This blog is about the intersection of the Alexander Technique (AT) and pain/suffering. The central question I will address is "Should medical care providers recommend the Alexander Technique?". My argument is that the AT should be recommended not only for back pain, but for any problem whose origins are based in habit (such as PTSD and anxiety). This is based on the science which supports underlying claim if the AT, and the science which supports its use for back pain. My argument is also based on the cost and safety of the AT. I will write that it is unfair and irrational to evaluate the AT on the basis of whether or not it "makes sense". Never-the-less, since the medical community is heavily swayed by such concerns I will write about the underlying mechanism of the AT and explain how it is effective.
I will write briefly about the magnitude of the chronic back pain problem. I will talk about the failure of the medical establishment to offer effective long term relief. I write about the consequences of the treatments that are offered. This is important not only because the commonly used treatment fail to provide long term relief. They also have disastrous implications for the suffers themselves, lead to addiction and death of others in the community, and cost the health care system enormous amounts of money.
I will define the AT. The definition I present is more broad and more accurate than the definition that is typically presented. With this definition I will show that the AT actually has two different mechanism by which it helps with pain and suffering.
The AT is not a cure all. For all its benefits it is limited. Although I am obviously a supporter of the AT, I will try to present the limits of what is known. It is also important to review the qualifications a medical care provider should make when recommending the Alexander Technique.
The underlying cause of common back pain is poorly understood by the medical establishment. They can not define it, measure it or objectively diagnose it. This failure is due to the lack of recognition of advances in pain theory. I will explain the mechanism behind chronic back pain using the most current theory of pain: the body-self neuro-matrix. For the first time, this theory present the factors that contribute to pain and it goes a long way towards explaining the role of the mind in chronic pain. This theory also explains that pain is not an isolated phenomena but has terrible implications for all aspects of the sufferer. Finally, the body-self neuromatrix describes not only pain, but also other disturbances of homeostasis, such as anxiety and PTSD.
Those who are aquatinted with my other blog will know that I aim to make each entry an argument towards my central thesis. However, each entry offers just a small slice of the complete argument. Although not presented in a logical progression, taken as a whole I hope that this blog will ultimately present a compelling argument for the medical establishment to recommend the Alexander Technique to those patients who suffer from chronic back pain as well as PTSD and anxiety.
Finally, I want to present a challenge to the medical community. Please consider that back pain might be like other health problems, with both a proximal cause and an ultimate cause. Also consider that back pain might be cured. Without even considering that such things might be possible, we will never take the first steps towards effective treatment and prevention of chronic back pain.
Friday, May 31, 2013
Wednesday, May 15, 2013
Prologue
Once a medical diagnosis is made, how does a medical care provider choose an intervention?
If it is based on science, the decision to recommend an intervention would consider:
- the number and quality of the scientific studies supporting the intervention
- the cost of the intervention
- the safety of the intervention
- the availability
- and then compare this intervention with other alternatives.
But in my 14 years as a Physician Assistant, I have found that medical care providers typically have other considerations. Such considerations might include:
- is the intervention something I was taught in school?
- is it the community standard?
- is it what the patient is asking for?
- is it recommended by professional organization?
- have I read about it in journals?
- will I receive financial compensation?
- will it expose me to litigation?
- is it already a part of my medical practice? Is it my habit?
- Do I have a family member that has benefited from this intervention?
- Have other patients of mine benefited?
- Have those whom I trust found benefit?
But the two most influential of all are:
- Have I benefited from direct experience of the intervention?
- Does the intervention make sense? Do I feel comfortable with my understanding of the mechanism of action?
I want to be very clear that I believe that medical care providers should give tremendous weight to the first set of scientifically based considerations. The medical profession has a very long history of doing tremendous harm when we stray from then.
But at the same time, I have to acknowledge that medical care providers are human and naturally swayed by other considerations. In addition, we simply do not have the robust evidence to clearly recommend an intervention for all our patients ills.
This blog reviews the rational for recommending the AT in the medical setting. I will review the first set of criteria that I hope will be used when considering a recommendation. But I will also acknowledge that medical care providers are human. I will resist recommending that medical care providers try the Alexander Technique for themselves. A sample of one should never be considered. I will, however, make every effort to describe how the Alexander Technique works using my limited knowledge of anatomy, physiology and science.
