In the field of manual and guided movement therapies, the word “holistic” has become overused and has virtually lost its meaning. Many alternative systems of somatic practice, as well as many conventional medical approaches, now pay lip service to holistic intervention and often claim to include holistic philosophy in their treatment protocols. Yet very few of these disciplines, whether alternative or conventional, appear to appreciate the true attributes of a holistic approach.
A holistic approach, in addition to restoring local function, strives to bring a higher level of integration to the whole person. Most systems of manual and movement therapy do not teach a holistic approach, but rather a loose collection of effective corrective strategies designed to treat local problems symptom by symptom.’ In this piecemeal approach to sequencing treatment, no account has been made of how local interventions impact the whole person. Thus, somatic theorists need to further examine the question of what constitutes a holistic treatment approach and what constitutes a principle of intervention.2
This paper has two purposes. The first is to provide a clinical commentary that examines the philosophical assumptions behind current corrective approaches of somatic therapy and to propose an integrative viewpoint based on findings from phenomenology, evolutionary biology, and cognitive science. To clarify holism the clinical commentary also proposes and examines five holistic principles of treatment intervention and their taxonomies of assessment. The second purpose is to present a case study that illustrates holistic treatment design based on the proposed intervention principles and assessment taxonomies.
METAPHYSICAL DUALISM: THE CORRECTIVE AND RELAXATION PARADIGMS OF PRACTICE
Maitland has elsewhere defined the symptomatic and localized approach to faulty postural alignment and movement dysfunction as the “corrective paradigm” .1,2 Examples of corrective manual practices would include many forms of physical therapy, chiropractic, osteopathic, and myofascial release methods as they are typically practiced. Somatic techniques that are oriented solely toward producing the relaxation response to help modulate pain fall under the relaxation paradigm.’,’ Examples of relaxation practices are certain massage and trigger point techniques. Just as holistic treatment is usually beyond the scope of corrective treatment, direct treatment of faulty posture and movement is usually beyond the scope of the relaxation paradigm.
Philosophically, both the corrective and relaxation paradigm interventions are based on Descartes’ assumption that the body is a machine. 1,3,45 In Cartesian dualism one views the body as a soft machine and the mind as a ghost-like entity that inhabits it. Although contemporary philosophy and cognitive science have offered comprehensive critiques of the Cartesian view of mind, most of science still remains committed to the Cartesian conception of body.3, 4,5,6,7 Viewing living organisms as natural machines compels the somatic practitioner to see the body as a complex piece of hardware composed of simpler pieces of hardware. Certainly machines can be successfully treated correctively because they are made of parts. Parts break and can be repaired or replaced, but humans cannot be disassembled into components without destroying the living integrity of the organism.
PHILOSOPHICAL VIEWPOINT OF N0N DUALISM: THE HOLISTIC PARADIGM OF PRACTICE
Since the third paradigm of practice, the holistic paradigm, treats the whole person and not just local dysfunctions, it must be based on a different philosophical assumption than the mechanistic assumptions underlying the corrective and relaxation paradigms. The holistic paradigm draws on insights from the branch of philosophy called phenomenologye.9 as well as on new developments in the biological and cognitivesciences. 10,11,17,13,14,15,16,17,18 (Since”monism”19 in philosophy rests on the same premises that generate dualism, we have elected to call this approach “non-dualism.”) A nondualistic approach argues for a unity of “mind” and “body” by challenging the central Cartesian assumption of contemporary science – that the body is a soft machine.
Expanding on the phenomenological insights of Merleau-Ponty”?9 and thecognitive theory of life articulated by Maturana and Varela,5,16 Maitland has maintained that the mechanistic model of living organisms is unable to fully simulate or capture the nature of perception.” Although “perception” can be extended to the abilities of certain sophisticated remote sensing robots, the act of perception among living beings involves an ability that no machine does or is likely to possess. When living beings perceive they do not just register changes in the environment as machines do. They also sense themselves sensing a world.” Merleau-Ponty called this selfsensing ability, which contributes to every organism’s anonymous sense of identity, “corporeal reflexivity’,89 an ability that mechanistic models of human consciousness cannot likely account for. How biological systems create the ability to self-sense is not presently known.
Self-sensing is the root of what we recognize as perception and awareness. Human “consciousness” occurs when self-sensing is fused with the human acquisition of language and reflective thought. This ability to represent, or step back and reflect on, the experience of oneself linguistically and reflectively is what produces our experience of consciousness and self.
