Complementary and alternative therapies: beyond traditional approaches to intervention in neurological diseases and movement disorders

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Complementary and alternative therapies: beyond traditional approaches to intervention in neurological diseases and movement disorders

DARCY A. UMPHRED, PT, PhD, FAPTA, CAROL M. DAVIS, DPT, EdD, MS, FAPTA and MARY LOU GALANTINO, PT, PhD, MSCE

The use of complementary and alternative methods (CAMs) in the treatment of patients with neurological disorders and resultant movement problems is evolving into common practice. Clinicians and patients/clients are seeking nontraditional approaches to relieve signs and symptoms of neurological diseases, syndromes, and movement disorders as well as to attempt to alter the progression of diseases of the central nervous system (CNS) through unconventional movement therapies and manual therapeutic approaches. It is important that professionals working within a traditional rehabilitation environment understand the principles and practices of complementary, alternative, and even transdisciplinary approaches to the treatment of movement problems because many of these therapeutic approaches are being proposed as options in the management of body system problems and restrictions in daily life activities and independence resulting from neurological problems. The clinician needs to be cautious in the application of these treatment modalities. We do not want to accept alternative therapies as intervention solutions without significant evidenced-based research substantiating the use of these approaches. The reader must also be reminded that evidence comes from effectiveness, and many complementary approaches have established effectiveness.1

This chapter presents a sampling of alternative therapeutic models and philosophies that are available and could potentially assist patients/clients who have movement dysfunction because of CNS pathology. Most of the techniques discussed in this chapter have been firmly established by sound research; some less–evidenced-based models are also included to widen the scope of therapeutic models. Clinicians are continually being exposed to the therapeutic potentials of less scientifically established theories and therefore need to be aware of their existence and potential. Creating evidence-based practice is not an all-or-none principle, nor do we suggest that models that do not have a strong research base are ineffective. We do suggest that to adopt a model because of belief or the charisma of the founder will be and should be challenged by colleagues today and in the future. Models whose theoretical constructs are based on sound rationale or that link effective-based practice across multiple areas need to be scrutinized and approached cautiously but should not be nullified as potential alternatives. In time, if those models maintain their sound base, more research will be developed and their efficacy established. New models will also be created in the future that link and integrate theories with practice, and our professions will continue to evolve and offer better-quality care to the consumer.

Historical perspective

Jennifer M. Bottomley

Darcy A. Umphred

A historical perspective of how complementary and alternative therapeutic approaches have evolved to become increasingly part of the medical and rehabilitation landscape can be helpful to obtaining a broader scope of how they link to allopathic medicine of today. The language and rationale encountered in alternative methods can seem confusing and foreign to clinicians unfamiliar with modalities outside of the realm in which they were taught. With many of our patients/clients seeking alternative methods of intervention beyond what the traditional Western medical model can offer, the time has arrived for us to explore and understand the scientific basis for the apparent effectiveness of these interventions. The positive results experienced by many patients/clients who have received alternative interventions cannot be ignored. This is the impetus for the growing acceptance of alternative forms of therapy by the general public and many health care practitioners. Can we scientifically explain the effects of complementary and alternative interventions? And if so, how can we best integrate complementary and alternative approaches into our accepted, current, and changing approaches to neurological rehabilitation?

Looking at the evolution of health care throughout the world over hundreds and even thousands of years, general categories or worldviews have developed that best categorize philosophy of management of individuals with health care issues and their respective rationales for practice. In the following paragraphs a further discussion of these four worldviews will help the reader identify how the practice of health care today still fits within the second worldview but has begun to fractionate into the third worldview as linear research based on two variables does not explain the multiple variables involved both in disease or pathology and in recovery of function. In their book The Second Medical Revolution, Laurence Foss and Kenneth Rothenberg described levels of academic learning as being three tiered.2,3 Starting at the top, the third tier comprises the applied studies and subjects for therapists, such as therapeutic exercise and electrotherapy. The second tier is the pure sciences on which these subjects are founded, such as anatomy, chemistry, physiology, and biology. The first tier is the “assumption of reality” (day-to-day observations) on which the pure sciences are based. This first tier consists of the basic assumptions found in “worldviews” today. Different worldviews yield different scientific bases, whether pure or applied. Alternative approaches used in medicine and rehabilitation are well established in “premodern” and “postmodern” worldviews. This is in contrast to the “modern worldview” customarily taught in current Western medical training. To present these methods in overview, it would be helpful to discuss these worldviews and how physical therapy (PT) and occupational therapy (OT) may fit into the scheme.

Essentially, there are four worldviews4: the premodern, modern, “fracturing or splintering,” and postmodern views. The first worldview developed during prehistoric times and lasted until the sixteenth century. This is called the premodern view. In this perspective, time is cyclical rather than linear. In other words, it was believed that the sun, the moon, and the stars circle around the earth, the tides ebb and rise cyclically, and the seasons circle back again and again, using the same patterns each time, connecting with “deep time.” Deep time is compared with profane time. Profane time is tangible, as in the time it takes rice to boil; or visible, as in the sundial; or sensible, as in the heartbeat. In deep time such perceptions are suspended, profane time stands still, and one becomes a part of time. It is in deep time that premodern man finds reality. Infused in this thinking is that life and death, the earth and the sky, are mysterious or mystical. In other words, they contain truth beyond human comprehension.

