Angela Beattie

Randomised controlled trial of Alexander Technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain. Design Factorial randomised trial. Setting 64 general practices in England. Participants 579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription. Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling. Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain. Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage −0.58, 95% confidence interval −1.94 to 0.77, six lessons −1.40, −2.77 to −0.03, 24 lessons −3.4, −4.76 to −2.03, and exercise −1.29, −2.25 to −0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score −2.98 and −4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons −18, six lessons −10, massage −7) and quality of life improved significantly. No significant harms were reported. Conclusions One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons. Trial registration National Research Register N0028108728. How does the Alexander Technique work? What are the authors findings about the clinical and cost effectiveness of the treatment? Watch this video to find out (12 mins). 10.1136/bmj.a884V1

Primary care patients' expectations and experiences of online Cognitive Behavioural Therapy for depression: a qualitative study

Objective  To explore expectations and experiences of online cognitive behavioural therapy (CBT) among primary‐care patients with depression, focusing on how this mode of delivery impacts upon the therapeutic experience.

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation

Objective An economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain. Design Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial. Participants 579 patients with chronic or recurrent low back pain recruited from primary care. Interventions Normal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse. Main outcome measures Costs to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves. Results Intervention costs ranged from £30 for exercise prescription to £596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from £50 for 24 lessons in Alexander technique to £124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value (£61 per point on disability score, £9 per additional pain-free day, £2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional £64 per point on disability score, £43 per additional pain-free day, £5332 per QALY gain). Conclusions An exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above £20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option. How does the Alexander Technique work? What are the authors findings about the clinical and cost effectiveness of the treatment? Watch this video to find out (12 mins). 10.1136/bmj.a2656V1

‘They don't quite fit the way we organise our services’—results from a UK field study of marginalised groups and dementia care

The accessibility of dementia services to two groups of marginalised service users (people under 65 years of age and people from minority ethnic groups) was examined as part of a UK field study. In 61 interviews with a purposeful sample of professionals and paid carers in dementia care, the main issue in service access related to the small numbers of potential service users and their geographical dispersal. Other issues reflected those faced by people with dementia in general. At present, it seems as though decisions on care are based mainly on financial considerations and perceptions of the risk and dangerousness posed by people with dementia. These findings are linked to broader debates within the social model of disability about the need to address issues relating to people with learning impairments.

‘What ever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study

Objective  Individuals who have had one diabetic foot ulcer (DFU) are at high risk for developing further DFUs. This study was designed to examine the emotional and behavioural consequences of living with this heightened risk of re‐ulceration.

OP36 Evaluating youth mentoring for young people at risk of exclusion from secondary school: results from a feasibility randomised control trial study

Background Youth mentoring is used with vulnerable young people to help improve their health, well-being and educational attainment. While there is growing interest in mentoring programmes among policy makers and practitioners the evidence base is weak with no randomised control trial (RCT) yet undertaken in the UK. The aim of this study was to assess the feasibility and acceptability of conducting a definitive RCT of the effectiveness and cost effectiveness of the Breakthrough Mentoring programme targeted at secondary school students who are at risk of exclusion from school. Methods Thirty-one young people were approached and twenty-one were recruited to the feasibility study. Participants were aged 12–16 years (mean age = 14.10 years) and randomised to either receive weekly 2-hour mentoring sessions for one academic year (n = 11, intervention) or care as usual (n = 10, control). Participants were asked to complete self-reported questionnaires on a range of measures including the Strength and Difficulties Questionnaire, which were analysed descriptively. Qualitative interviews were conducted with participants and with parents, schools staff, mentors and commissioners as part of the process evaluation. Interviews were facilitated using a topic guide, were audiotaped, transcribed verbatim and analysed thematically. Results Follow-up at 6 and 12 months was 100% and 86% for 18 months. Participants were happy to complete the self-report questionnaires, showed a good understanding of randomisation and were accepting of this study design. Control group participants reported wanting a mentor and some were mildly upset at not achieving this. Intervention group participants indicated that having an adult mentor, unconnected with the school that they could talk to about their problems helped them to give voice to and deal with difficult feelings. Some mentees reported negative experiences of the way that the mentoring relationship ended. The process evaluation showed that the study design and intervention were acceptable to parents, mentors, schools and commissioners. A need for further evidence on the effectiveness of mentoring was highlighted by commissioners, and parents and schools staff expressed a wish to be informed of progress made by mentees during mentoring sessions. Conclusion It is feasible and acceptable to recruit, randomise and retain students at risk of exclusion from school to an RCT for 6, 12 and 18 month follow-up. Further research is required to characterise youth mentoring in schools in the UK and to investigate how to best measure its effectiveness before a definitive trial can be considered.