Preliminary evidence for feasibility, efficacy, and mechanisms of Alexander technique group classes for chronic neck pain

Highlights

• Ten adults with chronic neck pain attended ten group Alexander technique classes.

• A multiple-baselines design was used to assess regression to the mean.

• Power spectral density from sternocleidomastoid was used to assess neck fatigue.

• Post-intervention, subjective pain and objective fatigue were lower and correlated.

• Benefits were maintained five weeks after classes ended.

Abstract

Objectives

To determine feasibility and potential of Alexander technique (AT) group classes for chronic neck pain and to assess changes in self-efficacy, posture, and neck muscle activity as potential mechanisms for pain reduction.

Design

A single-group, multiple-baseline design, with two pre-tests to control for regression toward the mean, a post-test immediately after the intervention, and another post-test five weeks later to examine retention of benefits. Participants were predominately middle-aged; all had experienced neck pain for at least six months.

Intervention

Participants attended ten one-hour group classes in AT, an embodied mindful approach that may reduce habitual overactivation of muscles, including superficial neck muscles, over five weeks.

Outcome measures

(1) self-reports: Northwick Park Questionnaire (to assess neck pain and associated disability) and Pain Self-Efficacy Questionnaire; (2) superficial neck flexor activation and fatigue (assessed by electromyography and power spectral analysis) during the cranio-cervical flexion test; (3) posture during a video game task.

Results

There were no significant changes in outcomes between pre-tests. All participants completed the intervention. After the intervention: (1) participants reported significantly reduced neck pain; (2) fatigue of the superficial neck flexors during the cranio-cervical flexion test was substantially lower; (3) posture was marginally more upright, as compared to the second pre-intervention values. Changes in pain, self-efficacy, and neck muscle fatigue were retained at the second post-test and tended to be correlated with one another.

Conclusions

Group AT classes may provide a cost-effective approach to reducing neck pain by teaching participants to decrease excessive habitual muscle contraction during everyday activity.

Introduction

Neck pain is the 4th leading cause of disability in the U,¹ with annual global prevalence around 26%.² Possible causes include poor postural alignment and inefficient distribution of muscle activity. Support for a connection between neck pain and postural alignment comes from studies showing that people with neck pain may tend to habitually carry their heads forward from their spines (called forward head posture),3, 4, 5 and that forward head posture increases loading on neck muscles.6, 7, 8 Support for the connection between neck pain and inefficient neck muscle organization comes from studies showing increased activation of the superficial sternocleidomastoid muscles in patients with neck pain, along with an inverse relationship between activation of sternocleidomastoids and activation of deep cervical flexors responsible for support of the cervical spine.9, 10 This can be seen clearly in performance of the cranio-cervical flexion test (CCFT), which involves gently flexing the neck while lying supine.¹⁰

Successful treatment of neck pain by exercise has been associated with decreased activation of the sternocleidomastoids during the CCFT, thought to indicate an appropriate commensurate increase in activation of deep cervical flexors.¹¹ However, exercise programs can be time consuming, people suffering from pain may find exercise aversive, and compliance may be low.12, 13, 14 In addition, a recent meta-analysis suggests that exercise may not be as effective for neck pain-related disability as previously thought.¹⁵ Therefore, development of an effective non-exercise program that addresses patterns of neck muscle activity could provide an alternative for individuals who are unwilling or unable to participate in exercise programs targeting neck pain, while shining additional light on mechanisms underlying neck pain and recovery.

One possible alternative to exercise is embodied mindfulness education. Results of studies investigating the effectiveness of education for neck pain have not been encouraging.16, 17 However, ineffective studies have not included information or skills known to be important to musculoskeletal rehabilitation, such as how the spine functions and how to practically apply this knowledge to daily activities.¹⁸

Alexander technique is a non-exercise-based embodied mindfulness approach that aims to improve overall patterns of postural muscle organization by teaching people to observe and inhibit habitual patterns of reaction while maintaining an intention of length and integration.19, 20, 21, 22 Importantly, AT principles and skills are meant to be applied in everyday activities, rather than being tied to particular exercises. In a recent randomized controlled trial, 20 one-to-one AT lessons led to reduced neck pain and increased self-efficacy compared to usual care, with higher self-efficacy associated with lower neck pain scores one and seven months after lessons were completed.²³ This is a promising result; however, one-to-one lessons may be cost-prohibitive for some people. AT is often taught in groups.24, 25, 26 but the present study is the first to examine the feasibility or efficacy of AT group classes for people with neck pain. If group classes in AT lead to reduce neck pain and improve pain self-efficacy (as was found for one-to-one lessons), this could provide a cost-effective intervention.

The present study also investigated three possible mechanisms by which learning and applying the AT might reduce neck pain. If changing postural alignment is an important AT mechanism, the AT intervention should lead to reduced forward head posture, associated with reductions in pain. If AT alters patterns of postural muscle activation by inhibiting excessive contraction of superficial muscles, leading to more efficient overall self-organization of skeletal muscles,27, 28, 29, 30 the intervention should lead to decreased sternocleidomastoid activation and fatigue during CCFT, associated with decreased neck pain. If AT alters coordination through increased understanding, awareness, and ability to choose more comfortable posture and movement patterns, the group AT intervention should lead to increased self-efficacy.