A theoretical understanding of a disease process and a definition of the problem is fundamental and essential if we want to help patients. Having some idea of the disease process can suggests useful therapies and fruitful lines of investigation. Without this, we have no basis for discussion, no way to measure either the problem or the efficacy of our intervention.
Reviewing pain theory history might not meet these needs, but it might help to illuminate why there is a problem in defining pain. We might be able to see if there is any trends or trajectories to pain theory that might suggest the future of pain theory. We might also find the roots to erroneous assumptions - the origination of cultural biases that color our thinking but have gone unchallenged.
According to my very brief research, in very early times, pain was thought to be the effects of evil entering the body. These ill effects entered the body, caused pain, and when they left pain resolved.
It does not seem that there was a consensus among the ancient Greeks: some thought pain was an emotion, others an imbalance of vital fluids. The central pain center was thought to be located in the heart.
The next model suggested that pain is the result of God testing our beliefs or putting us on trial. The therapeutic intervention that was recommended was prayer to confirm our beliefs.
The next big revolution came with René Descartes who conceived of the body as a machine. He created a division between body and mind. He moved the pain center from the heart to the brain. He suggested that pain was damage to the periphery that traveled via some sort of pathway to the brain where something like a bell would ring. The stronger the stimuli the louder the ring.
Throughout the 1800s there was debate about receptors. It was first thought that there were dedicated pain receptors and transmitters. The Intensive Theory suggested that any sensation could cause pain as long as it was adequately intense. In 1943 the summation theory proposed that stimulation of peripheral fibers would have to exceed some threshold for the sensation to spill over and send a signal to the brain. Another theory proposed that only certain patterns of stimulation are able to create pain.
In 1953, it was observed that a signal carried from injury traveled on two types of nerves: one with a large diameter, one that was small. The large diameter fibers carried touch, pressure and vibration and these were found to inhibit the signal carried by the thinner pain sensation carrying fibers.
The final theory is the Gate control presented in 1965 by Ronald Melzack and Patrick Wall, and I'm quoting heavily from wikipedia. They proposed that both thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in the dorsal horn of the spinal cord. From there, transmission cells carry the pain signal up to the brain, but inhibitory interneurons impede transmission cell activity. Activity in both thin and large diameter fibers excites transmission cells. Thin fiber activity impedes the inhibitory cells (tending to allow the transmission cell to fire) and large diameter fiber activity excites the inhibitory cells (tending to inhibit transmission cell activity). So, if there is more large fiber (touch, pressure, vibration) activity relative to thin fiber activity at the inhibitory cell, the less pain is felt. This is why we rub an injury.
They pictured not only a signal traveling from the site of injury to the inhibitory and transmission cells and up the spinal cord to the brain, but also a signal traveling from the site of injury directly up the cord to the brain (bypassing the inhibitory and transmission cells) where, depending on the state of the brain, it may trigger a signal back down the spinal cord to modulate inhibitory cell activity (and so pain intensity). For the first time, the brain itself is an active participant in the transmission of pain.
There are several points that I wish to make about pain theory:
- In reviewing the evolution of pain theory there is a trend to locate the processing of pain from outside the the human, to their periphery, to the spinal column and to the brain.
- There is a trend from ancient times to view the sufferer as a simple receptor for pain to more modern theories that suggest the sufferer to be an active participant in it's creation and modulation. The sufferer was a passive victim, but is becoming more responsible for their own pain.
- New theories do not necessarily negate established theories. Reality is actually a vast fog that is beyond our comprehension. A theory describes a small part of it. Most of us live quite content in the well described center, but a few will go to the edges. Here they find unexplained phenomena and then develop a theory to explain the observation. The function of a theory then is not so much to finally describe reality, but to widen our edges of knowledge and give others the opportunity to explore further.
And here are some lessons that we have learned from the study of pain so far:
- No pain center has yet been found. Functional MRI imaging has found that the perception of pain is widespread throughout the brain.
- Destruction of pain pathways frequently do not yield long term pain relief.
- We have discovered "phantom pain". This is pain in a body part that has been surgically removed and no longer exists. Further, people can have pain and sensation in their bodies even after a verified sectioning of the spinal cord. People can even have sensation and pain in a limb that was non existent at birth.
And how is pain presently defined? In 1994 The International Pain Society defined pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. " Perhaps it is simply a reflection of my lack of intelligence, I frankly do not understand this. The Society also includes a paragraph to help explain their definition. I won't quote the whole paragraph but two sentence stand out "This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause."
All the above is a preface to a discussion of the most current theory, The Body-self Neuromatrix.
Friday, July 26, 2013
Saturday, July 20, 2013
The Importance of Pain Theory
In my 14 years as a medical care provider, I have gone to more than my share of medical conferences. I have attended conferences in primary care, emergency care, internal medicine, cardiology, urology and other specialties. Uniformly, they are a blend of theory and practice. One must have some grasp of the theory behind a disease process to make sense of the promises and pitfalls of the interventions.
So it was quite a surprise to me that at the annual conference of the Western Pain Society, very little was said about the definition of pain, and even less about the theories regarding it's pathophysiology. It was as if I had gone to a conference on the common cold and the presenters simple talked about the need for hydration, the merits of antihistamines, the role of antipyretics, etc without any interest in talking about the cold as a viral infection.