What phenomenologists call intentionality and what has traditionally been called consciousness is not an activity of a non-bodily transcendental mind, but rather a remarkable evolutionary adaptation of the living human body.20 Unlike Descartes’ and modem science’s concept of a somatic soft machine, the body may be better understood as a self-sensing psychobiological organism oriented in lived space and time, capable of knowing itself as an independent entity through self-reflection and language. Heidegger21 defined the intentionality of consciousness as a being-directed-toward-and-solicited by-a-world. Merleau-Ponty viewed consciousness as an activity of the lived body and defined intentionality as “oriented space.”‘ We would also define intentionality as “oriented time.”‘
The clinical implications for holistic somatic therapy and philosophical counseling are straightforward and provocative. If mind and intentionality are an evolutionary elaboration of the perceptual powers of the lived body, then thought and soma are two aspects of the same unitary living being. How one moves, feels, lives in the world, thinks about the world, and orients in space and time are all deliquescently intertwined. We can draw a functional distinction between soma (body) and world view (mind), but how one lives one’s world view is not separate from how one lives one’s body. As a result, it is common to work with patients whose problematic world views are so thoroughly interwoven with their somatic dysfunctions that the release of one requires the release of both. Thus, both the world view and the somatic aspects of a patient’s distorted orientation in space and time must be addressed in a holistic approach.
FIVE CONSTITUTIVE PRINCIPLES OF INTEGRATIVE PARADIGM INTERVENTION
Maitland and Sultan originally articulated the principle-centered decision-making process and Salveson later added important refinements.’2 The third paradigm approach is based upon the holistic principle. In its simplest form the holistic principle states that no principle of intervention can be completely fulfilled unless all the principles are fulfilled. Since the holistic principle states how the principles of intervention function together, it is properly called a meta principle.
A constitutive principle is defined as a fundamental rule from which a chain of reasoning proceeds – similar to the way the principle “add 2 to the last number” allows one to complete the sequence, “2, 4, 6,…”22.20 Like the rules that define a game, the holistic constitutive principles define the parameters of intervention and state the conditions for optimal human activity. Strategies and appropriate sequencing are then formulated in accordance with these constitutive rules. Note that the word “principle” can have other meanings. It may refer to a basic law, a fundamental property, or a value. We will refer to principle as a constitutive rule from which holistic strategies can be logically developed.
There are five constitutive principles: adaptation, support, palintonicity, continuity, and closure.22,2° If a local, corrective intervention does not account for one or more of these principles, the body will revert to its dysfunctional condition and/or the strain will be driven elsewhere in the soma. The adaptability principle is defined as the patient’s ability to assimilate and accept new options of self-perception, alignment, and motion into his life. The support principle is a specific application of the adaptability principle. It refers to the ability of the patient to adapt to changes in gravity as he moves and alters his body-position, or as he expresses perceptual shifts in his world view. The palintonicity principle is derived from the Greek word meaning “unity in opposition” (literally, “stretched back and forth”).’ Palintonic harmony describes the somatic and perceptual geometry of spatial order that is apparent in the body as it approaches integration. Frank and McHoseT3 have aptly described this palintonic”unity of opposites” as graceful, economic movement, where the person has the sense of two directions: “a sense of accepting gravity in the body, loading, dropping, or giving weight; and a sense of orientation to the space around one, to sky, inspiration, the ‘other’ in relationship.” Behind the continuity principle lies the recognition that restrictions or lack of restrictions at one level of human activity will in turn be reflected at all other levels. Likewise treatment interventions applied at one level will tend to cascade through the whole system, affecting all levels. Behind the closure principle lies the recognition that when the patient has achieved the highest level of somatic and perceptual integration possible within his current set of limitations, treatment should be terminated.
FOUR TAXONOMIES OF HOLISTIC ASSESSMENT
In order for the holistic practitioner to successfully apply the principles of intervention, she needs to conduct a comprehensive examination and assessment. She must be able to see the whole person and, at the same time, evaluate the fixations that manifest at every level of a person’s being. Fixations are more appropriately called order-thwarters because they represent dysfunctional whole patterns that affect the organization of the patient’s soma and perceptual orientation. The taxonomies are like classificatory lenses that allow the holistic practitioner to analyze and to operationalize order-thwarters into measurable outcomes. These outcome variables can, in turn, be reassessed over the course of treatment.
There are four taxonomies that may be assessed in the holistic evaluation: structural/ geometric, functional, energetic, and the taxonomy ofpsychobiological orientation.30’22
The structural/geometric taxonomy involves the assessment of biomechanical and geometric body alignment. This taxonomy may be operationalized as segmental postural position24,29 or, geometrically, as computerized topography.26
The functional taxonomy involves the evaluation of the quality and economy of movements. In older adults, for example, this taxonomy can be operationalized as timed mobility and balance tests and ratingscales.27,28
The energetic taxonomy relates to the energy fields and flows that are transmitted through the body. The energetic taxonomy can be operationally measured as direct microcurrents that are transmitted through the connective tissue network. 29,26 Autonomic activity, as operationalized by heart rate variability, has also been used as a measureof the energetic taxonomy30-31
The taxonomy of psychobiological orientation refers to what has traditionally been called mind and includes worldview32,33 as one of itstaxons. This taxonomy includes the body’s self-sensing ability, the perceptual and emotional orientation of the patient in regard to how he feels and views his movement, his self-image, and his place in the world. The worldview taxon has been operationalized through self-reports and rating inventories34.
