This Article


Creative Commons License
Except where otherwise noted, this work is licensed under Creative Commons Attribution-NonCommercial 4.0 International License.

Alexander Technique Training Coupled With an Integrative Model of Behavioral Prediction in Teachers With Low Back Pain

1 Department of Health Education, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran
2 Physical Medicine and Rehabilitation, Army University of Medical Sciences, Tehran, IR Iran
3 Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
4 Department of Biostatistics, Tarbiat Modares University, Tehran, IR Iran
5 Rehabilitation Faculty, Tehran University of Medical Sciences, Tehran, IR Iran
*Corresponding Author: Mohammad Ali Morowatisharifabad, Research Training Complex of Imam Reza, Behdasht Faculty, P.O. Box: 89165887, Yazd, IR Iran. Tel: +98-2536240691, Fax: +98-2536238555, E-mail: morowatisharif
Iranian Red Crescent Medical Journal. 18(9): e31218 , DOI: 10.5812/ircmj.31218 | PMID: 28144457 | PMCID: PMC5253206
Article Type: Research Article; Received: Jul 2, 2015; Revised: Jul 15, 2015; Accepted: Jul 29, 2015; epub: Aug 9, 2016; collection: Sep 2016


Background: Individuals suffering from chronic low back pain (CLBP) experience major physical, social, and occupational disruptions. Strong evidence confirms the effectiveness of Alexander technique (AT) training for CLBP.

Objectives: The present study applied an integrative model (IM) of behavioral prediction for improvement of AT training.

Methods: This was a quasi-experimental study of female teachers with nonspecific LBP in southern Tehran in 2014. Group A contained 42 subjects and group B had 35 subjects. In group A, AT lessons were designed based on IM constructs, while in group B, AT lessons only were taught. The validity and reliability of the AT questionnaire were confirmed using content validity (CVR 0.91, CVI 0.96) and Cronbach’s α (0.80). The IM constructs of both groups were measured after the completion of training. Statistical analysis used independent and paired samples t-tests and the univariate generalized linear model (GLM).

Results: Significant differences were recorded before and after intervention (P < 0.001) for the model constructs of intention, perceived risk, direct attitude, behavioral beliefs, and knowledge in both groups. Direct attitude and behavioral beliefs in group A were higher than in group B after the intervention (P < 0.03).

Conclusions: The educational framework provided by IM for AT training improved attitude and behavioral beliefs that can facilitate the adoption of AT behavior and decreased CLBP.

Keywords: Alexander Technique; Educational Model; Low Back Pain

1. Background

Chronic low back pain (CLBP) is a public health problem in many countries. Individuals suffering from CLBP experience major physical, social, mental, and occupational disruptions. The effects of low back pain (LBP) include the loss of physical functions, deterioration of general health, and constant or episodic pain (1). LBP is the primary cause of disability for individuals under 45 years of age, the second most common reason for physician visits, and the third most common diagnosis for surgery (2). Approximately 85% of LBP problems are nonspecific in that the pain is not attributable to a recognizable pathological cause, neurological problem, or anatomical defect (1).

Iran is similar to other countries in which LBP is considered to be a health and socioeconomic problem (3). It ranks third for cause of disability adjusted life-years in people aged 15 to 69 years (4). The general categories of risk factors for LBP are individual (genetics, gender, age, height, weight, body mass index (BMI), physical activity, spinal mobility, and smoking); psychosocial (stress, anxiety, and depression); and occupational (heavy lifting, pushing and pulling, repetitive work, statistical posture and vibration, keeping the head in a forward position for long periods, awkward postures such as trunk flexion with or without rotation, combined trunk flexion, and manual lifting frequent trunk bending).

School teachers as an occupational group contain a high prevalence of musculoskeletal disorders (MSD) at between 40% and 95% (5, 6). Factors such as sex, age, work experience, awkward posture, repetitively holding one position for a long time, and a head-down posture (as when reading, grading papers, and writing on a blackboard) are related to the high prevalence of MSD in teachers (7, 8). In occupational settings, educational programs can effectively decrease the incidence of LBP (9). Because CLBP is a multifactorial phenomenon in terms of etiology, approaches considered for treatment include medication, injections, physical therapy, behavioral therapy, manipulation, biofeedback, electromyography, traction, transcutaneous electrical nerve stimulation, orthotics, acupuncture, and spa therapy (4, 10). Strong evidence indicates there is no single therapy that is effective for patients with CLBP; therefore, most patients with CLBP are managed using various interventions having uncertain scientific evidence of effectiveness (11).