If we are going to talk about how to alleviate pain, we must present our definition and explicitly state the theory of we are using in our discussion. How else are we going to evaluate relative efficacy? How else are we going to discuss the mechanism of action?
The primary care provider might not recognize the need to examine a definition and theoretical explanation. Typically, we simply accept what the experts give us. For example, with type 2 diabetes we uniformly assume these needs are met with the A1c and the idea of insulin resistance. But chronic pain has no clear definition, no way to measure it, and no universally accepted pathophysiology.
The conference of the Western Pain Society left me with the feeling that the pain specialty is in confused disarray. The realization that the medical profession is actively seeking the participation of non medical providers initially gave me some hope. But then I realized that the reason we welcome others is that we have so little to offer that is safe and effective The medical providers, and the patients, are desperate.
To understand the present state of pain theory, I'll briefly review a history of pain theory.
So it was quite a surprise to me that at the annual conference of the Western Pain Society, very little was said about the definition of pain, and even less about the theories regarding it's pathophysiology. It was as if I had gone to a conference on the common cold and the presenters simple talked about the need for hydration, the merits of antihistamines, the role of antipyretics, etc without any interest in talking about the cold as a viral infection.
If we are going to talk about how to alleviate pain, we must present our definition and explicitly state the theory of we are using in our discussion. How else are we going to evaluate relative efficacy? How else are we going to discuss the mechanism of action?
The primary care provider might not recognize the need to examine a definition and theoretical explanation. Typically, we simply accept what the experts give us. For example, with type 2 diabetes we uniformly assume these needs are met with the A1c and the idea of insulin resistance. But chronic pain has no clear definition, no way to measure it, and no universally accepted pathophysiology.
The conference of the Western Pain Society left me with the feeling that the pain specialty is in confused disarray. The realization that the medical profession is actively seeking the participation of non medical providers initially gave me some hope. But then I realized that the reason we welcome others is that we have so little to offer that is safe and effective The medical providers, and the patients, are desperate.
To understand the present state of pain theory, I'll briefly review a history of pain theory.
Thursday, July 18, 2013
The Head Neck Back Relationship
I have mentioned that one explanation of the mechanism by which the AT helps with back pain is simply that it improves posture, balance and coordination. This is done by teaching the student to stop interfering with their inherent reflexes. But this explanation does not explain the full effect of the AT and does not adhere to modern pain theory.
To begin to have a more robust understanding of the AT, we need to look more closely at reflexs. Again, the reflexes of most importance are the righting reflex and the startle reflex. The righting reflex begins after an activity has been performed and, if working correctly, brings us back to a neutral, upright, poised, relaxed but ready position. This reflex works by comparing the desired ideal upright position with the current sensory information. These inputs include the somatosensory inputs from the neck which are rich with stretch receptors.
These and other reflexes were investigated by Rudolph Magnus. He now has one of them named after him. Magnus was very clear about the pivotable role the head-neck-back (HNB) relationship plays in our reflexes. So much so that his work is frequently summarized as "the head leads and the body follows." The HNB relationship is central to guiding the cascade of movements seen in reflex behavior This might suggest that the HNB relationship is some kind of control center. Of course, it is not. The HNB relationship is part of the peripheral, not central, nervous system and as such it controls nothing. But it is enormously influential.
Significant problems arrise should the brainstem be conditioned to replace a default upright and neutral reference posture with some other default state. This happens as habits influence our reflexes. We can even see this happening over time by viewing the old frontal and sagital photos of disrobed children as the progress through grade school. It is very sad to see this.
FM Alexander, independently of Magnus but at about the same time, also concluded that the HNB relationship was of primary importance. The work in the first few classes of the AT focuses on improving the use of the HNB relationship, replacing the unconscious use patterns with a new consciously directed ones. Alexander found that once the HNB relationship is improved, other habits of use of the self (such a stuttering, taking the eye off the ball durring a golf swing, etc.) are easily delt with.
But the process of improving the use of the HNB pattern is not trivial. The skilled hands of the AT teacher can bring the student into an improved relationship, and this typically produces a sense of lightness, ease and uprightness. But at the same time it can also feel unfamiliar and even wrong. Student will invariable fall into their old accustomed patterns quickly. So students are taught to rely, not on what is felt to be right, but on the tools provided by the AT teacher.
The second reflex of concern is the startle reflex. This is both a unique and central reflex. It is also of great interest clinically.
The Veterans Administration is very interested in post traumatic stress dissorder. The DSM-IV definition of PTSD is a blend of historical, psychological and behavioural factors. But also central to the diagnosis is one neurological finding: an elevated startle response.
Wikipedia defines the startle reflex as a reflective response. That is, the stimulation goes directly into the brainstem and the brainstem in turn stimulates the cranial nerves: blink and the shortening of the sterncleidomastoid and trapesius muscles. The shortening of the HNB relationship is first postural change one sees on highspeed photos of the startle reflex. One would not think such a reflectory reflex could by influenced, but indeed it seems to be. On one extreem PTSD heightens the response, and on the other, meditation seems to inhibit the response.
