world we like to see:
- reports published in respected journals by editors who have reviewed the findings.
- peer reviewed so that experts who know the field have reviewed the methodology.
- controlled trials, with the intervention compared with either placebo or standard care.
- Large numbers of participants to insure a statistical significance.
- Clearly stated primary and secondary outcomes.
- A patient cohort that reflects our patient population.
- Researchers should not be biased or have any stake in the outcome.
- We would also like to see several of these trials, hopefully with a meta-study to compile them.

The AT claims to improve the 'use of the self', with the 'self' defined somewhat broadly.  It does not claim that it will provide any narrow, particular benefit.  As such we there is currently no way to discover if the AT is effective.
      We can investigate if the AT helps with a narrow concern such as back pain.  But the outcome of AT/back pain investigations will have little bearing on the central claim made by the AT.  Metaphorically, nutritionists claim that eating well helps to improve health.  What does it mean if studies of those who have seen nutritionist fail to find improvement in visual acuity?

The flagship study of the AT and back pain can be found here.
   Very briefly, it was funded by the UK health care system.  It had 579 patients enrolled.  It measured the effects of several interventions inc normal care (which served as the control group), exercise, massage (to control for the hands on, one on one interaction), six lessons in the AT and 24 lessons.  Primary outcomes were Roland Morris disability score (number of activities impaired by pain) and number of days in pain.  The study was done in the UK and was done with 152 AT teachers and massage therapist.
    There were several very notable things about this study.
-The number of participant was quite large.
-This was a fairly impaired population.   For example, the control group at the end of the study reported 21 out of 28 days with back pain.
-The follow up was a full year after the intervention.
-  The study concluded "One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons."

This statement really does not capture the magnitude of the results.

The number of subjects exceed that to some metastudies of other interventions.

The one year follow up is also noteworthy.  There have been studies of a variety of non medical interventions that have suggested benefit in the short term.  But back pain is commonly recurrent and chronic back pain is one of the major problems in medicine today.   Why shouldn't we set our expectations high and ask for long term - even permanent - results?  

The authors are conservative in their conclusions:  to say that there was 'benefit' belies the magnitude of the result.  At one year follow up, the control group had 3 weeks in the past month in pain.  The 24 AT lesson group had 3 days in pain.  This is a 86% reduction.    This must be close to the background occurrence of back pain.    Also of note, the effect at 12 months was actually greater than the effect at 3 months.  When medical providers consider interventions we usually think about therapies, and therapies typically decline in efficacy over the years.  But the AT is an educational technique and the effects of it's use, apparently, improves over time.

In those people who do not carry a diagnosis of low back pain, how many days in pain would they confess to having if they were polled?  Does this study suggest that the AT has the potential to cure back pain?

The second outcome was disability, and here there was a 42% reduction based on the Roland Disability Score.  Again, to says this is "benefit" is rather an understatement.  I will present in future posts some thought on why the effects is not as robust as the days-in-pain result.

Again, the body of scientific evidence should be the primary consideration in the decision to recommend and intervention.  How far does this study go in meeting the need?
- It is not a meta study, but does include a great number of clinically relevant patients.
- It's researchers have no interests to disclose.
- Outcomes measure long term results.
- It was published in a major peer reviewed medical journal
- The results were unequivocal and dramatic.

Should the AT be recommended?  Again, based on our criteria above:
- Risk/reward: Chronic back pain has very significant global negative implication for the sufferer.  As such, we should accept a moderate amount of risk for an intervention that has shown efficacy.  However, for the AT, we do not need to accept any risk because there has never been an unwanted outcome from any study, including this one.
- The cost?  In my community, a lesson might cost $40.  24 lessons would cost $960.  However, a compelling argument can be made for recommending 6 lessons plus an exercise prescription.
-  AT teachers are available in most communities in the US.  Healthcare Saving accounts can be used to cover lessons in the AT with "back pain" as a diagnosis and "Alexander Technique/neurophysical re-education" as the recommended treatment.

This is a brief review of the scientific evidence regarding the AT and back pain, and it certainly does not negate the need for the caregiver to review the BMJ study.
I should be very clear that this is not the only study that has been done with the AT.  In subsequent posts I'll review other studies of the AT.    But for now, we should go back to the body-self neuromatrix to again consider it's efficacy in part to discuss the discrepancy between the days in pain result and the effects on disability.