The Alexander technique (AT) (12) is a self-care method to consciously alter habitual postural behavior and appears to be helpful for postural coordination (13). AT reduces unnecessary tension and elongates the spine in what has been referred to as the head-neck-back relationship using hand contact integrated with verbal explanation (14).

A randomized controlled trial in 2008 revealed that AT courses have long-term benefits for LBP and are more effective than massage and exercise (15). The effectiveness of AT training for CLBP has been proven (16). This technique is non-pharmacologic and is a complimentary treatment prone to fewer adverse reactions than drug treatments (17). In health education, the provision of knowledge only is not sufficient to change behavior, thus, understanding potential intermediate factors that may lead to successful behavioral changes is also important (18). Theory-based interventions can motivate people to change their attitudes and behaviors (19).

Psychological factors such as perceived risk of prolonged problems, self-efficacy, and behavioral beliefs, which form part of the theory of reasoned action (TRA), are considered during the management of CLBP (20). The integrative model (IM) is a combination of the theory of planned behavior (TPB), TRA, and other existing models and theories that have been suggested by Fishbein (21). IM creates a framework for understanding, predicting, and changing a behavior. This model consists of constructs such as attitude, normative beliefs, perceived behavioral control, and behavioral intention. In addition, it recognizes that environmental constraints, skills, and abilities can moderate the intention-behavior relationship. This model has predicted behavioral intention for fruit and vegetable consumption, cancer self-examination, cancer screening, smoking cessation, and behaviors related to AIDS prevention (22-26). TPB has been applied to hand hygiene habits, heavy lifting, proper and safe posture (27, 28), diet, exercise (29), the use of an elevator to transport patients, and self-management of rheumatoid arthritis (18).

2. Objectives

Theory-based intervention can motivate people to change their attitudes and behaviors; however, AT training has not been associated with health education models thus far. The present study was designed and implemented to assess the effect of the design of AT lessons based on IM among female teachers in southern Tehran, Iran.

3. Methods

This was a quasi-experimental study of female elementary teachers with nonspecific LBP in two governmental educational districts in southern Tehran, Iran. The study was carried out from January to December 2014. The districts were selected randomly and were assigned to either group A (AT based on IM) or group B (AT only) by simple randomization. The eligible participants were initially selected by purposive sampling or case findings using specialist prepared checklists and visiting primary schools in the two districts, then referring to physical medicine and rehabilitation specialists for confirmation of the medical diagnosis.

Inclusion criteria were being female, experiencing non-specific CLBP persisting for more than 90 days or recurrent LBP, and an agreement to take part in the study. Exclusion criteria were having a history of malignancy, infection in the vertebral column, vertebral fractures, spinal surgery, confirmed osteoporosis, severe postural deformity, congenital abnormality of the spine, confirmed spondylolysis, and an inability to walk more than 100 meters. Further exclusion criteria were having confirmed rheumatoid arthritis, referring pain to the legs, numbness or pins and-needles feelings in the feet or toes, difficulty in walking on the toes and heel, positive straight leg rising (SLR) test in 70 angles, morning stiffness lasting more than 30 minutes, no pain reduction after resting, and pregnancy. Patients with a low back complaint that had persisted less than 90 days were also excluded. Initially, 86 subjects were determined to be eligible and recruited. Following their diagnosis in the final review, 42 subjects in group A and 35 in group B participated in the intervention program. Program drop-outs all cited conflicting class schedules; however, no subjects dropped out as a result of the intervention.

3.1. Sample Size

The sample size was calculated as 30 subjects in each group considering α = 5%, a statistical power of 90%, (moderate effect size), and the following formula:

Considering a 15% drop up sample, we added five samples in the optimal sample size; thus, we considered 70 samples in total.

3.2. Study Instruments

An elicitation study was conducted to design the IM construct questionnaires about AT by preparing a semi-structural questionnaire based on a literature review (30). A total of 15 eligible teachers from the target group were interviewed about the pros and cons of applying AT, their attitudes toward AT, and environmental constraints. Content analysis was used to label the themes according to the IM constructs.

