onsdag 24. desember 2014

Same procedure

Same procedure as last year?

Same procedure as every year!


you decide to stop and
think before you act

to make it 

an even better Xmas
and a happier New Year!

søndag 14. desember 2014

Research on health benefits

Health claims from Alexander Technique teachers were recently labelled "wishful thinking" by an expert on research on complementary and alternative medicine (CAM). In the following discussions in social media there were some instances of argumentation not conducive to a constructive debate, something which I described as unwanted "habitual reactions". Most of the discussions, however, were engaging, stimulating thought provoking and instructive. The discussions made me think about the fundamental question: should we bother about research on health benefits? The Alexander Technique is after all an educational method.

Ulterior motives
One of the things that perplexed me in the recent discussions was that there seemed to be an underlying assumption that the reason for doing research on health benefits from the Alexander Technique was for the technique to be 'accepted by science'. Again and again this theme cropped up. I think this is entirely the wrong reason for doing research.

What does 'accepted by science' mean anyway? As I mentioned in my last article I have followed the debate on CAM in recent years. This thing about being accepted seems to be a recurring theme. Alternative health practitioners seem to have a yearning for being accepted, probably because research on CAM for the most part have yielded negative results, so they feel rejected. They haven't really got the hang of how science works. If the hypotheses of claimed health benefits fail the test they have to go somewhere else for acceptance.

I believe there is economical reasons for wanting to be 'accepted by science'. Health claims are made to promote methods of alternative therapies. Promotion is a necessary element of trying to make money to earn a living. This is fair enough, but should not be the main motive for doing research.

The reason for doing scientific research is for gaining knowledge. With a better knowledge about to what extent the Alexander Technique can benefit people healthwise we can give more correct information. This will help people to take more informed decisions.

As an Alexander Technique teacher I seek to be professional. To be professional about health claims I would find it very useful to have some knowledge beyond personal experience and shared anecdotal evidence. There are some questions I would in particular like to have some more clarity in. There are claims of health benefits out there made by Alexander Technique teachers which I think there could be reasons to question.

In the Cochrane database of systematic reviews there is one mention of the Alexander Technique. This is on asthma. Evidently someone have found the claims made on behalf on the Alexander Technique concerning asthma prevalent to such a degree as to be worthy of inspection. As there is yet no research the effects of Alexander Technique on asthma the conclusion in the Cochrane paper is that: "Robust, well-designed randomised controlled trials are required in order to test claims by practitioners that AT can have a positive effect on the symptoms of chronic asthma and thereby help people with asthma to reduce medication."

Another issue I would like to have some more clarity in is the effect the Alexander Technique might have on 'frozen shoulder syndrome' (adhesive capsulitis). As mentioned in the article Wishful thinking, the very experienced Alexander Technique teacher Walter Carrington once said that the technique had limited effect on such conditions. Was he right? And what about the Alexander Technique and trigeminal neuralgia, or what about torticollis or focal dystonia?

There is information on the internet indicating that the Alexander Technique may give help with these conditions. I think it is only natural and right that these claims should be put to the test so that sufferers can have better information about to what extent the Alexander Technique may help.

But to do my work as an Alexander Technique teacher, do I really need to know in detail what conditions the technique can help or not? No, not really.

Should we stop making health claims?
One teacher in the recent discussion concluded that: "Let's just stop making claims. Period. We don't need them". Coming to the Alexander Technique via the field of music making and teaching I have great sympathy with this view. and if possible I think it is also the best position to take.

As Alexander Technique teachers we help people using themselves to their best advantage in anything that they do. Health benefits are incidental. We teach, we don't cure.

The problem is that the claims of health benefits are out there, and we have to deal with them. Putting forward claims of health benefits has been part of the tradition of Alexander Technique teaching during all its history. I think it is unrealistic to believe that the Alexander Technique profession as a whole is going to follow an admonition about stop making claims.

There is also another reason why stop making claims is not realistic, and that is the fact that the Alexander Technique actually give health benefits. The results from the ATEAM trial on Alexander Technique and back pain is a strong indication of this.