DESIGNING HOLISTIC TREATMENT DERIVED FROM THE PRINCIPLES AND TAXONOMIES
Three questions face every practitioner: what do I do first, what do I do next, and when am I finished? To answer these questions the holistic practitioner must identify somatic and worldview fixations by proper examination and assessment. Once identified, the practitioner must determine whether the client’s body has sufficient adaptability, support, palintonic balance, and continuity to maintain the proposed changes and sustain them after treatment. (Figure 1) If the answer is no to any of these intervention principles, then the fixations specified by the principle in question must be remedied in an order appropriate for the patient. By addressing the specific orderthwarters the clinician proceeds toward establishing the highest level of somatic and perceptual integration that the patient can assimilate within his limitations.” A treatment that effects one of these principles, as assessed by the taxonomies, will always involve a reciprocal shift in all the principles at once. All treatment strategies are evaluated on the basis of how well or poorly each principle is being fulfilled throughout the unified seamless living whole person.
FIGURE 1. Holistic Third Paradigm Intervention: The Principles of Intervention and Associated Assessment Taxonomies
The decision-making process that utilizes holistic principles and taxonomies stands in sharp contrastto the conventionally accepted corrective strategies that are employed by many therapists from various fields.-35 In the corrective paradigm, specific problems are approached with minimal concern for how these problems represent an expression of the whole patient and how he lives in his world. At times certain dysfunctions can be handled correctively without looking beyond the particular local somatic dysfunction or the particular conceptual or logical confusions of the client. More often, however, a particular somatic or cognitive-counseling intervention may not produce the intended effect or may drive strain elsewhere because the whole person cannot adapt to, support, or sustain the intervention. Cottingham and Maitland have recently presented a case study involving chronic low back pain in which an alternative holistic treatment protocol provided a successful solution for such a dilemma.2
The case study that follows describes a patient diagnosed with amyotrophic lateral sclerosis (ALS) who had balance and mobility deficits.The case was selected from the author’s (JTC) physical therapy practice.
CASE STUDY DESCRIPTION
Amyotrophic lateral sclerosis, or ALS (Lou Gehrig’s disease), is a progressive degenerative disease of the central nervous system that involves the motor neurons.” Unlike other motor neuron disorders, ALS can affect both the brain and spinal cord. ALS is also the most frequently occurring motor neuron disease among adults. In 5 to 10% of the cases the disease is inherited as an autosomal dominant trait whereas in the remaining 90 to 95% of the cases there appears to be no family history of the disease.36
The common early symptoms of ALS are weakness in the arm, leg, and bulbar musculature (i.e., the muscles of swallowing and speech.) The muscle weakness progresses over time to include serious impairment of balance, mobility, swallowing, speech, and breathing. The disease does not usually affect the sensory and thought processes? Bowel, bladder, sexual, and other autonomic nervous system functions are also normally not affected The most frequent cause of death is from breathing complications, and only about 50% of patients survive more than three to four years after the onset of symptoms without mechanical ventilation to assist breathing.
PATIENT OUTCOME MEASUREMENTS
In order to assess and reassess the structural, functional, energetic, and psychobiological orientation taxonomies over the course of treatment, the following outcome measures werechosen for the initial evaluation.
1. Forward Head Posture. Excessive forward head alignment combined with other faulty postural patterns may be linked to balance deficits found in patients with neurologicalpathologies.39,z8 Since the head’sposition appears to serve as a “reference” for upright posture in gravity, slight adjustments in head-neck alignment could make the difference between standing and falling for a patient 28 To quantify the patient’s excessive forward head posture, we selected and adapted Garrett’s90 cervical range of motion(CROM) instrument for a structural taxonomy assessment. This instrument consists of the following components: (1) a horizontal bar with an attached gravity goniometer that measures forward head position in cm and (2) a vertical arm with an attached gravity goniometer for designating the anatomical position of the neck. The CROM instrument has demonstrated good intratester and intertester reliabilities.40
2. Balance and Functional Mobility. Since balance problems are normally associated with decreases in overall mobility, a timed walking test, Timed “Up and Go”, was selected as a functional taxonomy assessment.27 The Timed “Up and Go” measures the time it takes for a patient to go from sitting to standing, walk a specified distance, and sit down again. This test has demonstrated high interrater and intrarater reliabilities as well as good validity for measuring balance and mobilityin older adults.27,28
