søndag 30. november 2014

Wishful thinking

Edzard Ernst is a leading expert on the research on CAM (complementary and alternative medicine). He writes an entertaining and informative blog which I recommend to anyone interested in this field of research.

Recently he wrote about the Alexander Technique pointing out discrepancies between the claims made by Alexander Technique teachers and the existing scientific evidence. The blogpost had the title Alexander technique: some evidence and plenty of wishful thinking.

The evidence
In his blog Ernst draws on two systematic reviews. A systematic review aims at collecting, evaluating and summarizing the result of all existing research.

"Strong evidence exists for the effectiveness of Alexander Technique lessons for chronic back pain and moderate evidence in Parkinson's-associated disability. Preliminary evidence suggests that Alexander Technique lessons may lead to improvements in balance skills in the elderly, in general chronic pain, posture, respiratory function and stuttering, but there is insufficient evidence to support recommendations in these areas."

"Evidence from RCTs and CTs suggests that AT sessions may improve performance anxiety in musicians. Effects on music performance, respiratory function and posture yet remain inconclusive."

Ernst's conclusion is that:
"So, there you are: if you are a performing artist, AT seems to be useful for you. If you have health problems (other than perhaps back pain), I would look elsewhere for help."

I think it can be said that Ernst's conclusion did not go down well with Alexander Technique teachers.

The claims
Ernst is comparing the existing evidence from research to a list of health claims found on the highest ranking Alexander Technique website on google search, The Complete Guide to the Alexander Technique which says that the Alexander Technique can help you if:
  • You suffer from repetitive strain injury or carpal tunnel syndrome.
  • You have a backache or stiff neck and shoulders.
  • You become uncomfortable when sitting at your computer for long periods of time.
  • You are a singer, musician, actor, dancer or athlete and feel you are not performing at your full potential.
Ernst is a little lenient when saying that the Alexander Technique may be useful for performing artists. The evidence at present only supports helping musicians with performance anxiety, not for improving performance. The claim that the Alexander Technique can help against backache is actually the only claim on this list that at present is backed up by scientific research.

Now, are these claims only 'wishful thinking'?

According to Merriam-Webster Online, wishful thinking is:
"an attitude or belief that something you want to happen will happen even though it is not likely or possible".

Lack of scientific evidence does not in itself justify labelling a claim 'wishful thinking'. It has also got to be unreasonable or unlikely to be true.

If it is reasonable to say that the Alexander Technique can improve quality of movement, then it is not unreasonable to say that it can help performers. If it is reasonable to say that the Alexander Technique can improve body awareness, then it is not unreasonable to say that it can help the office worker. And if it is reasonable to say that the Alexander Technique helps people to "do everyday tasks with less muscular and mental tension", as Ernst himself says in his definition, then it is not unreasonable to suggest that the technique may be of help against stiff neck and shoulders.
For the same reason it can even be said that it is not entirely unreasonable to suggest that the Alexander Technique may give some help to people suffering from repetitive strain injury or carpal tunnel syndrome.

It might seem as if Ernst chose the wrong list for his criticism.

Medical conditions
I think, however, that Ernst raises an important question. In principle I do agree with him. In my view health professionals like Ernst, should as far as possible only give advice based on evidence. When he does not recommend the Alexander Technique, apart for back pain, he is entirely correct in doing so.

What we do as Alexander Technique teachers is a different thing. But we face a challenge: what are reasonable claims and what is 'wishful thinking'?

The Alexander Technique has a long tradition for making unsubstantiated and even unreasonable claims. Alexander himself had the idea that his technique could be of help against tuberculosis and the common flu. Wishful thinking, if there ever were any.

Where should the line go ? This is an ethical question. What do we say to our pupils? What kind of expectation are we entitled to give them?

In Norway the law that regulates CAM says that one is not permitted to claim to treat specific conditions. You may say that you improve breathing, but not that you cure asthma. In light of this I feel it is questionable to have repetitive strain injury and carpal tunnel syndrome on a list claiming health benefits for the Alexander Technique. Explaining the technique in an article and giving a reasonable suggestion for why it might work is slightly different. On lists claiming health benefits I think we generally should avoid listing specific medical conditions.

The easiest solution to the problem of unreasonable claims would be to stop making health related claims entirely. After all, the Alexander Technique is not a therapy, but an educational method. It is unrealistic, however, to believe that Alexander Technique teachers would stop making claims of health benefits. It is part of how most of us are trying to make a living.

The Alexander Technique does have an influence on health anyway, as confirmed by the ATEAM trial. The technique influences health indirectly by improving general use. This also means that there are limitations to the health effects. Even though 'manner of use' will impact most conditions, the influence will vary. In the case of repetitive strain injury, for instance, it could be that managing work load by taking frequent breaks is more important than improving manner of use.

The truth is that we don't know the limitations of the Alexander Technique. There is no agreement either. Walter Carrington, one of the most experienced Alexander Technique teachers in the world, said that it was limited what the technique could do in the case of a 'frozen shoulder'. Despite this there is an abundance of websites on the Alexander Technique claiming that the technique is effective against 'frozen shoulders'.

What is the truth? We don't know. At present we have only anecdotal evidence, and anecdotal evidence is not sufficient for drawing a conclusion.

Faulty sensory appreciation
It should be apparent to any Alexander Technique teacher why anecdotal evidence is not sufficient. Unmasking self delusions is part of our daily work. We do this by making it possible for the pupil to have new experiences of being and moving, so that they can compare the new to their habitual way of doing things.
  • Anecdotal evidence is normally an individual case story. Since it is not compared to cases not having Alexander Technique lessons it is impossible to say whether improvement of for instance a 'frozen shoulder' is due to the technique or not.
  • Conditions tend to improve over time anyway, and, added to that, the Alexander Technique more often than not is not in the first line of treatment. By the time the person comes to us improvement could have been inevitable.
  • When considering the condition it is also possible that the pupil gives a more positive description than warranted because of a subconscious wish to please the teacher. We can in the same way chose to interpret what we hear in the most favourable way.
  • We normally only see the pupil while he/she is taking lessons. This means that we can't tell whether the improvement was permanent or only temporary, or if there was a subsequent deterioration.
  • We are humans and we tend to remember the success stories. To make a real assessment we have to include all the cases where we did not succeed. How often do we do that?
The conclusion must be that for the most part we don't really know how much effect or how large influence the Alexander Technique has on health problems. That the Alexander Technique influences health is a reasonable proposition. Use is bound to affect functioning. We just don't know how much.

If you find information about the Alexander Technique that contains what you consider to be unreasonable claims or 'wishful thinking', you will do the Alexander Technique profession a service by informing the teacher in question about your views, or by taking contact with the relevant professional organisation. It is not in our interest to be seen making unreasonable claims based on 'wishful thinking'.

I have wondered, by the way, if Ernst actually knows quite a lot about the Alexander Technique and that 'wishful thinking' is a pun alluding to the process of thinking 'directions'. Anyway it is quite a fitting expression in several ways I'm afraid. There is quite a lot of 'wishful thinking' going on in the Alexander Technique world. Scientific research will challenge that kind of thinking, and Alexander Technique teachers, like all human beings, are making every possible effort to hold on to their delusions. I'm not that sure that the Alexander Technique profession is up to the challenge posed by scientific research. More about that in my next article.

Please feel free to comment below!

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