Chronic Pain

This is an article by an Alexander student who has since become an Alexander Teacher. Karen began to study the Technique after many years of chronic pain and recurring headaches.  She describes her experience with the Alexander Technique and how it has helped her make changes and different choices that have greatly reduced her pain.

The Alexander Technique and Chronic Pain: A Personal Story and Advice for Teachers

by Karen G. Krueger

Chronic pain can devastate your entire life. It can destroy careers and relationships, and rob you of the enjoyment of everyday life. Even if it does not prevent normal activity, just experiencing pain saps both energy and the ability to be fully present.

Students who come to an Alexander Technique teacher because of pain are likely to be suffering the effects not only of the pain itself, but also of months or years of unsatisfactory conventional treatment.

For example, most doctors have two ideas about how to help: surgery and medication. Surgery does not address many causes of chronic pain. Medication does not always help, either. If it does help, it may have debilitating side effects; and it may be difficult to get because of cost or narcotics control laws. In addition, pain patients sometimes deal with physicians who think they are malingerers or drug addicts. Doctors may tire of patients who do not get better and begin to resent, even dislike them. While this history increases the challenges of teaching students with chronic pain, it also increases the students’ motivation to learn.

This article offers suggestions to Alexander Technique teachers working with students suffering from chronic pain, based on my own experience as a chronic pain patient studying the Technique. I do not wish to suggest that what I have to say holds true in every case. I have found that the truth about my own state of being evolves as I continue to question and explore. What follows is an effort to set forth my beliefs and thoughts, from my own experience, at this moment.

Introduction: My Experiences with Chronic Pain and the Alexander Technique

I first took lessons in the Alexander Technique to help me deal with severe, chronic headaches that were making it impossible for me to continue working as a partner at a large New York law firm. I found the Technique after years of struggling, without success, to solve my problem through conventional medical approaches.

I believe my chronic headaches began as a result of what I did to myself while pursuing a career as a lawyer, in the course of many years of working at a desk and computer for 60–80 hours a week, under conditions of almost constant stress and sleep deprivation. At first the headaches occurred several times a year. Gradually, they became more frequent and increasingly severe, until I was having them several times a month. The pain was so severe that even sitting up produced violent nausea, and movement and conversation were intolerable. These attacks, which struck without warning, lasted anywhere from twelve hours to five days. Eventually, I was in almost constant pain.

I first sought medical help for the headaches when they began to occur every few months. I saw four different neurologists and a pain management specialist, all highly recommended, prominent physicians at major medical centers in New York City. The five doctors gave me three different diagnoses. Some said I had migraines; others said I had tension headaches; later, after the headaches became almost constant, some doctors called them “chronic daily headaches.”

Each doctor made a diagnosis during my first visit and proceeded to prescribe medication according to the established protocol for that diagnosis. When one medication proved ineffective, each doctor had me try another, then another, and then various combinations. Not one doctor was willing to reconsider the initial diagnosis or therapeutic approach when the medications failed. When I questioned this approach, I was told that it was just a matter of finding through experimentation which medications worked. In order to get a fresh perspective, I had to move on to the next doctor. In most cases, the new doctor would tell me the old doctor was completely wrong about the diagnosis, the treatment plan, or both.

I tried dozens of drugs of two types: 1) to stop pain when a headache began and 2) to prevent headaches from occurring. None of the drugs provided lasting relief. In fact, I believe the prophylactic medications may have caused the pain to shift from episodic to nearly constant. The prophylactic medications also caused a wide array of unpleasant and frightening side effects.

After several difficult years of physician-prescribed experimentation, I was in constant pain and unable to work. I was forced to take a disability leave from my job.

Just before my leave, I changed doctors for the fourth time. My new doctor was a pain management specialist who told me that the previous diagnoses––migraines and chronic daily headache––were all wrong. According to him, I had chronic tension headaches with trigger points in my sub-occipital region, and the treatment course that I had been pursuing had actually caused the problem. This seemed reasonable to me, because of a simple demonstration: I went to him when I had a headache, he injected my trigger points with a lidocaine (anesthetic) solution, and the headache went away.