3. Parasympathetic Activity. Somatic therapists have long contended that stored autonomic “charge” can be elicited or “discharged” through appropriate manual and movement methods. Levine31 has recently tied repressed traumatic life experiences]to “frozen” and dissociated autonomic states of high sympathetic arousal. For example, because of the traumatic psychobiological consequences associated with progressive neurological diseases, a patient may exhibit excessive sympathetic “arousal” activity and a reciprocal decrease in parasympathetic “nurturing” activity. To assess the patient’s energetic taxonomy, a measurement of parasympathetic activity, vagal tone, was selected.41 Vagal tone, or respiratory sinus arrhythmia, is defined as the amplitude of the heart rate variability linked with normal breathing. Vagal tone has been shown to be a reliable and valid measurement of parasympatheticactivity.41,42
4. Worldview Shifts. To assess the worldview taxon, the patient’s selfreports were recorded. The clinician asked the patient questions pertaining to how he views his movement; how he views his self-image; and how he views his place in theworld.20,33
This 61-year old man, who will be called “Travis,” arrived for his appointment using a wheeled walker and accompanied by his wife. He had been referred by his primary physician for evaluation and treatment for a balance problem and an overall loss of mobility. Approximately 1 1/2 years previously, Travis had been diagnosed with amyotrophic lateral sclerosis, non-inherited type. Over the last month he reported falling three times: (1) while bending forward, (2) while reaching for an object, and (3) while moving from sitting to standing. He was using a straight cane when these falls occurred. One week prior to this, his primary physician had recommendeda walker with front wheels for better stability as well as the purchase of a manual wheel chair. Travis also complained of trembling and twitching in both legs and cramping and weakness in both hands. He reported losing his breath easily and having trouble swallowing certain foods, such as meat. He also had difficulties with fine coordinated activities such as buttoning shirts and tying a necktie. Travis had had prior physical therapy involving a corrective protocol of exercises for balance, strengthening, and stretching. He also had had a respiratory consult for the use of a Bipap external intermittent positive pressure breathing device.36 Travis is retired and lives with his wife. Several years ago he developed an interest in Christian contemplative prayer.
RELEVANT MEDICAL HISTORY
A review of Travis’ recent medical testings included electromyographic (EMG) reports that indicated the following pathological findings: decreased motor action potentials that suggest active denervation in the arms and legs and abnormal recruitment patterns of motor units in the legs and to a lesser extent in thearms.31,36 The sensory system andautonomic functions appeared to be intact. Other neurological evaluation showed lower motor neuron signs including muscle weakness, muscle cramps, fasciculations, and atrophy. Also evident were upper motor neuron signs of spasticity and hyperreflexes.
EXAMINATION AND EVALUATION
ASSESSMENT OF STRENGTH
Travis’ muscular strength was manually tested as described by Kendall and McCreary.43 The neck extensors, trunk extensors, hip extensors, and knee extensors testedbetween 3+/5 and 4-/5. The neck flexors, abdominals, and knee flexors tested in the 4-/5 to 4/5 range. The ankle plantar flexors tested 4/5 whereas ankle dorsiflexors were 3+/ 5. The intrinsic hand muscles tested 3+/5. Note that the reliability of manual muscle tests is uncertain.44
Static balance was first evaluated by having Travis stand with his feet together and eyes closed. He was instructed to keep his balance while rotating his head from side to side for one minute. He exhibited a minimal increase in postural sway during the testing time. Travis then stood on a foam rubber cushion with his eyes opened and maintained his balance for 50 seconds. With his eyes closed he kept his balance on the foam cushion for 48 seconds. The results of the first balance test suggest that Travis was able to successfully use somatosensory (tactile) and vestibular input when visual information was removed. In the second test, when the visual information was removed again and the somatosensory input was “altered” by the foam cushion, Travis still maintained his balance with vestibular input only.
From these tests, it was concluded that Travis’ balance dysfunction was not primarily related to sensory lesions but, rather, to the motor neuron deficits and motor recruitment problems associated withALS.39’38 This is also supported by hisEMG and sensory tests cited in the PATIENT HISTORY.
HOLISTIC ASSESSMENT OF POSTURAL ALIGNMENT AND MOVEMENT
From the integrative level of assessment, Travis’ overall standing posture and gait were now examined. The practitioner focused on identifying order-thwarters involving postural misalignments and aberrant move-ment sequences that, in turn, may be representative of underlying psychobiological dysfunctions. The examiner’s skills of visual observation are an essential tool for this level of holistic evaluation.
With Travis standing, the clinician observed that the anterior flexor muscle tone of the neck, torso, pelvis, and legs dominated over the posterior, extensor tone of the body. This analysis is given support by the manual muscle testing that found that the extensors were, overall, weaker than the flexors. Seen in the lateral view the head and neck were forward on the shoulders and torso, the shoulders were protracted, the trunk was slightly flexed at the waist, and the knees and hips were also flexed. Jones’l first compared this pattern to the posture associated with the startle reflex.46Increased sympathetic tone has also perhaps been linked to the startle reflex, with a reciprocal decrease in parasympathetic tone47.
