We use the term indirect effecs of I ncrtDus patholog' to indicate $stem Table t. Fxarnpla of Somc Possihle Intpainnents tlmt Are Direct Effects of pathologv that occurs in svstems other N eurunat om ic Patbo lo511t than the nervous s\stem as a sequela to the initial nen'ous svstem padrol- ogv. F'or example, skin breal 30 / 540 Phvsicai Therapvlr'olume 69, Number 7fiulv 7989 ri G" I + ,' : STROKE :' I INDIBECT EFFECTS Parietal *t lobe Musculoskeletal Cardiopulmonary # lesion * Psychologlc f Bursitis Capsulitis 5 & IM Flotator cuff tears q DlBECT EFFECTS & Gastroinlsstinalt\ lntegumentary ta,E** *j, -''e' INDIRECT EFFECTS Loss of percePtion/ interprelation HypolonicitY Musculoskeletal Cardiopulmonary I Psychologic Shoulder subluxation Pronated malaligned foot COMPOSITE EFFECTS lntegumentary Gestrointestinal srroutJLrlnand Decreased uPPer/lower syndrome Faulty extremitY balance endurance Emolional Social Mental Physical parienl, lobe lesion duing a stroke ln tbs represmtation' onh,cenain Fig.2. Modet applied to irdhidtnl utbo lns sufered a ;";;brrrrrts retatii to balanrce and to tlrc sbouldq are illustrated' in Tq'itchell,; and Sanes and Evarts,l8 we pathologies are also impairments that are comPosite These'indirea can predict that sensory loss, v'hether Figure 2 and, as indi- narure. itlustrated in peripheral or conical, will result in could themselves contriburc to -hrpotonia cated, Solving when and in decreased endur- effects on uPper Glinical Problem the comPosite Pathology ance. From the work of Critchlern and endurance. Furthermore, Neuroanatomic extremity Holmes,17 we can predio that an indi- pathology could ls Known the musculoskeletal vidual s'ith a parietai lobe lesion mav contribute indirealy to additional ner- upper the neuroanatomic have apparent paraivsis of the imPairments such as The knowledge of vous system extremin' as a result of the loss of Reflex basis of movement is ven'useful in refl ex sympathetic d1'strophy'le of the limb rather predioing the consequences of sensory awareness sympathetic dystrophy (or shoulder- motor ioss' in the patient q'1th CNS than as a result of a true hand sl,ndrome) then becomes Yet impairments to the patholop'.7 From *'ork on motor con- another contributing source of the neuroanatomic over the past cenrun', \'e can pre- The knon'ledge impairment of loss of endurance for rol us to effecrs of basis of movement aiso leads activity. This dict manv of the exPected upper efiremity -example posrulate a relationship benteen pari- under- specific imPairmens. For examPle, ri*.s to illustrate the multiple and baiance we can the work of CritchleY,a Ltal lobe lesions lying causes ttlat can contribute to from 541 t 3r 1989 Phvsical TherapyA/olume 69, Number 7'Jul1' those rmpairmenls lhat have the same I effeo for the patient mav have a mul- FJampl* oI lmpainnents tfut /\re Direct Effects o! a lsion and Tbeir Pos- Table 2. tiplicin' of causes. For example, fauln, sible Consqumces balance ma1'result directlv from a nervous svslem lesion.- several areas lmpalrment Consequence such as the basal ganglia and the ves- tibular brain stem svstem have been implicated as directlv responsible for Sensory lossa s l7 18 a Hypotonia, neglect, decreased endur- ance the integration meciranism of balance lesponses.7.8 With lesions in these Motor loss6'7'o Paralysis areas, we can predict that fauln,bal- Abnormal motor planningT s Apraxia, inability to learn new tasks ance will be a direo effeo of the Abnormal motor programmingT s lncoordination, apraxia, dyskinesia pathologv. There are, however, a Abnormal motor initiation and Rigidity, dyskinesia number of other potential causes of cessalion ol motor outputT s' fauk"" balance. Figure 3 illustrates the Abnormal response lo sensory Spasticity use of the modei to idenrifi, the vari- stimulationd en'of pathologies and impairments that could lead to faulw balance. As Wa6on ( Valenstein E: Neglect and related dircrdem. In Heilman ( Valenstein E (eds): "Heilman K previouslv discussed, faulry balance Clinical Nzuropwchology-, ed 2. New York. NY, Oxford Univemirv Pre;.s Inc, 1985, pp 24j-294 Dschaumburg may be a consequence of sensorv loss HH, Spencer PS, Thom:rs PK: Disorders of Peripheral Nenes. Philadelphia, Pd FA secondan,to a parieul lobe lesion. Davis Co. 1983 Faulry balance has been identified as A Fronul lobes svndrome, In Vinken PJ, Bruvn C\r( (ecfu); Handbook of C,inical Neurolop;v. 'Luria an efect of incoordination following New York, NY, Elsevier Science Publishing Co New York, 1962, vol 2, pp 225-25i d)'oung cerebellar disease and could be con- RX, Viegner Av': Spasticiry. Clin Orthop 219:5O42. 1987 sidered an impairment of motor prograrnming.' Fauiry balance also I occurs in the apraxic patient and can be considered an motor- Table 3. Fsnmpl* of Impatummt tlnt Are Indirea Efex of a Ision and Their effeo of Posible Consquenca planning defi cits.zo Faulry- balance might also be associated u,ith spastic- irv secondarv to certain strokes. Fur- lmpalrment Consequence thermore, one can predict from clini- cal experience that fauln'balance M usculoskeletal' could result from an indireo muscu- as Thoraco-lumbo-pelvic immobility Decreased balance loskeletal imparrment such limiu- tion in lumbo-pelvo-femoral mobiliw Cervicothoracic immobilitt' Drooling or malalignment of the foot. lntegumentary skin breakdownla Flexor muscle spasms Cardiopulmonaryb Decreased endurance Treatment Strategies when Psychological" Fatigue, depression ileuroanatomic Pathology ls Known "Prediaed. 'BrinkmannJR, Hoskins TA Ph,vsical conditioning and altered self 32/542 Physical TherapyA/olume 59, Number fiuly 1989 qi t I t ganglia Basal INDIHECT EFFECTS Veslibular sYStem Musculoskeletal C€rdlopulmonary Psychologlc DIRECT EFFECTS Gastrolntestinsl lntegumEntary Weakness Loss of Perception/ interpretation INDTRECT EFFECTS Apraxia lncoordination MusculoskBl€tal Psychologlc CardloPulmonsry SpasticitY Loss of trunk mobilitY t Malaligned foot COMPOSITE EFFECTS lnlegumontary Nourologlc Gaslrolnte3tlnal Emotional Social Mental Physical balance' Underlying ca*ses of patbolog't and impaiflnert9 tbat ma1' contribfie rc faultv Fig. 3. Iltusration of cotnposite $ecs of tbat are an indirect pitt'otog"'impiiriiens tbaiare a direct efect of patbolog" a"4 inwinnents faul4t 6a1anu maf inctudi iou' effea of Patbologr'. predict potentid losses of sensory be underlving causes of their balance fauky balance, remediation maY of abiliry to inter- it maY be to perception and loss difficult because aPraxra has been impairments, Possible callv pret sensory Phenomena From to correct' If the de reatments that specifi notoriously difrcult "-ise i DEGENERATION NEUROANATOMIC PATHOLOGY PATHOLOGY Substantia nigra INDIRECT EFFECTS t Basal ganglia ) Musculoskeletal Cardiopulmonary Psychologlc DIRECT EFFECTS Gastrointeslinal lntegumentary FAULTY BALANCE Rigidity Alerting Mechanisms ) IMPAIRMENTS t Bradykinesia INDIRECT EFFECTS Plans/programs Musculoskeletal Psychologic CardioPulmonary Lumbo-pelvo-femoral mobility + COMPOSITE EFFECTS I i lntegumentary Neurologic Gastrolntestinal FAULTY BALANCE Bradykinesia a FUNCTIONAL DISABILITY Social Emotional Mental Physical Fig. 4, Model applied to indiuiduat uho lns Parkinson's disea-.e. Only tbose ttnpairments tlwt contribute to faulty balance are ernpt4sized in tbis diagram. Note ttfit impaired balance nny be botb a direct effect of tlrc patbologs' and a composite efect of otber imryinnents. voluntan' movement or impairment fauln,balance, as illustrated in Figure impairments could also contribute to of balance control. 4. Rigidiq, and impairments of alening balance impairment in patients with mechanisms (leading to bradl'kinesia) Parkinson's disease (fig. 4). It is use- Parkinson's disease provides another and motor planning-programming can ful, therefore, to evaluate the parient's example in which patholory and its be idenrified as direo effects of the exent of rigidity, loss of abiliqv to consequences can easily be predicted. pathologl'.21 \We can hlpothesize that combine motor programs, and Parkinson's disease has long been all of these impairments mav contrib- impairment of trunk and pelvic known to result in cardinal signs and ute indireall,to faulw balance, n'hich mobilin,. The therapist can then make swnptoms including rigidiry, tremor, is a composite effect of the insuh In clinical interpreutions or hlpotheses bradykinesia, and postural instability.zt addition we posrulate that rigidiw and regarding the extent to which each of Postural instability (or faulty balance) bradl,kinesia, rwo direc effects of the these other impairments contributes can be considered one of the direct pathologv of Parkinson's disease, Iead to the composite effect of faulw bal- effects of the pathology for Parkin- to musculoskeleul impairmens ance. Phlsical therapv may not be son's disease. A variety of other including a flexed posture with loss ven'effective in remediadng the impairments, however, may also con- of cervico-tho raco-lumbo-pel.,,ic direct effects of patholog,v of Parkin- ribute to the composite effect of mobility. These musculoskeleul son's disease on the integrative mech- 34/5M Physical Therapyl/olume 69, Number 7fluly 1989 I I ,; t $ s j : :- INDIBECT EFFECTS Musculoskeletal Cardiopulmonary Psychologic DIBECT EFFECTS Gaslrointestinal lntegumentary ? Altered percePtion ? Weakness ? SpasticitY INDIRECT EFFECTS ? FAULTY BALANCE Musculoskelelal Psychologic Cardiopulmonary ? Musculoskeletal limitations COMPOSITE EFFECTS Neurologic Gastrointestlnal FAULTY BALANCE Rule out: apraxia lntegumentarY Rule out: Positive suPPort J reaction \ Emotional Social Mental Physical cattses are ruled potential ca*ses of an obsen-ed disabilin' of natt{ers Note tbat cq'tain Potetltial Fig. 5. Model used to idetttifl' to identift potential as an impairmtu i1 tt'n po'ie?lt Tl)e patie?'tt is eL'eluated out b, clinical emmination Faul4' balance X iaenifiea contributions to tbe fauly' tnlance' we do resPonses. These rvro utions, and trgatment when anisms for baiance. Physical therap,v, for balance that the cause of not know the underlving Pathologl' however, couid be effective in examples illustrate shoulC for a padent. InterPreudon of a reducing contributions of other the patient's faulry balance patient's difficulw with transfers (a such as loss of trunk determine the srategy for remediat- impairments, phvsical disabilin') serves as a good and pelvic mobiliry, in remediating ing the imPairment. exampie (Fig. 5). In this instance, n'e balance impairments. The clinician, when sun from the disabilitv and work therefore, might focus treatment on Problem Solving PathologY upu'ard in the model tou'ard impair- the patient's abiliw to self-reia-r Neuroanatomic menls. Bv using this anahsis tech- to regain trunk and Pelvic ls Not Known rigidiw nique, we can consider all of the pos- mobiliry if these imPairments presented examPlas sible contributing impairmenls that appear to contribute to the faulw So far, w'e have able to ana- lead to transfer disabilin'. A fe$'exam- bilance. Rehabilimtion for balance in which we have been ples are imPaired balance, loss of impairment in patients with Parkin- lyze the cluses of impairmenls trunk mobiliry, apratia, and presence be directed because we knos'the pathologr'. Ve - son's disease might also reaction Each of also use this model, however, to of a positive support tos'ard their an'areness and con- can in clinical interpre- these causes should be either ruled scious use of correct mechanisms structure evaluation, 545 i 35 Phrsical Therapy/Volume 69, Number 7'Ju1i' 1989 or ruled out b\ e"'aluation of tht of thought. incluciirtg, techniques of p;rtl.rolopl and tlrt-rsc tl'rar arisc indi- pirtlent. jclint nrobili:zation ancl tl'rc technrques rectlv to help the clinician keep the r of lirbath,r .itthnstt.rt-tc,rr trxal patient in pcrspective and tc-r A\ Jn c.\am[)le. evaluatitlrl ol tlrc I"eldenkrais.2r artd lltxrd.:' I"urther [, r. ur ir)tcncrttion. Tltis senlrrJtl()n l)ruLirt $'iKr has drtlicultY u'tth tratls- more, the tlterllti.st can dcvtsc ttcu cnrl;hrsizcs the applicabilin and linri- ters migl-rt indicate that the paticnt tecl'rniques based ort an utrderstand- ntions of mo(lr control tl'reories in doe.s have a balance intpairntcnt. Fur- ing of probable causes and effecLs. thc treatment ol r-ieurologicallv tlrer evaluatron mighr rule c>ut apr:r-ria Success of a panicular stratepf itellts inrpaired individuals. Nlotor contrcil tlrcr.,n' relation- ()r a l)( }\rti\'(' sul)l)( )rt rcactioll :-L\ t() ..trppon tl-re intcrpreutit>tl tlle clirlt' helps ur identifr-tl-re causes of the difliculn's'ifi trartsfers. ciln lre. nr"rde. lf tlle trcatntel)l is ttut ship lrerween direct impairn-rents and We, therefore, might begin'*'ith a successful, or if improvement has dreir likeh consecluencesi motor con- clir-rical hrpotl-resis tl'rat there is a reached a plateau, evaluation findirlgs trol tireon tloes not address the ven' causal relatronship benveen the bal- should be reexamined to deterntine rcal issue ol'impairmenls that arise ance impairment and the tran.sfer dis- whether there are alternative explana- indirectlr,in systems such as the mus- abiliq'. Once thi.s cau.sal relationship dons for the disabiliw. The model culoskeletal and cardiopulmonary l-rirs been p<;stulated, it would also be should serve as a guide to potential svstems. Impairments that occur as a necessan'tci funher evaluate the alternative explan:.dons for disabilin' conrpcisite effect of nrultiple causes llatrcrrt to identrfv the imparrmenrs and serv'e as a guide to potential ltmi- are identified :LS a separate categon'. underlving the fauln, balance. Evalua- ations for recoven'. We m;rke clinical Some of the causes of these impair- tion hndrngs are used to predio judgmenrs or ltrptrtheses evcn' time menls can often be addressed bv *'hedrer fauin,balance is a direo \ve treat a patient. Tl-ris model is phvsical therapv intervention. and effect or a composite effect of some offered as one wav to har:;ess motor some cannot. we sugS;esr that those other impairmenls. F'or exart-rple, is control literarure into a clinical con- conributions that are indirect effefis altered perceptron a potential causei texl so that these judgments can be of a lesion are likelv to be most ame- Is n'eakness a cause? Do musculoskel- made within the context of current nal-rle to phvsical therapv intervention. etal iin-riutions contribute? I"igure 5 phvsiologl', anatomv, and kinesiologl,. This suggestion can be tested experi- illusrates the decision-making process menully. In focusing trealment. it is in q,hich the clinician works from Summary important to have a working hypothe- diftrculn'with transfers to identifr' the sis regarding what we can achieve \We q..hat probable c:luses of that disabilin' ir-r have presented a model that can and we cannot achieve. Treat- terms of possible impairmenLs that be used to organize current concepls menr is likelv to be most eft'ective occurred as direct and indirect eff-ecrs of neuroanatom\', neurophvsiolopl', uhen tire underlving cause is of the lesion. and moror control theory into a clini- addressed aiong u,ith the svmptom. callv relevant contexl. This model can lnterpretation and Glinical be used to postulate the causal rela- This model is intended to guide the Decision Making