He prescribed a muscle relaxant, a non-steroidal anti-inflammatory drug, and physical therapy. In addition, on my own initiative, I pursued massage, meditation, yoga, and swimming, and I did not use a computer at all. This regimen provided some relief: after several months, I was not in constant pain. But my life still revolved around my attempts to prevent headaches. I was always on the verge of pain, and the severe episodes continued to occur regularly.

During my disability leave, I realized that I had many habits that were either causing the pain or making it worse. However, neither my doctor nor my physical therapists could tell me how to change these habits. I strengthened and stretched my muscles, I arched my back and tucked my chin, I exercised, I “relaxed,” I had my vision checked, I tried to sit up straight, and so forth. But the minute I resumed the type of activities required by my job––even under non-stressful circumstances––the habits kicked back in and triggered the pain. At this point in my journey, I heard about the Alexander Technique from a friend who had taken lessons years before. She lent me Michael Gelb’s Body Learning.1 After reading a few chapters, I knew that I had to try this. The book makes clear that the Alexander Technique teaches how to change the way we habitually react to stress and other stimuli: the very thing I believed I needed to master in order to get better. And it identifies the head-neck-back relationship––the very part of my body that I believed was causing all my problems––as the key to good coordination and easeful movement.

Within a month, I had begun weekly lessons with Jessica Wolf. The learning process that unfolded over the next 15 months was fascinating and much farther-reaching than I had imagined. Unlike everything else I had tried, instead of providing immediate relief that soon diminished or vanished altogether, it resulted in slow, lasting improvements. Instead of requiring me to take time out from everyday activities to undo the damage those activities were causing, I could use it all the time so that normal life was less damaging in the first place. And instead of having debilitating side effects, it was fun and even sometimes exhilarating. Eventually I realized that I wanted to be an Alexander Technique teacher in my post-law life, and enrolled at the American Center for the Alexander Technique (ACAT) in New York.

I wish I could say that my story is like the one we sometimes hear in the Alexander community: a student comes to the Technique with severe pain and, after a course of lessons, is free from pain forever. I do not doubt that this does happen, but it has not happened to me. I still have episodes of severe pain from time to time. However, much has changed:

First, the episodes have become less frequent. My improved use means that I can engage in normal activities, like sitting for a few hours at a time, with much less likelihood of triggering the pain. I am much more aware of my whole self, so that I avoid pushing myself to the point of pain. The episodes that I now experience are not always related to any use issue that I can identify; often, they start when I wake up in the middle of the night with pain.

Second, I no longer react to pain or the threat of pain by bracing, which used to cause radiating pain throughout my head, neck, and back. By inhibiting this reaction and using my directions, I can counteract that pulling in, so that I do not perpetuate and exacerbate the pain through my own instinctive, subconscious reactions. When the pain ends, I feel much better, instead of compressed and shaky for hours.

Third, the pain is now much more localized. I have been on a journey deeper and deeper into my neck and head, shedding outer layers as I go. Now the pain occurs in one specific place near my occiput.

In addition to the dramatic improvement in the frequency and duration of these episodes, I have finally found a doctor who prescribed a migraine medication that eliminates pain when I have a severe attack. Even that is something I found through the Alexander Technique; I sought out this doctor because he is a neurologist who actually recommends the Alexander Technique to his patients and who understands why it helps me.

This doctor saw a pattern that no one else had perceived: he suggested that I do have migraines and that the nausea and vomiting that usually accompany severe pain episodes are a vagal reaction to pain, so that oral medication does not get into my system. He gave me a prescription for an injectable migraine medication. For the first time in the 20 years that I have been suffering headaches, I have something that actually takes away the pain. It is an indescribable relief not to be afraid that at any moment I may be forced to stop all activities and undergo hours or days of suffering.

I was also greatly relieved to be told that there is a component to my pain that is not the result of faulty use. I had reached that conclusion on my own, because it seemed to me that, after all my Alexander Technique training, my use had become much better and I did not know why I could not avoid the disabling pain. My new doctor explained that, like my grandmother, I probably have a genetic condition that causes migraines: nerve signals that are not experienced as pain by most people are interpreted by my brain as pain. I felt validated to know that the pain was not entirely my fault.