It is very natural to point out that the Alexander Technique may have an impact on health. We just have to make sure that it is done in an appropriate manner. I would expect all professional organisations to have some rules about what is appropriate. In addition the practice of Alexander Technique teachers is subject to the laws and regulations of the country of the teacher. I think the regulations in Norway which allows general claims but rules out claims of helping specific conditions gives a good general guideline.

The problem with only making claims of general nature is that it becomes like the claims from anybody else. Have a look at any web site for any 'alternative health method' and you often cannot discern between them. They all give the same promise of general wellbeing. So, maybe claims of health benefits are not, or should not be, our 'unique selling point' anyway?

It could be that the question about what constitute reasonable claims of health benefit is a question that Alexander Technique teachers in general should be more conscious about, and which needs to be discussed more.

Upcoming research
One very important reason for the need to deal consciously and constructively with the research on possible health benefits is that new research is under way. There is no way we can ignore it.

For teachers, who teach performers and who don't focus on health in their advertising or teaching, this may be not that important. But any teacher who has put claims of health benefits on their website and/or advertising material, or who puts forward claims in articles etc, are in my opinion obliged to deal consciously and constructively with information about the Alexander Technique and research on health benefits.

In the recent debate, there were teachers who were very negative towards the article by Edzard Ernst on claims of health benefits from AT teachers, and also negative towards science in general, but who had the information youtube video from the British Medical Journal on the ATEAM back pain trial prominently featured on their website. This is hypocrisy.

Dealing constructively with scientific research does not mean that we should necessarily accept everything. It means we should be able to criticise research without making mistakes like the ones I described in my article about "habitual reactions". This requires some literacy about how science works and about how medical research is carried out. It is not my impression that this kind of literacy is widespread in the he Alexander Technique community.

Defining ourselves
One thing that was striking in the recent discussions on the Alexander Technique and claims of health benefits was that there seemed to be a confusion between research on health effects and research on the mechanisms of the Alexander Technique.

To carry out research on health benefits of the Alexander Technique, it is not necessary to know the working mechanisms. What is necessary is to test something that is a representative version of Alexander Technique teaching. This poses a challenge to the Alexander Technique profession. There is no common definition of the Alexander Technique and no common agreement about what constitutes good quality Alexander Technique teaching. These are questions that themselves could benefit from scientific research.

Regardless of quality there are many different approaches one can take when teaching the technique. This also poses many questions that have to be taken into consideration when performing research on the technique, and which teachers who are involved should be aware of.

Kathleen Ballard, one of the teachers involved with the ATEAM trial, suggested in the article Public Misperceptions in Statnews (January 2008, vol . 6 issue 24), that we should make a distinction between the Alexander Technique itself, and the methods of teaching it, that is, between the skill taught (and used by the Alexander Technique teacher in the process), and the methods of teaching this skill.

This is a distinction not made by Alexander himself. To him it was all 'The Work'. I believe that for us to be clear about what the Alexander Technique is, and what we do as teachers, it is vital that we make this distinction.

A technique for prevention
Some say that the research on health outcomes of the Alexander Technique puts the technique in a too narrow frame. They are correct. But it is not medical research that do this in the first place. It is the AT teachers who put the claims forward.

Alexander himself was adamant that he did not propose a cure. His technique improved general functioning, which in turn would tend to improve health indirectly. We may use the same argument. The problem is that anyone not acquainted with the Alexander Technique will bring their own understanding to it and probably only take it as a promise for a cure. 

Alexander also stressed the importance of prevention. He argued it was prevention in a wider sense, not in the sense the term was used by doctors and others (see beginning of chapter IV, Universal Constant in Living).
Some have suggested that pointing out the possibility of prevention would be more tolerable than making claims of improvement. I think the opposite is the case. Claiming to prevent could be an even more widesweeping claim than promising improvement or relief. And maybe even harder to prove. We would still be making a claim and it would still be reasonable to wish for more than just anecdotal evidence.

To conclude. To practice as teachers we don't necessarily need verification of health effects. The Alexander Technique is an educational method. But as the technique arguably influences health, and health claims are made, the Alexander Technique community should feel an obligation to engage constructively towards the effort of research on health effects. This requires a minimum of knowledge about science and research methods, which the majority in the Alexander Technique community don't have. It also presents a challenge to the Alexander Technique teaching profession in terms of defining quality standards and explaining what we do and why we do it.