Even more interesting were the observations of Travis’ alignment pattern just before he initiated movement – what Godard” has called “pre-movement”. Just prior to initiating a sitting to standing movement, he shortened his sittingposture by (1) increasing the backward bending at the headneck level (atlantooccipital or A-O joints), (2) increasing the secondary curvatures in the cervical and lumbar spine, and (3) increasing the forward or anterior tilt of the pelvis.’ Figure 2 shows a lateral view of this premovement posture. The shortened head-necktorso alignment re-mained as he moved from sitting to standing. Similar postural patterns were found when he prepared and moved from standing to sitting, squatting to standing, standing to squatting, and reaching for an object while standing.
Unlike the results found from the muscle strength testing and the standing postural analysis, the posterior spinal extensors appeared to dominate the anterior flexors during pre-movement and the execution of basic movements. This pattern may be a compensatory response to keep from falling forward, because of the weak ankle dorsiflexors. Travis’ observed pattern is in sharp contrast to the configuration of integrative motion. According to Bond 49 the hallmark of integrative movement involves spinal lengthening combined with a fluid coordination between the cervical and lumbar curves during bending or straightening of the hips and knees.
TAXONOMY OUTCOME ASSESSMENTS
The initial evaluation was completed by testing the following four taxonomy outcome measures.
1. Structural Assessment: Forward Head Posture. Travis sat erect in a straight-backed chair. The practitioner first set the vertical bar of the CROM instrument perpendicular to the ground with one end placed on his marked C7 spinous process. Then the horizontal bar was placed parallel to the ground with the end plate touching his forehead. The examiner read the distance on the horizontal bar, from C7 to his forehead, to the nearest half-centimeter. Travis’ reading was 23.5 cm. For reference, a group of patients diagnosed with orthopedic disorders showed a mean forward head posture = 17.0 cm and a standard deviation = 1.8.40
2. Functional Assessment: Balance and Functional Mobility. To assess the Timed “Up and Go” test, Travis sat comfortably erect in the same chair. He was instructed to stand up, walk three meters to a wall, turn around, and walk back to the chair and sit down. The practitioner timed this activity with a stopwatch to the nearest tenth of a second. Podsiadlo and Richardson” proposed that test scores of less than 20 seconds indicate reasonable balance and mobility;scores between 20-30 seconds indicate some balance and mobility problems; scores of 30 seconds or more indicate serious balance and mobility dysfunctions. Travis’ score was 32.7 seconds.
3. Energetic Assessment: Parasympathetic Activity (Vagal Tone). To measure vagal tone, Travis was positioned supine with electrodes placed on the ventral surfaces of the wrists. Electrocardiogram activity was then monitored by an electrocardiogram amplifier. The output of the amplifier was input to a Vagal Tone Monitor for on-line analysis of vagal tone for 2.5 minutes. Vagal tone is expressed in logarithmic units on a scale of 1-10. Travis’ vagal tone level was 2.4. As a reference, vagal tone levels for a group of older healthy adults (ages 55-68) had X = 4.8 and SD = 1.2.42
4. Wordview Assessment: SelfReports. Travis expressed a dissociated concern about his recent falls and his difficulty in performing daily activities, “My body is not doing what I want anymore; I no longer think of this body as mine.”
As noted in the PATIENT HISTORY, Travis had already received a corrective protocol of exercises and stretches from another physical therapist. Since this corrective approach was not successful in increasing mobility and balance, and since Travis’ conflicted somatic and worldview fixations might interfere with further corrective strategies, the practitioner elected to implement a holistic intervention approach.2
From the initial evaluation, several constitutive principle issues became evident. Travis’ tendency to fall forward could be first viewed as palintonic imbalance between the extensors and the flexors of the spine. In standing and other static positions, Travis exhibited a flexor bias such that a posterior perpetration propelled him forward and in front of his center of gravity. In contrast, when he was preparing and initiating basic movements, the posterior extensors dominated with increased curvatures seen at the A-O joints, cervicals, and lumbars. This spinal extensor pattern may be a compensatory response to his fear of falling forward.
Weeks After Initial Evaluation – FIGURE 3. Structural taxonomy assessment: forward head posture. (Where TIE = initial evaluation, Treat# = treatment session, F/Up = follow-up assessment)
Weeks After Initial Evaluation – FIGURE 4. Functional taxonomy assessment: Timed Up and Go test. (Where l/E = initial evaluation, Tread = treatment session, F/Up = follow-up assesunent.)
Weeks After Initial Evaluation – FIGURE 5 Energetic taxonomy assessment: vagal tone. (Where l/E – initial evaluation, Treat* = treatment session, F/Up = follow-up assessment.)
The four taxonomy outcome assessments provide further insight in regard to the major intervention principle issues. The structural assessment of forward head posture indicated Travis’ head position was significantly forward of his center of gravity.39 The functional assessment, Timed “Up and Go”, suggested serious deficiencies in balance and functional mobility.27 Both the structural and functional assessments, as well as the therapist’s observations, point to problems of adaptability and support in terms of his responses to positional and movement shifts.2D The energetic assessment of decreased vagal tone (parasympathetic activity) also lends credence to the significance of the adaptability and support deficits.47 Because Travis’ low vagal tone also implies a reciprocal increase in sympathetic tone, some of his rigidity, in addition to the motor neuron damage, may be rooted to an immobility response associated with high sympathetic arousal .31 This arousal response may in turn be related to trauma from the disease process itself. Finally the support and adaptability issues are also reflected in the worldview taxon as assessed by Travis’ self-reports. He described his condition dualistically to the point of disowning his “useless body that can no longer carry” him.