The link between PTSD and pain is well established, and multiple theories on the relationship exist. These theories lack an understanding of the primacy of the startle response (and modern pain theory that I will discuss later).
Repeated and/or extreem triggering of the startle reflex creates a chronic shortening of the HNB relationship. This chronic tension produced by the effort to shorten the HNB relationship is the cause of the neck and back pain that is very commonly seen in PTSD sufferers.
The effects of the startle reflex do not stop with the HNB relationship but extend in a characteristic fashion throughout the body.
Durring lessons in the Alexander Technique students are taught, in part, to direct the use of themselves against the characteristic pattern seen in the startle response.
It is to Alexanders credit that he found that improvement in the use of the HNB relationship will lead to a less reactive nervious system and a lessening of the "fear response". This is quite remarkable since he knew nothing of theories regarding reflexes or PTSD.
In sum, the HNB relationship is important for the following reasons:
- It is the first region of the body to respond to the startle reflex
- The sensory apparatus gives the HNB relationship primary importance in deciding how to orienting the rest of the body and thus is very influential.
- the HNB relationship is the gateway through which the not only the startle reflex must pass to influence the entire organism, but also fear and anxiety.
- Our use of the HNB relationship can either amplify the startle response (and the emotions of fear and anxiety) or suppress the response.
The above is an introduction to the importance of the HNB relationship. The argument will be fleshed out once modern pain theory is reviewed.
To begin to have a more robust understanding of the AT, we need to look more closely at reflexs. Again, the reflexes of most importance are the righting reflex and the startle reflex. The righting reflex begins after an activity has been performed and, if working correctly, brings us back to a neutral, upright, poised, relaxed but ready position. This reflex works by comparing the desired ideal upright position with the current sensory information. These inputs include the somatosensory inputs from the neck which are rich with stretch receptors.
These and other reflexes were investigated by Rudolph Magnus. He now has one of them named after him. Magnus was very clear about the pivotable role the head-neck-back (HNB) relationship plays in our reflexes. So much so that his work is frequently summarized as "the head leads and the body follows." The HNB relationship is central to guiding the cascade of movements seen in reflex behavior This might suggest that the HNB relationship is some kind of control center. Of course, it is not. The HNB relationship is part of the peripheral, not central, nervous system and as such it controls nothing. But it is enormously influential.
Significant problems arrise should the brainstem be conditioned to replace a default upright and neutral reference posture with some other default state. This happens as habits influence our reflexes. We can even see this happening over time by viewing the old frontal and sagital photos of disrobed children as the progress through grade school. It is very sad to see this.
FM Alexander, independently of Magnus but at about the same time, also concluded that the HNB relationship was of primary importance. The work in the first few classes of the AT focuses on improving the use of the HNB relationship, replacing the unconscious use patterns with a new consciously directed ones. Alexander found that once the HNB relationship is improved, other habits of use of the self (such a stuttering, taking the eye off the ball durring a golf swing, etc.) are easily delt with.
But the process of improving the use of the HNB pattern is not trivial. The skilled hands of the AT teacher can bring the student into an improved relationship, and this typically produces a sense of lightness, ease and uprightness. But at the same time it can also feel unfamiliar and even wrong. Student will invariable fall into their old accustomed patterns quickly. So students are taught to rely, not on what is felt to be right, but on the tools provided by the AT teacher.
The second reflex of concern is the startle reflex. This is both a unique and central reflex. It is also of great interest clinically.
The Veterans Administration is very interested in post traumatic stress dissorder. The DSM-IV definition of PTSD is a blend of historical, psychological and behavioural factors. But also central to the diagnosis is one neurological finding: an elevated startle response.
Wikipedia defines the startle reflex as a reflective response. That is, the stimulation goes directly into the brainstem and the brainstem in turn stimulates the cranial nerves: blink and the shortening of the sterncleidomastoid and trapesius muscles. The shortening of the HNB relationship is first postural change one sees on highspeed photos of the startle reflex. One would not think such a reflectory reflex could by influenced, but indeed it seems to be. On one extreem PTSD heightens the response, and on the other, meditation seems to inhibit the response.
The link between PTSD and pain is well established, and multiple theories on the relationship exist. These theories lack an understanding of the primacy of the startle response (and modern pain theory that I will discuss later).
Repeated and/or extreem triggering of the startle reflex creates a chronic shortening of the HNB relationship. This chronic tension produced by the effort to shorten the HNB relationship is the cause of the neck and back pain that is very commonly seen in PTSD sufferers.
The effects of the startle reflex do not stop with the HNB relationship but extend in a characteristic fashion throughout the body.
Durring lessons in the Alexander Technique students are taught, in part, to direct the use of themselves against the characteristic pattern seen in the startle response.
It is to Alexanders credit that he found that improvement in the use of the HNB relationship will lead to a less reactive nervious system and a lessening of the "fear response". This is quite remarkable since he knew nothing of theories regarding reflexes or PTSD.
In sum, the HNB relationship is important for the following reasons:
- It is the first region of the body to respond to the startle reflex
- The sensory apparatus gives the HNB relationship primary importance in deciding how to orienting the rest of the body and thus is very influential.