This is a hard perspective for many to grasp, yet the role of the scientist is to be a passive observer. Numbers were used to describe observed events, such as the days between the circling of the sun and the moon, and the number of hours between the ebb and high tide, but “there was no widespread assumption in the western world that natural processes in general had any intrinsic relation to numbers, to mathematics.”5 In other words, in Western science, these perspectives were not tangible, visible, or sensible…and so, historically, science moved on.

The second worldview, which began with Copernicus, is known as the modern worldview. It is the one with which the majority of the Western population would be most familiar and feel at home. In this view time is linear, progressing from start to finish. “The world is a rational, predictable, clockwork universe. Every bit of it can be predicted if you know one part of it. Purpose in life is to describe, generalize, predict, and control. Human beings are fairly mechanistic, separate, discrete entities from the rest of the universe.”4

René Descartes (1596-1650), French philosopher and mathematician, and Isaac Newton (1642-1727) were two of the most important figures ushering in the “modern era.” To Descartes, the world was logical, predictable, and intrinsically expressible through mathematics. The whole was obviously equal to the sum of the parts—categorical and hierarchical. The role of the scientist became that of an active, experimental, objective observer. If the numbers did not fit, it could not be real.

The modern era of the second worldview spanned the 1500s through the twentieth century. However, the near perfection of the view began to falter in the early 1900s with important discoveries in the field of physics. Although the hold of the second worldview on Western culture is still immense, it is splintering, as can be seen within our own professions.

Worldview 3 is about this fracturing, about the realization that the categorical, orderly clockwork is not a complete or necessarily accurate picture. It is a prelude to worldview 4. A small but growing number of people see the world in worldview 3, and fewer yet in worldview 4, but the effects are starting to be felt.

Worldview 4, postmodern, is complex, integrated, and nonlinear. It is about self-organizing and self-regulating systems, looking for patterns, and knowing that a small variation in the pattern can produce large changes. Time is a dimension, interwoven with the dimensions of space. Time and space can change, expand or shrink, speed up and slow down. Rituals are an important means for creating order. The whole is greater than the sum of the parts, and “we know and yet don’t know.” Worldview 4 has a lot of similarities with worldview 1. The pure sciences that arise from this worldview include systems theory, quantum physics, cybernetics, string theory, and fractal mathematics, which in turn affect many other fields of study, such as meteorology, ecology, business and economics, medicine, theology, movement science, and computer science, to name but a few. Research parameters, technology, and interpretation differ significantly from the assumptions of worldview 2 because scientific description is no longer considered purely objective, but rather epistemology (the view from which knowledge is gathered) is becoming “an integral part of every scientific theory.”6 Western medicine has begun to shift from the second worldview into the third worldview because a total linear approach to explain efficacy has not proven inclusive and cannot always explain why individuals do and do not recover from disease or pathology or the functional loss they produced. The professions of PT and OT have run into the same dilemma as Western medicine and are also making similar shifts. The incorporation of alternative or complementary approaches that take into consideration the mind, body, and spirit is becoming more acceptable as colleagues embrace the shift in thought process. Change will come. The rate and the depth of that change will depend on the openness of all of us to accepting different research methodology and outcomes while still embracing those linear research models of today that we believe lead to efficacy or evidence-based practice.

Today we practice within the paradigms of our professions, which have in the past aligned with Western medicine. Thus, for our ease, we can first start where we are, look at the medical profession, and discuss models or strategies that parallel the worldviews.

The roots of Western medicine extend back to Hippocrates, 400 bc, who provided a holistic picture of the state of health, writing that “Health depends upon a state of equilibrium among the various internal factors which govern the operations of the body and the mind, the equilibrium in turn is reached only when man lives in harmony with his external environment” (p. 23).2 The basic assumption in this perspective is that health depended on a balance with mind-body and nature or the environment, and disease was a disturbance of this balance. Preserving the balance was the priority for the practitioner. Three means were used to ascertain the characteristics of an illness: a dialogue with the patient, observational assessment of the patient’s appearance, and palpation of the soft tissues and pulses. The most important component of this approach was considered the dialogue with the patient/client. It was believed that the “meaning” of the illness to the patient/client, and his or her attitude and expectations were valuable diagnostic and prognostic factors. This coincides closely with the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model accepted by rehabilitation professionals around the world.7

Descartes largely initiated the shift from a preservative approach for mind-body-environment integrity to the conventional curative thinking found in medicine today. He conceptualized reality as having two separate domains, one the body or matter, the other the mind. “The body is a machine,” said Descartes, “so built up and composed of nerves, muscles, veins, blood and skin, that though there were no mind in it at all, it would not cease to have the same [functions]” (p. 32).2 His ideas were closely tied to newtonian physics, which conceives the universe as a harmonious and well ordered machine. These concepts gave rise to the view that matter and nature were separate from humans, and thus one could observe without affecting what was being observed. The physician, then, could have complete objectivity when assessing the patient. The patient could be viewed as a biological organism whose function was reducible to interrelating physical parts.

The resulting medical model, known as biomedicine, was fully in place by the middle of the nineteenth century. Its characteristics may be considered as follows:

1. Disease or dysfunction is a “deviation from the norm of measurable biological parameters” (p. 23).2 A patient/client is a biological organism whose dysfunction is reduced to the identified deviations. Treatments or procedures are then used to cure or at least improve the deviations, which in turn improves the biological condition.