I continue to explore ways to improve my condition. The Alexander Technique is invaluable in this process as well. Because of my training, I am able to consider what might help, then try it out, understand whether it is helping or not, use my thinking to enhance what works, and trust that I have real insight into my own condition while still being open to insights from others.

Effects of Chronic Pain on the Psycho-Physical Self

The results of living with chronic pain included, for me:

  • Diminished ability to perceive proprioceptive information;
  • Reflexive bracing of my entire body;
  • Difficulty letting my teacher move the parts of me that hurt (my head and neck);
  • Deep emotional wounds, including fear, guilt, and anger;
  • Strong motivation to learn the Alexander Technique to address habits that I believed were contributing to my pain.

It was years before I was able to understand the connection between my use and the pain. In the meantime, without perceiving what I was doing, I held my whole body, especially my head, neck, and back, rigid in an attempt not to feel the pain. Thus, my lack of awareness of my body led to my pain, and my pain led me to try to block out awareness of my body: truly a vicious cycle.

I became used to having my accounts of my own experience dismissed by physicians. For example, once when I explained to a pain management specialist what I thought was happening in my own body, he replied, “When did you graduate from medical school?” I lost confidence in my doctors, one by one, when they would not reconsider their initial diagnoses, but persisted in advocating approaches that were not working or even making me feel worse. Such experiences can lead to anger, guilt, and difficulty trusting others. I feel lucky that I am not vulnerable to depression; without my in-born happy temperament, I might well have become severely depressed.

For me, the Alexander Technique represented a radically different experience that gradually undid the damage from years of pain. Alexander Technique teachers offer the following rare skills:

  • The ability to truly listen to and observe their students;
  • A willingness not to know, to continue to question and explore;
  • A practical way to unlearn harmful habits that contribute to pain;
  • Their own example of poise and competence in the face of life’s difficulties.

——————–

STUDY ON CHRONIC BACK PAIN

Scroll down to read responses from participants in this study.  They are individuals who were living with different forms of chronic back pain, and in many instances had tried other things and received advice from friends and family members….

Family Practice Advance Access published December 23, 2009

Family Practice 2009; 0:1–7 Ó The Author 2009. Published by Oxford University Press. All rights reserved. doi:10.1093/fampra/cmp093 For permissions, please e-mail: journals.permissions@oxfordjournals.org.

Patients’ views of receiving lessons in the Alexander Technique and an exercise prescription for managing back pain in the ATEAM trial

Lucy Yardleya,*, Laura Dennisona, Rebecca Cokera, Frances Webleyb, Karen Middletonb, Jane Barnettb, Angela Beattiec, Maggie Evansc, Peter Smithd and Paul Littleb

aCentre for Applications of Health Psychology, School of Psychology and bPrimary Care Group, Community Clinical Sciences Division, University of Southampton, Southampton, cAcademic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol and dDepartment of Social Statistics, University of Southampton, Southampton, UK. *Correspondence to Lucy Yardley, School of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK; E-mail: l.yardley@soton.ac.uk.

Received 13 February 2009; Revised 6 November 2009; Accepted 30 November 2009.

Background. Lessons in the Alexander Technique and exercise prescription proved effective for managing low back pain in primary care in a clinical trial.

Objectives. To understand trial participants’ expectations and experiences of the Alexander Technique and exercise prescription.

Methods. A questionnaire assessing attitudes to the intervention, based on the Theory of Planned Behaviour, was completed at baseline and 3-month follow-up by 183 people assigned to lessons in the Alexander Technique and 176 people assigned to exercise prescription. Semi-structured interviews to assess the beliefs contributing to attitudes to the intervention were carried out at baseline with14 people assigned to the lessons in the Alexander Technique and 16 to exercise pre- scription, and at follow-up with 15 members of the baseline sample.