The design of the self-report AT questionnaire based on IM was prepared using the results of the elicitation study. They were confirmed by a content validity ratio (CVR), content validity index (CVI), face validity, and Cronbach’s α. To evaluate the CVR, 11 specialists reviewed the questionnaire and expressed their recommendations on the necessity of every item. The Lawshe table was used to determine a score of 0.96 after items with CVR values of less than 0.59 were eliminated.

Specialists evaluated each CVI item for relevancy, clarity, and simplicity. After eliminating items with CVI values of less than 0.79, the score was determined to be 0.91. To determine face validity, the opinions of 25 eligible teachers from the target group concerning the intelligibility and clarity of items were applied. The internal consistency of the questionnaire was evaluated using a Cronbach’s α of 0.80. The design and grading of the IM construct questions were consistent with the Fishbein approach (21, 31). The 41-item AT questionnaire included demographic data, generalized intention, knowledge, attitude, behavioral beliefs, perceived risk, and perceived environmental constraints.

The inquiries were rated on a 1 to 7 Likert scale (7 = “I strongly agree” to 1 = “I strongly disagree”), except for the questions about knowledge, which offered true-false or “do not know” responses. Table 1 shows the IM constructs and sample CVI, CVR, Cronbach’s α, and attributable range for each construct. The validity and reliability of the Persian version of the Roland-Morris disability questionnaire has been confirmed (32). A visual analog scale questionnaire was also employed (33).

Table 1.
CVR, CVI, Cronbach’s Α, Sample IM Construct Questions, and Attributed Range

3.3. Educational Plan

Introduced AT books and DVDs by David Stuart Moore, director of the Australia AT School, were translated under the supervision of professors to produce a 90-page book in simple language (ISBN: 9786009434428) and a CD on the inhibition and directions for rehearsals. These were provided to both groups. The group instructors were the researcher (a Ph.D. candidate in health education), a specialist in physical medicine and rehabilitation, and a physiotherapist. The intervention plan in group A was based on the IM constructs, intervention mapping book (34), and related references (29). Group A had five sessions (AT based on IM) and group B had three sessions (AT only) that were taught. The common educational program between the two groups included: AT origin, concepts and principles, introducing and rehearsing inhibition and direction, chair work, and the application of AT in daily activities. Box 1 shows the methods and techniques used for AT training in group A.

Box 1.
Intervention Plan for Group A

The Helsinki codes were observed and the Ethics Committee of Shahid Sadoughi University of Medical Sciences, Yazd, Iran approved the survey. Oral consent was obtained in both groups. Educational authorities of Tehran city authorized us to visit schools and to hold AT sessions and also provided on-the-job training (OJT) certification for participants in both groups.

3.4. Statistical Analysis

All data were analyzed by the Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc., Chicago, IL, USA). Results for continuous variables are expressed as mean ± SD. Categorical variables are shown as a frequency (percent). For statistical analysis, parametric (independent and paired-samples t-test, univariate generalized linear model [GLM] [α = 0.05]) analyses were used to compare response variables according to the two groups. Also, chi-square and Fisher’s exact tests were used to compare proportions between the two groups.

4. Results

The 77 assessed teachers were divided into two groups. Group A (42 patients) attended AT training based on IM and group B (35 patients) attended AT training only. The mean age of the patients was 42.15 ± 6.19 years (range: 27 - 58 years). Married patients (77.9%) formed the majority of the study population. It was found that 49.4% of teachers had taken action to cure their backaches before the beginning of the survey; 21.5% had visited a doctor for CLBP while durance of LBP was 3.80 ± 4.21. Table 2 shows the basic demographic characteristics and the status of LBP in the subjects, and Table 3 shows the other matching variables. The results for the t-tests and χ2 tests showed no statistically significant differences between groups for baseline data (P > 0.05). The mean scores of the IM constructs at the commencement of the study are shown in the first column of Table 4. The t-tests showed no baseline differences between groups with regard to these constructs.

Table 2.
Demographic Characteristics of Attendeesa

Table 3.
Matching Variablesa

Table 4.
The Mean Scores of the IM Constructs

Table 5 shows the views of all participants concerning the environmental constraints. As seen, 60% believed there were no regulations in the ministry of education for standardized furniture and equipment for teachers, and 52 subjects (65.8%) believed there were no standardized furniture and equipment in schools. Furthermore, 16 subjects (20.3%) believed that nonstandard domestic equipment and furniture in their homes made back care more difficult.