- the HNB relationship is the gateway through which the not only the startle reflex must pass to influence the entire organism, but also fear and anxiety.
- Our use of the HNB relationship can either amplify the startle response (and the emotions of fear and anxiety) or suppress the response.
The above is an introduction to the importance of the HNB relationship. The argument will be fleshed out once modern pain theory is reviewed.
Thursday, June 27, 2013
A Mechanism of Action
There are several mechanisms of action by which the AT helps with back pain.
To explore these mechanisms, I'd like to start again with the cause of back pain. As I have said in previous posts, the cause of ideopathic back pain is our poor "use". Use is the accumulations of habits we've aquired durring a lifetime that lend a characteristic pattern which colors how we do everything.
I want to distinguish these habits, which are aquired, from reflexes which are not aquired. I'm particularly interested in the righting reflex and the startle reflex. These reflexes are brain stem mediated, hardwired into the reptilian brain. Based on research by Rudolf Magnus, who studied the decerebrate model, we know that these reflexes operate quite independently of the cerebral cortex. They are enduring and hardwired. In fact, wikipedia refers to the startle reflex as a "brainstem reflectory reaction".
This matter is simple in insects and reptiles. A spider or a frog react reflexively to a fly. But animals with larger cortexes can alter the expression of their reflexes. Dogs and cats can be trained. Human are an extreem example of an organisms ability to influence their reflexes. We have a large cortex that can exert great influence. In addition, we have greater neuroplasticity. Thus we have been able to adapt to a broad range of social and physical environments.
Lets consider a very basic relex, the startle reflex. Although wikipedia refers to it as "reflectory" humans have found ways to interfere with it. People who meditate have suppressed startle reflexes and the degree of suppression varies with the type of meditation. On the other end of the spectrum are those with PTSD. Part of the very definition of PTSD is the increased startle response. Meditators and trauma victims have aquired a habit of intefering with their startle response.
Students of the Alexander Technique are given the tools to stop the missuse, or the missaplication, of these basic reflexes. Some believe that students are given the tools to stop the interference in their reflexes. I would go a bit further: the AT gives the tools to help bring the students response to stimuli under conscious control.
This might sound confusing or impossible, but the medical care provider does just this - albeit in a crude simplistic way- on a daily basis. As part of my medical training I was frustrated in eliciting a reliable patellar reflex (knee jerk) response in more experienced patients. To those nieve to the exam, it was easy to elicit a response. The more experienced patients get very slightly nervious when they see the rubber mallet moving twards their knee. They subconsiously (habitually) tense their quadriceps This tension intefers with my ability to stimulate the patients stretch reseptors. I suppose it also intefers with the sudden contraction of the muscle that extends the knee in a characteristic fashion. I tried to instruct the patient to "relax" but I found that the habitual tension in the leg was not under their conscious control. It was a subconscious habitual response to a stimuli ie., the presence of a rubber mallet in my hand. When I mentioned this to my wise preceptor, she recommended that just prior to striking the patellar tendon I instruct the patient to interlock their hand and pull their arms away from each other. If my timing is good, this works quite well and I was able to elicite a more authentic reflex. By giving this instruction it confuses the patient, and distracts them from the rubber mallet. This is a very crude example - only distracting and confusing the patient, but it shows that the cortex can be used to interfere with the habit of interfering with a reflex.
In the AT students are given the tools to use their cortex - their thinking and intention - to stop interfering with the attitudinal and righting reflexes. Once these basic reflexes are allowed to express themselves without the influence of habit, people have less chronic tension, and move with greater ease and efficiency With regards to back pain, lessons in the AT have been shown to result in dramatically less disability and pain, even a year after the lessons.
But this is by no means the end of the story. The AT has other mechanisms of action that need to be explored. In addition, his formulation of back pain - that it is simply a musculoskeletal problem - relies on a theory of pain has been challenged.
To explore the full scope of how the AT works, we must go deeper into these reflexes, present some missing pieces of the AT, and discuss modern pain theory.
To explore these mechanisms, I'd like to start again with the cause of back pain. As I have said in previous posts, the cause of ideopathic back pain is our poor "use". Use is the accumulations of habits we've aquired durring a lifetime that lend a characteristic pattern which colors how we do everything.
I want to distinguish these habits, which are aquired, from reflexes which are not aquired. I'm particularly interested in the righting reflex and the startle reflex. These reflexes are brain stem mediated, hardwired into the reptilian brain. Based on research by Rudolf Magnus, who studied the decerebrate model, we know that these reflexes operate quite independently of the cerebral cortex. They are enduring and hardwired. In fact, wikipedia refers to the startle reflex as a "brainstem reflectory reaction".
This matter is simple in insects and reptiles. A spider or a frog react reflexively to a fly. But animals with larger cortexes can alter the expression of their reflexes. Dogs and cats can be trained. Human are an extreem example of an organisms ability to influence their reflexes. We have a large cortex that can exert great influence. In addition, we have greater neuroplasticity. Thus we have been able to adapt to a broad range of social and physical environments.