2. Objectivity provides the basis for diagnosis or assessment and the subsequent rationale for treatment. Patients’/clients’ descriptions of what they are experiencing and the clinician’s observation are considered “subjective” and not given as great a value as the “objective” findings, such as laboratory or other measured tests.

3. Eventually biomedicine can address virtually all medical problems at least adequately, if not fully, through more knowledge and research.

It goes without saying that the biomedical model has produced stunning and tremendous accomplishments. Yet its restriction to physical causes of disease, in light of diseases and dysfunctions that are more widely recognized as having multiple causes, is creating a search for other answers. More of the public and some physicians and other health professionals are turning to alternative forms of intervention and healing. As stated in Life magazine in September 1996, “Why have alternative therapies in this country started to migrate from the margins to the center? One reason is that as allopathic medicine, a term commonly used to describe western techniques, becomes better at what it can do well, its limitations become more conspicuous. Allopathy is clearly superb at dealing with trauma and bacterial infections. It is far less successful with asthma, chronic pain and autoimmune diseases.”8

Many of the alternative practices used in a medical setting today clearly come from premodern worldview sources, such as acupuncture, yoga, meditation, herbal remedies, and prayer. Just how some of these therapies work to restore health is difficult to perceive from a linear worldview 2 perspective. Frequently what happens is that alternative approaches are used to address areas of limitations in the biomedical model, in a complementary fashion. Alternative practices used this way do not supplant traditional medicine; rather, they support and enhance the options available in health care. A new worldview and medical model would not necessarily arise from this relationship, yet the conceptual framework is no longer cohesive. Ideas from ancient sources, as well as postmodern sources, are changing the previously complete and adequate image of the second worldview and consequent medical model. Grappling with these issues places one in worldview 3.

Evidence of these dynamics is apparent in the professions of PT and OT. In neurorehabilitation, for example, proprioceptive neuromuscular facilitation and neurodevelopmental techniques were developed in the middle of the twentieth century at a time when “rehabilitation” was being established as an integral part of unquestioned biomedical order. Both approaches, in their early form, worked primarily with the nervous system, and both used hierarchy and order. Patients/clients were to progress through a sequence of skills, such as the developmental sequence, that was invariable. The hierarchy was also found regarding the role of the therapist as the professional who could identify the pathokinesiology and “fix” it with the appropriate technique. The patient was the recipient of the treatment. With the advent of motor control, motor learning, and neuroplasticity theories over the last couple of decades, these fixed approaches have changed because the new concepts have influenced them. The developmental sequence, now termed learning sequence, no longer uses a strict hierarchy based on movement development of a child. Its treatment approach is moving away from emphasizing the therapist’s role in identification and resolution of pathological movement and moving toward a science of functional movement that is based to a large extent on the role of the patient in his or her own capacity to problem solve, self-monitor the motor control system, and help establish outcome expectations on the basis of function, not pathological conditions. Last, an entirely new entity of neurorehabilitation has been formed recently as a result of concepts from motor control, motor learning, dynamical systems theory, and the understanding of neuroplasticity, which is known as the task-oriented or functional approach. Masters of the past used the available science to justify their respective approaches, but the one thing that all masters seemed to hold in common was a close relationship with their clients. They all let that relationship and the needs of the client determine how treatment progressed irrespective of the verbal explanation given for any sequential progression of treatment. They wanted the client to become functionally independent and have the highest quality of life that was possible for that individual. Those masters in the past did not have the science of today to explain why a treatment was effective. The fact that they created an environment that brought about the functional change in the patients would suggest that they intuitively used motor learning, motor control, and neuroplasticity because their patients improved in function over time.

One of the tenets of dynamical systems theory, as noted in the journal of the American Physical Therapy Association (APTA) in 1990, is that “biological organisms are complex, multidimensional, cooperative systems. No one subsystem has logical priority for organizing the behavior of the system” (p. 770).9 The nervous system, then, is no longer a dominant subsystem with neurological patients. Rather, it is part of a self-organizing system that has multiple subsystems such as arousal, gravity, learning style, body weight, center of gravity, cardiovascular function, and so on. “No one subsystem contains the instructions for [an action]. . . . The behavior of the system is instead an emergent property of the interaction of multiple subsystems” (p. 771) (see Chapters 4 and 5).9

Added to these developments was the emergence in the 1980s of a new field of therapy intervention: vestibular habilitation for posture and balance, which is multisystem and multifunctional and inherently demands the use of motor control and learning principles and understanding of the mechanism of neuroplasticity and interactive systems theories. Systems concepts are used for both balance and the task-oriented approach, the concept being that “movement emerges from an interaction between the individual, the task, and the environment”10 (see Chapters 11 through 17 and 19 through 31).

Orthopedic, or manual, PT appears to be firmly committed to the biomedical model, yet there is interest found in “being holistic,” and treatment and exercise approaches are continually being developed that endeavor, to various degrees, to work with movement and function in a broader and more integrated manner (see Chapter 18).

Thus we find that today therapists are incorporating systems concepts, motor control, and motor learning theories into practice and experimenting with ancient sources of healing, such as yoga, tai chi, acupressure, and meditation, as well as refining skills in the traditional biomedical aspects of therapy. For our professions, holistic approaches have created and will continue to create change, and change can be confusing, threatening, and exciting all at the same time.

Worldview 2 still remains the dominant model within the Western allopathic health care delivery system. Two distinct observations may be made that show the prevalence of a worldview 2 approach. The first is that many colleagues continue to consider themselves to be objective observers separate from our patients. The second is that we endeavor to understand ancient, modern, and postmodern therapeutic concepts and research, frequently from a linear, mechanistic, categorical worldview 2 epistemology. Yet such a view at times does not suffice to explain what is happening. That is the dilemma of worldview 3.