Table 5.
Absolute and Relative Frequency of Environmental Constraintsa

The improvements in groups A and B immediately post-intervention were strongly significant for all constructs (P < 0.001). In group A, the univariate GLM test revealed significant improvements for the constructs of direct attitude (P = 0.03) and behavioral beliefs (P = 0.03).

5. Discussion

This semi-experimental study investigated the effect of the design of AT lessons based on IM in teachers with LBP. The results show that, although improvements were seen in all IM constructs in both groups right after the interventions, the results for the constructs of direct attitude and behavioral beliefs were greater for group A than for group B. The design of the AT training based on IM significantly improved these two constructs over the results for AT alone; this indicates that the IM strengthened the AT training. Yardley (30) found that at 3 months post intervention, attitude and perceived behavioral control for the 24-session AT group had improved and surpassed those for the 6-session group. In the present study, the possibility of improvement at 3 months post-intervention in scores for group A with IM constructs should be further investigated.

The importance of these findings is that group A participants showed more positive attitudes. This improvement in attitude and behavioral beliefs could relate to the different techniques used to improve attitude, such as verbal encouragement and persuasive SMSs. The techniques used to increase the other IM constructs might also have provided a new and interesting teaching method.

This is an important finding because a meaningful relationship has been found between attitudes and primary beliefs and intentions (26). Additionally, moderate to high changes in intentions have been found to result in mild to moderate changes in behavior (35). Bleakley (36) revealed that attitude, normative beliefs, and self-efficacy predict 54% of intention variance and that attitude was the most important predictor. An increase in positive attitude has been found in response to AT over prescribed exercises (30), which is consistent with the results of the present study. Reddy (37) reported that participants reported greater skill, less pain, and better posture after six 45-minute AT training sessions.

The mean pain and disability for teachers was 5.17 ± 1.49 and 6.25 ± 4.28, respectively. Only 49.4% of teachers had taken action to cure their backaches before the beginning of the survey, which indicates a general lack of focus on personal health. Moreover, just 21.5% had visited a doctor for CLBP. Mannion (38) found that not all people suffering from LBP sought medical care for their problem; this trend increases the probability of pain and disability and a consequent decline in work efficiency as well as high absenteeism. Undoubtedly, health authorities should focus on the health of the teachers in addition to that of the students in terms of MSD, especially for LBP.

It was found that 76.6% of teachers stated that there are no regulations for use of standardized furniture from the Ministry of Education. Moreover, 66.2% of teachers believed that there was no standardized furniture for teachers in schools. It appears that the main concerns of teachers focused on suitable and standard furniture. Janbozorgi (39) reported that the main disorder caused by muscle and spinal problems is backache and confirmed that the use of standardized equipment in schools decreased the incidence of spinal disorders, especially LBP. Van Niekerk (40) found that all subjects having different working positions experienced less back pain after the use of standardized chairs. Proper equipment and standardized chairs are considered important accompaniments for AT to improve upright posture (41).

More attention to this issue is recommended and investment in ergonomically-correct furniture could be facilitated by the sponsorship from corporations and charities. Studies have found that intention does not predict behavior unless it is accompanied by a supportive environment (26). To improve the effectiveness of AT principles, it is suggested that a supportive environment be taken into consideration in addition to familiarization with AT.

These results highlight the utility of IM-based intervention and the explicit use of the behavioral model to design AT sessions to promote the adoption of and adherence to AT; this will also improve the cost effectiveness of AT. Lessons for AT that are carried out in several sessions with an experienced teacher may not be economically feasible in developing countries. However, our results suggest that IM-based intervention using printed materials about AT combined with methods to increase the knowledge, intention, attitude, and risk perception of participants can be useful in this situation. Hollinghurst explained that if AT training is accompanied by exercise, it is more cost effectiveness than AT training alone (42).

Although this data and analysis is useful in practice, it has limitations. First, the data is self-reported and subjective; thus, it may be less accurate. Second, the present study was performed on a small scale and more comprehensive research must be planned to evaluate both short-term and long-term benefits of incorporating IM into AT training. AT is an acceptable alternative in Iranian culture when the instructor is compatible with the class participants.


