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(1) The Alexander technique offers long-term relief for back pain
(2) Study shows improved quality of life for older women on HRT

(1) The Alexander technique offers long-term relief for back pain
(Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain)
http://www.bmj.com/cgi/content/abstract/337/aug19_2/a884
(Editorial: Conservative non-pharmacological treatment for chronic low back pain)
http://www.bmj.com/cgi/content/short/337/aug19_2/a974

Alexander technique lessons in combination with an exercise programme offer long-term effective treatment for chronic back pain, according to a study published on BMJ.com today.

Back pain causes more disability than almost any other condition in Western societies, but very few effective long-term treatments are available to patients.

Previous research shows that the Alexander technique* and massage may help relieve back pain in the short-term, but little is known about the long-term outcomes.

A team of researchers from the University of Southampton and the University of Bristol compared the effectiveness of massage, exercise and the Alexander technique for the relief of back pain over one year.

Professor Little and colleagues recruited 579 patients with chronic or recurrent back pain from 64 general practices in the south and west of England. Patients were randomised to receive normal care, massage, six Alexander technique lessons, or 24 Alexander technique lessons. Half of the patients from each of the groups were also prescribed an exercise programme (brisk walking for 30 minutes per day five times a week).

Patients were sent disability questionnaires at three months and one year to record which activities were limited by their back pain. For example, walking more slowly than usual or getting out of the house often.

The authors found that after one year, exercise combined with lessons in the Alexander technique significantly reduced pain and improved functioning whereas massage offered little benefit after three months.

After one year of Alexander technique lessons, patients reported fewer days with back pain over the past four weeks. Patients receiving normal care reported 21 days of back pain, compared to those who received 24 lessons of Alexander technique who experienced 18 fewer days of pain. Those who had six lessons reported 10 fewer days of pain and those having massage said they had seven fewer days of pain.

In addition, patients receiving Alexander technique lessons reported improved quality of life.

Interestingly, six one-to-one lessons in the Alexander technique followed by exercise had nearly as much benefit (72%) as 24 lessons in the Alexander technique alone.

The researchers conclude that: "Massage is helpful in the short term…[but] the Alexander technique retained effectiveness at one year…the results should apply to most patients with chronic or recurrent back pain."

In an accompanying editorial, Professor Maurits van Tulder from VU University in the Netherlands, says that exercise therapy has also been shown to be effective for chronic lower back pain and calls for further research to compare the Alexander technique with different types of exercise.

Notes to Editors:
*The Alexander technique involves a personalised approach to help patients develop lifelong skills for self care to improve postural tone and muscular coordination. It is an educational technique taught to be practiced by patients on their own and is not a form of exercise.

Contacts:
Paul Little, Primary Care Group, Community Clinical Sciences Division, University of Southampton, Southampton, UK
Email: psl3@soton.ac.uk
Editorial: Maurits van Tulder, Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, Netherlands
Email: maurits.van.tulder@falw.vu.nl

(2) Study shows improved quality of life for older women on HRT
(Health related quality of life after combined hormone replacement therapy: randomised controlled trial)
http://www.bmj.com/cgi/content/abstract/337/aug21_2/a1190

New evidence published on BMJ.com today shows that hormone replacement therapy (HRT) can improve the health related quality of life of older women.

HRT guidelines should be reviewed in light of this evidence, say the authors.

Previous research has suggested that HRT can improve general quality of life (the way patients feel or function) and reduce the number and severity of symptoms associated with the menopause, but these studies have used general rather than more sensitive condition specific measures.

Professor Alastair MacLennan and colleagues present the findings on health related quality of life from the WISDOM trial*. The WISDOM trial began in 1999 and aimed to evaluate the long term benefits and risks of HRT in postmenopausal women over 10 years. It randomised 5 692 healthy women aged 50-69 from general practices in the UK, Australia and New Zealand to receive either combined HRT (oestrogen and progestogen) or placebo.

All women were monitored for an average of 12 months, and in addition to the main clinical outcomes of cardiovascular disease, fractures and breast cancer, a detailed assessment of the impact of HRT on quality of life was recorded.

Quality of life was measured using a modified version of the women’s health questionnaire designed to assess physical and emotional components of health such as depressed mood, memory and concentration, sleep problems and sexual functioning, and a symptoms questionnaire.

After one year, the researchers found significant improvements in sexual functioning, sleep problems and vasomotor symptoms (hot flushes and sweats) in the combined HRT group compared to the placebo group.

Significantly fewer women in the HRT group reported hot flushes (9% v 25%), night sweats (14% v 23%), aching joints and muscles (57% v 63%), insomnia (35% v 41%), and vaginal dryness (14% v 19%) than in the placebo group, but more reported breast tenderness (16% v 7%) and vaginal discharge (14% v 5%).

Other menopausal symptoms, depression, and overall quality of life were not significantly different in the two groups.

These results are consistent with the findings of the Women’s Health Initiative and support the conclusion that after one year, women who started taking combined HRT many years after the menopause, experienced reduced hot flushes and night sweats, improved sleep, and less bodily pain, say the authors.

These findings may have important benefits for many symptomatic women, claim the authors, but they caution that the health related quality of life benefits must be weighed against the risk of increased cardiac events, venous thromboembolism and breast cancer.

Notes to Editors:
*The WISDOM trial was halted early when another trial, the Women's Health Initiative (WHI), which also initiated HRT on average 13 years after menopause, found that elderly women taking HRT had more heart attacks than non-HRT users. This was not seen when HRT was initiated near menopause, which is the common time of use.

Contact:
Alastair MacLennan, Department of Obstetrics & Gynaecology, Women's and Children's Hospital, University of Adelaide, AUSTRALIA
Email: alastair.maclennan@adelaide.edu.au

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