But why should the underlying mechanism be important? Certainly, if we are considering a pilot study or a large scale study, we would only want to spend scarce research money to large studies where intervention in question is theoretically promising. But this blog is written for the primary care provider who struggles every day to help suffering patients.
But truly does it matter how the Alexander Technique works? Lets consider the really crazy idea that the mold from bread inhibits bacterial growth and that a very good study shows that it is safe and effective in curing sepsis. Well it's just nuts to consider it as an intervention because there is no scientific reason for it to work.
The first medical providers who reviewed the efficacy, safety, alternatives and availability of penicillin and prescribed it are heros: they stepped up and did the right thing. I suppose there were other medical care provider who waited 17 years till the correct chemical structure and mechanism of action was elucidated. Perhaps these care providers had some pride because they did not harm anyone by providing an intervention that was not fully tested, reviewed and accepted. But what of the very substantial harm they caused by waiting? These are not scientist but arrogant people who put too much weight on the importance of their understanding. They actually have two little faith in scientific principles.
This blog is an argument that to help patients with chronic pain we have to follow the best science and study modern theory. We have to look at our fundamental assumptions and rely on skepticism. If we do all this, there is a tremendous opportunity to make giant strides to solving one of the most pressing problems in medicine today.
If it is based on science, the decision to recommend an intervention would consider:
- the number and quality of the scientific studies supporting the intervention
- the cost of the intervention
- the safety of the intervention
- the availability
- and then compare this intervention with other alternatives.
But in my 14 years as a Physician Assistant, I have found that medical care providers typically have other considerations. Such considerations might include:
- is the intervention something I was taught in school?
- is it the community standard?
- is it what the patient is asking for?
- is it recommended by professional organization?
- have I read about it in journals?
- will I receive financial compensation?
- will it expose me to litigation?
- is it already a part of my medical practice? Is it my habit?
- Do I have a family member that has benefited from this intervention?
- Have other patients of mine benefited?
- Have those whom I trust found benefit?
But the two most influential of all are:
- Have I benefited from direct experience of the intervention?
- Does the intervention make sense? Do I feel comfortable with my understanding of the mechanism of action?
I want to be very clear that I believe that medical care providers should give tremendous weight to the first set of scientifically based considerations. The medical profession has a very long history of doing tremendous harm when we stray from then.
But at the same time, I have to acknowledge that medical care providers are human and naturally swayed by other considerations. In addition, we simply do not have the robust evidence to clearly recommend an intervention for all our patients ills.
This blog reviews the rational for recommending the AT in the medical setting. I will review the first set of criteria that I hope will be used when considering a recommendation. But I will also acknowledge that medical care providers are human. I will resist recommending that medical care providers try the Alexander Technique for themselves. A sample of one should never be considered. I will, however, make every effort to describe how the Alexander Technique works using my limited knowledge of anatomy, physiology and science.
But why should the underlying mechanism be important? Certainly, if we are considering a pilot study or a large scale study, we would only want to spend scarce research money to large studies where intervention in question is theoretically promising. But this blog is written for the primary care provider who struggles every day to help suffering patients.
But truly does it matter how the Alexander Technique works? Lets consider the really crazy idea that the mold from bread inhibits bacterial growth and that a very good study shows that it is safe and effective in curing sepsis. Well it's just nuts to consider it as an intervention because there is no scientific reason for it to work.
The first medical providers who reviewed the efficacy, safety, alternatives and availability of penicillin and prescribed it are heros: they stepped up and did the right thing. I suppose there were other medical care provider who waited 17 years till the correct chemical structure and mechanism of action was elucidated. Perhaps these care providers had some pride because they did not harm anyone by providing an intervention that was not fully tested, reviewed and accepted. But what of the very substantial harm they caused by waiting? These are not scientist but arrogant people who put too much weight on the importance of their understanding. They actually have two little faith in scientific principles.
This blog is an argument that to help patients with chronic pain we have to follow the best science and study modern theory. We have to look at our fundamental assumptions and rely on skepticism. If we do all this, there is a tremendous opportunity to make giant strides to solving one of the most pressing problems in medicine today.
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