Please feel free to comment below!

Related articles:

mandag 8. desember 2014

Habitual reactions

- impressions from discussions on the Alexander Technique and medical research (written with the Alexander Technique teacher in mind)

Alternative therapies have come under scrutiny in recent years, following books like Trick or Treatment by Ernst & Singh. In Norway we have had similar books, and a very popular TV series on the same subject. Since the Alexander Technique is commonly categorised as an alternative therapy I have followed the debate on alternative treatments closely. I have to say that in my opinion practitioners of CAM (complementary and alternative medicine) have difficulties in dealing constructively with criticism.

Some time ago Edzard Ernst, an expert on CAM research, posted an article on his blog where he said that health claims from Alexander Technique teachers mostly were 'wishful thinking'. It was with some apprehension I posted a link to the article on social media. How would Alexander Technique teachers respond?

There was a great variation in responses and interesting discussions followed, but there were also signs of the typical habitual reaction of the average CAM practitioner.

It is not uncommon for CAM practitioners to want to ignore results from scientific research when they don't like them. Several in the Alexander Technique community said we should ignore Ernst's article. This is an ignorant thing to do. Ernst points out the fact that most of the health claims made by Alexander Technique teachers are not backed up by scientific evidence. Ignoring him does not make this fact go away.

Others claimed that Ernst was the ignorant, saying that as he had no experience of the Alexander Technique, he would ''not know what he was talking about''. I hope we Alexander Technique teachers aren't that bad at explaining the technique in words. You don't need first hand experience of the technique to assess research papers. The only caveat I would put down is that you have to understand that the Alexander Technqiue is something you learn. This understanding you can get from reading about the technique.

Someone commenting on Ernst's blog asked him if he had taken lessons, and if so, what his experiences were. Clearly, the person asking is ignorant about how science works. Ernst's experiences, or lack of experiences, changes absolutely nothing about the state of research on health benefits from the Alexander Technique. Even if Ernst had had lessons in the technique, and found them valuable, he could still have had the opinion that Alexander Technique teachers exaggerates their claims.

Some even answered Ernst's critique with the 'argument from ignorance', an example of fallacious argumentation. They said that lack of proof of effect didn't prove that the Alexander Technique doesn't have health effects. They also said that Ernst, if he disagreed, was free to disprove it. Yet another fallacious argument. The burden of proof is on the claimant. The only thing achieved by using this sort of argumentation is proving your own ignorance.

And someone was even in complete denial, arguing that since we don't regard the Alexander Technique as a therapy, we are not making health claims either.

Ad hominem
Ad hominem arguments is a speciality among CAM practitioners. Fortunately there were few of them from Alexander Technique teachers. One said that Ernst didn't seem to ever have had "an internal experience of positive change that made him wonder".

Another commentator said Ernst's blog was an example of hubris, presenting a façade of credibility with a list of degrees and "impressive databases" acquired through google. Quite a few others were eager to discuss Ernst's possible (hidden) agendas, seeing it necessary to find "enough information to make an evaluation of Ernst".

Even if there were few ad hominem arguments, there were sadly also very few comments that directly addressed what Ernst had written on his blog. Of hundreds of comments, only two or three criticised Ernst constructively.
There were comments which were emotional in character, Alexander Technique people finding Ernst ''dismissive'' or ''unfair'', his reporting ''irresponsible'' and ''insulting to the AT''. How can the Alexander Technique be insulted? The technique is not a person.

One commentator said Ernst's article was ''unscientific''. Labelling something as ''unscientific'' is, ironically, a very popular strategy among CAM practitioners. Ernst's article was further described as ''quack science'' with ''no scientific method'', ''no rigour of analysis, erroneous conclusions, and obvious bias presented as facts''.

Other commentators said Ernst had an ''opinion based attitude'', that there was''bias in his approach'', that he could be ''more objective'' and that he was ''not such a rational person as he likes people to think''.

This critique falls flat on its face because this was a blog article, not a scientific paper. It is perfectly all right to express ones opinion in a blog. The critics also fail to present arguments that supports their view. They are themselves only expressing an opinion, which as a matter of fact only ends up being empty words.