when tionship 3mong pathologr'. impair- clinician in m;ri 36 / 546 Phvsical Therapr'/Volume 69, lr-umber 7fiult' 7989 5 Twitchell T: Senson' factors in purposive 14 Schneider F: Traumatic spinai cord rniun. Acknowledgments 1911 ln: Umphred D (ed)r Neurological Rehabihu- m()vement. -l Neurophvsiol 17 :139-35?' rion. SI Louis, MO, CV Mosbv Co, 1985, pp 5 Dalakr"s MC, Haleit M: The ;x-rst-Pxrlio q'n- 31+111 we gratefully acknowledge the invalu- drome. ln Plum F (ed): Advances in Grntem- Davts l5 Sclrnrrdt E\, Snllrn()v E\', llvalvl'a \'5: able commenls and critiques of Alan ;xrran' Neurologl l'hiladelphia, ['A. F'A Resulrs rll tlte seven-rear Pr()sl)ecll\c stucir ri C0, l9t]lJ, PP 57+]u MJete, PhD, ff, Ile$e Ann Harris, srroke patrenL:. Stroke 19:942-949, 19tttj 7 Ilrtxrks V: The Neural Basis oi N4otor Con- Lo lvlonaca, and Yahr Mr Parkinsonism: Onset, Mi, PT, Emmanuel trol. Oxford, England, Oxford Universirv Press, 16 HGhn M, MGH progressir:n, and monalin. Neuroi - Audiovisuals Catalog J a- -ra a r- from APTA a ra -ra - 3 Subtotel ffier No. QrrrntitY Pricc Av-7 Sriload $ $ Vlrthh rcdd'dt fr 4+t'h t.hr r'r s Toad $ $ udated, comPrehensive, anno- to APTA to This recently Or rcnd &cclr PYeHc ordering information eddress on revcrec ffc of tbc crrd' tated catalog features areas' including PIeTypc aHnt- for audiovislals on l6 topic administration, APTA, back care, cere- brovascular accidents, geriatrics, modalities' 'dnd Namc oncology, sports-related injury, more' three-ring binder format allows you to Strect Addrcss The update, include Your own "finds.'' City (100 pages, tabbed) State z-rP Members: $25'00 Daytrme TelePhonc No' $40'00 Visa or MC No. Nonmembers Send orders lo: APTA,1111 N Fairtax St' Alexandria, VA 22314 PT 7/89 547 / 37 Physical Therapyl/olume 69, Number 7lJuly 7989 Reprinted from MEDICAL PR.OBLEf,{S Of PERIORMING A"RilSTS, Published by HANLEY & BELFUS, lNC., Philadelphia PA O 1989 P erformer' s P erspectiqte The Feldenkrais Method: An Interview with Anat Baniel Mary Spire, M.M. Mary Spire: I understand that you studied and worked most straighrforward way to get to the ultimate goal. closely with Dr. Feldenkrais and have worked with In the Feldenkrais work, we reintroduce into the many pedorming artists both here in the U.S. and in leaming process many variations of movement and Europe. action, which could be regarded as mistakes or irrel- Anat Baniel: Yes, I had the good fortune to study and evant to the goal the student is trying to achieve. work with Dr. Feldenkrais for manv years. I have also What actually happens is that each variation includes been fortunate to work with many musicians. an important element for the desired outcome. With vari- MS: Anat, would you tell us about the Feldenkrais Method? a little patience, fun and understanding, these AB: Most simply put, the Feldenkrais Method heips people ations, rvhich have included all the necessary essential to berter organize their movement and actions. it ingredients, just as with a child, wili spontaneously helps people to improve their ways of moving towards integrate into a coherent, effective intentional action an optimum level' which we were looking for to begin with. ideas underlie I would iike to mention a few that MS: So what you're saying is that in the Feldenkrais Method, this work. The Feldenkrais Method has idenrified and you intentionally play about, make mistakes, and have defined conditions thar dramaticallv accelerate and fun while leaming? enhance the learning of motor skills, Some of these findings contradict popular beliefs. For instance, in AB You could say it that way. Another observation that the leaming process, looking at it from an adult, Iog- tends to be overlooked is that each skiil we acquire ical point of view, our tendency is to attempt to get is based on prior skills and has a developmental order to our desired outcome in a linear, straightforward to it. So for a musician ro acquire movement skills, and direct way. If you observe babies and young chil- we intentionally create conditions for certain differ' , -dren, you'll notice that thev seem to "muck about" enriations to happen. For instance, someone siarting aimlessly and to have lots of fun doing it until, sud' to play a violin doesn't knorv anything about it, in- denly, they can do something they couldn't do before. cluding how to hold it. Initially, he has to stan with \?hen thinking about baby development, let's de- the very firsr differentiations which allow him the first fine for the moment the goal as standing and walking, step, then the second and third and so on. ln the then all the things babies do previously like rolling, Feldenkrais Method, there is a very detailed under- crawling, lifting the head, etc. mav seem like a waste standing of ivhich movement ingredients need to come of time. But if you look closely at what they leam before other movement ingredients can be intro- while doing these seemingly unnecessary deviations, duced. So when rve rvork with a musician, beginner you can see that it's the most ingenious if not the or professional, we see rvhich elements are not avai[- able or haven't been differentiated and integrated into the desired skill. We help the person leam those de- Anar Baniei is an inrernacionallt rerutruted teachn of rhe Febnkrais tails that gradually integrare and create a more evolved She hru a pritate practice in Srrn Francjsco and' coru)utcs Mechod. system. professiorwL trainings for Feliznkrais tcachers She h.rs tuorked exren' voluntary moventents need a process sruell tuith musiciaru in rAe U. S onl Europe and terches at the Tan' ln humans, all gte*iood Mrsic Centet. Marl Spire is a FeLLc.nkrars practitioner anl a of apprenticeship. Leaming to w'alk, taik, or plav an muicion. She earned the N{,rsrr's in Music in Pirino Petfornwnce from instrument requires an extended time period. Dii{er- the l.Jni"-ersitl of Sorrchern Cotit'omia- She hrrs a pritate practrce in entiation and integrarion underlie the neuroiogical and eaches at the Tangbu't;od N1raic Center. Addiress Sun Francisco processes of any leaming. You will find that each canesponltncd to Mary Slire, ffi ' rvhich allows for e*14408 I-,ANAT Morion Systems, 260 Srimr,rir Mue, Corte leaming process has an order to it Marlera, CA 94925. some flexibilitv. It consists of repetitions leading by q / frPc/+a{ frt/!- B -"K"P"-1C^- ry 70 \ December 1989 159 s/o' sql'34 / R lvay of successive approximations towards the desired atic, gentle, and global approach and technique to goal. That way., we creare an asymprotic approach to provide a person rvith sensorl-motor rraining, which the ideal peformance. rvill serve as an important ingredient in high-qualiry In the Feldenkrais Method we have an understand- performance. The qualitv and accuracy of the move- ing rhar gentleness, delicacy, and slowness are very ment are central for the musical oLrtcome. The Fel- important. Movements done this way increase the denkrais Method offers to train the propriocepri','e sensitivitv of the student, who can f'eel more of rvhat mechanisms, the ability oi the musician to feel horv he or she is doing and, as a result, become more aware he or she moves. It oflers the musician the tools to of his or her acrions. The increased sensitivity and refine the organization of his movements on an on- awareness are important tools the student and teacher going basis. work rvith in the learning process. MS: How is this work done? Another understanding we have is of the necessity AB: The work is done in groups or one on one. In either to differentiate benveen the leaming process and the mode, we take the.student through a gradual and actual perfbrmance. The learning process is not a gentle process of many movement variations. In each "clean" one. Judgments of success and failure need to lesson, which normally lasts between 45 minutes and be eliminated. When a student is judged for quality one hour, we create the condirions for that person to of pertormance during the learning process, his or her form the necessary neuromuscular differentiations that attention and energy tend to be absorbed in rrying to rvill eventually be integrated to form the desired skill. reduce fear and increase his or her safety by pleasing Each lesson is different from orher lessons so the sru- the adn.rired authority as quickly as possible. In the dent does not fall into automatic, habitual patems of Feldenkrais Method, from the student's pornr of vieu.', movement. The lessons are designed to be interesting, the learning process is not goal-oriented. It is ex- tun, and absorbing for the student. They are created ploratory. The student's atrention and energy are di- ro match the student's level of ability so that the rected to increase the student's self-arvareness and to srudent is taken from his or her existing level of skill experiment with many different wavs of doing. That ro the next possible level. No one ever tails and people way, the tools to achieve the goals are formed. In the are less inclined to overexer! or hurt themselves. The leaming process, we need to omit the judgments and srudent is given the opportunity to leam the ingre- criteria rhat belong ro the performance, rvhereas when dients necessary to arrive at the next level of perfcr- the srudent has acquired the means bv which to per- mance. form, these criteria become relevant. N{S: Do you have specific movement patterns you teach In the Feldenkrais Method, the lessons are inrro- the musicians wirh whom you rvorkl For instance, do Cuced in a slow, gentle, and pleasurable way. This vou tell the student horv ro sir, rvalk, srand, play, brings the student to know himself or herself and to be curious. The increased playfulness, curiosiry, and AB: No, this work does not come with fixed notions of sense of safety help the student move away {rom nar- how any specific action should be done. We attempt rou,, predefined notions of good and bad or right and ro create conditions which rle believe simulate what wrong wavs of doing, and help form a wide basis from happens in the nervous svstem during spontaneous, rvhich ro choose how ro acr. Learning this way reduces successful movement leamrng. compulsive, self-destructive movement pattems. The The Feldenkrais Method approaches movement both authority of the teacher serves mosrly to guide the iiom the neurodevelopmental point of view and rhe student toward that process. We depend on the ten- mechanical-structural aspect rhat explores the possi- dency of all people, given a chance, to do things in b'ilities available to the human structure. Some con- a way rhat is optimal and unique ro rhem. iigurations of movement and postural organizations MS: Horv is the Feldenkrais Method relevant for a musi- are valuable for everyone and *,i[ er,hance any per- cian i tormer. Then there are specriic movements a person AB: The Feldenkrais Method addresses rhe movement as- needs to learn depending on the instrument he or she pect oi music makinq. It seems to me rhar ofren, in rlays and his or her idioslncrasres. The Method offers the process of training musicians, the movement as- ihe musician a rvay to experience the sensory-motor pect is raken for granted, meaning rhe student is some- configurarions, both general and idiosl'ncratic, upon ho*'supposed to do the necessary movements correctl', *hich he or she can buiid his or her skill. *'ithout undergoing any specific movement appren- When done well, the mo!ement becomes effortless, trceship. Both the studenr and rhe teacher work to- auromatic and with varied possibiIities so the musician rvar& a desired musical outcome. The srudent pracrices rs freed to attend to the arristic expression. I believe with this desired outcome rn mind. What the Fel- that inrroducing this process is invaluable both for denkrais Method has to offer is our understanding thar the formation of a musician and in helping a skilled playing an insrrumenr demands a highlv complex use musician to continue growing through occasional pla- of the neuromuscular apparatus. We ofter a s)'srem- reaus and difficulties. 160 \'ledical Problems oi Performins Artists MS: What are the reasons musicians come to you? practicing their instruments. They have daily or- AB: In my practice, people come ro me mosrly due to chestra reheanals, chamber music rehearsals, and master difficulties that started affecting the quality and con- classes, in addition to their usuai number of hours sistency of their performance, such as pain, tension spenr in indiviudal pracrice. So, the main reason I and reCuced or disturbed movemenr abilities. Also, am brought in to reach the Feldenkrais Method, and musicians come to me who know about the work and an important goal of the classes, is to help musicians find it useful in enhancing their performance. avoid music-related injuries. Leon Fleisher, Artistic MS: As you rvill recall, I initially came ro you for lessons Director of the Tanglewood Mr-rsic Cenrer, told me because oi pain in mv lefr hand and shoulder which rhat before the inclusion of the Feldenkrais Method was diagnosed as tendiniris. Afrer working wirh you, in the curriculum, there used to be "a small army of the pain disappeared. Whar surprised and pleased me musicians who'd have overLrse or pracrice-related in- was the discovery rhar I could perform again, nor only juries, whereas last summer there ,uvas only one." rvithout pain and strain, but with greater conrrol, MS: You're talking about the increased amounr of pracrice refinemenr and pleasure. and rehearsal time making the studenrs vulnerable to AB: Yes, other musicians have had similar experiences. injuries. They are also under considerable emotional You see, as the organization of movement improves, stress. Do you address this in your classes? not only do the pain and discomforr tend to disappear, AB: Not directly, but during rhe movemenr lessons, I ad- but frequenrly the quality of playing improves as well. dress it by talkine a lot abotrr arrirudes to leaming, MS: What is your approach in helping a musician who to perfbrmance, and to pain. An important ingredienr comes to yotrl in the classes is to teach rhe studenrs to listen to rheir AB: I observe the way rhe musician moves and look for own inner feelings so rhar rhev can use rhis abiliry ro rhe pattem of movemenr that directll' or indirecrly is manage stress, including emotional stress. Some oi likely to be creating rhe problem. Verv often, the them hear tor rhe first time in their lives that their problem is not rvhere rhe disorder is perceived. It is difficulties or pain are nor a necessiry. When rhe very common that the disorganization is more global movemenr lesson alleviares or greatly reduces the rhan the local discomfbrt. problem, rhe emotional difficulry often disappears or MS: Can you give an examplel is greatly reduced and the srudent feels a sense of AB: If someone comes with pain in the wrisr, one is very safety. Then if there's anv further or greater emorional likelv to find thar there is significant disorganizarion problem, it needs to be addressed, but nor by me. in the wav the shoulder, lower back, and pelvis are MS: It seems to me rhar musicians rarely think of them- used. After the lesson, when that configuration is selves as being highly skilled in movemenr the rvay a changed for the betrer, the pain