Results. Questionnaire responses indicated that attitudes to both interventions were positive at baseline but became more positive at follow-up only in those assigned to lessons in the Alexan- der Technique. Thematic analysis of the interviews suggested that at follow-up many patients who had learned the Alexander Technique felt they could manage back pain better. Whereas many obstacles to exercising were reported, few barriers to learning the Alexander Technique were described, since it ‘made sense’, could be practiced while carrying out everyday activities or relaxing, and the teachers provided personal advice and support.

Conclusion. Using the Alexander Technique was viewed as effective by most patients. Accept- ability may have been superior to exercise because of a convincing rationale and social support and a better perceived fit with the patient’s particular symptoms and lifestyle.

Keywords. Attitude, complementary therapies, exercise, low back pain, patient acceptance of health care, qualitative research.

Introduction

In a recent clinical trial of management of back pain in- primary care (the ‘ATEAM trial’1), a series of lessons in the Alexander Technique resulted in substantial reductions in pain, maintained for one year. The Alex- ander Technique is a self-care approach that facilitates the recognition and understanding of harmful habits of muscle use and enables people to avoid them. Teachers employ specialized hand contact, integrated with verbal explanation, to help individuals learn to attend to head poise and lengthening of the spine, in a way that facilitates normal postural tone, balance and

coordination. In the ATEAM trial, the Alexander Technique was compared with a GP prescription of ex- ercise followed up by behavioural counselling from a nurse. The exercise prescription resulted in significant but smaller reductions in pain, while the combination of a series of six Alexander Technique lessons followed by the exercise prescription was nearly as effective as 24 Alexander Technique lessons alone.

Qualitative and quantitative process studies of pa- tients’ experiences of interventions can offer valuable insights into why these may or may not be effective.2 It is known that psychosocial factors influence the out- come of management for back pain; for example,

variability in the effectiveness of interventions that re- quire patients to undertake physical activity may be partly due to poor adherence.3–5 The questionnaire sur- vey and qualitative study presented here were nested within the ATEAM trial in order to evaluate patients’ beliefs and experiences that may have influenced moti- vation, adherence and hence trial outcomes.

The analysis below focuses principally on the Alex- ander Technique, as this proved the most effective, and we are aware of no previous research on patients’ views of this method of managing their back pain. For comparison, we examined patients’ views of the exer- cise intervention, which has parallels with being taught the Alexander Technique since both interventions re- quired patients to actively engage in self-management of their back problem. As a theoretical framework for evaluating patients’ views of the interventions, we em- ployed the Theory of Planned Behaviour (TPB),6 which has been used successfully to identify and assess the beliefs and attitudes predicting health behaviours,7 including adherence to exercise-based rehabilitation programmes.8 In a mixed methods design, we used a questionnaire to assess the key elements of the TPB in a large sample and interviews to gain a more detailed understanding of the beliefs and experiences that shaped patients’ attitudes and intentions.

Methods

The trial within which these studies were nested was carried out between 2002 and 2004 in the South and West of England; full details are reported elsewhere.1

Questionnaire study

The items in the TPB questionnaire were constructed by standardized methods,7 using two 7-point scales to mea- sure each of the key elements of the TPB. For each in- tervention, respondents indicated: how helpful/harmful and useful/useless it would be (attitude); whether people important to them would think that it would be helpful/ useful (subjective norm); how easy/difficult and simple/ hard it would be (perceived behavioural control) and how likely/unlikely they were to carry out the interven- tion (intention). Baseline alpha coefficients for sub- scales assessing each construct ranged from 0.89 to 0.93.

The TPB questionnaire was administered by post at baseline and 3-month follow-up together with other measures used in the trial. It was completed at both time-points by 183 people assigned to lessons in the Alexander Technique (63.5% of the trial sample) and 176 people assigned to exercise prescription (61.5% of the trial sample). Characteristics of respondents and non-respondents did not differ significantly (see Table 1), using independent t-tests for continuous variables and chi-square tests for dichotomous variables.