As for the ''biased position'' as someone called it, it is clear that Ernst's attitude is that claim of health effects should be based on sound evidence. One can disagree with this position, but I don't think it is correct to call it ''biased''.

Cherry picking
When it comes to the much loved sport of 'cherry picking' I'm not sure if CAM practitioners are most zealous of practicing it themselves or of accusing others for practicing it. In the debate on Ernst's article on health claims made by Alexander Technique teachers, I'm happy to say that there was only a little hint about Ernst practicing 'cherry picking'. It was alluded that by 'not supported by evidence' he actually meant 'not supported by the studies he cited'.

To support a claim that Ernst was cherry picking, one would have to show that he had omitted relevant studies of sufficient quality. Since his article is based on systematic reviews there is very little material he could have omitted. I don't know about any further studies that could have shown a more positive effect for the Alexander Technique.

CAM practitioners very often blame it on cherry picking when trials with positive results are omitted. The reason for the omission is normally bad quality trials. Studies of bad quality is a big problem in CAM. When only studies of good quality is included, the positive results tend to disappear. Homoeopathy is the prime example.

There are a lot of other factors that can reduce the reliability of a study. Size is one such factor. A case relating to the Alexander Technique was mentioned in the discussion. A pilot study on musicians in Denmark indicated that the technique was effective against high blood pressure. For years this study has been cited by Alexander Technique teachers. Later it has come to light at this is an over interpretation of the results. We have no evidence after all.

Failed medicine
Attack is the best form of defence, as the saying goes, and CAM practitioners, when criticised, routinely point out the failure of doctors, the health service and the pharmaceutical industry.

Someone posted a rant on Ernts's blog about the problem with opoid drug addiction in the US. This is a real problem and it is easy to sympathise with the writer. But the comment is entirely misplaced. Both because Ernst is writing about CAM and has nothing to do with conventional drugs or the use/misuse of it, and because even if the Alexander Technique were to be found effective against more than just back pain, the technique will never be an alternative to analgesics.

It is easy to point out failures in the practice of medicine. In the discussion about Ernst's article, among the examples given were the failure of a doctor to see the connection between arrhythmia and digestive issues, or the link between voice problems and the locking of the knees.

It is easy to agree with this, especially as an Alexander Technique teacher. I see regularly how people for instance are aggravating their problem by the exercises given to them by physiotherapists. Some basic understanding is lacking.

But what do this mean for health claims made by Alexander Technique teachers? Sharing the understanding that 'use affects functioning' might have made Ernst think twice before he wrote ''wishful thinking''. But if by that he only meant 'not supported by evidence', it wouldn't change a thing.

If we Alexander Technique teachers present claims, the burden of proof is on us. The fact that doctors make mistakes does not change this.

Too subtle
A claim often made by practitioners of CAM is that their method is too subtle to the object of scientific research. Among the objections made towards Ernst's article were that the Alexander Technique : ''is more subtle than to be subject to this matter-of-fact testing'', and that ''the Technique is an exceptionally difficult thing to build a scientific test for''.

In relation to testing claims of health benefits, this is nonsense. You don't need to know or understand the working mechanism to test the health benefits of a method. Of course, you need to make sure that what you are putting to the test is a representative version of the method. In the case of the Alexander Technique this can be a challenge, but this is a problem on another level.

And if the method is too subtle to have a measurable effect, then the claims of effect definitely are wishful thinking.

Double standards
There seems to be a myth among CAM practitioners that, when it comes to the requirement of evidence base, there are double standards in their disfavour. In the discussion on Ernst's article it was said that the established health care system should ''go under same scrutiny as is used towards alternative approaches" and that they wished that ''the same degree of scrutiny were applied to drug treatments''.

It was also said that Ernst was criticising health professionals for using CAM, but that there was ''no looking into how evidence based is the normal practice''.

This gives the wrong impression. It is true that a considerable part of what is done in 'normal practice' is not evidence based. But that there is no scrutiny is positively wrong. The practice of medicine is constantly changing, and, thanks to an evidence based approach, mostly improving.