The authors wish to thank the authorities of Yazd University of Medical Sciences for their financial support. We also extend our appreciation to Dr. David Stuart Moore, Dr. Ebrahimi, the Director of the Iran Physical Therapy Association, Dr. Mohammad Kamali, Dr. Tavafian, Dr. Hassan Okati, Dr. Leila Sabzmakan, the authorities at the ministry of education, the teachers and managers of school districts 15 and 19 in Tehran, and to all those who helped us in this research.


Authors’ Contribution: Tahereh Kamalikhah performed the intervention, Mohammad Ali Morowatisharifabad supervised this project, Farid Rezaei-Moghaddam confirmed cases, Mohammad Ghasemi helped to write the content, Mohammad Gholami-Fesharaki analyzed the data, and Salma Goklani taught most of the lessons.
Financial Disclosure: The authors declare there is no conflict of interest.


  • 1. Tavafian SS, Jamshidi A, Mohammad K, Montazeri A. Low back pain education and short term quality of life: a randomized trial. BMC Musculoskeletal Disorders. 2007;8(1) [DOI]
  • 2. Noori S, Ghasemi GH, Khaiambashi K, Karimi A, Minasian V, Alizamani S. . Effect of Exercise Therapy and Physiotherapy on Patients with Chronic Low Back Pain (In persian). J Isfahan Medical School. 2011;151:1091-7.
  • 3. Ebadi S, Ansari NN, Henschke N, Naghdi S, Van Tulder MW. The effect of continuous ultrasound on chronic low back pain: protocol of a randomized controlled trial. BMC Musculoskeletal Disorders. 2011;12(1) [DOI]
  • 4. Nezhad Roomezi S, Rahnama N, Habibi A, Negahban H. The effect of core stability training on pain and performance in women patients with non-specific chronic low back pain (In persian). J Res in Rehabilitation Sci. 2012;1(1):57-64.
  • 5. Erick PN, Smith DR. A systematic review of musculoskeletal disorders among school teachers. BMC Musculoskeletal Disorders. 2011;12(1) [DOI]
  • 6. Chong EYL, Chan AHS. Subjective Health Complaints of Teachers From Primary and Secondary Schools in Hong Kong. International J Occupational Safety Ergonomics. 2015;16(1):23-39. [DOI]
  • 7. Chiu TT, Lam PK. The Prevalence of and Risk Factors for Neck Pain and Upper Limb Pain among Secondary School Teachers in Hong Kong. J Occupational Rehabilitation. 2006;17(1):19-32. [DOI]
  • 8. Horng YS, Hsieh SF, Wu HC, Feng CT, Lin MC. Work-related musculoskeletal disorders of the workers in a child care institution. J Phys Med Rehabil. 2008;36(1):15-21.
  • 9. May S. Self-management of chronic low back pain and osteoarthritis. Nat Rev Rheumatol. 2010;6(4):199-209. [DOI]
  • 10. Nachemson AL, Waddell G, Norlund A. Epidemiology of Neck and Low Back Pain. Philadelphia: Lippencott Williams & Wilkins; 2004.
  • 11. Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P. Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life. Spine J. 2003;3(4):270-6. [DOI]
  • 12. Cacciatore TW, Gurfinkel VS, Horak FB, Cordo PJ, Ames KE. Increased dynamic regulation of postural tone through Alexander Technique training. Human Movement Sci. 2011;30(1):74-89. [DOI]
  • 13. Cacciatore TW, Horak FB, Henry SM. Improvement in automatic postural coordination following alexander technique lessons in a person with low back pain. Phys Ther. 2005;85(6):565-78.
  • 14. Cacciatore TW, Gurfinkel VS, Horak FB, Day BL. Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique. Gait & Posture. 2011;34(4):496-501. [DOI]
  • 15. Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. Bmj. 2008;42(12):565-8. [DOI]
  • 16. Woodman JP, Moore NR. Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review. Int J Clinic Pract. 2012;66(1):98-112. [DOI]
  • 17. Ehrlich GE. Alexander technique lessons were effective for chronic or recurrent back pain at 1 year. Evid Based Med. 2009;14(1):13. [DOI]
  • 18. Safari M, Shodjaiezadeh D, Ghofranipoor F, Heydarnia AR, Pakpour HA. Theories, models and methods of health education and health promotion. Tehran: Sobhan; 2009.
  • 19. Mc Clendon BT, Prentice Dunn S. Reducing Skin Cancer Risk: An Intervention Based on Protection Motivation Theory. J of Health Psychology. 2001;6(3):321-8. [DOI]
  • 20. Foster NE, Thomas E, Bishop A, Dunn KM, Main CJ. Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care. Pain. 2010;148(3):398-406. [DOI]