in the wrist ,,vill dancer wouid. disappear, oftentimes withour my having worked di- AB: Yes, and musicians move at least as much and in as rectly on rhe wrist. In other words, the problem is highly complex and demanding rvays. These lessons not necessarilv where it is perceived to be. It is in give the students an opportunirl, to refine their sen- the more elusive aspect of the dynamic organizarion sory-motor appreciation for use in their muical life, of the movement of the whole body. Each person not in association with a problem or a limitarion, bur forms his unique disrriburion of forces through rhe in association to growth, excellence, and pleasure. body during movement and each has his or her own lv{S: Currently there is a lot of talk about misuse and over- proportional use of differenr parrs of the body. This use. What is your understanding of rhese phenomena/ distribution of force can be akered in any number of AB: I agree that many of the problems musicians encounrer ',vays thar mav create problems or eliminare them. are due to misuse. What do \'!,e mean by misusel Some problems are more common than others, and N'{ovements that are done in a pc,orlv organized fash- ir seems rhat ofren, in order to get rid of a given ion. Specificallr', in a well-organi:ed movement, rhe difficultv, one has ro reorganize the rvay the move- forces generated by the muscular contractions are ment is done. translated into movemenr or inro pressure exerted on MS: You have taught the Feldenkrais Merhod at Tangle- an extemal object. When the movemenr is poorly rvood fbr che past ibur summers. Tell me about l,our organized, forces are created that generate unneces- ',t'ork there. san, heat in rhe joints, wirh sheannq and other srresses AB: Ar Tanglervood, I give group classes ro rhe musicians. in the joinr and muscles. And r', hen such movements The groups are divided accordinq to the field of spe- are cione repeatedly over rime, drrrnage and injury are ciirlry, e. g. , string players, conductors, singers, erc. I more likely ro occur. also do scme private citnsultations tor musicians rvho \{s: I-{orv do vou know if 1'ou are cioinq a w,ell-organized have specific quesrions or needs. or hieh-qualiry movemenr? you As know, the program at Tanglervood is very AB: We do not have an intemal \{'a_v ro measure rhe qualiry intense. During rhe eight weeks, the srudenrs increase of our movemenr and irs efficiency in objective terms considerably the amount of rime spenr playing and as defined by larvs of physics. The onlv thing we can Decemher 1989 161 I do is subjectively feel degrees of comfort, ease, plea- need more input, which could be done in any number sure, elegance, and reliability of movemenr-or pain, of ways. The materials and the teachers are available discomfort, agitation, etc. The degree of objective and programs could be created. efficiency of movement is highly correlated ro rhe MS: In our past iiiscussions, you have stressed thar the subjective experience of pleasure and ease. It's also Feldenkrais Method offers an educational answer to important to remember that pain is thought of today mechanical problems such as misuse and overuse. as an event in the central nervous system and can be ABI Yes, you have to establish an educational process. Not regarded as information to the person thar his way of until people agree and accept the imporrance of ed- doing is endangering him. ucating the musician in the movement aspect of MS: What about the popular belief of "no pain, no gain?" music-making will rhey find the time, space, and money AB: I believe rhat "no pain, no gain" is a misconceprion. ro do it. Once that's done, ir's prerty straighrforward Actually, the more gently movements are done during and the results speak for themselves. leaming, rhe more ability to discem fine changes in- MS: Is the Method scientifically basedi creases. Done this way, the person can direct himself AB: Dr. Feldenl:rais was a physicist, engineer, and math- towards acquiring the optimal neuromuscular config- emarician. He also was a highly accomplished martial uration necessary to create a desired outcome, the arrisr and sports person educated in the neural sci- speed of leaming is increased, and, more importantly, ences. The Feldenkrais teaching is strictly scientific it's done rvithout physical or emorional trauma. That both in content and in methodology. All assumptions also helps avoid unwanted habits. ln our understand- ("hypotheses" or "theories" in scientific parlance) on ing, pain is alu.,a1s a signal of some form of disorga- u'hich it is built are derived from fundamentals of nization. physics such as gravity and laws of motion, from ther- MS: Do vou think that music teachers could benefit from modynamic concepts such as minimum energy path- exposure to the Feldenkrais Methodl ways, from well-esrablished basics of animal (and AB: Yes, I knorv many music teachers who immediately human) funcrioning that depend on anatomy, and on started using what they had experienced themselves nervous transmission. The methodology used by Dr. rvith their students and found it to be very useful. A Feldenkrais, and the only one that he considered valid, lesson is built so it's enough for the teacher to re- rvas based on rhe ciassical methods of "hard" sciences member its effects on him or her and to remember such as physics, of which he himself was a practitioner hou' it was done in order for it to become beneficial for a major part of his career. He rejected any state- for others. The more lessons the teacher has experi- ment conceming the functioning of human beings encr:d, the greater the repertoire from which he or that could not be objectively substantiated indepen' she can respond to his or her students' needs. Many dent of time and place. Another key feature of the of the general understandings in this method can be scientific method is the requirement that theories be adopted and utilized crearively by each teacher, e.g., operational, meaning that one can test in pracrice force reduction, inrroduction of many variations aiound coruequences derived from theory. Theories that make the rheme being leamed, avoiding fatiguing the sys- statements in transcendental terms about concepts tem, eac. It seems to me that the importance of move- that cannot be directly related to practice are strictiy ment in music education is often underestimated and, excluded. Dr. Feldenkrais considered the value of the- even when realized, the know-how is not always avail- ories and models he constructed to be strictly mea- able. The Feldenkrais Method can answer the need sured by their effectiveness when rranslated to practice' for teachers and musicians to ieam the language of He was extraordinarily ingenious in conceiving trans- movement. lacions of abstract theories into sequences of move- MS: S1'mphonv management today is very interested in ment. When effectiveness did not satisfy him, he helping find an answer ro rhe high absenreeism of modified his theories to improve them just as any good rheir players due to injury. Is there a program you experimental scienrist does. couid inrroduce that would be both accessible and 1n general, no belief or faith is required for under- useiul for the symphony playerl standing, leaming, and practicing the Feldenkrais AB: I believe thar if vou provide the musicians with an \{erhod except openness of mind and the exercise oi ongoing process of educating them in movement skiils, unbiased observation of self and of others. In short, their tenciency to become injured rviil decrease sig- like an,v other scienrific discipline, the Feidenkrais nificanrlv. \fethod is to be judged by the consistency and per- practice' MS: Ho*, would 1ou implement an cngoing educational !lnence of resulrs achieved tn its process foi an orchestra player? lv{S: Anat, thank you. It's been a pleasure talking to -vou AB: ldeally, rhere could be an ongoing program of weekly about the Feldenkrais Method and your work rvith group classes, private work if the need is there, and musicians. intensive one- or two-day workshops throughout the AB: Thank you very much, Mary. it's been my pleasure, vear. Around times of high stress, the musicians might too' 162 N{edical Problems of Perfbrminq Artists Ps7clotog{ Eemeats 1!.-r. Steiset, Stephan G. The Oients Eryeriootl gf qe in Fuactjoaal lat4ration. PhD Mass. School o{ Pro{o'*ioaal Psychotogy. Uaiversity Microfilms, Ans Arbor, MI lg93 TT{E CLIENT'S EXPERIENCE OF TFIE PSYCHOLOGICAL ELENMNTS IN FLn\i CTI O NAL I I\rIE G RATI O N Stephan G. Steisel }vTAS SACHUSETTS S CHOOL OF PROFESSIONAL PSYCHOLOGY Chairperson: Ethan Pollaek, Ph.D. ABSTRACT The intent of this study *'as to elucidate the psycl:ological elements experienced by clients of a form of neuromuscular education } are reporLed, tle emphasis of the baining is on physical interventions and the focus on proprioceptive sensations. The iiterat'ure reviewed indicates gaps particularly in the banslation of theory int'o a systematic way of integrating psychological techniques into the practice of F'i' Furthermore' haining competently and metlodically addresses the neuromuscular assessment of funclioning, yet there is litt'ie guidanee in psychological assessment. v Ten clients were interviewed in open ended interviews to develop a baseline understanding of the F.I. client's experience of ttre psychological elements of this psychophysical method. Findings'vlere anaJyzed according to the tenets of phenomenologically based research in a:: effort to capture the client's erperience and elucidate the psychological elements. The follox'ing six Lhemes were absbacted from tle interviews: Body/lvlind InteracLion, hactitioner/C I ient Rel ationship, Ch an ges, Emotions, Awareness, and Memories. The body of data was compared ald conkesbed with flndingp i:r the literature review. Implications for training, tleory ard practice of F'I' and body-oriented psychotherapies in general were discussed. Suggestions for fuvther researsh ri/ere presented. \ar Changes in Coordination, Economy of Movement and Well Being Resulting from a 2-Day Workshop in Awareness Through Movement (ATM). Stephens J. Pendergast C, Roller BA, Weiskittel RS. Widener University, Institute for Physical Therapy Education, Chester pA I 90 I 3. (6101 499 -427 3), (J ames. [email protected]) Purpose: The purpose of the study was to examine the effects of a}-day ATM (a process of learning body organization, awareness, and movement) workshop on performance of functional v tasks general trl and heatth status in a group of elderly subjects. t- Subjects: 3 1 residents ( I I male and 20 female) of a retirement community participated. Subjects r.l were between the ages of 68 and 89 years, able to get up from the floor without assistance and \\,- o F. walk on a treadmill without holding. Groups were matched for age and gender. vl vl Methods: The ATM group participated in a workshop in which they experienced a sequence of \ 0 \ M. 10 Awareness through Movement lessons during the period of 2 consecutive days. The control * group performed their normal daily activities. AII subjects were assessed before and after the \) workshop for health status (SF-36), forced vital capacity, 3 measures of economy of walking on a (l( !o treadmill: 1) physiological cost index (PCl= (HR walk - HR rest) walk (f / speed); 2) vertical -7) displacement of the sacrum (average displacement over l0 seconds); head a, 5 3) stability. The last ..r two were assessed using PEAK Motus video rnotion analysis. Coordination was assessed in a -\ supine to stand movement by measuring the total time and the number of movement units, also -q c\ using PEAK motion analysis. The ATM group gave subjective feedback on perceived changes in U IT perlormance after the workshop. Data Analysis: One and two- way ANOVA .-t? were used with parametric data. Sign test was used (- with non-parametric data. Alpha levels of 0.05 were used to test for significant differences. s Subjective feedback was reported as frequency data. < Results: Subjective feedback on suggested that subjects walked more easily (43%) and got up from the floor more easily (93%). Groups were blocked by age (young:6g-Za; old:Zg-gg). There was a differential response by age group within the ATM group. Measures of economy of movement showed a trend toward increased head stability in the young/ATM group. There was a significant decrease in sacral deviation in the both old groups and a slight trend toward increased deviation in the young/ATM group. There were no differences seen in PCI. Coordination measures showed no significant difference in movement units in the supine to stand movement. There was an almost significant increase in movement time based on %o change across treatment and in the old/ATM group. This was supported by a significant increase in movement time in the old/ATM based on real time difference. SF-36 analysis showed significant increases in the mentat health and vitality subscales for the experimental group Conclusions: Data suggest changes in movement skills resulting from ATM that are different based on age grouping. The young/ATM group showed a small decrease in movement time (faster) while the old/ATM group showed a larger increase (slower). This is particularly interesting in the light of the broad subjective response (93%) indicating that ihe supine to stand movement was easier after ATM. This, associated with the improved SF_36 vitality and mental health scores in the ATM group suggest that different age groups may adopt different strategies to accomplish improvement in function;that qualitative improvement in function may look different for different people depending on age related physiological changes. Treadmill data are more difficult to interpret. because subjects had different levels of skill in treadmill walking and many subjects improved just by practice in the test procedure. pCI was not a sensitive measure for this sample in which about half the people were iaking medications which suppress heart rate response to exercise. Relevance: These preliminary data suggest that ATM may contribute to improved physical performance and perception of health status. This process is well tolerated b.y elderly persons and can performed be in groups. It may be an irnportant acl.iunct to physical therapy treaiment and fitness and health maintenance programs ftr- the elrlerlv COMBINED SECTIONS MEETING A<"u C I et& 1999 ABSTRACT FORM INFORMATION FOR PRIMARY AUTHOR AWARENESS THROUGH MOVEMENT@ AS A METHOD OF (MUST BE A MEMBER OF SECflOi/ TO WHTCH IMPROVING FUNCTION AND QUALITY OF LIFE IN AESTRACT'S OR SPONSORED SUBMITTED, INDIVIDUALS WITH MULTIPLE SCLEROSIS. Stephens JL, Call BY A MEMBER OF SECTION TO WHICH Institute ABSTRACT'S SUBMITTED) S, Evans K, Glass M, Gould C, Lowe J. Widener University, for Physical Therapy Education, Chester PA. NAME: StEP hens James L Last First MI PIIRPOSE: We are reporting on a multiple case study done ADDRESS: Instltute for Ptr-ysical , as a pilot for a larger research study. Oqr purpose rvas to assess the effectiveness of Awareness Through Movement (ATM) as an ADDRESS: TherapY ation, intervention for people with multiple sclerosis (MS). SUBJECTS: advertisment in the Iocal MS chapter ADDRESS: Widener University Twenty people responded to an newsletter. Four were selected to participate in a series of 10 ATM CITY Chester classes because they met the inclusion criteria which included being ambulatory with or without assistive devices for 75 feet, being able to :TATE: PA zlP:19013 rise from supine to stand unassisted, and being able to come to the classes. All four participants were lvomen between age 29 and 47 (ave. DAYTIME TELEPHONE: (6ro) 499-427 3 38.5) and had a deflnitive MS diagnosis with symptom onset betrveen J time outside the EVENTNG TELEpHoNE: (610) 642-827L and 9 years ago (ave. 7). AII were employed full horne. This group was intentionally selected to be fairly homogeneotrs. FAX NUMBER (610) 499-123r TREATN'IENT: ATM focuses on development of the kinesthetic sense and awareness of the organization of body movement l,earning James. StephgnsGwidener. edu E-MAIL: ways to reduce effort to a minimum is on of the goals. Movement lessons were presented to the group verbally The teacher suggested a SECTIOI.