# Alexander Technique vs. Targeted Exercise for Neck Pain--A Preliminary Comparison
## 4 Discussion
### Relation to Prior Work  
Previous studies have shown that one-to-one [PERSON] lessons can lead to reductions in knee pain [19], back pain [22], and neck pain [23]. In particular, the ATLAS study, a large RCT of [PERSON] technique for chronic neck pain, found that a series of twenty 30 min lessons reduced NPQ score by about 11%--the same reduction in neck pain/disability that we found after this [PERSON] technique group class [23]. The ATLAS study found an additional decrease in pain 6 months later. The absence of further decline in pain after the course ended in the present study suggests that 10 classes may be enough to immediately decrease neck pain but not enough to instill long-term habits that will promote further improvement. Interestingly, the 4% reduction in NPQ reported for the control group in the ATLAS study is comparable to the result seen here in our exercise group and to the 5% NPQ reduction seen in other brief exercise studies [39]. The retention rate for our group [PERSON] class was also comparable to that seen in one-to-one lessons, with a few people dropping out at the beginning and a very high attendance rate for the remaining students [25]. We also found ratings of class enjoyment similar to those seen in other populations [40; 41]. Converging evidence suggests that group [PERSON] classes are a highly acceptable intervention. The ATLAS study, unlike the present study, found a substantial increase in pain self-efficacy following [PERSON] lessons [39]. This could be due to participant differences (to qualify for the ATLAS study, participants had to score 28% on the NPQ, whereas a score of 16% was sufficient to qualify for the present study), difference between group and one-to-one sessions, the longer duration of the ATLAS class series (20 weeks vs. 5 weeks in the present study), or simply their larger sample size. Considering our finding that participants in the [PERSON] group were more likely than those in the exercise group to report that they learned how their movement habits contributed to their neck pain and to choose different ways to carry themselves, it may be that it takes longer than 5 weeks for that learning to translate into an increase in pain self-efficacy. This explanation is supported by the numerical tendency for self-efficacy to increase between the first and second post-test in the [PERSON] group but not in the exercise group, and by the increasing correlation between NPQ and PSEQ across the three testing sessions. [PERSON] classes led to reduced activation of SCM, a muscle whose overactivation has been implicated in neck pain [13]. This is consistent with our previous study of group [PERSON] work, which found a near-significant reduction in SCM activation. The contrasting increase in SCM activation in the exercise group was surprising. Previous work has found that some exercise programs focusing on training the motor control and coordination of cervical flexors resulted in a decrease in SCM activation during the CCFI, while others had no effect [16; 42]. It is worth noting that exercise programs vary in their content and emphasis. For instance, the program of [PERSON] et al. [16] focused on training the coordination and control of the cervical flexors using constant direct feedback by a physiotherapist, while our program included feedback to participants only during the brief retraining portion of the exercise class. Feedback was only given if the subject was clearly overusing the SCM muscles or performing the exercise incorrectly. This leads to an interesting question about the amount of manual feedback needed to see positive results in patients with neck pain with different interventions. Participants in both groups had minimal individualized attention from the instructor, but only the [PERSON] class led to a reduction in SCM activation, suggesting that the indirect, whole-body approach of the [PERSON] technique may be more effective than the direct, neck-focused approach of the targeted exercise, particularly in a group class context with limited manual contact.