  • 21. Fishbein M. A Reasoned Action Approach to Health Promotion. Med Decis Making. 2008;28(6):834-44. [DOI]
  • 22. Bleakley A, Hennessy M, Fishbein M, Jordan A. How Sources of Sexual Information Relate to Adolescents' Beliefs About Sex. Am J Health Behav. 2009;33(1):37-48. [DOI]
  • 23. Hughes AK, Rostant OS, Curran PG. Improving Sexual Health Communication Between Older Women and Their Providers: How the Integrative Model of Behavioral Prediction Can Help. Research on Aging. 2013;36(4):450-66. [DOI]
  • 24. Buhi ER, Goodson P, Neilands TB, Blunt H. Adolescent Sexual Abstinence: A Test of an Integrative Theoretical Framework. Health Educ Behav. 2011;38(1):63-79. [DOI]
  • 25. Hennessy M, Bleakley A, Fishbein M, Brown L, DiClemente R, Romer D, et al. Differentiating Between Precursor and Control Variables When Analyzing Reasoned Action Theories. AIDS Behav. 2009;14(1):225-36. [DOI]
  • 26. Uhrig JD, Davis KC, Rupert D, Fraze J. Behavioural precursors and HIV testing behaviour among African American women. Health Education J. 2010;71(1):102-14. [DOI]
  • 27. Fogarty GJ, Shaw A. Safety climate and the Theory of Planned Behavior: Towards the prediction of unsafe behavior. Accid Anal Prev Vet Med. 2010;42(5):1455-9. [DOI]
  • 28. Kudo Y, Satoh T, Kido S, Watanabe M, Miki T, Miyajima E, et al. A Pilot Study Testing the Dimensions of Safety Climate among Japanese Nurses. Ind Health. 2008;46(2):158-65. [DOI]
  • 29. Milne S, Orbell S, Sheeran P. Combining motivational and volitional interventions to promote exercise participation: Protection motivation theory and implementation intentions. British J Health Psychol. 2002;7(2):163-84. [DOI]
  • 30. Yardley L, Dennison L, Coker R, Webley F, Middleton K, Barnett J, et al. Patients' views of receiving lessons in the Alexander Technique and an exercise prescription for managing back pain in the ATEAM trial. Family Practice. 2009;27(2):198-204. [DOI]
  • 31. Rahmati Najarkolaei F, Niknami S, Amin Shokravi F, Tavafian SS, Gholami Fesharaki M, Jafar M. R. . Sexual behavioral abstine HIV/AIDS questionnaire: Validation study of an Iranian questionnaire. J Edu Health Promot. 2014;3(10):777-80.
  • 32. Mousavi SJ, Parnianpour M, Mehdian H, Montazeri A, Mobini B. The Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale: Translation and Validation Studies of the Iranian Versions. Spine. 2006;31(14):454-9. [DOI]
  • 33. Rezvani AM, Sirati NM, Ebadi A, Moradian T. The correlation between MPQ and VAS in patients with choronic low back pain(In persian). J Qom Uni Med Sci. 2012;6(1):31-4.
  • 34. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion program An Intervention Mapping Approach. 1 ed. Sanfrancisco CA: Jossey Bass; 2006.
  • 35. Webb TL, Sheeran P. Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychol Bull. 2006;132(2):249-68. [DOI]
  • 36. Bleakley A, Hennessy M, Fishbein M, Jordan A. Using the Integrative Model to Explain How Exposure to Sexual Media Content Influences Adolescent Sexual Behavior. Health Educ Behav. 2011;38(5):530-40. [DOI]
  • 37. Reddy PP, Reddy TP, Roig Francoli J, Cone L, Sivan B, De Foor WR, et al. The Impact of the Alexander Technique on Improving Posture and Surgical Ergonomics During Minimally Invasive Surgery: Pilot Study. J Uro. 2011;186(4):1658-62. [DOI]
  • 38. Mannion AF, Wieser S, Elfering A. Association Between Beliefs and Care-Seeking Behavior for Low Back Pain. Spine. 2013;38(12):1016-25. [DOI]
  • 39. Janbozorgi A, Karimi AK, Rahnama N, Karimian R, Ghasemi GA. An ergonomic analysis of musculoskeletal disorder risk in tutors by Quick Exposure Check (QEC) method and the effect of 8-week selective corrective exercises and ergonomic intervention on their encounter.(In persian). J Res Rehabil Sci. 2012;8(5):919-27.
  • 40. Van Niekerk SM, Louw QA, Hillier S. The effectiveness of a chair intervention in the workplace to reduce musculoskeletal symptoms. A systematic review. BMC Musculoskelet Disord. 2012;13(13):145. [DOI]
  • 41. Cranz G. The Alexander Technique in the world of design: posture and the common chair. Journal Of Bodywork and Movement Therapies. 2000;4(2):90-8. [DOI]
  • 42. Hollinghurst S, Sharp D, Ballard K, Barnett J, Beattie A, Evans M, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation. Bmj. 2008;337(112):2656. [DOI]