If there really are double standards, they work the other way round. Practitioners of CAM can for the most part do whatever they like, someone in the health care system can't. CAM practitioners can do what they have done 'for thousands of years', someone in the health care system may have to change their practice due to increased knowledge. CAM practitioners can sell sugar pills and claim it is 'medicine', the pharmaceutical industry are not allowed to. (Not that they are not trying). CAM practitioners should be very pleased with having double standards.

Big medicine and Big business
If CAM practitioners feel they are not getting the aknowledgment they believe they deserve from scientific research, they tend to blame someone else for it. Big pharma, Big medicine and Big business are the usual culprits. This is also so according to voices in the Alexander Technique community.

It was said that large corporates have no interest in doing research on the Alexander Technique. This is true. And why should they? The Alexander Technique is tiny, probably only a few thousand teachers world wide. Why spend money on the Alexander Technique when there is so much else to study? The technique is tiny even when compared to CAM, which is a global billion dollar industry.

Someone criticised Ernst for not pointing out this fact. I'm afraid that sounds more like an attempt at excusing making claims of health benefits.

CAM practitioners often point to ulterior motives. It was claimed in the discussions that the Alexander Technique would be a threat to the '' thousands of scientists and billions of dollars'' in medical research. Amusing thought.

What is not so amusing is when some CAM practitioners come up with conspiracy theories to explain why their claims are not accepted. There were some glimpses of conspiracy theories in one of the discussions I followed. The problem with conspiracy theories is that they imply that a lot of people are evil. Such a position is ethically questionable. Most CAM practitioners come across as very nice people. All they want is to help others. But there is a dark side to CAM. Conspiracy theories is a sign of this. We shouldn't go there.

Failed science
When scientific medical research does not support the claims of health effect of an alternative method, CAM practitioners sometimes come to the conclusion that then it must be science that is wrong.

One of the discussions on Ernst's article I was following, hardly touched upon the question of validity of health claims by Alexander Technique teachers before heading into debating the limits of science. It was interesting stuff in the view of science philosophy, but in the context of questionable health claims it looked more like an attempt at avoiding the problem.

It was said that the 'scientific method' does not exist as such,, which is true at some level. But randomised controlled trials, which are normally used to test an hypothesis of treatment effect, is very close to being an example of what is commonly known as 'the scientific method'. Arguably randomised controlled trials exists.

It was argued that no matter how many randomised control trials that are being performed, they will always be within the context of the framework for the research, which is true of course, but beside the point. Alexander Technique teachers putting forward health claims have already put themselves within the scope of medical research, and within the very narrow frame of the question: does it work?

It was also argued that there is no common agreement of what constitutes a good quality trial. This is not quite true when it comes to assessing the quality of randomised controlled trials in medical research. Anyway, pointing to the fact that scientists disagree is usually an indication that the person has not got the hang of how science works.

Celebrity based medicine
Edzard Ernst wrote a paper together with another scientist, tongue in cheek, about ''celebrity based medicine". This could be seen as a comment on the fact that CAM practitioners love to use famous people as case stories to prove the trustworthiness of their method. Alexander Technique teachers are not much different. When it was revealed that Victoria Beckham had lessons, the story was all over the place.

Someone put a comment on Ernst's article saying that a Dr so an so, M.B, B. Ch, BAO, FRCS, D.L.O., Senior Surgeon, president of this and that, was of the opinion that the Alexander Technique should be part of medical trening of doctors. I don't think Ernst was much impressed.

This is called appeal to authority and is a fallacious argument. It does not say anything about the veracity of the health claims made by Alexander Technique teachers. I also find it embarassing. This is not the way we should put our arguments forward.

What now?
What I have written here does not show the whole scope of the discussions that have taken place in response to Ernst's article on the Alexander Technique and claims of health effect. I have only quoted fragments, rephrasing comments with my own words, and according to my own impression of the meaning. It is totally subjective and not based on science.

My aim has been to try to show examples of what we as Alexander Technique teachers should not do in a discussion about the technique and medical research. More discussions will take place in the future. My hope is that we will do better next time.

But should we bother about medical research at all? The Alexander Technique is an educational method, not a therapy. This is a question I'll discuss in my next article.

Please feel free to comment below!

Related blog posts:
Research on health benefits

Related blog posts in Norwegian: