a service evaluation of alexander technique for pain clinic patients (seat) … preliminary findings...

A Service Evaluation of Alexander Technique for Pain Clinic Patients (SEAT)…preliminary findings

Dr Stuart McClean, UWE BristolDr Lesley Wye, Bristol University

Background and Context

• Pain Management at St. Michaels Hospital

• STAT Alexander Technique

• Evidence-base context: Little et al. (2008)*

*Little, P. et al. (2008) Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ, 337:a884: 438-452

Evaluation Aims:

• To identify any differences in health status, quality of life, wellbeing, or NHS costs found amongst service users before and after their use of an Alexander Technique (AT) service in the Pain Clinic

• To examine the patients’ experiences of the service, as well as their perspective on the effect of Alexander Technique on changes to their condition

• To explore the experiences of Pain Clinic staff of the benefits and drawbacks of an AT service for patients

Mixed methods approach• Outcomes evaluation (BPI, EQ-5D, MYMOP,

CSRI-cost-effectiveness)

• Impact evaluation (Interviews with patients and pain clinic staff)

• Process evaluation (Interviews with Alexander Technique teachers and pain clinic staff)

Challenges of ‘real world’ evaluation

• Small numbers (preliminary data; n=24). Full data: n=45

• No control group• Referral was not random• Not all participants attended the full number of

sessions.• AT teachers had to distribute and collect

questionnaires as well as provide the intervention• Little information about those who dropped out

MYMOP(initial)

Patient identified outcomes

MYMOP scores

No: of patients

Baseline mean (SD)

6 WK follow-up

mean (SD)

3 month follow-up mean (SD)

Mean change

baseline & 6 week

(SD)

Confidence intervals

Mean change

baseline & 3 mos.

(SD)

Confidence intervals

Symptom 1 24

3.5(1.6)

2.4(1.7)

2.4(1.9)

1.1(0.8)

0.8, 1.91.1

(0.8) 0.8, 1.9

Symptom 2 18

3.7(1.7)

2.4(1.8)

2.0(1.6)

1.3(0.9)

0.9, 1.71.7

(1.2) 1.2, 2.3

Activity 233.6

(1.6)2.0

(1.3)1.9

(1.5)1.6

(1.1) 1.2, 2.1

1.7(1.2)

1.2, 2.2

Wellbeing 242.9

(1.9)1.6

(1.5)1.4

(1.4)1.3

(0.9) 0.9, 1.7

1.5(1.1)

1.1, 1.9

MYMOP profile 22

3.4(0.1)

2.1(0.2)

1.9(0.2)

1.3(0.9)

0.9, 1.71.5

(1.1) 1.0, 2.0

Brief PainInventory (BPI)

Pain severity

Pain interference

General activity

Mood Walking Work Relat-ionships

Sleep Life enjoy-ment

Mean 7 domains

Baseline 4.3 4.5 4.1 5.3 3.9 4.2 4.8 4.6

6 weeks 3.7 3.8 3.2 4.0 3.2 3.8 3.5 3.6

3 months 4.8 4.5 5.4 4.2 5.2 5.0 5.0 4.9

EQ5-D(with VAS)

Quality of life (EQ-5D)

EQ-5D Visual analogue scale

Patients’ accounts: Key findings

• Impact of AT on pain, health and wellbeing– Positive impacts

• Experiences of AT Service– Motivation for taking part– Expectations– Experiences

• Sustainability: barriers to momentum– Continued impact of and relationship to pain– Other strategies– The future

Positive impacts

With the help of ..[AT].. my back has improved a great deal to make my life a lot easier, with the things I’ve been shown and helped with…it was explained in detail and it was carried out in detail and I’ve benefitted from it (126)

Positive impacts: self-awareness/changing directionI mean the best thing for me was you know

what she was showing me with the model, the everyday movements that you do and how much stress it puts on your .. on your back, I don’t think you think about it until she shows you and every time… I know I still do things but every time I do it I always think oh you know I shouldn’t be doing it that way and if I take time then… then um I can do it the right way that she taught me but it did take time to kind of put it, you know, get it into your mind that’s the way of doing it (109)