Proceeding holistically, treatment strategies were prioritized accordingto the principles of intervention 20.22The practitioner chose to first work with the support and adaptability issues because Travis lacked a sufficient base for balance. At this time he probably would not accommodate any shifts toward higher palintonic harmony in terms of spinal extensor-flexor balance.
TREATMENT AND RESULTS
Following the initial evaluation, Travis was seen for five sessions over a period of twelve weeks. Session length was approximately 45-55 minutes. The four taxonomy outcome measurements (forward head posture, Timed “Up and Go”, vagal tone, and patient self-reports) were assessed after each treatment session and also at three voluntary follow-up testings. Figures 3, 4, and 5 summarize the results of these assessments.
The somatic treatment protocol for this patient was based on the Rolf Method of soft tissue manipulation and movement integration.50s1 Rolf’s system is a form of manipulationmovement education that focuses on the whole person’s organization in gravity. Aspects of Alexander’smethod were also incorporated.52’45These techniques have been described elsewhere.2,30,54,53
TREATMENT SESSIONS 1.3
In the first three sessions, the soft tissue intervention focused on support and adaptability fixations found in the lower extremities, pelvis, breathing diaphragm, spine, A-O joints, and upper extremities. During the first and second sessions, soft tissue manipulation was applied on each side to the interosseous membrane between the fibula and tibia of the lower leg, the hamstring attachments on the ischial tuberosity of the pelvis, the lateral hip rotator attachments on the greater trochanter of the femur, and to the iliopsoas as it passes superficially, superior to the inguinal ligament. All of these paired myofascial groups demonstrated reduced flexibility as determined by passive range-of-motion measurements.” During the second and third sessions, soft tissue manipulation was applied to the pelvic floor along the ischial and pubic rami and to thediaphragm just below the costal arch. Also during the second and third sessions, soft tissue techniques werer administered to the superficial neck extensors, the deeper cervical muscles of the suboccipital triangle, the three layers of back extensor muscles, and the interosseous membrane between the radius and ulna of the forearm.
In the latter portions of the first three’ sessions, guided movement awareness techniques were employed to address order-thwarters related to palintonic balance issues. The strategy involved a lengthening of the spine by reducing the noted secondary curvatures during the preparation and initiation of any given movement. For example, as Travis prepared to move from a sitting to a standing position, he was instructed with tactile and verbal cues to “drop his weight” into the chair while he concurrently “embraced the space” around him. In all three sessions, when the therapist’s tactile and verbal guidance were present, Travis clearly shifted his premovement and movement execution patterns. If, however, the clinician’s assistance was removed, he reverted to his maladaptive pre-movement and movement patterns outlined in the initial evaluation.
The taxonomy assessments obtained after the first three sessions also support these movement and postural observations with the structural (forward head posture), functional (Timed “Up and Go”), and energetic (vagal tone) measurements essentially tially unchanged from their initial evaluation levels (Figures 3, 4, 5). From the practitioner’s analysis, Travis seemed to have the somaticL ability by late in the second treatment session to support and adapt to a5 higher level of palintonic balance and to occupy a more integrative spatialorientation. Yet in this particular case he appeared to have difficulty in adopting and supporting the worldview necessary to occupy this new orientation in space and time, as seen in his continued dependence on the therapist’s guidance.
Since Travis expressed an alienated worldview, the practitioner, at this time in treatment, began to engage in dialogue with him about philosophical questions. Travis was most attracted to questions pertaining to the meaning and nature of his existence – that is, to questions of an ontological nature. Through the course of treatment he particularly pondered the following question posed by the clinician: who is it that observes your suffering and who is it that is suffering? Towards the end of the second treatment Travis replied to this question, “The Mind of Christ is the witness of my pain; and I’m the one suffering, but I’m no longer concerned with this dying body…. That’s why I need your helping hands to direct my body.” Although he experienced some solace in identifying with the witness of “Christ,” a dualistic separation still remained between his sense of self and his afflicted body.
TREATMENT SESSION 4
During the manual and movement procedures of the third and fourth sessions, the practitioner continued to focus on the question of who is observing and who is experiencing the suffering. Then in the fourth session, Travis experienced a dramatic somatic and perceptual shift while the practitioner was gently working on his diaphragm area just below the costal arch. He began shivering and trembling while his face flushed. He then sobbed for several minutes. Following this autonomic discharge, Travis’ movement patterns were also significantlytransformed, but this time the changes were independent of the therapist’s guidance. The spine lengthened during the preparation and execution of basic movements. Concurrently, his forward head-neck alignment moved superior and back over the shoulder girdle while he executed a more fluid, quicker paced movement sequence.