{ TO WHICH ABSTRACT IS SUBMITTED: sense of doing the movenlent (LtsT oNLY ONE) movement to be done and the kinesthetic in a variety of ways was explored. J'he lessons lasted approxinrately 1 Neurology hour rvith each person taking whatever rest was needed during the lesson. The lessons included an introduction to the concepts of body ARE YOU A MEMBER OF THE SECTION TO organization, effort and base of support: nlovenlents of the pelvis in WHICH THIS ABSTRACT IS SUBMITTED? short sit, long sit and supine; rolling to the side and to sitting: standinq x yEs NO weight shifts; standing from the floor and from a chair; and walking. The content ofthe lessons was driven by the needs and requests ofthe APTA MEMBERSHIP NUMBER: 2566 participants. All participants attended all 10 classes over a 10 rveek. OUTCONIES: The Fatigue Severity Scale (FSS), the Index of Well IF NO, NAME OF SPONSOR WHO IS MEMBER analysis of gait and supine OF SECTION TO WHICH ABSTRACT IS Being (IWB) and PEAK Motus 2D motion SUBMITTED: to stand (STS) u'ere used as objective outcome measures before and after the series oflessons. Participants also gave subjective feedback on their experience of the outcome of the lessons. Subject l,(KC)' reported improvements in FSS, IWB. She increased rvalking speed and APTA MEMBERSHIP NUMBER: coordination of STS. She reported dressing more easily and having she TYPE OF ABSTRACT: much better bala-nce and control of movement. After the 4th lesson (cHECK ONLY ONE) had now more falls and reported that she rvas able to prevent herself from failing by making small adjustments in her balance. Subject 2, _ RESEARCH x Case sruDY (LK), reported improvements in FSS, IBW, increased rvalking velocity using smaller steps, and a slower STS time with more movement uttits. SPECIAL INTEREST THEORY She rported functionai intprovements in her sitting and standin-q rvhat like to be stesdy again. -TYPE OF PRESENTATION DESIRED:- balanmce and that she remembered it felt (?HECK ONLY ONE) Others reported similar changes. CONCLTISIONS: All participants experienced fluchrations in symptoms during the 10 weeks but were X posreR _ PLATFoRM able to continue productive learning. Responses to the grotrp lessons were very individualized with each person addressing their own IS THIS MATERIAL ORIGINAL? problems and learning at their own rate with each lesson. The plrimary x ves outcome was a generaliy increased sense of rvell being, and improvenrent of balance and control of movemettt. All participants lF NO; WHERE ANOWHEN WAS-No THIS MATERIAL were so excited about the learning prospects that they engaged another PREVIOUSLY PRESENTED? teacher to continue a series of classes with them. DO NOT WRITE AREA ABSTRACT CODE: q'nin, and paroxerine (Paxil). Her involvement (Engleu'ood, CO). In the supine-ro-srand move- in a program hippotherapy ,, of continued menr, parricipants were set up u.irh a 1 reflec- throughout rhe course of the study. tive ball on rhe top of their heads and given one Case #3 (CR) was a 4}-year-old woman rvho pracrice trial. Next they, rvere asked to stand up lived with her significant orher. She had been at their normal comfortable pace, and then to diagnosed with MS 2.8 years ago. She had a stand up as fasr as rhey could. The movemenr master's-level education and worked full-time as \\,as scored for rotal rin.re and for number of member a of the managerial sraff of a labor acceleration unitsl as measllres of coordination. union local. Her most recent exacerbation was An accelerarion unir denores a change in velocity. six months before the srart of ATM classes. of the ongoing movemenr and reflects a chrngl InitiallS her strengrh, endurance, and mobility in the underlying muscular recruirmenr parrern. were normal. She reported thar she used a cane For gait anall'sis, parricipenrs \\.ere ser up with only rvhen she felt weakness in her legs. She had eight reflective markers. Each person rvas asked no history of falling. She had hyperrension that to do several trials of r.r,alking across a 15-foot was being successfully treated and received u,alkrva.v. The video was anall,zed for velocitl., monthly chiropractic trearments for low back cadence, forward trunk lean, head stability,, and stiffness. She took no medications and was nor verricaI displacement of the sacrunt.5 involved in any structured exercise or therapy At the beginning of each ATM class and at program. rhe final data collecrion session, each participanr Case #4 (LB) was a 46-year-old woman who rvas asked ro complete an open-ended quesrion_ Iived with her husband and rwo teenaged chil- naire commenring on any changes in her medical dren. She had been diagnosed with MS 7.5 y.a., or funcrional starus she had noted since the pre_ ago. She had a mastert-level education and was vious session. Finalll', tvu,o of rhe parricipanrs employed as a nurse at a university clinic. There n'ere inrerr,ierved by telephone ro assess their sra- was no report of a recent exacerbation. She had tus and rhe impact of the ATNI one year follow_ weakness and mild spasticiry in her left leg and ing rhe inrervenrion (Table t ). Sorh of rhese used a walking stick assist to her with disiance \\'omen had engaged another Feldenkrais pracri_ and balance. Her transfers were slow, with com- tioner ro do another series oi eight ATJ\{ classes pensation for the left leg weakness. She reported for rhem dr-rring rhe spring and summer of 199g. occasional falls. Other medical diagnoses All dara collection and AT\,1 classes included hypothyroidism u.ere and pituitary: ade- held in air-conditioned classroon-rs ar Widener noma, which were successfully rreated. Her med_ Universit.v's Instirure for phr.sical Therapv ication regimen included baclofen. She was not Education in Chesrer, PA. All data collection !i,as involved in any other structured exercise or ther- done at the same rime of da1.. parricipanrs firsr apy program. filled our the quesrionnaires, rhen a marker was placed on their heads and rheir supine-to_stand Measurements and lnstrumentation nrovelnents rvere videotaped. Other markers \\'ere then added and gair rvas videoraped. Each Background and demographic informarion rvas collected using the Incapacirl' Srarus Scale and TABLE 1 Environmental Sratus Scale of the lr{inimal Record of Disabilirl'.rs Farisue u,as assessed usin.e Weekly questions before ATM the Farigue Severitv Scale.r, The Farigue Severiri 1. Have you had an exacerbation Scale i,,'as developed to differentiare normal or any increase in sympioms since the last ATN,I class? yes, fatigue from fatigue associated l{ briefly rvirh chronic expiain what the symptoms are and how they medical conditions. Its internal consisrencr., affect your function in daily activrties. validirl', and sensirivin' ro change in fatigue over 2. Have you noticed any changes in your functional time has ability been established rvirh people ,.lith N{S. .' since the last ATM class? li yes. briefly t Qualin' of life rvas measured using rhe Index of exp)arn. \\/cil-Being.to This insrrumenr \\ias developed to assess overall qualitv of life in rhe general popLr_ larion. The sensirivirr'. r,alidin, and consisrencv oi this insrrumenr har.e been esrabrlished for peo ple u'ith NlS.'' ffii,#:-:s=.eia..;#:_ . . -{ nLrmber of objecrire meJ.suremcnrs \\.erc Lj#ErciF.rs done. l\r'o rvpes of rnovement w,ere assessed id#.t'Ii',' usins rhe PEAK Nlotus video rnorion analysis t i.i .:,i: l 5C Phpkal lherapy Gse Re[rcrB lb/rrrre 2/],hnl>tr 2 participanr'was allowedias much rest as she I needed TABLE benareen trials. The entire data .olt".rio., 2 process took less rhan 30 minures per individual. Quantitative dara were comparei for changes from before the intervention to ,i., ,f,. ir*.- Week To pic ventio.n. Only changes of more than 10olo were Organization, effo(, breathing, considered significant. base of support, speed of movement, environmental factors Intervention 2 Sitting in a chair, pelvic movemenB ,,pelvic clock " Ten weekly 3 ATM classes were held through the Long sining, hook lying: pelvic movements summ.er.and early fall of 1997- Each partilipant 4 Pelvic movements and rolling attended all 10 classes. Each .lrr, *u, 5 mately 90 minutes "pp.o*i_ .a long and focused , Ii..ifi. 6 sequence of functional movements. ""participanrs were. encouraged ro resr as needed throu[hout the class. All classes were.taught by th. p.ii.ip"t a uthor (JS), a certified Feldenlkrai s' p;r;;;;"... The first class was an introduccion to the principles of ATM. Using an ,.tiu. rnou.*.r,, process, the participanrs explored the kinesthetic sense associated with small changes in position and posture. variew Attention was direcied ,o ih. fol_ of srraregies ro approach a mol.emenr Iowing: problem- Parricipanrs u.ere insrrucred ro search for comforr and ease in 1) How much effort rheir erplorarory process. rvas needed to achieve and It u'as maintain emphasized thar rhere ,r.r, no ,ingi. .o._ a position rhrough a series of recr wav changes, of doine an\. movement. 2) Where thar efforr was being made, 3) Vhether Outcomes breathing conrinied normally or q,-as held during rhe process, Six.rhemes emerged 4) Vhere the base from the ri.eeklr, subjecrive of support was in relarion ro feedback (Table the 4): organization of rhe orher bodi. seemenrs, 5) How-changes 1)There in rhe base of supjorr'related \1'as an increase in the arvareness of to effort, and manv aspecrs of movemenr. This included 5) Hou, rhe speed of movemenr and different sensing rhe cenrer of gravin., the center of environmental pre.ssure. fearures affecred the sense of rhe posirion of rhe limbs, rhe size the body. and speed of mor.emenrs, and rhe p.o.ess of breathing or holding the brearh.'This Each individual panicipared in her o*,n ,"r.av Iast . \\'as not *'rit[en ahour in commenrs a1 her.own pace, resting rl,henever but u.as 1d n....rr.i, a fre.quenr ropic of discussion Occasionallli when there and even jok_ *,as confusio" in-q meaning during rhe classes. of a verbal insrrucrion, manual "b";;;;;guidance 2) There \\'as an increase in fle,xibiliry rvas given by the instructor, another" and a or parrici- decrease in stiffness. pant's movement was used as , darnonrt."rion. 3)There \r'as an improvement balance Th.e nine subsequenr classes in as u.ere organized relared to rhe around explorarion performance of dailv acriviries of movemenr possibiiries in and an a varierv impro,:.ment in the .o.,,.oi of move, of posirions (Table 2). Th; lesson topics were selecred based on what rhe participanrs 4) There \\'as an increase in the awareness of rhe rvanted to improve in their p..fo.-rn... As an effort involved in doing things, with com- exlmgle, an excerpt from rhe lesson on w,eek .l is menrs related ro increased ease of movement included (Table 3). and more energv available to do acrivities. . The instructor's goal during rhe class was nor 5) There *'as recognition and undersranding of to rmprove movement performance per se, bur ro rhe possibilin of the reorganization of move- improve the parricipanis' abiliry to b..o-. aivare menr, nored by such things as using smrller of hou' rhev organize their *tr,.*".,a, ro sense sreps or puning rhe center ofgraviry over the rvhat their bod,"* feels iike under diflerenr condi- feet in a different way. rions, and ro experience rhe possibilin' of using a 5) There was an improved mental oudook. r-e ?lq*Cllxr4y W Volume 2tN n*cr 2 61 TABLE 3 Speaker Dialogue JS Sit on the mat, leaning back on your hands behind you, with your legs straight out ... lf you get tjred shift your hands around ... and any time you need to lie on your back anJ rest ... Try jit.rint posrtions and notice how much strain there is on your wrist ... Notice the comfort of drfferent areas of vour body, your back, shoulders, neck... S I feel pressure at my elbows ... lS Bring your hands close to your body so that you are sitling straighter up ... Notrce the pressure on your hands... Notice howyour back feels... Notice your breathing._. Find a positjon where you.r" rort comfortable and again start pushing into your arm so that your head goes up ... Can you feel your shoulder blades moving? 