Motivation and Expectations

There’s not a kind of magic wand, nobody can make everything better and take all the aches and pains away and stuff. So I had before sort of magic bullet expectations that things would be amazingly better overnight, just with a pill or a small tweak of lifestyle, and they weren’t obviously (121)

Experiences: the teacher

I found the practitioner helpful, understanding, intuitive, she was very knowledgeable, she was very helpful...she seemed to be incredibly knowledgeable and as a result of her experience she was intuitive about what I could expect from it (116)

Experiences: ‘student’ not patient

The lady who was doing my sessions puts her own books out and you could sit and browse them while you were waiting. Over the weeks I was reading a couple of chapters, but that sort of gave you a bit of background knowledge as you were going, and she gave pretty comprehensive handouts for us as well, which I found very beneficial…I didn’t know much about it before I went and I thought the handouts backed up and supported the sessions very well (121)

Momentum & Barriers: motivation, space, time and money

When I was actually going to the clinic I did find it quite helpful but not quite so helpful when I was doing it for myself…I did find it much more beneficial when I was hands-on with the lady doing it (122)

So the question then becomes did I want to shell out £35/40 whatever a practitioner costs a week and the answer is of course it’s difficult to have that sort of money to hand (116)

Continued impact of and relationship to pain

…it meant that there was a significant shift in my relationship with my pain…acknowledging that when it’s there I have got a choice to carry on having pain or I could just breathe and relax and let it go and quite often that’s the thing that makes the difference (115)

Other strategies

I’m a very positive person despite the pain (104)

I don’t like taking medication, in fact I’ve stopped a lot of my medication now (108)

I don’t try to take medication, I try to get the pain away by myself (124)

Attitudes towards the future

In order to move forward in my particular case I would need to go and see somebody regularly so that it became part of my habit (116)

Alexander Teacher accounts: key themes

I would say its been a real privilege you know for me to work with um people who perhaps couldn’t afford to have Alexander lessons who couldn’t afford to come and see me in the clinic in Bristol and feeling that in a way that's where I would really like to work with people who can’t access this kind of service and so that's... basically I like helping people to help themselves and that's what I feel I have been able to do here and make a difference to people’s lives…

…it was quite a remarkable, well for me very moving, very, very moving remarkable experience that in six lessons um the principles of the Alexander Technique in very adverse conditions i.e. chronic pain can make... can touch people to that extent that they come out with this, so it makes a real difference. So very, very rewarding and very successful…

Alexander Teacher accounts: challenges

– Time and energy consuming, building up systems and relationships

– Need for fuller understanding of evaluation process– Clarity around roles & responsibilities in new service– Need for realistic costing– Teaching people with extreme chronic pain and other

complex conditions such as anxiety and depression, & social problems

– Adapting to NHS & different relationships with ‘patients’ (not ‘students’) – but also shifting that relationship

– Time periods of sessions, no leeway; 6 sessions too short for complex ‘cases’

Conclusions• AT service appears to have helped participants achieve

and sustain their own goals and well being

• Over time participants' relationship to their pain may change as a result of AT and they become more aware of how pain interferes in their lives

• High patient satisfaction for AT sessions and the 1:1 focus

• Sustaining impact: some struggle with momentum at 3 months suggests need for other strategies

• AT and the NHS: teachers responded flexibly and professionally to a number of organisational challenges

With thanks to…

• Anita Bennett, AT Teacher and Service Lead• Dr Peter Brook, Lead consultant, St. Michaels• Dr Nilish Chauhan, Consultant, St. Michaels• Rachel Molyneaux, Specialist nurse, St. Michaels• Jayne Connell, Psychologist, St. Michaels• Bethan Evans, AT teacher• Anne Lamaar, AT teacher• Gudi Schepokat, AT teacher• Rachel Stevens, AT teacher• Sally Cottrell, APCRC• Louise, Maggie and Janet at St. Michaels

Thank you for listening

Our contact details:

Stuart.McClean@uwe.ac.uk

Lesley.Wye@Bristol.ac.uk