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Cover of Alexander technique and Supervised Physiotherapy Exercises in back paiN (ASPEN): a four-group randomised feasibility trial

Alexander technique and Supervised Physiotherapy Exercises in back paiN (ASPEN): a four-group randomised feasibility trial

Efficacy and Mechanism Evaluation, No. 1.2

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Author Information and Affiliations
Southampton (UK): NIHR Journals Library; .


This study found that the trial of the Alexander technique and supervised physiotherapy exercises in back pain was feasible and that these interventions may provide clinically important benefits in back pain.



The Alexander technique probably helps back pain but it is unclear whether or not it can be combined with physiotherapy exercise classes, how many lessons are needed and what mechanisms might be involved.


To undertake a feasibility trial of the Alexander technique and supervised exercise classes and perform exploratory biomechanical and neuromuscular physiological marker analyses to better understand mediators of recovery.


Feasibility parallel-group randomised controlled trial.


General practices in southern England.


Patients with recurrent back pain (at least 3 weeks’ duration of a current episode).


Participants were allocated by an external randomisation line to four groups: (1) normal care, (2) 10 Alexander technique lessons, (3) 12 physiotherapy exercise classes, (4) Alexander technique lessons plus exercise classes.

Main outcome measures:

The feasibility outcomes were recruitment, acceptability and follow-up. The clinical outcomes were the Roland–Morris Disability Questionnaire (RMDQ), days in pain, the Von Korff pain and disability scale, overall improvement, fear of activity, enablement, the Oswestry Disability Index and the Aberdeen pain and function scale. Laboratory-based markers were axial muscle tone and flexibility, electrical activity, muscle tone and mechanical properties of elasticity and stiffness, trunk strength, and proprioception.


In total, 83 patients consented, 69 were randomised and 56 (81%) were followed up at 6 months. Most patients had long-standing pain (median > 300 days of pain). The RMDQ and other instruments were sensitive to change and the preliminary evidence suggests that the Aberdeen scale could be a useful measure. Study procedures were feasible and three methods of recruitment were successfully piloted. At 6 months the control group had changed little (RMDQ 1 point lower than at baseline) and, compared with the control group, clinically important improvements in RMDQ were seen in all groups, albeit not significant [Alexander technique −3.0, 95% confidence interval (CI) −6.7 to 0.8]; exercise classes −2.9, 95% CI −6.5 to 0.8; combined Alexander technique + exercise classes −2.50, 9% CI −6.20 to 1.19]. Novel biomechanical variables strongly associated with RMDQ score at 6 months were muscle tone (0.94 increase in RMDQ per unit increase in Hz, 95% CI 0.48 to 1.40; p < 0.0001), lumbar proprioception (1.48 increase in RMDQ per degree, 95% CI 0.83 to 2.12; p < 0.0001) and muscle elasticity (−4.86 increase in RMDQ per unit log decrement, 95% CI −0.01 to −9.72; p < 0.05). At 3 months the Alexander technique improved proprioception and exercise classes improved trunk extension strength. At 6 months the Alexander technique improved the timing of multifidus muscle onset and the active straight leg raise test and exercise classes improved multifidus muscle thickness and the ability to contract. The combined effects of the Alexander technique and exercise classes were improvements in muscle tone, elasticity and thickness and contractile ability. These observations provide possible links between intervention, proprioception, muscle tone and elasticity and outcome. In terms of harms, one patient fell in the exercise class group.


The trial is feasible and the interventions may provide clinically important benefits. Exploratory analysis suggests that muscle tone, elasticity and proprioception are strongly associated with improved RMDQ score and are likely to be modified by the interventions.

Trial registration:

Current Controlled Trials ISRCTN51496752.


This project was funded by the Medical Research Council through the Efficacy and Mechanism Evaluation Board.


Article history

The research reported in this issue of the journal was funded by the EME programme as project number 09/160/23. The contractual start date was in January 2011. The final report began editorial review in October 2013 and was accepted for publication in April 2014. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The EME editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Paul Little is editor-in-chief of the Programme Grants for Applied Research journal.

Copyright © Queen’s Printer and Controller of HMSO 2014. This work was produced by Little et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK259305PMID: 25642555DOI: 10.3310/eme01020


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