Further changes will be experienced when a critical mass of the population turns fully, in all aspects of personhood, to “worldview 4,” which, again, has great similarities to worldview 1. A big difference, though, is that at this time in history, we have scientific methods for understanding our nonlinear, complex, evolving, multidimensional, multilevel, continually interacting, irreducible world. Through systems theory we can handle, with sophistication, this multitude of complex detail, by working with its “sweeping simplicity and order in overall design.”3 Throughout the twenty-first century, as the growth of worldview 4 continues to evolve on many levels and in many fields of endeavor, it is entirely possible that it and its sciences will indeed replace, and not simply complement, worldview 2. And from there, the future has yet to be conceptualized and belongs to future students willing to venture beyond what is comfortable to best meet the health care needs of a world society.

Alternative models and philosophical approaches

Darcy A. Umphred

Approaches to patient management that do not fall within a traditional allopathic medical model are often considered alternative or complementary. Although many of these therapeutic approaches have not been able to show effectiveness or efficacy in totality as an approach to medical management, neither has Western medicine. Although the evidence-based method of medicine is the accepted term for identifying outcome measures by reliable and valid instrumentations and interventions, there is controversy within the literature as to the validity of evidence-based medicine.816 Personally, I have been a patient for the last two decades with interactive health issues that medical practitioners cannot explain. I have been told by at least seven excellent medical specialists that, when looking at their specific area of specialization, they have never seen the specific system problem that my body system presented. Thus, not knowing what it is, each doctor does not know specifically how to treat the problem. Medical doctors know there is some genetic basis and understand the specific system problem from a descriptive perspective, but cannot explain how and why the system problems interact. Thus a syndrome exists without a medical diagnosis. My medical case was submitted to the National Institutes of Health (NIH) as a potential syndrome for which they might find a diagnosis. NIH returned the case saying they do not have the ability to determine the diagnosis because it is much too complex. Doctors have had to stretch beyond their comfort zone to help me and work with me in order for me to remain on this plane we call life.

Medical practice is evolving, as are the practices of PT and OT. Future research will help validate many aspects of Western medicine, and some areas will be discarded. The same will happen to OT and PT practice. Similarly, research will demonstrate the effectiveness of many components of complementary approaches, although some components will need to be eliminated and new creative ideas and therapeutic techniques developed. One research problem encountered with complementary approaches is that these approaches consistently focus on the patient as a total human being with all the interactions of all bodily systems. This philosophy of the whole does not coincide with the linear, reductionistic physical research accepted by Western medicine, in which one variable is studied while another is controlled. PT and OT involve the same approach to research, in which one approach may be compared with another, such as overground walking versus body-weight–supported treadmill training. One may or may not be more efficacious, but the investigations as to why it is or is not, and what other variables are affecting the results of the study may be needed. These answers are still beyond our understanding. Until research models are developed and instrumentation becomes available that measures multiple systems at multiple levels of consciousness simultaneously, it will be difficult to prove the strengths of many aspects of alternative approaches to patient management. That does not mean the evidence is not there. It means our research skill may not have developed to the level of measuring all the influences that are interacting simultaneously during a complementary approach intervention. Finding those research models with supporting instrumentation is and will continue to be a challenge to therapists who choose to incorporate these interventions as part of their professional management of patients with neurological disabilities. If doctors had made the decision to stay within their respective branches of evidence-based medicine, I (D. Umphred) would no longer be editing this textbook. There are many holes in our understanding of movement science, just as there are holes in medical science. Answers to questions often do not come from research scientists but from clinicians finding solutions to specific patient problems. Once those potential solutions have been identified, research may be able to refine and identify the specific components that are affecting change as long as the tools are available to accurately identify the initial problem(s) and the intervention(s) creating change.

All of the models for patient management presented in this chapter have a common thread. All approaches focus on helping the patient/client maintain or regain a quality of life that is within that person’s potential. The specific philosophy or conceptual framework embraced by any one approach varies. As various approaches are introduced in the following sections, subheadings will help the reader categorize similarities of philosophies. Even with the discussion of any or all of these approaches, whether accepted by our professions as the best available today or considered complementary, it still seems that we are looking through holes at what is total. The whole or total is made of all possible interventions that have, are having, and will have efficacy. When we no longer need to view problems with a specific model influencing our approach but are able to base our decisions on truth, we will finally be able to access what is truly available to us as practitioners and give the best possible guidance and suggestions to our patients to help them regain or maintain motor function as they experience life on a daily basis.

Movement therapy approaches

Equine-assisted therapy

Kerri Sowers, USEF National Paraequestrian Classifier

Introduction to hippotherapy and therapeutic riding.