Lets consider a very basic relex, the startle reflex. Although wikipedia refers to it as "reflectory" humans have found ways to interfere with it. People who meditate have suppressed startle reflexes and the degree of suppression varies with the type of meditation. On the other end of the spectrum are those with PTSD. Part of the very definition of PTSD is the increased startle response. Meditators and trauma victims have aquired a habit of intefering with their startle response.
Students of the Alexander Technique are given the tools to stop the missuse, or the missaplication, of these basic reflexes. Some believe that students are given the tools to stop the interference in their reflexes. I would go a bit further: the AT gives the tools to help bring the students response to stimuli under conscious control.
This might sound confusing or impossible, but the medical care provider does just this - albeit in a crude simplistic way- on a daily basis. As part of my medical training I was frustrated in eliciting a reliable patellar reflex (knee jerk) response in more experienced patients. To those nieve to the exam, it was easy to elicit a response. The more experienced patients get very slightly nervious when they see the rubber mallet moving twards their knee. They subconsiously (habitually) tense their quadriceps This tension intefers with my ability to stimulate the patients stretch reseptors. I suppose it also intefers with the sudden contraction of the muscle that extends the knee in a characteristic fashion. I tried to instruct the patient to "relax" but I found that the habitual tension in the leg was not under their conscious control. It was a subconscious habitual response to a stimuli ie., the presence of a rubber mallet in my hand. When I mentioned this to my wise preceptor, she recommended that just prior to striking the patellar tendon I instruct the patient to interlock their hand and pull their arms away from each other. If my timing is good, this works quite well and I was able to elicite a more authentic reflex. By giving this instruction it confuses the patient, and distracts them from the rubber mallet. This is a very crude example - only distracting and confusing the patient, but it shows that the cortex can be used to interfere with the habit of interfering with a reflex.
In the AT students are given the tools to use their cortex - their thinking and intention - to stop interfering with the attitudinal and righting reflexes. Once these basic reflexes are allowed to express themselves without the influence of habit, people have less chronic tension, and move with greater ease and efficiency With regards to back pain, lessons in the AT have been shown to result in dramatically less disability and pain, even a year after the lessons.
But this is by no means the end of the story. The AT has other mechanisms of action that need to be explored. In addition, his formulation of back pain - that it is simply a musculoskeletal problem - relies on a theory of pain has been challenged.
To explore the full scope of how the AT works, we must go deeper into these reflexes, present some missing pieces of the AT, and discuss modern pain theory.
Wednesday, June 19, 2013
What is the Alexander Technique?
The most definitive definition of the Alexander Technique (AT) can be found in the writings of F. M. Alexander. His most popular book is The Use of the Self.
Or can go to Wikipedia, but this is written by a consensus of people with unclear knowledge. On can go to may of the online definitions written by Alexander Technique teachers. The pitfall here is that contemporary teachers might be defining the technique in simplistic terms that makes the AT sound appealing to a prospective student.
A traditional way of explaining the AT is to describe it's origins. F.M. Alexander lived between 1869 and 1955. He was a professional actor and reciter. As he became successful he began to lose his voice. He consulted with medical professionals and no significant underlying pathology was noted. He was told to rest, and this seemed to help initially. But when he resumed performing his problems reoccurred. Along with this physicians, he deduced that he must be doing something wrong while performing. He set up mirrors so that he could observe himself. He made observations regarding his actions, his "use", while performing and found correlations between what he was doing and the manifestations of his problems. He observed that his patterns of poor use were nearly universal among others he observed. He distilled his insights and developed a teaching technique to help others. Towards the end of his life he started a teacher training program.
But where is a medical professional, who cares for patients with back pain, to turn for an accurate definition? Where is the sufferer of back pain to turn if they want a complete definition based more on science than metaphor? By no means am I the first to take a stab at this, but most of the definitions that I've read are inadequate. I've tried to define the Technique in my sister blog, but that was written for those interested in the intersection of Zen practice and the AT. In subsequent blogs I'll reference the studies and theories that I'm using to make my claims.
To precisely define the AT, with acknowledgement to modern science, I think it is best to first consider the cause of back pain. Most people believe their back pain is caused by a defect in the condition of the body. That is, there is a lack of strength in some areas of our body, or lack of flexibility or balance, or we are too active, or not active enough. This is the generally held belief despite the fact that no intervention that improves our condition has been found to help in the long term. Another consideration is that there is something wrong with our "use". "Use" is our underlying tendencies to do everything we do in a characteristic fashion. We use our bodies in a variety of tasks but with consistent and observable underlying tendencies. These tendencies tend to shorten and narrow the body.
The Alexander Technique improves this use, but it does not teach one how to stand, sit, walk, bend, or type. Instead it works at the level of our habitual, characteristic patterns that color all our activities. The AT is a educational technique that gives the student the tool to be free from their habits. I want to be quite clear that I am not refering to habits of body only. I am refering to habitual ways of responding to stimuli in a very broad sense. Since habit of body and mind influence every corner of our life, a student can expect global changes. It is not that the technique itself is particularly profound. But the AT produces a wide range of changes because it works with the habitual unconscious ways of responding and these habits govern quite a bit of how we respond to the world. The AT does not claim that it's application will make any specific changes. That specific changes happen are a positive side effect from mastering habits and better use of the self. The AT also does not make any claim other than that it teaches students how to use themselves better. The teacher is an expert in finding defects in use, and helping the student work through barrier to imporve their use. But teacher are not taught to predict what changes improved use will bring. As I'll discuss later, it is not unreasonable to expect much less back pain, anxiety and relief from PTSD.