Table 1.

CVR, CVI, Cronbach’s Α, Sample IM Construct Questions, and Attributed Range

IM Constructs and Sample Questions CVR CVI Cronbach’s Α Attribute Range
Generalized intention (4 questions): I intend to apply AT principles to daily activities. 1 1 0.88 4 - 28
Knowledge (11 questions): Position of the head on the spine plays no role in LBP. 0.92 0.97 0.81 (-3.63) - 11
Attitude (8 questions): Difficult↔Easy (bipolar adjectives). 1 0.98 0.88 8 - 56
Behavioral belief (7 questions): AT improves LBP without taking drugs. 0.92 0.97 0.79 7 - 49
Perceived risk (6 questions): LBP decreases work output. 0.78 0.97 0.78 6 - 42
Perceived environmental constraints (5 questions): No rules exist in the education ministry about standardized furniture. 0.86 0.92 0.67 5 - 35
TOTAL 0.91 0.96 0.80

Box 1.

Intervention Plan for Group A

Techniques Used to Increase Perceived Risk
Teaching methods: lectures. Equipment: photos, video projector. Fear arousal, anticipated regret, scenario-based risk information.
Techniques Used to Increase Knowledge
Teaching methods: lectures, demonstrations, questions and answers (Q and A).Equipment: photos, video projector, chair, desk, mirror, pillow, bed, model of the spine, book. Chunking (example): head forward and up, torso lengthened and widened, legs release away, shoulder out to the side, advance organizer, elaboration, create cues.
Techniques Used to Shape or Change Attitudes
Teaching methods: lecture, Q and A, group discussion, role playing. Equipment: photos, video projector, SMS. Direct experience: self-reevaluation. Persuasive communication: verbal encouragement, persuasive SMS, social comparison and modeling, repeated exposure (reminder SMS every week, installation of posters in the classroom and corridor of the institute, two reminders to install in the home), anticipated regret, one-sided messages (up to the third session), two-sided messages (after the third session).
Techniques to Improve Perception of Environmental Constraints and Change Environment
Teaching methods: lecture, Q and A. Equipment: photos, video projector. Advocacy, change system, training in problem solving.
Techniques to Change Habitual Behavior
Teaching methods: lecture, Q and A. Equipment: photos, video projector, posters, SMS. Implementation intentions, early commitment, modeling, stimulus control, environmental clues, attribution.

Table 2.

Demographic Characteristics of Attendeesa

Matching Variables Group A Group B P Value
Age 42.59 ± 5.85 41.62 ± 6.62 0.49
Work experience 19.30 ± 6.61 18.82 ± 6.49 0.75
BMI 27.79 ± 3.97 27.94 ± 3.71 0.87
Roland-Morris score 5.66 ± 4.1 7.06 ± 4.44 0.157
Pain score 5.25 ± 1.53 5.06 ± 1.53 0.57
Duration of LBP 3.21 ± 3.6 4.6 ± 4.8 0.16
Marital status 0.88
Married, No. (%) 34 (75.6) 28 (82.4)
Single, No. (%) 11 (24.4) 6 (17.6)
Education 0.48
AA degree, No. (%) 24 (54.5) 14 (43.8)
High school diploma, No. (%) 16 (36.4) 16 (50.0)
MS degree, No. (%) 4 (9.1) 2 (6.3)
a Values are presented as mean ± SD unless otherwise indicated.

Table 3.