At the 1952 Helsinki Olympic Games, a Danish dressage rider named Liz Hartel won the silver medal and inspired a renewed interest in the field of hippotherapy and therapeutic horseback riding (THR). Liz used horseback riding as a form of rehabilitation to aid her recovery from poliomyelitis, which left her lower extremities paralyzed.17,18 The use of horses in therapy to improve physical and mental health has its founding roots in Greek culture. The term hippotherapy originated from the Greek word hippos, meaning “horse.”19 The renewed interest in hippotherapy and THR grew first in Europe and was especially popular throughout England. In 1969, the North American Riding for the Handicapped Association (NARHA) was founded; this organization established standards for the developing THR centers in the United States.1720 Recent studies conducted in North America show that approximately 90% of children with disabilities participate in THR programs, and the remaining 10% participate in hippotherapy sessions.21

It is crucial to understand the differences between hippotherapy and THR, as both programs are commonly offered at the same facility and are often mistakenly thought to accomplish the same goals. The American Hippotherapy Association (AHA) defines hippotherapy as “a term that refers to the movement of the horse as a tool by physical therapists, occupational therapists and speech-language pathologists to address impairments, functional limitations and disabilities in patients with neuromuscular dysfunction. Hippotherapy is used as part of an integrated treatment program to achieve functional outcomes.”20 During hippotherapy, the horse is used as a modality or treatment tool; the therapist and his or her assistants control the horse in order to effect a change in the patient/client. In contrast, THR teaches the client specific riding skills that allow the rider control of the horse’s movement; the focus is on teaching horseback riding skills to riders with disabilities. AHA attempts to clarify the difference by stating that hippotherapy “treatment takes place in a controlled environment where graded sensory input can elicit appropriate adaptive responses from the client. Specific riding skills are not taught as in therapeutic riding but rather, a foundation is established to improve neurological function and sensory processing.”20

Benefits, indications, and precautions.

Hippotherapy and THR are felt to be beneficial because the equine walk provides a multidirectional input resulting in movement responses that closely mimic the movement of the pelvis during the normal human gait. The movement is both rhythmic and repetitive and allows for variations in speed and cadence. In hippotherapy the horse is used as a dynamic base of support (BOS) to assist in improving trunk control, postural stability, core strength, and righting reactions to improve balance.22 Vestibular, proprioceptive, tactile, and visual sensory inputs are incorporated during a hippotherapy session. As stated by the AHA, “the effects of equine movement on postural control, sensory systems and motor planning can be used to facilitate coordination and timing, grading of responses, respiratory control, sensory integration skills and attentional skills.”22

Hippotherapy is indicated for neuromuscular conditions characterized by reduced gross motor skills, decreased mobility, abnormal muscle tone, impaired balance responses, poor motor planning, decreased body awareness, impaired coordination, postural instability or asymmetry, sensory integration deficits, impaired communication, and limbic system dysfunction (impaired arousal or attention skills).18,22,23

Common conditions that may benefit from hippotherapy and THR include autism spectrum disorder, cerebral palsy, developmental delay, genetic syndromes, learning disabilities, sensory integrational disorders, speech-language disorders, traumatic brain injury (TBI), and cerebral vascular accidents.22

There have been a multitude of suggested therapeutic benefits from hippotherapy and THR, which affect many body systems. Suggested physical benefits include improvements in endurance, symmetry, and body awareness; development of trunk and postural control; improvements in head righting and equilibrium responses; normalization of muscle tone; mobilization of the pelvis, lumbar spine, and hip joints; and improved sensory awareness. Suggested cognitive, social, and emotional benefits include improvement in self-esteem, confidence, interaction with others, concentration, attention span, and communication skills.18,19,24

Contraindications for the use of hippotherapy or THR include excessive hip adductor or internal rotator tone accompanied by potential hip subluxation or dislocation, lack of head control (in large children or adults), pressure sores, spinal instability, or anxiety around animals.18,24

Regulations.

AHA offers a Clinical Specialty Certification for therapists demonstrating advanced knowledge and experience in the practice of hippotherapy. Physical therapists, occupational therapists, and speech-language pathologists must have been practicing in their profession for 3 years (6000 hours) and have had 100 hours of hippotherapy practice within the 3 years prior to application. Certification is valid for 5 years; once applicants pass a multiple choice test they are entitled to used the designation HPCS.22,25

APTA recognizes hippotherapy as a treatment tool to address impairments and functional limitations in patients with neuromusculoskeletal dysfunction. APTA recommends that PT sessions that incorporate hippotherapy be billed as neuromuscular education, therapeutic exercise, or therapeutic activities based on the treatments completed. The American Occupational Therapy Association (AOTA) also recognizes hippotherapy as an interventional tool, which can be billed as neuromuscular education, therapeutic exercise, therapeutic activities, or sensory integrative activities.

Evidence and clinical implications.

Research and studies concerning the use of hippotherapy and THR are limited but expanding. At the time of publication of this text, there have been no large, well designed, randomized controlled trials investigating the use of hippotherapy or THR. There have been several fair-quality randomized controlled trials and many nonrandomized trials that do support the use of hippotherapy in children with cerebral palsy. One systematic review investigating the use of hippotherapy and THR found improved gross motor function; normalization of pelvic motion; improvements in weight shifting, postural and equilibrium responses, muscle control, and joint stability; improved recovery from perturbations; and improved dynamic postural stabilization.21 Studies have supported that hippotherapy can improve postural stability in individuals with multiple sclerosis (MS) and can assist in treatment of balance disorders.26,27 Hippotherapy has also been shown to reduce lower-extremity spasticity in patients with spinal cord injury.28 Support for hippotherapy has been shown by improvements in the areas of muscle symmetry, gross motor function (as measured by valid and reliable tools), energy expenditure, and postural control. Researchers suggest that hippotherapy will lead to improved head righting and equilibrium reactions and dynamic postural control, normalization of abnormal muscle tone or symmetry, improved muscle control, and better endurance. In addition, hippotherapy has the potential to contribute to psychosocial well-being and improved motivation by allowing interaction and acceptance with another living being and the opportunity to be mobile while astride the horse; being positioned high up on a horse gives the child the chance to be at eye level with his or her peers, and the fun of riding encourages participation and enjoyment of the therapy sessions. Continued research into hippotherapy and THR using larger, randomized controlled studies that investigate specific outcomes and account for the variations within a variety of neuromusculoskeletal conditions will be necessary to conclusively determine all potential benefits that exist.