There was a very skewed distribution of responses on the TPB scales that could not be corrected by transfor- mation, and so we dichotomized the scores into those scoring <12 vesus >12 (attitude, subjective norm and intention) and <10 versus >10 (perceived behavioural control). To examine change on these scales between baseline and 3-month follow-up, we used the McNemar Q-test.

Interview study

We purposively recruited patients from each interven- tion arm by phone, including men and women of vary- ing ages and levels of initial pain; none refused to be interviewed. The analyses presented here are of inter- views with 24 people, 14 of whom had been assigned to lessons in the Alexander Technique and 16 to exer- cise prescription (6 participants had been assigned to both interventions). These comprised 11 men and 13 women, with an age range of 31–61 years, and base- line Roland–Morris scores9 ranging from 4 to 21. Baseline interviews were completed before the partici- pants started the intervention. Follow-up interviews were completed 3 months later with 15 members of the baseline sample (nine had received Alexander Technique lessons and nine had done exercise); one patient interviewed at baseline declined to be re-inter- viewed, and eight could not be contacted or were un- available for interview within the timeframe available.

The interview schedule was designed to elicit beliefs relating to each construct in the TPB (see Box 1). In- terviews lasting 20–60 minutes were carried out by non-clinical interviewers in participants’ homes and were tape-recorded and transcribed verbatim.

A thematic analysis10 was carried out by two of the authors, using both deductive and inductive approaches

TABLE 1 Baseline characteristics of trial participants who did and did not complete the TPB questionnaire

Alexander Technique lessons

Exercise prescription

Number of men (% of sample) Number of women (%)
Mean age (SD)
Mean Roland-Morris score (SD)

Respondents

61 (33.3) 122 (66.7) 46.08 (10.48)

10.84 (5.20)

Non-respondents

116 (29.3)

280 (70.7) 45.22 (10.58) 10.99 (4.98)

Respondents

52 (29.5) 124 (70.5) 46.27 (9.40) 10.69 (4.88)

Non-respondents

125 (31.0)

278 (69.0) 45.15 (11.00) 11.05 (5.12)

TABLE 2 TPB ratings at baseline and 3-month follow-up in patients randomized to exercise prescription and lessons in the Alexander Technique

BOX 1 Baselineinterview schedule

Questions to elicit behavioural beliefs
Do you have any ideas about (intervention)?

Prompts: have you done anything similar before?

Can you tell me about it?
How do you feel about doing (intervention)?

Prompts: what do you think will be the good things about do- ing (intervention)?

What do you think might be the bad things about doing (in- tervention)?

Questions to elicit normative beliefs
What have you heard about (intervention) from other people?

Prompts: family, friends, health care professionals, media. What do you think about what you have heard?

Does this affect how you feel about doing the (intervention)? In what ways?

How do your friends and family feel about the (intervention)? Prompts: do they think it’s a good thing or a bad thing?

Do their opinions of the (intervention) affect the way you see the (intervention)?

Questions to elicit control beliefs

How easy do you think it will be to fit the (intervention) into your daily life?

Prompts: do you think you may have any problems carrying out (intervention)?

Do you think there are any ways you might overcome these problems?

What things do you think might help you to carry out (intervention)?

Note: at follow-up the same questions were slightly rephrased to ask about their experiences of the intervention.

Exercise prescription Attitude

Subjective norm Perceived behavioural control
Intention

Alexander Technique lessons

Attitude
Subjective norm Perceived behavioural control
Intention

Baseline (%)

76 (43.2) 75 (42.6) 89 (50.6)

76 (43.2)

90 (49.2) 89 (48.6) 95 (51.9)

101 (55.2)

3 months Chi-square P (%)

Perceived behavioural control scores were lower; around half the sample indicated that it would be ‘quite’ or ‘extremely’ easy to carry out the intervention.

At 3-month follow-up, there was very little change in attitudes and perceived behavioural control in the exer- cise arm. Intentions to carry out exercise were slightly but not significantly lower. Attitudes to the Alexander Technique became significantly more positive, although paradoxically intentions to carry it out were slightly lower. The questionnaire responses were therefore examined separately in those randomized to 6 and 24 Alexander Technique lessons (Table 3). Positive atti- tudes to the Alexander Technique increased most in those randomized to 24 lessons, whereas intentions to carry it out dropped in those who had completed their lessons.