The taxonomy outcome measures also reflected this transformational shift. Travis’ forward head posture was reduced by 3.5 cm. His balance and functional mobility improved as seen by his shortened Tuned “Up and Go” of 19.0 seconds. The sympathetic discharge described above was also reflected by a large reciprocal increase in parasympathetic tone, or “relaxation response.” 3′ Vagal tone increased to 4.6 as compared to an initial evaluation level of 2.4 logarithmic units. Travis’ own words equally portray a dramatic shift from a dualistic and alienated worldview to one of a non-dualistic unity: “Before that breakdown [autonomic release in the fourth session], I imagined that I was one with the eternal Christ … and what was happening to my dying, degenerating body was no longer a real part of me. But after that breakdown I saw things differently. I now realize Christ is also living and suffering in my sick body….”
FIRST AND SECOND FOLLOW-UP ASSESSMENTS, FIFTH TREATMENT, AND FINAL FOLLOW-UP
Travis agreed to contact the practitioner when another treatment session was needed. To allow further reassessment of the four taxonomy measurements, he also voluntarily returned for a first follow-up assessment a week after the fourth session (six weeks after the initial evaluation) and for a second follow-up visit (twelve weeks after the initial evaluation). At both testings Travis arrivedat the clinic using only a straight cane. He again exhibited the smoothness and efficiency of movement that he displayed at the conclusion of the fourth session. Likewise, forward head posture, Timed “Up and Go”, and vagal tone demonstrated levels similar to the fourth session testings (Figures 3, 4, 5). Travis reported improved balance and functional mobility in terms of walking, handling eating utensils, climbing stairs, and transfers. Concerning his perceptual orientation, he remarked: “Time and space seem to have slowed down, as if there is more time and space available to move in.”
Three weeks after the second followup assessment (13 weeks after the initial evaluation), Travis called and stated that he had fallen and that he was “losing ground and feeling very weak.” He reported having trouble catching his breath and difficulty swallowing. A fifth session was scheduled for the next day. Travis arrived in a wheel chair with his wheeled walker and accompanied by his wife. Because he struggled to keep his head up, the clinician recommended a cervical collar. A home health care aide, as well as home physical, occupational, and respiratory therapy was also recommended to assist his wife in the daily care of the patient. During this session he had difficulty with the guided movements, and standby assistance was provided by the practitioner. His worsening condition was evident in the taxonomy outcome measurements as well. Forward head posture had increased to 28.0 cm (Figure 3); the Timed “Up and Go” test had increased to 43.2 seconds (Figure 4). Vagal tone, in contrast, remained essentially unchanged, which implied no further accumulation of sympathetic charge(Figure 5) .13-11 From the worldviewperspective, Travis stated that he wastrying to “accept” and embrace his weakening and deteriorating condition. Because of his rapid loss of strength, endurance, balance, and mobility, Travis and the therapist mutually agreed to stop further outpatient treatment. Upon Travis’ request, a third and final follow-up was scheduled in three weeks.
On arrival for his last follow-up assessment (16 weeks after the initial evaluation) Travis, wearing a neck brace, appeared noticeably weaker and fatigued as he sat flexed forward in his wheel chair. He was wearing hand splints on both hands to prevent clawing of the fingers and anterior flexor braces on both feet to prevent foot drop. The forward head posture and Timed “Up and Go” test indicated increased structural and functional balance-mobility deficits, respectively (Figures 3, 4). His vagal tone level again exhibited little change (Figure 5). Travis’ last selfreport eloquently expressed his evolving transformed worldview: “It’s terribly frightening at times, but then I remember that… [in Christ]… I am both the eternal witness of my pain and the one who is suffering it.”
For about a two-month period, Travis exhibited a remarkable improvement in balance and functional mobility (Figure 2). Specifically, he demonstrated improvements in head-neck alignment, speed, balance, and coordination of basic movements as demonstrated on the structural and functional taxonomy assessments and the practitioner’s visual analysis. For that two month span, he was functionally and structurally improved despite his degenerating motor neuron condition.
However, by the fifth session (13th week after the initial assessment), and as evidenced by his functionaland structural taxonomy measures, Travis’ balance, mobility, and forward head posture had suddenly regressed back to, or below, pre-treatment levels. The most plausible explanation is that the degree of motor neuron damage had finally reached a critical level and had thereby become an insurmountable somatic limitation for Travis to overcome. Such sudden losses of movement and balance skills are commonly reported in the ALSliterature.38,36,37
ENERGETIC (AUTONOMIC) AND WORLDVIEW ASSESSMENTS
Although the functional and structural taxonomy assessments after the fifth and final session had reverted to pre-treatment levels or below, Travis’ autonomic activity (vagal tone) remained remarkably unchanged since the increased shift noted after the fourth treatment assessment. This enhanced vagal tone pattern, like the transformed worldview evident in his fourth session selfreport, remained through the final follow-up assessment taken 16 weeks after the initial evaluation (Figure 5).