5 t feel some tightness in the middle of my back. J5 Yes, there are muscles there that pull your shoulder blades up and down ... Notice your breathing ... lf it just has rtopped. breathe normally again ... Notice how your legs are resting oa ihe floor ... W]thout looking, can you imagine what directton your left and right toei are pointing? ... Now start slowly rolling your right leg so thjt the outside of the foot goes toward the floor and th.n rolls back ... bon,t All of rhe parricipanrs excepr KC experi- improved in one person (LK). Three of the four enced an increase in the ler.eI of their s].mprorns participanrs had large increases on rhe Index of during the 10-w'eek period bur rvere srill able to \\tll Being. Interesringlr., the onlr. person who participare fulh' in the ATNI lessons. did nor heve a posirir,e change on rhe Index of The nature of changes seen in rhe obrjecrir.e \\Iell-Being (CR) ri'as the person ri.ho performed measures (Tables -i-8) sr-rggesrs rhar each person ar the highest level, had the highest Index of benefited in her or.,'n rvar.. Tu'o people improved \11ell-Being score ar rhe ourser, and rvas dias- considerabh. in rhe supine-ro-stand rask coordi- nosed most recently. nerion measures; rwo people declined. In the 1-vear follor,,'-up inrervierr-s (Table 9),] Inrerestinglr', rhe individual u-ho impro,,.ed rhe rhe nvo ma jor rhernes ll.ere greater ease of rnove- rnost (CR) \i'as rhe one n,ho iniriallv performed menr and better funcrional balance (KC did nor et the highesr Ievel. Althoueh gair r.elocirr fall for eighr months foilorving the rhird ATlvl increased in onll'onc case, in all cases rhere iverc class), and a pervasive sense of improved qualiry. noticeable changes in riniing and movemenr o[ of life and mental outlook. cadence, rrunk lean, head stabilitl., and verrical displacemenr (see Tables 5-8, bottom secrion). Discussion E}**u':.4Ji;iJ, ,,'i In one person (KC1, the Incapacirv Sratus :.:-:!REPORTS -_*;.i..i;,i:,: Scaie score in'rproved; in trvo (CR, LB) it Alrhough in the selection process \r-e arrempted dedined. T&e Farigue Ser.erirl. Scale score ro idenrih' a sroup of people rvho performed at 62 f$icatfherapy Cae Reporls l:o/roze 2Number 2 a TABLE 4 ,i ,.t'.' Week Patient No. Responses 1 1 Change in awareness oi how to do things 2 Able to identify my center of gravity better during hippotherapy... feit surprisingly stable for a fleeting moment. That is the exact moment I gained hope for the future. I suddenly remembered what it felt like to be sready ) Changes in thinking about ho\r'r to support myself 4 lncreased awareness of the base of support while initiatrng movement 2 1 Betler sitting balance ... easier to put on socks and panty hose lncrease in MS symptoms ... increase in knee weakness and decrease in balance 4 Attempting to minimize efforts required for activities 3 1 lncreased flexibility oi hip movements 3 lncreased awareness of the movement and placement of my legs ) More control when leaning and reaching in a chair 4 Walking with awareness of pelvic movements and by taking smaller steps 4 1 lmproved hip movements -.. better standing balance ... had a fall, knee a little stiff 3 Gallbladder surgery... increased awareness of movements needed to turn and roll and get out of bed without pain 4 lncrease in movement planning to transition from supine to sittinq 5 1 Did not fall this week 4 lncreased pain in left knee and improved awareness of weaker leg 6 I Numbness in both legs below knees after sitting in the chair toc long 2 lncreased stiffness from urinary tract infection ... increased dose of Baclofen and paxil ... Improved awareness of standing balance f lncreased numbness on the left side ... increased level of fatigue 4 Started using MAFO which was previously being serviced 7 1 Better standing balance .._ improved steadrness in the snower ) Started taking Amantidine for fatigue .._ more aware of pressure on feet while maintaining standing balance 3 Able to do standing, weight shifting movements oi the lesson without feeling unsteady lncreased awareness of keeping my weight over my feet ' Movements bf walking easier :?ecreasq in lefi foot drop . . decrease in upper body balance shoulders : i,: I :., the same level, this did not occur. The perfor- During the AT\1 classes, man)' suggesrions mance levels varied from one person ,"r'ho could rvere made to direcr artenrion in a varietv of run up and dou,n the srairs w'ithour anr' 355i5- \1'avs for all people. bur no one rr'as rold that anv tance to another person u'ho needed two canes particular \\'av of rlalking, sirring, or rransferring and an elevator to get ro the classroom. In addi- \1'as berter for her. Because the intervention tion, three parricipants had periods of increased process is one oi self-discover\', each person was s)'mptom expression during rhe 10-$,eek period. free to learn at her orvn pace and ro deal u'ith her Plrpkal lherapy Case Reports lb/rrae 2/Number 2 6l TABLE 5 Nature ol Type of Measure Pre-ATM Post-ATM % Change Change Fatigue Severity Scale 39 +29 0 lndex of Well Being 149.32 165 44 +10.9 lncapacity Status Scale (MRD) 17 14 17 €, + Supine to stand time: seconds (normal speed) 12.17 9r -25.2 + Supine to stand time: seconds (fast) 10 47 847 -19.1 + Supine to stand. acceleration units (normal) 17 lb -5.9 0 Supine to stand: acceleration units (fast) 18 t1 -33.3 + Gait: velocity (mph) 1.1 1.2 +13.5 + Gait: cadence (steps per minute) 88.9 88.9 0 Gait forward lean (min-max) (degrees) 15.F21 0 16.1-21.5 5.1 +5.8 ' 0.461 0.475 . stud,y. Naturb of own specific problems in each lesson. For this We make the claim, and our parricipanrs reason, each person may have taken a different told us, that their awareness improved. What lesson ar,"'av from the same class. All the partici- evidence supports this? The video data shorv, pants seemed to appreciate the idea that there and all participants reported, a reorganization of was no right way to do anyrhing. The possibility their movements (e.g., gait and supine-ro-stand of working in groups in this rvay reduces rhe cosr movements, documented in Tables 5-8). This to each person and allows people to learn from \r'as mosrly experienced outside of the classroom each orher. In addition, the possibiliry of rvork- and on their own initiative follow'ing suggesrions ine rvith people at differenr funmional levels ri'ith u'hich they had experimenred in class. To together makes the group process even more do this, thev needed to recognize horv rhey per- appealing. formed a task and then ro do ir a different rvav. TABLE 6 Nature of Type of Measure Pre-ATM Post-ATM % Change Change A) Fatigue Severity Scale 50 -14.0 + lndex oi lVell Being ac 1( 144 71 +57.9 + lncapacity Status Scale (MRD) 11 11 0 0 Supine to sland time. seconds (normal speed) 4bb +4.0 0 Supine to stand time: seconds (fast) 22.10 27.1 +34.8 Supine to stand: accelerailon units (normal) 59 60 + I_b 0 Supine to stand: acceleration units (fast) 19 32 +68.4 Gait: velocity (mph) 0.77 0.83 +7.9 0 (? Gait. cadence (steps per minute) 52.2 a +0.6 0 Gait: forward lean (min-max) (degrees) 1 7. 1-35.8 20.5-31 .2 Gai!: {orward trunk lean (range) (degrees) 18.7 42.7 Gait: head nability 0.288 . 0.325 +12.8 Gait: vertkal displacement.x.weight (in . lb) 469.O 252.0 J6.2 -<-Eiliil:-t: ! ' ' A change of greater than 1O% is considered a significant change for the purposes of tnii stuOy. Nature of change: + ":?*+:Iiti<.+-Eti.ii.at" =' . ., ;..',r, .sr?5'l#;,..,;.. . -...,j ;';' ;:j.i..i, ;,..:',' u Pfy*al fherap,y Case ReporG trb/sze 2[Numbq 2 r TABLE 7 Nature of of Measure Pre-ATM Post-ATM % Chanqe Fatigue Severity Scale 28 30 r7 1 0 lndex of Well Being 209 87 I 96.1 0 -6.2 0 lncapacity Status Scale (MRD) +50 0 Supine to stand time: seconds (normal speed) AO 53 - r0.0 + Supine to stand time: seconds (fast) AA 3.9 -15.5 + Supine to stand: acceleration units (normal) 10 c 7 5 + Supine to stand. acceleration units (fast) 5 2 -60.0 + Gait: velocity (mph) 2.32 -3.3 0 Gait: cadence (steps per minute) 11) 1 121 .7 +1 .2 0 Gait: fonauard lean (min-max) (degrees) 12.3-16 1 14 5-19.5 Gait: fonarard trunk lean (range) (degrees) )a 50 +31 .5 Gart: head nability 0.305 +10.5 Gait: vertical displaeement xweight (in . lb) a1A > +2.3 ,.. ; . ' o A'drange of rmprovement chdnge: + -- =OO ', .'.,]:,. . This process requires awareness. These rvere not The idea of rvorking w.ith au,areness as an changes that they made on rheir orvn before par_ intended ourcome, rvhich might later be trans- ticipating in the classes, so rhey may have devel- formed into improved performance, may seem oped rhis use of their arvareness during rhe like a srrange concepr ro manv phvsical rhera- classes. There is experimental evidence also sug_ pists. The process does nor direcr people ro*,ard gesting thar ATlr{r: and kinesrheric training:r a specific ourcome, bur suggests that thev improve the accuracy of motor control, and that explore a varien' of movements to develop a ATM is associared rvith changes in body imaee.-,, kinesrhetic unCersranding of hou' they can orga- The role of arvareness in the explorarorv and nize their movemenr in different rvai,s. This is a learning process may be to recogniie an arrracror perceprion-acrion c1.cle of searching for rvhat around ri'hich a new coordinative structure for feels more comfortable, stable, or useful. A vari- moventenf might be orgirnized.j, en' of outcomes could emerge from this process. TABLE A Nature of Type of Measure Pre-ATM Post-ATM % Change Change Fatigue Severity Scaie 54 53 -1 8 0 lndex of Well Being 1Cl 1( 17A 87 +i 5.6 + lncapacity Status Scaie (NIRD) 5 8 +50 C Supine to stand time: seconds (normal speed) 80 9.70 +2 1.3 Suprne to stand time: seconds (fast) 64 663 +3.6 0 Supine to stand: acceleration (normal) units I 11 l? c Supine to stand: (fast) acceleration units 8 9 +12.5 Gait: velocity (mph) I O,r 1.01 Gait: cadence (steps per minute) 1 05.2 5 15.5 )o A Gait; forward lean (min-max) (degrees) 19.2-24.0 22.2-26 6 Gait: forward trunk lean (range) (degrees) ol 0 Gait: head 5tab;liry o.478 0.422 11) + Gait: vertic4[ displacement x weight (in lb) 313 0 140 0 cq ) +. A change of greater:than . 10% is considered.a significant.change for the purposes of this study Nature pf :; ilmprovement .n.ng., *l=,, .*;:ilr!;;:J : 'i' :--." :-'. . : li;;: t ":;:-. . lt .--. .'-:^;..t PhpicalTherapyr- ,6fi t TABLE 9 _"; -'! l Patient No. Comment :a:!! 1 (KC) "My balance is better as long as lkeep up the movements. lstill do the pelvic clock every day. lt 1!1 helps a lot with sitting and standing. l'm able to recover my balance. yesterday lfell, but lwas trying to carry 6 pairs of shoes and using only one crutch. Thats the first time l,ve fallen in g months. " : "l stopped taking the Baclofen. lt makes me too tired. lthink lcan manage the stiffness using the Awareness Through Movement." "lt's easier to move. I can do standing activities longer.,, "lt (the ATfvl) gives me a lighter mental artitude. When I do it I feel better mentally. I feel more relaxed ... I have better control and it! easier to do things. Tension is so easy to build up ... This is a.way I use to relieve tension in my upper body and that helps my walking." (LB) 4 'Bejng someone who.always moved quickly, I becarne aware that quick and large movements with smaller.mdvements more slowli and dei:this method. I have found a little. I It does not require the performance of many rep- reporred ro be related ro awareness of hip rnor.e- etirions, although ir mav use manv. ir does not ments (KC) and leg placemenr (CR) in rvalking, require rhe use of rcsisr.urce or cxcessivr efforr betrer sitring balance (LK), and easier ,"r.alking ("no pain, no gain"), althor.rgh ir nrav use resis_ (LB). Clearlr., rve need to develop a berrer under- tlnce in a task and drat.s arrenrion to recogniz_ srandine of rhe factors thar affecr rransfer and ine the efforr that is used. The focus is on an gcner.rlizrrion of le.rrning. internal cognirive process and nor on perfor- \\/e did nor assess balance in any formal rvar.. mance, althoueh performance enhancement When u'e assessed gait, r-rsing the pooled group ofren occurs. Ir is an inquisitive and erplorarory data, ir appeared rhar rhere u,ere onlv individu- process more akin to plav than u.ork or exercise: alized and inconclusii'e changes. The head srabil- for this reason, ir is diffrcLrlr for some adulr irv data and verrical displacen.rent dara mal. be in patients ro undersrand. As nored bv LB (Tatrle 9). conflict. Borh should change in a negarive direc- is coenirivell. it a challenging process rhar nor rion to indicare increased stabilirv and decreased evervone is u'illing or able to do. Ir is verr.simi_ efforr.t- Hou,ever, rhe research on rhis in people lar ro the learning srr Ie clescribed bv Lanser rvith r\1S ma1, be inconclusive. Gehlsen er al.i crrlled "mindful learnine."r" \\,e are beeinning ro stared thar verrical displacerne nr ma1' either understand thar a process like rhis mav bc impor- increase or decreirse rvhen people w-irh Iv{S make tent for motor learning;''-.rnd rehabiiirarion.is In adaptive changes in rheir gair. Whr. did our par- this context, there appears to be a transfer oi ticipanrs reporr rhar their ri.alking \\'as easier and learning from one n-pe of acrivirv ro anorher. their balance betrer? As nored in the ourcomes Perhaps :-:.8?1,f.'i.', awareness of the process of learning is (Tables ,i-8), each prrticipanr had a different ;::YSCASE: - rhe ker ro rransfer learning. oi For exaniple pattcrn of changes in her gair. Ho*,ever, in er.e11. (Tables 2,4), in rveek 3, a lesson done in long sit case excepr CR, rhe direction of change of rhe i,,-El and hook lf ine and using pelvic movemenrs, \\.as con.lponenrs could be used to e_xplain easier, 66 Physical lher-apy Case ReporG 1 b /rrzr e 2 / \ u nt b e r 2 more efficienr, and more srable u,alking. As an berter outconre.'r As phvsical rherapists, \\.e rrv erample, in the case of LB, a decrease in-velocitv to instill confidence in our parienrs. \\t try to and cadence was acconlpanied by an increase in empo\ver chem and bring rhem ro rhe point head stability of and a decrease in verrical displace_ being independenr, crearive problem-solvers. ment (Tables 8-9). An increase in velocin. is nor Perhaps ATN{ is a good \r'av ro achieve rhose alrval's betrer. goals :rnd address the perfornrrnce issues at the We also need ro remember thar a formal sanre time. video motion analysis assessment of gait is nor a The outcomes of this intervenrion have real-life situation, rvirh irs changing te-xrures, sur_ rtrised some interesring quesriorls and provide a prises, and distractions. The ,rn.l" irn be said for no,,'el vierv of aspecrs of physicrrl rherapl, pracrice rhe formal video anali,sis of supine-to-stand ir.r irs u'irh people rvirh N{S. Tliis study t..r,., ,r, a pilot relationship ro balance. Alrhough it may be a for furure research. A future studv should be good lneasure of coordinarion for rhis move- based on a larger sanrple and rvould use a true ment, ir is r.rot clear that a fasrer movement with experimenral design. This level of inrernal valid_ feu'er acceleration units rvould be a safer or bet_ ity is imporranr due ro rhe narural variarion of ter mo!'emenr for a person wirh .l\.{S someone or symptoms and performance seen in N{S. We rvho is elderlr'..r, rvould use different measures, such as an lr.tS Pope and Tarlov,0 include quality of life as qualiry of life insrrumenr ro assess general healrh an area of major significance in disabilirl, assess- status, a measure of self-efficacy to look for asso_ menr. The clearesr and perhaps most inreresring ciation with the Index of Well-Being, a func_ finding of rhis study is the subjecrir.e reporring tional assessment balance, a prospecrive record of improvemenr in facrors related ,o qrrliry oi of falls, and a ph1'siologic assessment of energy life and Iarge increases in rhe Index of V/ell_ expenditure using oxl'gen consumption. Ir rr,ould Being scores, excepr in one case. This has been be valuable ro repear the qualitarive reported before with aspects studies using ATM in peo_ using a more formal procedure of qualirative ple rvith lr{S']' and wirh the well elderly.re.4r \{zhar dara analvsis. It u,ould also be imporranr ro find is rhis phenomenon? Why rvould there be a per_ out if rhe ourcomes suggesred here can be vasive ps1'chological ourcome fronr an interl,en- extended to a rr.ider range of functional levels tion such as this? \yhat is rhe importance of this within the N,IS popularion rarher rhan just rhe for phi'sical therapy rrearment and ourcome independenr amhuiarors represenred in this pro_ assessmenr? The phenomenon is besr described jecr. AT\1 seenls ro be a r.erv helpful rr.pe by participants in the of l-l'ear follor.v-up inrervier.". intervention ro add to rhe rehabilirarion (Table 9): pio..r, for people w'irh NIS. KC: "lt [ATM] gives me a lighrer menral arti_ tr-rde. When I do it, I feel betrer mentallr.. Acknowledgments I feel more relaxed . . . I have b.tt.. con_ trol and it's easier ro do things." The aurhors acknot'le dge rhe u.ork of llichael Coleman, LB: "I am betrer emorionallv and menrally. It's Coleman Techno)ogies. Inc., for u,rir_ ing the sofnvare very challenging ro do this method. I hai.e progranrs used in dara reduc_ found rhar I could do rhings thar I didn'r tion and analvsis, ancj rhe Grearer Delan,are trelieve I could do. I could ger rhar lirtle Valler-Chaprer of rhe Narional .Nlultiple Sclerosis roe ro move a lirtle. I could calm dow.n Socierf ior rheir assisrance in volun- teer and breathe and just feei rhe movemenr. ir recruitment. \l'as i.erv empor,r,ering. It has reallr. stimulared my crearivir!..,, References L,nharrced imaginarion of rnovirrg in different and increased confidence "r'ar.'s and abilirv ro find 1. Fuller K. Dege neraiir.e drseases oi rhe central nen.ous crerrrive solr.rrions to problems are factors that svsrem. In: Coodman CC, Boissonrulr \\'G, eds. are relared ro improving qualiti. of life. This is P*bolo91,: Intplic;tiotts f'ctr tlte plrysicaL Therapist. Philadeiphia: direcrly relared to Bandura's definirion of per_ \\'B Saunders; 19 9 8 :7 3 5-7 12. r. Baum HNI, Rorhschild ceived self-efficao': "the belief that one has rhe BB. lrlultiple sclerosis and mobiliw phys capabiliry- to organize and execure a parricular restriction. Arch tled Rehab. 