Feldenkrais method of somatic education

James Stephens

The Feldenkrais method is about learning the following:

Development of the feldenkrais method.

As a boy in Palestine, Moshe Feldenkrais developed a method of hand-to-hand combat that was used by settlers for self-defense. Later, as a student in Paris where he trained in physics at the Sorbonne, he studied judo and became the first person in Europe to receive a black belt. When he injured his knee playing soccer, he relearned pain-free walking on his own. Later he studied with F. M. Alexander, Elsa Gindler, and Gurdieff. He also studied psychology, progressive relaxation, bioenergetics, and the hypnosis methods of Milton Erickson. And he was familiar with the physiology of his day: Sherrington, Magnus, Fulton, and Schilder. With this background, Feldenkrais developed two approaches to facilitating learning that are now known as Awareness Through Movement (ATM) and Functional Integration (FI).30

Feldenkrais was ultimately interested in the development of human potential. He saw that, although all people encounter trauma and difficulty in their lives, those who are most successful develop new, adaptive behaviors to overcome those difficulties. He proposed that a type of learning that reconnected the brain to the control of the musculoskeletal system would be the most effective way to approach this problem of adaptation. His initial thinking in this area is set out in his first book, Body and Mature Behavior: A Study of Anxiety, Sex, Gravitation, and Learning.31

Background theory—dynamical systems theory.

For Feldenkrais, learning was an organic process in which cognitive and somatic aspects were completely integrated and interactive. Presented first in 1949, this idea prefigured our current sense of dynamic systems functioning of the brain and body.32 The learning should proceed at its own pace in an individualized way following the learner’s intention and guided by the learner’s perception that the performance of the task, movements of the body, and interaction with the environment become easier.31 This interactive cycle of action and perception has been described well by the motor learning model proposed by Newell.33

Learning is a complex process with overlays from the intention of the learner, interference from environmental distraction, misperception of the task and the body, desire related to self-image, fear of injury, or incorrect performance. Thus it is possible to learn poorly, incorrectly, or in such a way as to interfere with performance and not improve it. This kind of process has been suggested by Byl and co-workers34 as the underlying cause of focal dystonia. One of the definitions Feldenkrais gave for learning took this process into account: “Learning is the acquisition of the skill to inhibit parasitic action (components of the action unrelated to the intention behind an action but resulting from a secondary intention) and the ability to direct clear motivations as a result of self-knowledge.”31 An adult engaged in learning to walk again after a stroke with a fear-related reluctance to bear weight on the involved limb would be an example of such a secondary intention.

The process of learning proposed by Feldenkrais is one of discovery. The outcome desired is one of increased awareness. Vereijken and Whiting35 have proposed that discovery learning, in which learners are free to explore any range of solutions in learning to perform a task in any way that they want, is as effective as or more effective than any formal approach to motor learning involving controlled schedules of practice or feedback. This process of discovery has the added dimension of allowing learners to focus on the perceptual understanding of the body/task/environment as a component of the learning process. In the Feldenkrais method this discovery and perceptual learning process is explicit.

Our understanding of how experience and learning restructure almost all areas of the CNS is expanding rapidly.36 A large focus of current thinking in rehabilitation is how to translate neuroplasticity concepts into more effective techniques for rehabilitation.3739 The method developed by Feldenkrais and practiced by people around the world who are trained in this method is clearly explained by these new principles, creating new approaches to rehabilitation.

Approaches to feldenkrais method.

The two approaches to facilitating learning created by Feldenkrais, ATM and FI, are similar in principle and process although they differ in practice. They are essentially two methods for communicating a sensory experience that the client can consider and act on. The first requirement of the process is to create an environment that is comfortable, safe, and conducive to learning, whether the learner is being moved passively or creating the movement experience voluntarily. The second requirement is that the amount of effort associated with making the movements be reduced greatly so that it is possible to make fine discriminations about the effects of force acting on the system from outside, from inside, or both. The goal is to develop a rich understanding of changes throughout the system produced by small perturbations. This understanding becomes the basis for creating new solutions to movement problems as the client progressively approaches functional movements that she or he desires to perform.40

In FI the practitioner will manually introduce small perturbations into the learner’s system after placing the learner into a safe position closely approximating some desired activity to be learned. Here the practitioner is providing the force inputs and the client is asked to attend to the changes created in response to the perturbation. For example, the practitioner might press gently into the bottom of the client’s foot and ask the client to notice where in the body movement and pressure are felt as a result. This will be repeated a number of times and then some other forces or movements will be introduced. The guiding idea for the practitioner might be to build sensory experiences in the body that are associated with a particular movement, such as rolling. This goal is rarely explicitly expressed to the client and is left to emerge in the client’s understanding of the experience: “Oh, now I am rolling,” or “This feels like rolling to me.” Also there is no strict expectation by the practitioner about what specific movement might emerge. Thus it is possible to create novel and unexpected outcomes of how a particular task might be best performed by this particular person at this time. This allows for a process of assessment that is continually evolving as the intervention is unfolding.40

In ATM the practitioner verbally provides suggestions for movements for a client to explore and asks the client to focus on the sensory outcomes throughout the body. Thus the client introduces the experimental forces into his or her own system with the intention of understanding how the body as a whole responds. The underlying idea, however, is the same. In my practice, I use FI as a form of communication when clients do not understand how a force might act on the body or when they are unable to produce a range of movements that we might desire to explore. An example might be in a case where spasticity prevents fine discrimination in both sensory and motor realms.