To go a bit deeper into a definition of the technique, we can consider why people have defects in use. This is a huge topic, but ultimately people use themselves poorly because of their beliefs. The AT teacher is trained to help students let go of beliefs that are related to their poor use patterns. This may sound like some kind of therapy, but typically in a lesson there is not much talking. As opposed to approaching beliefs on a verbal, or intelectual plane, AT appears to be a physical technique because beliefs are approached by gentle touch. Westerners are very "mind centric" and conceive of beliefs as being mental or psychological. But it is a fundamental premise in the Alexander Technique that there is no useful distinction between the mental and physical. Our beliefs are reflected, created, and supported by patterns of habitual shortening and narrowing of our bodies. These patterns color how we do everything. The AT calls the sum manifestation of these patterns our "use". The AT gives students the tools to alter their habits, lossen the beliefs and change their habitual use patterns.
A classic definition of the AT is that it teaches how to bring reason to bear on our response to stimuli. Habits are by definition not conscious - we are not aware of them. The AT teacher provides two concrete tool for the student to employ in their daily life. The AT teaches, first, how to stop a habitual response. Next, it teaches how to use the conscious, reasoning, thinking mind to direct ourselves to a new and improved way of responding. To support and clarify these tools the student is also provided with several principles over a course of instruction. The AT is a way to replace subconscious responses with conscious direction. It teaches how to replacing habit with reason. The AT improves the use of the self.
The AT is about change but the end result is not clear. Habits are known to us, are predictable and if not comfortable then reassuring. Habits are the 'known'. But they are also restricting and by nature prevent change, growth and progress. The AT shows how to move from the known to the unknown.
The AT improves the use of the self. Those who practice the tools of the technique have less pain, less anxiety, etc as a byproduct of the improved use. Imagine a nutrition referral, would taking the advice of a nutritionist treat obesity? No, but it it not unreasonable to assume that taking the advice of a nutritionist will lead to global improvements including helping with obesity. Improved use is every bit as important as eating well.
It is absolutely essential to understand that the AT is an educational process - emphatically not a therapeutic modality. It requires the active participation of the student (not "patient"), and it requires diligents, effort, interest and homework. The AT model is not dissimilar to the music teacher who see students for individual lessons for 1/2 to one hour lesson. Generally, student progress faster with more than one lesson per week initially. How many lessons is needed is unclear but studies generally involve six to 24 lessons, but traditionally more than 24 are recommended.
This has been an attempt to define the AT from a variety of angles. The next post will be to try to define the AT in a way more comfortable to the scientist or medical professional.
Or can go to Wikipedia, but this is written by a consensus of people with unclear knowledge. On can go to may of the online definitions written by Alexander Technique teachers. The pitfall here is that contemporary teachers might be defining the technique in simplistic terms that makes the AT sound appealing to a prospective student.
A traditional way of explaining the AT is to describe it's origins. F.M. Alexander lived between 1869 and 1955. He was a professional actor and reciter. As he became successful he began to lose his voice. He consulted with medical professionals and no significant underlying pathology was noted. He was told to rest, and this seemed to help initially. But when he resumed performing his problems reoccurred. Along with this physicians, he deduced that he must be doing something wrong while performing. He set up mirrors so that he could observe himself. He made observations regarding his actions, his "use", while performing and found correlations between what he was doing and the manifestations of his problems. He observed that his patterns of poor use were nearly universal among others he observed. He distilled his insights and developed a teaching technique to help others. Towards the end of his life he started a teacher training program.
But where is a medical professional, who cares for patients with back pain, to turn for an accurate definition? Where is the sufferer of back pain to turn if they want a complete definition based more on science than metaphor? By no means am I the first to take a stab at this, but most of the definitions that I've read are inadequate. I've tried to define the Technique in my sister blog, but that was written for those interested in the intersection of Zen practice and the AT. In subsequent blogs I'll reference the studies and theories that I'm using to make my claims.
To precisely define the AT, with acknowledgement to modern science, I think it is best to first consider the cause of back pain. Most people believe their back pain is caused by a defect in the condition of the body. That is, there is a lack of strength in some areas of our body, or lack of flexibility or balance, or we are too active, or not active enough. This is the generally held belief despite the fact that no intervention that improves our condition has been found to help in the long term. Another consideration is that there is something wrong with our "use". "Use" is our underlying tendencies to do everything we do in a characteristic fashion. We use our bodies in a variety of tasks but with consistent and observable underlying tendencies. These tendencies tend to shorten and narrow the body.