19g3: o-1:i91-5q6. course of acrion.",: Self-efficaci, has been shor,,.n -1. Gehlsen G. Beekmrn L. Assmann ro b,e direcrlv relared ro success in rehabilitarion N. Seidle lr{, Certer A. Gait characrerisiics in multiple sclerosis: in the sense thar those u.ho har.e a higher self- Progressive changes and efiecrs oi exercise on parame- efficao' eoing into rhe process generaliv har.e a ters. .-1rcl Pbl,s irled Rr/.,.rp. 1985:62: j j5_-i j9. Physkallherpy Gse Rerrorts lb/roae 2iNunber 2 6,) 4. Holden lt{K, Gill Ki\1, lr{agliozzi lr,IR. G:rir assess- 10. 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Neu- York: Narionel \lulriple Sclerosis 1 7:E35-81 1. Socien'; 1985. 12. Shapiro RT, Lar.en L. iv{uhiple sclerosis. In; Good 29. Krupp LB, LaRocca NG, lr{uir-Nash J, Steinberg DC, Crouch JR, eds. Htndbook of Neuroreha\tilita- AD. The farigue severitl. scale: Application ro paricnrs llorr. Nerv \brk: l\,larcel Dekker; 199.11_5j1-559. *'irh mulriple sclerosis and svsremic lupus en.themato- 13. Johnson KB. Exercise, drug rrearment, and rhe opti- sus. Arrl., Neurol. 19E9;15:7121-i 123. mal care of multiple sclerosis parienrs (edirorial). ,{rl 30. Campbeil A, Converse P, Rogers \I. Tbe euali4,of N eu rol. 199 6;39 :122-423. .*nerican Li/e. Nerv \brk: Russell Sagel 1976. 1-1. Petajan Gappmaier E, $"/hire JH, A! Spencer ltIK, i 1. KIuzik J, Fetrers L, Con ell J. Quentification of con- Nlino L, Hicks RW. Impact of aerobic treining on fir- rrol: A preliminan- srudv of the effecrs of neurodevel- ness and qualin' of life in rnultiple sclerosis. Arzl opmental rrearmenr on reaching in children rvith spas- N eurol. 1996:39 :1 32441. tic cerebrai palsv. Pll,s Ther. 1990;70:6j-78. Ii. Svensson B, Gerdle B, Elert J. Endur;nce treinin: in i2. Sarasu ati S. Llle, 68 Ftt)rsid ffr€{-dpy C6€ Reports I'r,/rn re 2 /N ru lt er J primate model for studving focal dvstonia and repet- Toward a National Agenda ir.tr Pra,uttictn. \\'rrshingron itive strain injury: effeos on rhe primar)'somarosen- DC: National Academy Press; 1991. sory cortex. Pbys Ther. 1997;77:259-254. 41. Gutman GN1, Hebert CP, Brorvn SR. Feldenkrais 39. Srephens J, Pendergast C, Roller B.\, Weiskirtel versus convenrional exercises for the elderli.. / RS. Straregie-. For lmprouentent of Coordination and G e rontol. 1977 ;32: 5 52-572. Economy of lvlot,enzent in Older Adults. 42. Bandura A. Seli-Efficac)': Tlte Excrcise of Control. Unpublished l\lasrer's thesis, Videner Universitv, New York: \VH Freeman; 1997:3. Chesrer, PA. Poster presented ar APTA Combined 43. Buckelew SP, Huyser B, I{ewetr JE, er al. Self-effi- Secrions Nleering, Boston, NIA, February 1998. cacv predictinq outcome among fibronrl,rlgia subjects. 40. Pope A_1r1, Tarlov AR. Disabilitl, itr America: Arthritis Care and Research. 1995;92\:97-104. D Lbysical Tberapy Case Repons is activelr. soliciring Case Reporrs, C' Clinical Profiles, and Innovarions manuscriprs. We u.elcome submis- sions that describe: r l- unique or complex clinical cases l- r innovative use of technolog,v r evidence-based pracice TT r documentation of functional ourcomes c) r differential physical therapy diagnosis r preferred prtcrice pitterns =, r clinical decision-making r contemporary service delil'ery models E Novice as r.vell as experienced rvriters are encouraged to submir manu- -, scripts. See Instruction to Authors in the January 1999 issue. For a rI.I complete Insrruction to Aurhors packer cal|919-785-0213, iax 919- d 78 5 -2740, or E-mail [email protected] er?- ftqdcd Tlt€r-+y (.6€ Reports lb/rrrrc 2/Number 2 59 EFFECTS OF AWARENESS THROUGH MOVEMENT, A MOTOR LEARNING STRATEGY, ON HAMSTRING LENGTH IN I{EALTHY SUBJECTS. Stephens J, Davidson JA, DeRosa JT, Kriz ME, Saltzman NA; Institute for Physical Therapy Education, Widener University, Chester, PA5 USA. PURPOSE: Hamstring length is important for optimal athletic performance, reduction of some kinds of back pain and good posture. Awareness Through Movement (ATM) is a motor learning strategy which focuses on development of awareness of the body and the process of motor control using a variety of movement activities. Anecdotal reports and clinical experience suggest that ATM can be I t used to produce dramatic increases in hamstring muscle length which a may not have good carryover. James, Kolt, McConville and Bate d (1998) reported that a series of ATM lessons did not improve r, hamstring length. The purpose of the study was to determine t whether ATM can be used effectively to lengthen hamstrings. , lr SUBJECTS: 33 healthy college students, agerange2l to38, who met the criteria of having more than a 15 degree deficit of fulIknee a EXtENSiON WErE rEcruited. METHODS AND MATERIALS: rQ t' Subjects were randomly assigned to ATM and groups. - control The * control group (n:15) carried out their normal daily activities while t the ATM group (n:18) was trained with one initial ATM lesson, .! then given that lesson on audio tape which they performed =( independently at home an average of 3 to 4, 15 minute sessions per week over 3 weeks. Hamstring length was measured before and after rt the 3 week intervention period using the Active Knee Extension Test a described by Gajdosik and Lusin (1983) and using the PEAK Motus q motion analysis system to record maximum knee extension angle. l- ANALYSES AND RESULTS: The ATM group increased hamstring James Stephens, P.T., Ph.D. Assistant Professor, Institute for Physical Therapy Education, School of Human Service Professions, Widener University, Chester PA and Owner of Movement Learning and Rehabilitation, Havertown, PA Proof and reprints to: James Stephens, PT, PhD Institute for Physical Therapy Education Widener Universitl' One University Place Chester, PA 19013 (6to) 499-4273 (610) 499-1231 (fax) email: James.Stephens@ n'idener.edu Scheduled for publication in Orthopedic Physical Therapy Clinics of North America in September 2000 ) INTRODUCTION When I began my physical therapy education in 19t32, motor learning as a treatment intervention was just on the horizon. It did not hal,e a central place in the curriculum. In 1998, the Guide practice to Physical Therapist listed motor learning among the standard set of therapeutic exercise interventions that physical therapists perform and suggested its use with all populations and most diagnostic groups.,n Horvever rvhen I started teaching a course in therapeutic exercise in lg4 and got the standard text by Kisner and Colby 28 for my students, I lvas surprised to discover that other than one page in the introduction rvhich listed coordination, balance and functional skills as a goal of therapeutic exercise and a short paragraph in the final chapter on exercises to increase skill, there rvas nothing devoted to the explanation, justification, understanding, use and practice of motor learning, learning applied to the acquisition of coordination and skill. I believe that this is a basic and essential area of physical therapy intervention rvhich is underappreciated and underutilized in the areas of orthopedics. In the area of rehabilitation, Feldenkrais Method (FM) offers and approach to inten ention rvhich focuses on expanding kinesthetic arvareness as a basis for improl,ing function. FM offers guidelines for directing a learning expenence for a patient w,hich are individualized yet based in common features of human anatomy and pattems of movement. Training in FM has taught me to ask rvhat a patient needs to leam to rehabilitate him/herself and has provided strong guideposts for selecting learning tasksiproblems for patients. In the follorving pages, I ivill describe some of the history and philosophy of the FM and summarize relevant scientific literarure assessing it use. I rvill then describe horv the use ol FM is integrated into a physical therapy practice using descripti!,e outcome data and case studies. FELDENKRAIS@ METHOD Historical Background J Moshe Feldenkrais was born in Russia and migrated to Palestine at the age of 14. In Palestine, he worked construction and tutored younger children with leaming difficulties. He is also know for developing a system of hand to hand combat which was used by settlers for self defense. As a young man, he went to Paris and earned his doctorate in mechanical and electrical engineering with later work in nuclear physics. 2'3u While in Paris, he studied Judo and became the first Europea.n black belt He later 13'14 published several books on Judo. g" was also a soc@r player and in competition injured his left knee. This injury was motivation for him study anatomy and physiology and develop his own process of rehabilitation to restore function of his knee. This was the beginning of his work which later developed into Awareness Throlgh Movement and Functional Integration.2l During W.W.II, Feldenkrais was in England working on development of antisubmarine technology. During this time he taught a series of public Judo classes during which he began to develop his thinking on how people learned to move and act in the way that they do. He studied psychology and human development and became familiar with the work of FM Alexander and Elsa Gindler. Through these studies and teaching experiences, he formulated theories about development and postural control which are expressed is his book, Body and Mature Behavior, published in 1949.1s After W.W.II, Feldenkrais returned to Israel where he worked in research and continued teaching his public classes which nolv were focused more on giving people an opportunity to move more easily and comfortably. He also was developing a method of using his hands to help people to learn movement. Because of public demand, he began to teach people to do what he was doing. He trained a small group of Israeli students starting in 1968 and began his first large public ftaining with 60 students in San Francisco in l9r.75.as He died in 19134 and was unable to complete his second major training program. Philosophical and Theoretical Background The basic philosophy of his work is expressed in Body and Mature Behavior: 4 "...the human brain is such as to make ... acquisition of nerv responses a normal and suitable activity. It is as if it were capable ofTunctioning with any possible combination of neryous interconnections until individual experience forirs the one which will be preferred and active. The active patternof doing is thbrefore, essentially personal. This gr&t ability to form individual nervouspaths and muscular patterns makei it possible for fa"ulty patterns to be learned. The earlier the fault occurs, the more.ingrarned it ippears, and is. fuitty behavior will appear in the executive motor mechanisnis rvhich wijf seem later, lvhen the nervous.systglr B. grown fined to the undesirable motility, to be inherent in the person and unalterable. It will remain largely so unless the nervous paths producing the' undesirable pattern of motility are undone and reshuffled intoa betbr config"uration.', 15 Feldenkrais clearly conceived the process of learning as producing nerv connections, pathrvays and associations in the central nervous system. He further understood leaming as both physical and interpersonal. This suggested that psychological factors such as fear and amiety, could limit the actil,e experience of a child and so limit the child's learning of a full range of development of physical and emotional expression. ts The idea that faulty functional patterns could be learned lvas ne\t,at the time. It was also accepted that the motor patterns, thought to be contained in the motor cortex, were stable. So the idea that learning nerv patterns of movement might alter the organization of the motor cortrex was radical. Today rve understand that the brain and central nen'ous system are extremely plastic and that the refinements of organization and function are molded by our erpenence. The evidence for this has developed over the last 25 years.26 The ideas have been drarvn together by Gerald Edelman in his w,ork Neural Darwiniyn: The Theort of Neurorwl Group Selection..t2 Others have studied the learning process and suggestecl that there is a continuous interplay betrveen the perceptual and motor processes in rvhat Karl Nerveli refers to as the perceptual - motor rvorkspace. Within this perceptual - motor workspace, exploratory activity guides the process of learning.tt,,t These elements have come together in several recent papers by Byl sholving that leeirning and periorrnance of a repetitive task by a monkey can cause dedifferentiation of the representation of the hand in the sensorl, motor cortex resulting in focal dy,stonia like symptoms including loss of sensory discrimination and loss of motor control.s The same krnds o[ problems are seen in humans 5 with repetitive strain injuries or focal dystonias involving the hand.a It has also been shown that training can improve sensory discrimination level,3r and it has been demonstrated that a process of exploratory and variable movement and relearning sensory discrimination may be a successful approach to rehabilitation from this type of problem. 6 For Feldenkrais, the question was not whether reorganization of motor pafterns could be done but how best to do it. He drew on the developing field of psychology and summarized its efforts by .....the saying that adult personality is the result of adjustment of initial urges to the surrounding 15 conditions.,, He understood adjustment as a..successful act of learning, ... the achievement 1s of a proper response,, whatever that proper response might be, from throwing a baseball to getting along with your mother_inJaw or having a satisfactory sex life. His atbntion thus became focused not on a particular style of adjustment (Freudian, Jungian, etc.) but on the process of adjustment itself, the process of learning. His work with Judo had given him an image of ideal control of movement. This consisted of 3 elements: 1) posture which allowed movement in any direction with the same ease; 2) ability to initiate movement without preliminary adjustnents in posture; and 3) performance of movement with minimum effort and maximum efficiency.rs With the learning and teaching of Judo as his laboratory, Feldenkrais blended these ideas into a method of working in a rehabilitative way with people with both physical and psychological problems. At the heart of this process is the idea that people can best learn new patterns of control by participating in non_habitual actions. TRAINING AND PRACTICE Feldenkrais developed 2 approaches to this process of somatic reeducation: Awareness Through Movement@ (ATM) and Functional Integration@ (FI). In FI, the client is made as comfortable as possible and outside sensory stimulation is reduced as much as possible so as to enhance the arvareness of internal processes and maxim ize the opportunity for new learning. The interaction betrveen the practitioner and the client is 6 essentially non-verbal lvith the practitioner using his hands to gently guide the client through simple movements and changes in posture. Through this process the practitioner gains an appreciation of resistance to movements rvhere there might ideally be none. Through his lifetime, each person organizes his nerv.ous system to perform certain sets of activities. With injury, chronic disease, aging or faulty learning this process may become disorganized and reorganized to compensate for those chronic processes. The goal in FI is to help guide the client through a process of learning optimal patterns of control. 