Expectations described at baseline interviews

Most themes were common to some people in each of the interventions (see Box 2). In terms of behavioural beliefs, before starting the intervention, most patients had cautiously positive expectations. Few hoped for a complete cure but many were desperate to attain some degree of pain relief. Patients also sought insight into how to prevent or manage episodes of back pain better:

I don’t think it will cure the pain but I think it will, hopefully, help to ease it. That’s what I’m hoping for. And at least make me, I’m hoping that, you know, if I’m doing things wrong it will correct it. (Participant 0401, ATX6 and EP)

Results

Quantitative changes in attitudes and intentions

In both intervention arms, initial attitudes and intentions were favourable; >40% of the sample gave at least one top rating of seven, indicating that they considered that the intervention would be ‘extremely helpful’ and that they were ‘extremely likely’ to carry it out (see Table 2).

TABLE 3 TPB ratings at baseline and 3-month follow-up in patients randomized to 6 or 24 lessons in the Alexander Technique

I went for like an assessment with somebody lo- cally where they sort of explained that the Alex- ander technique was to do with moving in a better way, you know, holding your body in a better way and possibly sort of improving pos- ture and getting up and sitting down and not sort of putting a strain on different parts of your body. And it did all sound, it did all seem to make sense. (Participant 0202, ATX24)

Before starting the intervention, the main antici- pated problem with completing the intervention (i.e. control belief) was concern that it could be difficult to fit into their lifestyle, but most patients expressed de- termination to find a way to do so. With regard to nor- mative beliefs, the views of family, friends and even professionals were described as mainly positive, but not necessarily reliable or influential:

Anything, anything, yes, do it! Shut up and do it and stop moaning! . . . No, they encourage me to do anything. (Participant 0107, EP)

I wouldn’t be swayed by anybody else because what I have learnt is what works for somebody doesn’t work for somebody else… So you’ve just got to try it I think. (Participant 0401, ATX6)

Experiences described at follow-up interviews

At 3-month follow-up, many patients, especially those who had learned the Alexander Technique, reported varying levels of pain reduction. Some people de- scribed immediate and striking easing of back pain af- ter carrying out the technique. However, due to the fluctuating nature of symptoms it was sometimes diffi- cult to be certain of whether and why pain was getting better or worse. Many people therefore described a process of coming to conclude that it could prevent or partially relieve pain (behavioural beliefs):

I generally feel better after doing it. I have had very little back trouble recently which I think must be due in part to the Alexander technique. (Participant 0103, ATX24)

I would say it was pretty much approaching half way [through the course] before I was convinced it was doing any good. (Participant 0202, ATX24)

With regard to control beliefs, many obstacles to ex- ercising were reported, including lack of free time or suitable opportunities, bad weather, cost and lack of social support. Some enjoyable experiences of exercise were reported, but exercise was often viewed as un- pleasant or difficult to keep up:

I have tried all sorts of things. I have tried striding on my way to work, but I carry a case so that is not very good for my back. Also I get very hot

Alexander Technique (6 lessons)

Attitude
Subjective norm Perceived behavioural control
Intention

Alexander Technique (24 lessons)

Attitude
Subjective norm Perceived behavioural control
Intention

worth trying even when expectations for benefit were not great:

I’ve got nothing to lose and hopefully a bit to gain so, yeah, I mean both my daughters turned round and said it’s a good thing and I thought well I’ll give it a try. So if it does help, in any way, even if it helps 25% that’s still 25% better so that’s the way I’m going to look at it. Anything is a bit of a bonus really. (Participant 0101, ATX6)

An important factor was the opportunity to try something new since previous attempts to relieve back pain had generally proven unsuccessful:

It must be something different than what I’ve had … —I’m hoping it’s going to help more because it’s something different. (Participant 0207, ATX6)

Previous experience of exercise had resulted in some scepticism. Although some people welcomed support to try it again, others reported past problems with exercise and wanted reassurance that the type of exercise prescribed would not make the pain worse:

I was doing the exercises—the wrong ones. Not the ‘Mind Your Back’ ones, the ones more keep fit, kind of. I hurt my back even more then. I mean it was one of those days when perhaps I should have taken it easier than I did. So it is worth doing those exercises that are designed for people with my problems. (Participant 0304, EP)

In contrast, using the Alexander Technique was typi- cally seen as a gentle and appropriate way of relieving strain on the back:

Pre-intervention expectations

Expected outcomes of doing intervention (behavioural beliefs)

Opportunity to try something positive, hopeful or desperate for improvement, nothing to lose since not harmful

Partial or total pain relief—generally modest expectations

Other benefits e.g. resume normal activities, relax/loosen muscles, reduce medication, weight loss (exercise)

Improve coping/prevention for the future—learn better posture/ movement (Alexander Technique lessons), build strength in back

Increase pain temporarily or aggravate back condition

Expected attitudes of others (normative beliefs)

Others believe the intervention is worth trying, could be benefi- cial—mainly family and friends

Expected ability to carry out recommended activities (control beliefs)

Might be difficult to find time or opportunities

Time required not great, flexible lifestyle provides opportunities, determined to find time

Post-intervention experiences

Outcomes experienced

Partial or total pain relief (mainly Alexander Technique lessons)

Other benefits, especially reduced tension in muscles/back (mainly Alexander Technique lessons)

Improved coping/prevention for the future (mainly Alexander Technique lessons)

Increased pain—temporary or persistent

Doubts about intervention effectiveness, appropriateness

Experienced attitudes of others

Family and friends generally supportive or neutral

Experiences of ability to carry out recommended activities

Difficult to find time or opportunities (mainly exercise prescription)

Was able/determined to find time

The Alexander Technique is difficult to master—requires extended time, expert supervision

Note: if a theme was found mainly or solely in one intervention group this is noted in brackets.

and feel sweaty and that is not a good way to start the day. (Participant 0204, EP)

[Interviewer: How easy has it been to fit the pre- scription exercise into your daily life?] . . . A night- mare! There is a cre`che at the gym but that is £3.75 an hour and . . . by the time my husband gets home in the evening, there isn’t any time to get to the gym. (Participant 0206, ATX24 and EP)

Many fewer barriers to learning the Alexander Technique were described. Although it was not always possible to find somewhere to lie down undisturbed, many of the techniques could be practised while carry- ing out normal activities:

Often in the day if I am in the office just sitting in the chair and I sit back, and I stretch my back and my neck muscles, which you can quite easily do once you know the technique. (Participant 0101, ATX6)

Additional aspects of the Alexander Technique val- ued by patients (behavioural beliefs) included the hands-on care, emotional support and detailed advice provided by the teacher and the opportunity to relax and take time for oneself:

I must admit I was apprehensive, I didn’t know what I was going into. But once she started to talk to me, explained—even then it didn’t make sense. But once she started to work on me, and then af- ter the second one, which I kind of knew what I was going into, everything just seemed to click to- gether and it all made sense of what she was tell- ing me, of what I should be doing …Half an hour, no dogs, no kids, no nothing, on my own. I put some music on, I have some nice chill out moods, and I put that on. I just lay there for half an hour and concentrate getting my whole body into alignment. (Participant 1006, ATX6 and EP)

Part of what is nice about it, is that when you go to your Alexander teacher you have got 30 or 40 minutes, or however long a session is of time where they are totally focused on you. My teacher L, L is really, really lovely so she will always say ‘How has your week gone?’ (Participant 0202, ATX24)

Many people felt that learning the Alexander Tech- nique had improved their ability to prevent back pain in the future. However, many also said that learning it was initially difficult and could not be accomplished quickly or without a teacher:

I think unless you have been to classes and had a teacher it is hard really to get an understanding. I did read books about it, one was given to me by the Alexander teacher. But the books wouldn’t mean much to somebody who wasn’t having les- sons with a teacher. (Participant 0103, ATX24)

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