In practice with an individual client, it is common to move back and forth between ATM and FI during the same session. The session is usually focused on the development of understanding and performing a specific function: turning, rolling, standing, stepping, and so on. ATM is a verbal process in which clients perform their own movements; thus a practitioner can work with many individuals simultaneously. At the same time individuals within the learning group are free to respond differently from one another in ways that may be appropriate only for them as individuals.41 Because ATM is under the active control of the client, this method is often a more effective tool in reestablishing voluntary control (Case Study 39-1).

CASE STUDY 39-1 image   SUE: HEREDITARY SPASTIC PARAPARESIS

Sue was a toe walker as a young child. She remembered her father sitting in a chair all the time, his legs too stiff and weak to walk. In her mid 20s, she too began to develop weakness and stiffness in her legs. At the age of 36 years she was diagnosed as having “uncomplicated” hereditary spastic paraparesis (HSP).

Uncomplicated HSP involves extreme spastic weakness, some loss of sensation in the lower extremities, and hypertonic bladder reflexes. It progresses slowly over many years without exacerbations or remissions. Individuals experience progressive difficulty walking and often require canes, walkers, or wheelchairs. They typically retain normal strength and dexterity of the upper extremities, have no involvement of speech, chewing, or swallowing, and have a normal life expectancy.

Sue was first seen in our outpatient clinic when she was 38 years old. She worked as an office manager at a local college. Her office was up a set of stairs that was becoming more difficult to negotiate. She also owned a horse that she had not been able to ride because she was no longer able to mount because of her increased spasticity. Sue was a large, muscular woman at 5 feet 10 inches and 175 pounds.

On initial examination she reported pain in her right knee with weight bearing (8/10) and pain in her low back (5/10). Her proprioception appeared to be intact. She had decreased passive range of motion (ROM) in dorsiflexion bilaterally and hyperextension of her knees bilaterally, greater on the right. There was tightness in the iliotibial band and hip adductors, flexors, and rotators bilaterally and the extensors of the back from the lumbar through the cervical spine. Her muscle strength was 3+ to 4−/5 at all joints of both lower extremities, with the right being generally weaker than the left. She also had mild weakness in her trunk flexors (3+/5). There was sustained clonus in plantar flexors bilaterally and one beat clonus in her quads on the right. She had normal active ROM throughout her upper extremities with normal (5/5) strength throughout. Sue stood statically with her hips externally rotated, knees hyperextended, hips forward with her back extended in a stiff swayback posture. Her shoulders were retracted and tight. She was unstable to a moderate challenge and reported falling frequently. Her gait was stiff with knees hyperextended and toe drag bilaterally. She achieved swing by doing a lateral trunk tilt with contralateral circumduction with each leg, no arm swing and a foot flat landing. She used a straight cane for balance. Her self-paced gait speed was greater than 75 ft/min (1 mph = 88 ft/min). She reported “it feels like I have a stick up my back and if I try to go faster, my knees lock and I’m really in trouble.” Sue was assessed to be a good candidate for a Feldenkrais intervention, and a series of FI and ATM lessons was planned.

The first FI lesson was an exploration of the organization of turning and rolling from supine. I began this exploration with Sue supine and observed her postural organization in that position. She lay with her arms flat at her sides, palms up. Her legs were adducted and externally rotated and her back arched away from the mat table. I put a small towel roll under her neck and back and a 4-inch roller under her knees to allow her extensors to relax somewhat. I began the exploration by rolling her head gently and found a lot of resistance to that movement. Attempts to do small amounts of turning of a leg or bending of the knee also met with similar resistance. I then began working through a process of manually shortening muscles that were tight and overworking. I began with neck extensors by gently holding the cervical spine in a slightly more extended position progressing to the extensors of the trunk by compressing the ribs from the side to cause a slight lateral flexion first on the right then on the left. The relaxation focused last on the legs by holding the knee and hip in a slightly more externally rotated and flexed position first on the right, then on the left. Going back to the neck, pressure was exerted down through the first rib on the right to cause a slight lateral flexion to the left through the spine. This movement was now easier than before, with force being translated further down the spine into the lumbar area. Next the pressure was combined with rolling of the head to the right, first passively, then with small active movements. The instruction was to turn the head only as much as could be done with almost no effort. The same process of compression of the spine and turning of the head was repeated from the left side of the neck. The interaction then progressed to the right leg by pushing through the right foot so that the force translating up the leg caused lateral flexion of the spine to the left, then again from the left leg. The right foot was then turned to initiate external rotation and flexion of the right leg first passively and then actively. Sue began to be able to control that small movement on the right leg with minimal effort and then repeated on the left. We then began to link the movement of the legs, trunk, and head together in a sequence in which she began to be able to roll her head to the right, flex her right leg and left leg together toward the right, and allow her trunk to flex and turn toward the right. During this process, Sue’s attention was directed to sensing the movement and timing of different body segments; to feel the forces created in her body by the movement of one segment and how they impeded or facilitated movement of other segments. This lesson ended with Sue being able to roll more easily onto her side from supine than she had been able to do in a long time. This session took about 45 minutes, during which I was doing some work with another patient at the same time. When Sue came up to standing after this lesson, she reported feeling like she was stuck into the ground solidly. She felt shorter, softer, and better balanced. Her feet were flatter on the floor, and when she walked she did not drag her toes on the floor.