1? In ATM, the practitioner uses verbal guidance to take a client through a series of changes in posture. In this process, the client is asked to repeat a small movement a number of times and attention is directed to detecting changes in the feeling of stability, effort, relationship of body segments, use of momentum, elements of timing, relationship to breathing, and to the sense of the body in response to this process (larger, smaller, more or less comfortable, warner or colder, closer to the floor, etc.). The intention is to make the movement an exploratory process, introducing non_habitual elements, disconnecting the client from his habitual processes of goals and controls. in this rvay it becomes possible for the client to learn nerv patterns of control and accept or reject them as useful within the range of possible behaviors and actions. The goal of ATM is the same as that of FI. The process is slightly different in that ATM requires more internalll. generated action. If a person is unable to generate a variety of explorator), movements or if the process of generating and performing movements is too difficult or painful, FI is the more satisfactory approach. One advantage of ATM is that it can be done rvith many people at the same time, responding to the same set of verbal instructions. In this situation peopie hear and interpret the instructions in slightly different wa),s as they are able to perform them and so involve themselves in slightly'different w,avs w'ith a lesson and take slightly different, individually appropnate leaming from the experience. The goal is not for people all to learning to do something in the same way but to explore and discover the usefulness of new alternatives 7 for movement and posture. The movement might be as simple as rolling from supine to the side. In the process, a person might discover that they habitually hold their head off the floor, stop their breathing at the initiation of movement or keep a leg stiff when it would be easier to let it bend. Through the process of exploratory movement, they learn to resolve these difliculties and control the movement in a manner that is closer to the clearest intention of the movement. This process may become a microcosm for life in which a person discovers how they deal with the relationship between their intentions and their actions. It is possible to learn a lot more than how to learn a little easier.37 A sample of Awareness Through Movement lessons is available in the book by that title.16 REYIEW OF RESEARCH LITERATURE ON FELDENKRAIS@ METHOD 11 DeRosa and Porterfield have listed Feldenkrais Method@ (FM as one of the approaches rvhich can be used to achieve their objective of enhancing neuromuscular function in the treatment o[ lorv back pain. The process of ATM also addresses the issues of introducing nondestructive forces to the injured area and gil'ing the patient active instruction in optimal biomechanical function; thus addressing 3 of the four objectives thel' suggest for lorv back pain rehabilitation. These three activities may then also promote analgesia, achieving the fourth objective. The research belorv suggests that FM may be used to address a rvide variety of orthopedic problems. The common feature is that all the results may somehotv come dow'n to modiflication of Processes of motor control. Pain Management While there are no large, randomized controlled tnals demonstrating the effectiveness of Feldenkrais Method on pain management, there are a number of small studies which suggest that FM can be used successfully to reduce pain and improve function. I,ake " published case summaries of 6 patients rvith back pain who had been unresponsive to other inten'entions. All these patients achieved relief from pain and arcompanying postural changes w'ere documented. FI w'as used as a treatment but, 8 unfortunately there was no description of the specific processes of the interventions which were used and no information about the course of responsiveness or length of treatment. 10 Dennenberg studied 15 patients most of rvhom had back pain diagnoses and used FM as an adjunct to physical therapy treatment. There tvas a reduction in pain and increased functional mobility. Another interesting result was the demonstration of changes in the health locus of control in these patients. Unforfunately there tvas no control group, using only standard physical therapy, in this study. Phipps and 36 Lopez retrospectively studied 34 patients who had been through a chronic pain program in which they received FM and/or yoga as part of their program. Trvo years later thanTOVI more of these people reported moderately to completely reduced pain, a higher level of function and were continuing to use the skills rvhich they learned during the program. I Again there was no control group. Bearman and Shafarman used an intensive 8 week program of ATM lvith 7 chronic pain patients rvho rvere follorved through the Santa participants Barbara Regional Health Authority. show,ed significant decrease in pain and increase in functional mobiliry. There rvas also a decreased use of medications. All these changes were maintained at a 1 year follow-up. A most interesting finding tvas a 4O7o decrease in the cost of the care for these patients compared to the year pnor to the ATM intervention. Several other studies have been directed at more specific populations lvhere pain is e a major problem. Dean and associates rvorked rvith 5 subjects rvith fibromyalgia using ATM lessons over a period of 8 w,eeks. They, reported improvements in posture, gait and body awareness and significant improvements in parn reduction, sleep and fatigue levels. In an effort to repeat these results lvith a controlled design, Herrera et. al.zz sfudied g people with fibromyalgia using a repeated measures design w,ith a baseline control perid followed by 3 weeks of ATM. The variability, in the baseline penod made conclusions about the effects of ATM impossible; holvever, 6 of the g people reported improvemena in functional self-efficacy. In a single subject design across four subjects rvith rheumatoid 9 arthritis, Narula "'" found decreased kinetic energy for sit to stand, increased speed ol rvalking, decreased levels of pain and improved function follorving 6 weeks of ATM. All of these studies are too small to drarv broad conclusions but suggest that Flr4 can be used effectively as a method of pain management across a broad spectrum of people w'ho hal'e problems with pain. Range of Motion and Muscle Activity Feldenkrais' theory suggests that people can find more efficient ways of organizing their movement. In a group of 21 subjects, performance of a supine flexion task rvas found to require a decreased amount of flexor emg activity and was perceived as being easier after a single ATM lesson. It ri'as also shorvn that these changes were not a result of the imagery and suggestion used in the ATM process suggesting that they were a result of performing the exploratory movements alone.T Another study of 30 subjects, using a single ATM lesson, reported an increase in supine neck flexion range of motion and a decrease in the perceived effort used to make this movement.3s Ideberg " did a kinematic assessment of gait before and after 10 FI lessons in 10 patients lvith chronic back pain. Pelvic obliquity in the pain group rvas decreased compared to a healthy control grouP throughout the study and pelvic rotation increased follow'ing the FI in the pain group. Walking velocity rvas unchanged. There ivas no assessment of the effects of FI on the pain itself. Several studies have been done to assess the effects of ATM lessons on hamstring length. In the first, 38 subjects n'ere divided into control and ATM grouPs. Five ATM lessons w'ere done over a period of 2 ri'eeks. Only one of these lessons addressed hamstring function. Authors reported no change in hamstring length in the ATM goup." In another study, w'ith 33 subjects divided bett'een control and ATM groups, subjects n'orked rvith a variety of hamstnng ATM lessons daily over a period of 3 rveeks. Results demonstrated a clinically and statisticalll'significant increase in hamstring length. These 10 results were not correlaled with amount of practice time suggesting learning rather than stretching as the agent of change.aa Posture and Breathing The idea that motor control and organization can be altered suggests that posture can be modified. Changes in posture resulting from FM w,ork have been reported by Dean,e in patients ,o with fibromyalgia follorving 8 weeks of ATM lessons; by L_ake for 61 patients rvith low back pain compared to matched controls following a mean of 4 FI lessons. The use of FM for improving posture and balance has been suggested for people rvith Parkinson's disease.{ Shenkman et al also describe the use of ATM and discuss the effects on pos[ure, balance, breathing and mobility in 2 patients lvith parkinson,s disease.al Breathing has been sholvn to be improved by a series of ATM lessons, with increases in movement at the level of the abdomen, increase in erector spinae muscle activity and increased peak florv rate compared to controls.3e Recently Buchanan 3 has shown that a single ATM lesson has effects which alter a large number of standing posture variables compared to similar length inten,entions of rela.ration or stretching. This effect w,as suggested to support the idea that an ATM lesson rvas able to destabilize the habitual postural control pattern and allow, for a nerv paftern to be learned as is postulated in dynamic s1,'stems theon,.27,a6 Functional Mobility and euality of Life I have already mentioned improvements in functional mobility noted by phipps and ,o InWr36 and Dennenberg in relation to surcessful pain management. Chinn has reported significantly reduced perceived exertion in a functronal reach task compared to a control group after an ATM lesson.8 Jackson reported a 94Vo increase in uprvard displacement of the center of mass and concomitant increases in acceleration, velociry*, lvork and power afier an 8 rveek Feldenlirais professional Training program in rvhich jumping $,as not taught or addressed.2a In a group of 23 healtiry elderly people, mean age 75, 12 subjects who participated in 6 w,eeks ol ATM classes showed a significant 11 improvement in the Timed Up-and Go test compared to the control grouP.' There were also improvements in other functional measures. Another study reported improvements in functional mobility in a group of elderly people.a2 The first research using Feldenkrais Method was publishedin 1977. Gutman eL a1.20 looked a series of physiological, functional and quality of life measures in a group of well elderly people before and after a 6 week series of ATM lessons. They found improvements in several physiological and functioRal measures which were matched by changes in another exercise Broup and a control group. They found no differences between any of the post ATM goups. The strongest change reported as due to the ATM lessons was an improvement in a measure of quality of life. Stephens also found significant improvements, in a group of 18 healthy elderly between the ages of 68 and 89 compared to an age matched control group, in the vitality and mental health subscales of the SF-36 o' following a}day ATM workshop.a2 Stephens has also recently reported improvements in quality of life in a group of 4 women with multiple sclerosis following 10 weeks of weekly ATM lessons, using the Index of Well Being. ANALYSIS OF A FELDENKRAIS / PT PRACTICE I have a small, independent, part time physical therapy practice in which I see people rvith orthopedic, neurologic and cardiopulmonary diagnoses. i see people once per lveek or once per 2-3 w'eeks and give them major responsibility for an active home prograrn of ATM or regular PT exercises. Rarell', I see people tlvice per rveek in acute situations or with children. I rvork w'ith each Person one on one for an hour. This process allorvs people to achiel'e a madmum amount of learning and benefit in a session rvith me and then to continue exploring this lesson and its effect in their lives over a period of days to further develop and incorporate the learning. I have recently completed a utilization review'of the practice over the last i0 )'ears. There have been a total of 180 musculoskeletal patient-episodes of care. Tlventy-three of t2 these rvere consults only. These people lvere seen for evaluation and/or consultation and were seen only one or tw,o times. The remaining 157 cases were seen through to discharge. The utilization review is a simplified version of the data set created by FOTO, Inc. includes It 20 variables. The gender distribution was35To male and 65Vo female. The age range tvas from 15 to 86, with a distribution as shorvn in Table 1. For purposes of description only, cases are divided into groups by primary body region involved. In treatment, I do not approach this region as a single focus of intervention. The approach is to integrate sensory - motor function throughout the body as a rvhole as seen in the case descriptions. The body region variable contains 16 descriptil.e levels. Eleven body region variable levels are represented in the musculoskeletal cases. The most commonly seen are listed in Table 2. A list of the range of the primar),diagnoses by body region, by ICD_9, is shorvn in Table 3. Outcomes have been tracked in 2 rvays: ( 1) percentage of goals met (see Table 4 for definitions) , and (2) number of treatment sessions until discharge. It can be calculated from Table 5 that 9l7o of the cases rvere discharged having achieved most or all of their goals established at initial evaluation. This ranged from 4OTo for cases involving the foot and ankle to7l7o for the thoracic spine to greater thang6To for all the other regions. The average number of sessions per person for all cases and diagnoses together w,as 12.5. This average ranged from 4.0 for people ri,ith pnmary' referral for TMJ to 17.6 sessions lor people rvith diagnoses including rheumatic or other inflammatory types of processes. For several body regions, the median number of sessions is considerabll,.less than the mean. This indicates that the distribution of number of sessions is not normal but is negatil,ely skerved rvith a small number of people receiving a high number of sessions. (see Table 5) 1e The preferred practice patterns for musculoskeletal diagnoses suggests a range of expected number of visits from 3 to 87 depending on w,fuch of the 9 patterns is being considered. 