The Back Pain Choice: Chapter 5


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Past Episodes

The hypothesised effects of treatment were related to proposed mechanisms. The mechanism of action of the Alexander technique technique was proposed to be through improved muscle tone, proprioception position sense and motor control of spinal movements indicated by earlier onset of EMG , and the importance of these was supported by the graphical CHAIN model. The physiotherapy exercise classes involved activities that would be expected to improve muscle strength, proprioception and motor control.

These mechanisms were partially confirmed by this preliminary study, but confirmation and fuller exploration of the likely mechanisms requires a larger study. The graphical CHAIN model at 6 months see Figure 2 and Tables 19 and 20 indicates that the most predictive measures of the primary outcome at 6 months and other laboratory measures were proprioception, parameters of muscle mechanical properties measured using the MyotonPRO device and muscle thickness measurements using USI.

These were more predictive than EMG, which is a gold standard laboratory technique used in back pain research.

Strengths and limitations

It is important to stress here that the relationship between clinical outcomes and biomechanical and neurophysiological markers commonly used in back pain research has yet to be clarified. It is widely reported that lower back pain is associated with abnormal muscle morphometry thickness at rest and change during contraction and motor control. Measurements of these two parameters using USI and EMG are often used to target interventions but baseline tests are not predictive of outcome 47 and changes in muscle parameters pre—post intervention may not correlate with clinical outcomes, although limited evidence exists for change in multifidus thickness.

In previous studies on which these observations of abdominal and lumbar spine muscles were based, the tasks used to elicit involuntary contraction of trunk muscles were mainly arm lifts some used voluntary abdominal muscle contraction, which is not as functional as automatic contraction. We therefore used leg lifts to see whether or not correlation with clinical measures could be improved, as leg lifts might be more functionally relevant to the lumbopelvic muscles than arm lifts.

We also used novel tests of muscle characteristics that would be relevant to altering muscle tone, which the Alexander technique aims to influence. These novel tests were 1 the trunk rotation test, which was recently found to be sensitive to a reduction in resistance to rotation immediately after an Alexander technique session in people with lower back pain, 20 and 2 MyotonPRO technology for testing non-neural tone and mechanical properties of muscle, including stiffness and elasticity.

Another important point to highlight is that lack of correlation between the clinical measures and the laboratory measures does not necessarily mean that the muscle tests are insensitive to change; it could indicate that, although an intervention has been clinically beneficial in reducing symptoms and improving function, it may not have been effective at treating the muscle impairment.

An example of this possibility was demonstrated by a study of targeted multifidus exercises compared with medical treatment in acute lower back pain, which found that muscle wasting did not recover without exercises but that symptoms resolved in both the treatment group and the control group. The multifidus and abdominal muscle thickness measures were related see Figure 2 , as expected from the literature, 47 but there is very limited evidence available on the predictive value of ultrasound muscle thickness measurements.

The Myoton and axial trunk rotation devices both provide indications of muscle tone state of tension and so might be expected to show similar findings. However, there were insufficient data from the trunk rotation device to enable their comparison at this stage. The Myoton observations are novel as research on the technology is in the relatively early stages.

Myoton parameters relate to proprioception and muscle thickness measures. The axial rotation test is also relatively new, with limited existing literature on the test.


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Muscle strength gives an indication of functional capacity and testing is commonly used in back pain studies but relies on volition. Maximal effort can be affected by pain or fear of pain and so the lack of effect of interventions on trunk muscle strength may have been influenced by the methodology.

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Furthermore, maximal effort was not confirmed by twitch interpolation electrical stimulation, for practical reasons. Turn recording back on. National Center for Biotechnology Information , U. Show details Efficacy and Mechanism Evaluation, No. Search term. Chapter 5 Discussion. Strengths and limitations This study is the first to assess a week course of Alexander technique lessons, to provide some comparison with a tailored group physiotherapy exercise class regime, to explore both the possible benefits of combining Alexander technique lessons and physiotherapy exercises and also possible biomechanical markers of recovery.

Feasibility outcomes Several methods of recruitment were piloted: opportunistic recruitment in surgery i. Feasibility of laboratory biomechanical tests All tests proved feasible although we had limited data from the axial tone testing device as it broke down and required a new part. Mechanisms of treatment effects during recovery The hypothesised effects of treatment were related to proposed mechanisms. Sensitivity and predictive value of assessment tools for later studies The graphical CHAIN model at 6 months see Figure 2 and Tables 19 and 20 indicates that the most predictive measures of the primary outcome at 6 months and other laboratory measures were proprioception, parameters of muscle mechanical properties measured using the MyotonPRO device and muscle thickness measurements using USI.

This work was produced by Little et al. 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. Chapter 5, Discussion. In this Page. Other titles in this collection.

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The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5
The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5
The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5
The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5
The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5
The Back Pain Choice: Chapter 5 The Back Pain Choice: Chapter 5

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