At the beginning of the second session on the following day, Sue was tested again on the treadmill and was now able to walk about 120 ft/min. The second lesson began again in supine and reinforced and developed the movements of the first lesson. Sue learned to slowly roll to her right side, moving her arms at the same time so that she could take weight on them, flex her legs until they came over the side of the mat table and then push herself up to sitting all in one motion and then reverse this process slowly until she was lying supine again. She learned to roll herself into a fetal position back and forth from the left to the right without her legs stiffening in between, and when she sat up she was able to actively flex her legs up to put her shoes on, which she had not been able to do for at least a year. After this lesson she reported that she had been able to move her foot easily from the gas to the brake in the car without slipping and that she was able to get onto and ride her horse for the first time in several years.

In the third lesson, we worked more purely with ATM because Sue was now able to control more movement more easily herself. During this lesson Sue learned to roll with minimal effort to the left and right while holding her knees and then to reach to her ankles and roll while holding her ankles without stiffening her neck in the process. Flexing her hips had become easy.

The fourth lesson involved standing, weight shifting, and turning. The instructions related to keeping movements small and slow and maintaining a feeling of softness that she now had developed. She explored movements of allowing her knees to flex while she shifted weight to one foot and moving her body over the weight-bearing foot to get a sense of how she could distribute weight differently across her foot on the basis of changing the configuration of her upper body and movements of her hips. These movements included exploring the effects of intentionally stiffening and softening her back and neck to feel any changes that happened in control of her weight bearing, knee flexion, and ankle. Weight on one side was increased while the other was unweighted, and the unweighted leg was lifted in a controlled manner, easily and effortlessly, feeling the support of the skeleton for the process of lifting. At the end of this lesson, Sue was able to lift her foot easily up onto the 19-inch-high surface of the mat table and bring it back to the floor without disturbing her balance. At home she was now able to step up onto her horse from a low step without other assistance.

In the fifth and final session, more time was spent doing an ATM lesson related to standing balance, turns in walking, and bending to the floor. In this session and at the end of the previous one, we also spent time in transfer training with toilet, tub, car, and floor transfers and gait training on smooth and uneven surfaces and for speed on the treadmill. She still used a cane for balance (or a single hand support on the treadmill) but now was able to walk on the treadmill at 175 ft/min, well more than double her initial speed, without dragging her toes or hyperextending her knees. She did complain of some back pain and calf pain, but this was determined to be from exercising muscles that had not been used in years and resolved after several days. I recorded the ATM lessons with a lapel microphone and recorder as we did them and gave her the tapes to use at home as part of her home exercise program.

Three months after discharge, as a passenger in her sister’s car, Sue was in an auto accident and sustained a herniated disk at C5-6. After this she had decreased mobility for several months. During this time she lost her understanding of how to control her movement and returned to us 6 months after her initial visit to review what she had done earlier. After several series of lessons over a period of several months, she achieved a level of function higher than previously so that she was able to walk and go up and down stairs without any support.

Evidence of effectiveness.

The theory underlying the Feldenkrais method predicts that there should be changes in perception of the body or body image. Although there have not been a lot of studies in this area, there are several that support this prediction. Elgelid42 reported positive changes in body perception, as evaluated by the semantic differentiation scale in a group of four subjects after a series of ATM lessons. Dunn and colleagues43 reported that subjects who had had a unilateral sensory imagery ATM lesson perceived their experimental sides to be longer and lighter and demonstrated increased forward flexion on that side, linking the changes in perception to changes in motor control. Batson and co-workers44 have shown that ability to image movement is improved in people poststroke after a series of ATM lessons, and furthermore that there is a high positive correlation between the Movement Imagery Questionnaire (MIQ) score and improvements in balance assessed by the Berg Balance Scale.

There is not a lot of literature evaluating the efficacy of the Feldenkrais method in general and even less specifically for people with neurological diagnoses, as a result of the complexity of the problems and the multiple system involvement of the individuals. Evidence-based studies on effectiveness are more easily identified. In a review, Stephens and Miller40 divided the literature into four different areas: pain management, postural and motor control, functional mobility, and psychological and quality-of-life impact. Much of the literature is in case report format. A small amount of the literature is controlled study format, with some of that using randomized control groups. The work on pain management suggests that the Feldenkrais method may be especially effective in treating pain that is biomechanical in origin. This concept may be applied to work with pain in patients with neurological diagnoses, especially pain caused by biomechanical malalignment. No research has been done in this area with neurological patients. Hall and colleagues45 found improvements in balance (Berg Balance Scale [BBS]), mobility (Timed Up-and-Go Test [TUG]), functional activity (Frenchay, Short Form 36 [SF-36]), and vitality (SF-36) in a large group of elderly women compared with control subjects as a result of a 16-week ATM intervention. These results have been confirmed by Vrantsidis and colleagues46 and Connors,47 also using ATM with a group of elderly women. In the areas of psychological and quality-of-life impact, Kerr and colleagues48

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