... in order to restore our body's own healing ability, everything should be brought back into balance. The Chinese Taoists call this balance Chi (the balance and flow of energy by integrating the internal and external environments), the Japanese Buddhists call it Zen (full absorption into all sensations without judgment as to self), and the Yogics of India call it Prana (body mind integration). These ancient bodymind concepts translate to our language as 'intrinsic energy' ... energy defined as vital life force. p. 20 Ai Chi: Balance, Harmony & Healing by Ruth Sova with Jun Konno, 2003
After looking through the study outlined in the previous post, I am not convinced that reporting on scientific research that is using current methods and approaches will ever do full justice to the aquatic therapies being tested, nor fairly serve the people who are benefiting from those therapies and those who are facilitating this.
I suggest that we need a far more broad-minded, inclusive, way of demonstrating the value of aquatic therapies and promoting their applications. This in no way denies the importance of safety, of evaluating potential adverse effects of treatments, and all other reasonable precautions to 'do no harm'.
Some personal reports from practitioner-instructors of their experience with Ai Chi (a form of exercise in warm water at chest level that has similarities to Tai Chi and is gaining popularity in aqua clinics) may serve to illustrate this need to keep a balanced perspective. That is, after all ,a special quality of Ai Chi.
Ai Chi (means 'love energy') was developed in 1993 by Jun Konno, former coach of the Japanese swimming team, as a prelude to Watsu. It aimed to allow the receiver of Watsu to relax, gain stability, coordinate breath and feel confidence in the giver. Now it's a practice in its own right. Read more here: Oriental healing arts take to the water
As a recent discussion on the ATRI e-list about the benefits of Ai Chi for people with fibromyalgia shows, much of the therapy is 'poorly described'. Even so, subjective and anecdotal reports of experiences (which are intransigent to scientific study) over long periods of time appear positive and very individual.
Writing on the ATRI e-list (1 Feb. 2010), Jeff Sauter (Aquatic Director at Dove Healthcare South, Eau Claire, WI) said that he had an opportunity to present on 'The impact of aquatic exercise on fibromyalgia' (FM) and sought assistance:
'Is there a body of information or 'personal experience' stories that would allow me to present this topic in a positive light? Many FM clients have not had positive experiences with exercise providing any respite from their condition and if possible I'd like to convey aquatics as a beneficial alternative.'
He had quick responses from several colleagues who are finding Ai Chi to be helpful with this condition, both personally and as practitioners. The replies are pertinent to the question I have been exploring in this post and in previous posts regards the subjective (difficult to assess scientifically) dimension to benefits.
Janet MK Gangaway (University of Hartford, CT) who is currently conducting a funded research project investigating the benefits of Ai Chi for fibromyalgia wrote:
'There is significant literature on the use of hydrotherapy and fibromyalgia, although most of the 'therapy' is poorly described, the benefits of immersion are clear.'
Note: Janet is also the author of an article for ATRI: Download Evidence-based aquatic therapy (J.Gangaway)
Mary Essert who has taught an FM-specific aquatic class for several years, noted that 'the value is different for each individual' and that 'Motivation and self responsibility are two major issues'. This was corroborated by Barbara Blank (Aquatic Specialist/ Ai Chi instructor) who replied:
'I have had many fibromyalgia clients in my arthritis classes....and yes, it is a different experience for each one EACH day....and it will change during the workout, sometimes. So far, the exercise is much more positive for them in the water that they return.'
Johan Lambeck (Katholieke Universiteit Leuven, Belgium) added that although, 'in the last year a considerable amount of systematic reviews have been published' that examine hydrotherapy for FM (he listed these), there has been no published evidence for Ai Chi with this condition.
He did reference an unpublished thesis (2004) with positive effects on the Berg Balance Scale in an FM cohort study, and his own RCT (randomized control trial) on Ai Chi for balance and fear of falling in the elderly which showed 'amazingly good effect sizes'.
What might a scientist say?
The author of a recent review article in Chiropractic & Osteopathy (2009, 17:10), Steve Hartman has provided a careful and valuable outline of the issue science takes with using these kinds of reports of effective treatment to validate the treatments. Note: I am not saying the above folk were being unprofessional or unscientific here, they were just being human. Read on ...
Download Why do ineffective treatments seem helpful (S.Hartman)
It is an important article to read for anyone who wishes to make a claim about the effectiveness of their therapeutic work, whether in a clinical or non-clinical setting. Science is a strong opponent when it comes to unverified claims. But what if not everything that is healing to someone can be proved scientifically?
Alongside his call for proper scientific analysis, Steve acknowledges that 'universal acceptance of the evidence-based healthcare paradigm has faltered'. He puts this down to all manner of human failings, which is convincing until you remember that we are humans not machines or computers or randomized trials. Writes Steve:
Medical historians have recognized ... therapeutic failure for what it was: a well-intentioned but desperately ill-informed struggle of our prescientific past....This lengthy record of misplaced medical confidence has done little to halt similar, 21st century errors in judgment. That is, universal acceptance of the evidence-based healthcare paradigm has faltered. Patients - and many practitioners - remain shackled by the same confounding factors that randomized trials, meta-analyses, and the Cochrane Collaboration were designed to circumvent.
Where does this leave the value of the scientific methodology in real-life application? Steve explains in a clear and compelling way the following 'three related components to this deductive malfunction' [by which he means faith in ineffective treatments]:
I. due to natural history of disease, regression to the mean, and the placebo effect, real signs and symptoms often improve - with or without treatment;
II. patients and practitioners often convince themselves that treatment was effective - when it was not (due to confirmation bias and other human cognitive imperfections); and
III. personal evaluation of efficacy is quick and convincing but properly controlled, scientific determination can be slow, complex, and costly.
II. patients and practitioners often convince themselves that treatment was effective - when it was not (due to confirmation bias and other human cognitive imperfections); and
III. personal evaluation of efficacy is quick and convincing but properly controlled, scientific determination can be slow, complex, and costly.
I speculate that not much of this addresses the issue of whether a treatment is helpful in the subjective ways that humans appreciate, respond to, and often depend upon. If something is complex, costly, and outside the comprehension of most of us, does that make it as valuable as some suggest?
Here is the abstract to Steve Hartman's article which you can read in full by downloading the above pdf:
After any therapy, when symptoms improve, healthcare providers (and patients) are tempted to award credit to treatment. Over time, a particular treatment can seem so undeniably helpful that scientific verification of efficacy is judged an inconvenient waste of time and resources. Unfortunately, practitioner's accumulated, day-to-day, informal impressions of diagnostic reliability and clinical efficacy are of limited value. To help clarify why even treatments entirely lacking in direct effect can seem helpful, I will explain why real signs and symptoms often improve, independent of treatment. Then, I will detail quirks of human perception, interpretation, and memory that often make symptoms seem improved, when they are not. I conclude that healthcare will grow to full potential only when judgments of clinical efficacy routinely are based in properly scientific, placebo-controlled, outcome analysis.
What do you think? Are we humans faulty machines or evolved souls or? Can a balance be struck between our left-brain skills and right-brain knowing? Isn't Ai Chi a wonderful thing? (I recently spent a day gaining my certification with Ruth Sova and will write more on this soon.)
For an outline of all 9 posts in this series on seeking evidence for the effectiveness of aquatic therapy, with a focus on 'alternative' approaches, see Faith and Facts in Aquatics: A digest
Water provides us with an internal barometer, a temperature gauge, and a measuring cup; it is the element of balance. Anon.