Matching Variablesa

Matching Variables Group A Group B P Value
Yes No Yes No
Any treatment 18 (42.9) 23 (54.8) 20 (57.1) 13 (37.1) 0.11
Going to doctor 7 (16.7) 35 (83.3) 9 (25.7) 26 (74.3) 0.224
Resting 4 (9.5) 38 (90.5) 3 (8.6) 32 (91.4) 0.634
Standard shoes 0 (0) 42 (100) 2 (5.7) 33 (94.3) 0.203
Diet 0 (0) 42 (100) 2 (5.7) 33 (94.3) 0.203
Pain relief pills 5 (11.9) 37 (88.1) 2 (5.7) 33 (94.3) 0.298
Swimming pool 3 (7.1) 39 (92.9) 3 (8.6) 32 (91.4) 0.571
Take care 1 (2.4) 41 (97.6) 3 (8.6) 32 (91.4) 0.224
Physiotherapy 2 (4.8) 40 (95.2) 0 (0) 35 (100) 0.294
Walking 1 (2.4) 41 (97.6) 1 (2.9) 34 (97.1) 0.706
Exercise 7 (16.7) 35 (83.3) 6 (17.1) 29 (82.9) 0.596
Increasing class focus 5 (11.9) 37 (88.1) 2 (5.7) 33 (94.3) 0.29
Meditation class 1 (2.4) 41 (97.6) 2 (5.7) 33 (94.3) 0.431
Time management 3 (7.1) 39 (92.9) 2 (5.7) 33 (94.3) 0.587
Yoga 2 (4.8) 40 (95.2) 2 (5.7) 33 (94.3) 0.620
Relaxation 2 (4.8) 40 (95.2) 2 (5.7) 33 (94.3) 0.620
Related classes 3 (7.1) 39 (92.9) 0 (0) 35 (100) 0.157
a Values are presented as No. (%).

Table 4.

The Mean Scores of the IM Constructs

Evaluated IM Constructs Before, Mean± SD After, Mean± SD P Value Between Groups
Direct attitude 0.03
Group A 34.37 ± 1.105 51.31 ± 1.05 < 0.001
Group B 32.771 ± 0.547 47.87 ± 1.21 < 0.001
P value 0.20 0.001
Behavioral beliefs 0.03
Group A 30.13 ± 4.83 44.67 ± 0.81 < 0.001
Group B 28.55 ± 2.27 41.89 ± 0.94 < 0.001
P value 0.59 < 0.001
Intention 0.41
Group A 17.666 ± 0.587 23.10 ± 0.35 < 0.001
Group B 16.857 ± 0.487 22.65 ± 0.40 < 0.001
P value 0.11 0.49
Knowledge 0.48
Group A 1.320 ± 0.260 8.87 ± 0.339 < 0.001
Group B 0.850 ± 0.213 8.50 ± 0.391 < 0.001
P value 0.31 0.18
Perceived risk 0.09
Group A 29.13 ± 1.198 36.82 ± 0.906 < 0.001
Group B 28.50 ± 1.450 34.47 ± 1.042 < 0.001
P value 0.92 0.49
Environmental constraints 0.86
Group A 26.166 ± 0.911 26.52 ± 0.91 0.90
Group B 26.000 ± 1.004 26.25 ± 1.11 0.85
P value 0.90 0.85

Table 5.

Absolute and Relative Frequency of Environmental Constraintsa

Environmental Constraints Completely Disagree Disagree Disagree to Some Extent No Idea Agree to Some Extent Agree Completely Agree
Education ministry lacks rules for standardized furniture 1 (1.3) 1 (1.3) 1 (1.3) 10 (13) 1 (1.3) 4 (5.2) 59 (76.6)
Place available in school to lie down and rest back muscles during break time 35 (44.5) 2 (2.6) 4 (5.1) 8 (10.4) 7 (9.1) 1 (1.3) 20 (26)
Standardized furniture and footrests in school 51 (66.2) 2 (2.6) 7 (9.1) 3 (3.9) 3 (3.9) 2 (2.6) 12 (15.6)
Sufficient and standardized seats in transportation service 38 (46.8) 8 (10.4) 1 (1.3) 13 (16.9) 4 (5.2) 4 (5.2) 11 (14.3)
Lack of standardized domestic equipment and furniture 30 (39.0) 7 (9.1) 7 (9.1) 9 (11.7) 3 (3.9) 6 (7.8) 15 (19.5)
a Values are presented as No. (%).