The Alexander Technique improves this use, but it does not teach one how to stand, sit, walk, bend, or type. Instead it works at the level of our habitual, characteristic patterns that color all our activities. The AT is a educational technique that gives the student the tool to be free from their habits. I want to be quite clear that I am not refering to habits of body only. I am refering to habitual ways of responding to stimuli in a very broad sense. Since habit of body and mind influence every corner of our life, a student can expect global changes. It is not that the technique itself is particularly profound. But the AT produces a wide range of changes because it works with the habitual unconscious ways of responding and these habits govern quite a bit of how we respond to the world. The AT does not claim that it's application will make any specific changes. That specific changes happen are a positive side effect from mastering habits and better use of the self. The AT also does not make any claim other than that it teaches students how to use themselves better. The teacher is an expert in finding defects in use, and helping the student work through barrier to imporve their use. But teacher are not taught to predict what changes improved use will bring. As I'll discuss later, it is not unreasonable to expect much less back pain, anxiety and relief from PTSD.
To go a bit deeper into a definition of the technique, we can consider why people have defects in use. This is a huge topic, but ultimately people use themselves poorly because of their beliefs. The AT teacher is trained to help students let go of beliefs that are related to their poor use patterns. This may sound like some kind of therapy, but typically in a lesson there is not much talking. As opposed to approaching beliefs on a verbal, or intelectual plane, AT appears to be a physical technique because beliefs are approached by gentle touch. Westerners are very "mind centric" and conceive of beliefs as being mental or psychological. But it is a fundamental premise in the Alexander Technique that there is no useful distinction between the mental and physical. Our beliefs are reflected, created, and supported by patterns of habitual shortening and narrowing of our bodies. These patterns color how we do everything. The AT calls the sum manifestation of these patterns our "use". The AT gives students the tools to alter their habits, lossen the beliefs and change their habitual use patterns.
A classic definition of the AT is that it teaches how to bring reason to bear on our response to stimuli. Habits are by definition not conscious - we are not aware of them. The AT teacher provides two concrete tool for the student to employ in their daily life. The AT teaches, first, how to stop a habitual response. Next, it teaches how to use the conscious, reasoning, thinking mind to direct ourselves to a new and improved way of responding. To support and clarify these tools the student is also provided with several principles over a course of instruction. The AT is a way to replace subconscious responses with conscious direction. It teaches how to replacing habit with reason. The AT improves the use of the self.
The AT is about change but the end result is not clear. Habits are known to us, are predictable and if not comfortable then reassuring. Habits are the 'known'. But they are also restricting and by nature prevent change, growth and progress. The AT shows how to move from the known to the unknown.
The AT improves the use of the self. Those who practice the tools of the technique have less pain, less anxiety, etc as a byproduct of the improved use. Imagine a nutrition referral, would taking the advice of a nutritionist treat obesity? No, but it it not unreasonable to assume that taking the advice of a nutritionist will lead to global improvements including helping with obesity. Improved use is every bit as important as eating well.
It is absolutely essential to understand that the AT is an educational process - emphatically not a therapeutic modality. It requires the active participation of the student (not "patient"), and it requires diligents, effort, interest and homework. The AT model is not dissimilar to the music teacher who see students for individual lessons for 1/2 to one hour lesson. Generally, student progress faster with more than one lesson per week initially. How many lessons is needed is unclear but studies generally involve six to 24 lessons, but traditionally more than 24 are recommended.
This has been an attempt to define the AT from a variety of angles. The next post will be to try to define the AT in a way more comfortable to the scientist or medical professional.
Monday, June 3, 2013
An Overview of Idiopathic Back Pain
How does the Alexander Technique help with back pain?
I'd like to begin by talking a bit about back pain. First, the type of back pain that I'd like to discuss is the most common form. This type is not caused by something that can be clearly identified. Cancer of the spine, a stab wound: this is not what I'm discussing. I'm talking about the back pain whose cause is unknown.
To be clear, there are at least two types of causes. First, there is the proximate cause. I lifted the casserole from the oven wrong. I twisted my back last week. I pulled my back weight lifting. I blew out a disc sneezing. These are all the causes that are temporally closely related to the experience of this round of back pain. The second cause is not closely related in a time sense, but is the underlying cause. The ultimate cause of back pain creates the conditions that predispose one to experiencing pain. In cardiology, the proximate cause of a heart attack is a plugged coronary artery. The ultimate cause is a lifetime of high blood pressure and high cholesterol.
At a medical conference I recently attended, the presenter claimed that this very common form of back pain should be called "non-specific" back pain. That is, the obvious causes have been excluded and the cause is not specific. Patients will tell us the proximate cause, but it is not very helpful: It is not helpful to tell patients "Well don't sneeze!" or "Don't lift anything!". Many patients will believe that the cause of their back pain is arthritis which was seen on a X-ray, or a blown disc that was seen on a MRI after their last bout of back pain. But it is very important to note that 60% of people with no pain at all with have at least one bulging disc on MRI. Also it has been shown that radiographically proven arthritic changes are poorly correlated with symptom severity. The bottom line is that the vast majority of back pain has no known cause that is acknowledged by the medical community.
But that does not make this back pain "non specific". There may well be specific cause of back pain - it is just that it has not been medically acknowledged. More precisely this back pain is idiopathic. Per Wikipedia: "Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause." This is more precise.