80Vo of cases are expected to achieve goals rvithin these time frames. An t3 oyemll analysis of the musculoskeletal cases in this practice, without reference to diagnosis or practice pattern, shows that the SOVo ofpatients achieve most or all of their goals and are discharged by 17 sessions. This is well within the expected range. CASE PRESENTA.TIONS Introduction These cases are presented as an illustration of how Feldenkrais Method can be used within the context of physical therapy and rehabilitation in orthopedics. This is a representative sample of cases illustrating problems involving different diagnoses and body regions. In each case I will present a question which will focus the role of the Feldenkrais work in that case. Each presentation follows the format presentation and history, physical findings, assessment, the question, treatment plan, treatment progression, outcome. Case 1 M.D. presented with a diagnosis of DeQuen'ain's Syndrome. She had pain in the left hand radiating into the wrist, arm and shoulder w'ith resulting loss of range ol motion, strength and function in the L UE rvhich interfered w'ith ADL performance. M.D. is a 52 year old \\'oman rvho rvorks as a playrvright and loves to rvork in her florver garden. Both of these tasks as well as other ADL require intense use of the hands rvhich she x'as unable to do. M.D. had strained her L w'rist in an exercise class one year prior to my evaluation. She rvas treated rvith steroid injections ri,'hich gave temporary relief. The injury u'as exacerbated 3 months later w'hile she rvas using crutches follorvinB surgery on her R foot. Her L rvrist w'as strained again a month later w'hile canf ing a carpet over her shoulder. A subsequent series of physical therapl' treatments focusing on strength and range of motion of the L w'rist did not help her. She visited a hand specialist, rvho suggested surgerl'to T4 relieve the problem rvith pain, and she rejected the option of surgery. Her medications included estrogen and antidepresunt rvhich she had been taking for more than 1O years. Evaluation shorved inflammation and tenderness at the L radial styloid, the distal wrist flexors and extensors and intrinsics of the L thumb. There tvas a decrease in L rvrist flexion and extension ftmges to 45o but L thumb ROM w,as normal except parnful at all end ranges. There was mild weakness (+1, in the L lvnst and thumb in all ranges u,ith pain. Her pain increased throughout the day and rvith all hand functions including carrying, gripping, and tlvisting. Sensation was intact. There tvere unusual patterns of motor control in the hand. She did not use fingertip control in gripping, instead using lateral gripping patterns involving the thumb w,hich increased pain. She also maintained her rvrist in a slighfly flexed and ulnar deviated position rvith the thumb MCp in hy,perextension in many ADL tasks. This also caused pain. It seemed clear that M.D.,s pattems of motor control and her determination to continue to do her daily activities, w,hile admirable, were exacerbating her condition. The question for M.D. rvas: How could she become aivare of the role of her habitual movemenl pattems and learn to change them and at the same time improve her function? It w.as most important to inyolve her as an active agent in her orvn rehabilitation. The early treatment plan involved anti-inflammatories and icing to control inflammation, active motion of the thumb into abduction w,ith the MCp and DIp flexed (5 set o[ 10 reps each da1), use of thumb and finger tip control of objects and development of aw,areness effort in the handirvrist activities rvhich increased and decreased strain, and nerv functional positions of the rvrist and hand. After the second session, a tennis ball became her constant companion. Her task rvith the tennis ball w.as to hold, manipulate and squeeze it using her finger tips to keep the thumb out of the adducted and hl.perextended position and to move the ball around through space bl.mol.ing the w,nst through all ranges w,hile maintaining relaxation through the rest of the arm and shoulder. At the beginning of each session I lvould ask her to tell me w,hat she had learned that w,eek about using her hand. In 15 this way she began to develop awareness about how shb organized her hand to do different tasks and her use of fingertip control became more habitual. By the 4th session inflammation was controlled and PRE with wrist flexors was begun. This was progressed over time to include all ranges of wrist movement done in positions which kept the thumb abducted. By the fifth week, pain was more localized around the radial styloid and while weeding in the garden she felt her thumb extensor tendon snap, "like something snapped back inlo placn", following which she was able to do full range, painfree wrist extension. AfterT sessions (9 weeks), she was discharged with full function, ROM and normal strength and only occasional twinges of very localized pain. Her concluding remark was that she was "much more thoughtful and careful now about how I use my hand so as not to reinjure it. My activities are not limited. I just have many different strategies now for doing things." Case 2 F.D. presented rvith disabling lorv back pain and neck stiffness. Pain exacerbated rvhen he w'ould stand or sit for more than 5 minutes or with bending and trvisting. He is a 63 year old high school math teacher so standing and sitting are critical to his work and life. His goals were to be comfortable in his teaching work, to be able to exercise and w'ork in his garden. F.D. rvas a stocky, muscular man rvhose past medical history included hypertension for 20 y'ears rvhich $'as controlled by medication and diet, and polymyalgia rheumatica. Two years previously he rvas treated for a frozen shoulder follorving an exercise iryury and one year previously he undenvent arthroscopic cleaning of his R knee. Evaluation revealed tenderness to palpation al C2-6 andlA-5. Range of motion rvas moderately limited (507c) in the C spine; severely limited in the trunk (forw,ard flexion to 15" above the floor, Iateral flexion 4" above the knee);and slightll'limited at the R shoulder and the hips B/L. Quads and hamstrings \\'ere verl' tight. He had normal strength 16 throughout except hip extension and abduction (+15). He fatigued very rapidly with simple repetitive leg movements. His pain rvas disabling during prolonged (> 5 minutes) sitting or standing activities but did not project down his legs. Sensation was normal. His standing posture showed a mild fonvard head and swayback with the trunk slightly rotated to the R, head tilted to the R and a mild C cune to the L in the T spine. His mobility rvas independent at all levels rvith good dynamic balance. He had difficulty gerting in and out of his car. His gait rvas slorv and stiff with decreased trunk rotation and decreased flexion in srving. When doing a floor transfer , he needed to use a lot of UE support and strength and had considerable pain. F.D. rvas rigid in the upright position possibly as a result of muscular development or possibly related to protection from pain. The question for F.D. w,as: Could he learn to use his trunk more in his movements? What would be the best w,ay to go about helping him to learn to do this to malie his functional mor.ement easier? Because the pain x,as not radicular in pattern, I didn't see pain as an issue from the beginning. Treatment plan: The long term goal rvas to develop control of trunk, posture, and mobility in a variety of tasks. in the second session, after evaluation, w,e began w,ith an ATM lesson in supine designed to improve control of flexors of the hips, neck, arms and trunk. It quickly became clear that this w,as too difficult and the movement goal became rolling to the side in a controlled manner using flexion. F.D.'s stiffness tvas so great that he was unable to do this lvithout losing his balance initiali),. The result x,as that he felt more relaxed and had less back pain and his w,alking felt more fluid during the subsequent rveek. The third session continued using small movements of the hips, arms, and neck in concert rvith trunk lvith some improvements in control of flexion movements in supine. In the fourth session we began an ATM lesson moving from long sitting (He needed to support himself rvith his arms to maintain this position.) to side sitting. During the next pain .,1 w'eek his movements became much easier. rvas not much of a problem and he said f,eel like I can see the light at the end of the funnel,,. The fifth session continued the fourth t7 by extending the movement from side sitting to standing through a half kneel position. At each point in this movement rve needed to find ways to control balance and use momentum. This required thinking about the position of his hands and knees and the movement of his arms and head. By the end of the 5th session he was able to do this activity (transfer floor to stand through half kneel) easily although not as a smooth continuous movement. His back pain was now much reduced, horvever this activity was extremely tiring for his legs. The next session continued the rvork of refining the control of the sit to stand movement by reversing the direction and working rvith control of stand to sit using a spiral motion guided by placement of the hands to the floor. During this session we also began aerobic conditioning on a Schrvinn bike after cleanng his cardiopulmonary.function. At home he began brief bouts (30-60 seconds) of squat rvalking to strengthen his legs and started lvalking to build his endurance. Over a rveek he increased his walking to 1 mile. At the beginning of the seventh rveek, he rvas able to laterally flex his trunk to 3,, below his knee and fonvard bend to 8" above the floor. He had no back pain, his n,alkrng was much easier (i.e. much less tiring) and he had started doing a little gardening. We continued working rvith the standing lloor transfer, worked in quadruped with movement of the hips, knees and ankles; and began rvorking rvith a movement of sitting and rolling back into supine. He had no pain *'ith this movement but rvas unable to coordinate the control of his trunk to do the movement ri,ithout loss of balance. The follorving *'eek he reported feeling great, having no pain and doing lots of rvork in his garden. In the last session, we refined control of the sit to supine roll, rolling up to sitting, continued w,ork with the spiral movement of sit to stand to sit and rvorked w,ith some trunli rotation movements in standing. At the end of the eighth rvee[ his forrvard bend reached 1" abol.e the floor and he was discharged rvith a home exercise program of rvalking, gardening, continuing to w'ork rvith the spiral floor transfer movement until it rvas smooth and easy' and the standing / turning ATM until he w,as able to place his palm on the rvall directh' 18 behind him without difficulty. In g sessions, F.D. was working without pain and had achieved all his other goals. Case 3 F.E. presented with a diagnosis of cervical and low, back strain and a left fiozen shoulder. She was referred by a colleague rvho, after 30 treatment sessions employing traditional stretching, strengthening, modalities and craniosacral treatments, rvas Irustrated by being unable to resolve the injuries sustained in an MVA. F.E. had w,atched in the rear view mirror as she lvas hit from behind by a drunk driver rvho tailed to stop at the light. She was not knocked unconscious, sustained no head injury, and there tvere no rotational movements as she was throrvn back against the seat and then fonvard against the steering rvheel. In the process her left shoulder rvasjerked by the seat belt. F.E. is a 38 year old rvoman rvhose pMH included asthma rvith pneumothorax x 2, removal of a benign breast tumor and hl,sterectomy 10 years prei,iousl1,. Her medications included estrogen, Slobid, and Asthmacort. The overall inpression of the irutial evaluation rvas that F.E. was tired and agitated. She was tighrly guarding the L side of her body, unable to do her normal activities and unable to sleep rvell. Specifically, in standing, her L shoulder rvas elevated and retracted and her lumbar spine ri as flat. She w,as only, comfortable in a sitting and supine positions. She rvas tender to palpation throughout the L neck, shoulder and back and her pain increased to a6lLOlevel w,ith rvalking or standing for 5 minutes and with all movements of the trunk. Cervical ROM w,as limited 50Vo inlateral flexion and painful at all end Enges. Trunk rvas limited greater than 50Vo in all ranges. The L shoulder shorved a restricted capsular pattern rvith flexion 135o, aMuction 1?0", and extemal rotation 6C)o. Sensation in the L arm rvas intact and strength appeared to be functional throughout but F.E. complained of weakness in the L arm and hand and of dropping objects. Finally her breathing pattern w,as rapid, shallorv and guarded. 19 What FE needed immediately was to be able to find some comfortable resting positions and get some good sleep. Also her history suggested that her rib cage had been traumatized in the past through asthma" pneumothorax and breast surgery and that this might be a sensitive/ difficult/ dangerous area for her psychologically. The question for FE was: How could she find some comfort and rest and then overcome her fear and pain and reestablish normal movement? The general teatment plan was to use FI to open up her breathing and establish comfort in sidelying and prone as well as supine and sitting; then to develop ATM lessons which would lead her back to establishing normal movement patterns with the L upper extremity and trunk, developing strength in the process. In the first session following evaluation, we worked in supine using FI. Gentle pressure was used first on the R then on the L to enhance the rib movements associated with breathing; then to improve the mmfort of L lateral flexion in the thoracic spine and extension in the lumbar spine. At the end of this lesson, short pieces of ATM were inkoduced: 1) supine bridging with the L leg only and reaching (shoulder protraction) with the L arm, and2) prone, the beginning of a pushup using only the L arm. Both movements were well within pain tolerance and introduced to grve FE a taste of some comfortable movement and strength involving her L shoulder. She was asked to work with these 2 small movements as her home exercise prograrn. At the end of fhis session she was breathing fully and deeply and had more color in her face. She had full ROM of her L shoulder with pain at (Ztlo)and full pain free extension and rotation of her trunk. Her next session was? weeks later. She reported being able to sleep comfortably, move much more easily but that she still had soreness around her L shoulder, scapula and mid-thoracic paraspinals. Again we worked with FI this time starting in sidelying and then moving to prone. I gently went through a series of movements with her L arm taking the scapula through its range in each movement and then integrating the underlying rotation, flexion and extension movements of the trunk and ribcage which support the movements of the arm. We then moved to prone and developed