The other crucial understanding is that it is not useful to think of back pain as an isolated physical problem. This is the medical approach and it has failed miserably. It is based on a deep cultural presumption which has never been supported scientifically - indeed there is much evidence to the contrary. But since patients are quite sure they have a purely physical problem and the physicians are trained to see problems as purely physical the assumption that back pain is simply a physical problem is never questioned. Perhaps this is why the medical community has never found any scientific evidence that any of their interventions are provide long term benefit with idiopathic back pain. Further, the science suggests that there are only two interventions that have been shown to help with back pain. And these two, yoga and the Alexander Technique, are quite rigorous at resisting dividing body and mind.
To understand back pain, we have to become a student of modern theories of pain. I will go into this in some detail in future posts, but for now I'll says that modern theories of pain acknowledge that a persons history, beliefs, levels of stress in the body and mind, the endocrine system all play a crucial role in the creating of pain. Although the dominant determinant in the creation of a sensation of pain comes from the periphery, the creation of the sensation of pain is done in the mind which is strongly influenced by other factors. In fact, so influential are these other factors, that one may have experienced pain in a part of the body which has been neurologically severed from rest of the body. Indeed, one can have pain in a part of the body that does not exist!
Lastly, just as the inputs that prompt pain are legion we need to acknowledge the adverse consequences of pain is not limited to the creation of undesirable physical sensation. Chronic pain can completely remodel the sufferer: physically, emotionally, socially. It can destroy a person.
In conclusion, to help patients with back pain we have to be willing to set aside out deeply held beliefs in the duality of mind and body and instead become a student of modern pain theory. We have to see our patients as a unified being that is suffering. This is not to say we have to set aside reason and logic. Just the opposite. It is unreasonable and illogical to adhere to beliefs that have been disproven.
I'd like to begin by talking a bit about back pain. First, the type of back pain that I'd like to discuss is the most common form. This type is not caused by something that can be clearly identified. Cancer of the spine, a stab wound: this is not what I'm discussing. I'm talking about the back pain whose cause is unknown.
To be clear, there are at least two types of causes. First, there is the proximate cause. I lifted the casserole from the oven wrong. I twisted my back last week. I pulled my back weight lifting. I blew out a disc sneezing. These are all the causes that are temporally closely related to the experience of this round of back pain. The second cause is not closely related in a time sense, but is the underlying cause. The ultimate cause of back pain creates the conditions that predispose one to experiencing pain. In cardiology, the proximate cause of a heart attack is a plugged coronary artery. The ultimate cause is a lifetime of high blood pressure and high cholesterol.
At a medical conference I recently attended, the presenter claimed that this very common form of back pain should be called "non-specific" back pain. That is, the obvious causes have been excluded and the cause is not specific. Patients will tell us the proximate cause, but it is not very helpful: It is not helpful to tell patients "Well don't sneeze!" or "Don't lift anything!". Many patients will believe that the cause of their back pain is arthritis which was seen on a X-ray, or a blown disc that was seen on a MRI after their last bout of back pain. But it is very important to note that 60% of people with no pain at all with have at least one bulging disc on MRI. Also it has been shown that radiographically proven arthritic changes are poorly correlated with symptom severity. The bottom line is that the vast majority of back pain has no known cause that is acknowledged by the medical community.
But that does not make this back pain "non specific". There may well be specific cause of back pain - it is just that it has not been medically acknowledged. More precisely this back pain is idiopathic. Per Wikipedia: "Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause." This is more precise.
The other crucial understanding is that it is not useful to think of back pain as an isolated physical problem. This is the medical approach and it has failed miserably. It is based on a deep cultural presumption which has never been supported scientifically - indeed there is much evidence to the contrary. But since patients are quite sure they have a purely physical problem and the physicians are trained to see problems as purely physical the assumption that back pain is simply a physical problem is never questioned. Perhaps this is why the medical community has never found any scientific evidence that any of their interventions are provide long term benefit with idiopathic back pain. Further, the science suggests that there are only two interventions that have been shown to help with back pain. And these two, yoga and the Alexander Technique, are quite rigorous at resisting dividing body and mind.
To understand back pain, we have to become a student of modern theories of pain. I will go into this in some detail in future posts, but for now I'll says that modern theories of pain acknowledge that a persons history, beliefs, levels of stress in the body and mind, the endocrine system all play a crucial role in the creating of pain. Although the dominant determinant in the creation of a sensation of pain comes from the periphery, the creation of the sensation of pain is done in the mind which is strongly influenced by other factors. In fact, so influential are these other factors, that one may have experienced pain in a part of the body which has been neurologically severed from rest of the body. Indeed, one can have pain in a part of the body that does not exist!
Lastly, just as the inputs that prompt pain are legion we need to acknowledge the adverse consequences of pain is not limited to the creation of undesirable physical sensation. Chronic pain can completely remodel the sufferer: physically, emotionally, socially. It can destroy a person.
In conclusion, to help patients with back pain we have to be willing to set aside out deeply held beliefs in the duality of mind and body and instead become a student of modern pain theory. We have to see our patients as a unified being that is suffering. This is not to say we have to set aside reason and logic. Just the opposite. It is unreasonable and illogical to adhere to beliefs that have been disproven.
Friday, May 31, 2013
Introduction to This Blog
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.
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.
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.
Subscribe to:
Posts (Atom)