The provocative simultaneous persistence of Travis’ heightened vagal tone levels and his new worldview orientation may be better understood in light of recent neuroanatomical investigations. Through the brain stem’s nucleus ambiguus, the right vagus nerve has numerous higher cortical connections involved in mobility, emotion, and cognitive processes.” Thus vagal tone is not only an index of parasympathetic response (respiratory sinus arrhythmia) but appears to also represent an index of higher neuralfunctions.56,57,42
CONSTITUTIVE PRINCIPLE ISSUES
As cited in the ASSESSMENT, the practitioner chose to first address the holistic principle issues of support and adaptability in Travis’ soma and worldview because these issues were apparently undermining his ability to accommodate to a higher level of palintonic balance. The somatic aspect of this conflict was first approached by identifying orderthwarters in Travis’ postural alignment and movement patterns. In the second and third treatment sessions the application of soft tissue manipulation and guided movementawareness techniques assisted Travis in experiencing a temporary suspension of his maladaptive alignment and movement configurations and in acquiring more integrative patterns. Yet his expression of these integrative options was still entirely dependent on the practitioner’s guidance and presence. At this point in treatment it became apparent that Travis’ adaptability and support dysfunctions were being buttressed by a dualistic perception of his condition and not entirely by somatic fixations as the therapist first suspected. Since Travis’ functional abilities were also being compromised by his worldview, the practitioner decided to pursue a philosophical intervention.
ONTOLOGICAL TRANSFORMATIONS OF W0RLDVIEW
During the initial evaluation, Travis exhibited a divided and highly conflicted view of his condition. His distorted worldview was evident not only in his dissociation from his body, but also in his dysfunctional postural alignment and movement in space. In his words, “I just want to get this … [movement activity] done with so I can forget this decaying body.”In the early treatment sessions Travis began to ponder the ontological question, posed by the clinician, of who the observer of the suffering is and who it is who suffers. By the third session he appeared to have experienced a partial discovery of what many spiritual traditions have termed the “witness-self.” Travis identified himself with the “Mind of Christ” whom he describes as the “eternal witness” of his pain, fear, and suffering. But at this time in treatment, he was still dissociated from his soma: “Christ is the witness… I am the one suffering, but I no longer feel connected to my sick body.” This dualistic orientation is also reflected in Travis’ noted initial improvements in balance, mobility, and postural alignment – changes that were totally dependent upon the therapist’s tactile and verbal cues. Without such guidance, he immediately reverted to his previous maladaptive patterns. As Travis commented to the practitioner, “My body needs your assistance; it can’t move in this easier way by itself.”
Then, upon completion of the fourth session, Travis’ worldview and somatic configurations underwent their most profound shift. Travis began to experience his awareness of self and soma as bi-directional aspects of his unified being, relatively free of body-mind conflicts. He reported, “I now realize that Christ is also living and suffering in my sick body…. Yet I witness this suffering through him.” Eight weeks later at the second follow-up assessment, he described how this transformed sense of space and time had consequently altered his coordination, movement, and balance: “Because I have more space and time to fill and move through, I no longer rush past my movements. It gives me time and room to adjust my body so I don’t fall forward….” Travis felt that this two-month span was a “most precious and important time” for himself and his wife.
About a week after these statements were made, Travis experienced a sudden loss of balance and mobility skills. However, his transformed worldview continued to evolve. It seemed to allow him a profound acceptance of his now rapidly deteriorating condition. At the final follow-up, he described an experience of terror and joy when his sense of being expanded spaciously beyond his dualistic boundaries of self to embrace eternity.
He said, “At times it’s the most godawful thing I’ve been through, and then suddenly pure joy, when the outside realm becomes connected with the eternal, as if I’m a part of what St. Paul called our ‘resplendent body’.”
In this case study, Travis’ somatic dysfunctions, within the limitations of his motor neuron disease, were found to be bolstered by a worldview that expressed his dissociation from his afflicted soma. Through an integrated holistic treatment protocol of soft tissue manipulation, guided movement, and philosophical counseling, Travis showed a clear enhancement in balance, mobility, and postural alignment for two months. It should be noted that an alternative explanation could be given for these results. Although rare in the ALS clinical literature, our patient could have “spontaneously” improved .36 However, we believe that the changes in worldview and autonomic activity, which are associated with Travis’ dramatic somatic changes, make this alternative explanation less plausible.
CLINICAL EFFICACYAND FUTURE RESEARCH
Whether integrative treatment interventions would produce similar results for other patients stricken with motor neuron disease (or for other neurological impairments) is beyond the scope of a single case study and must await further research.’ Investigations are needed that compare a holistic principlebased approach to conventional corrective approaches for treatment of patients suffering from ALS, stroke, and Parkinson’s disease. In other case studies, we found some success in applying holistic manualmovement interventions for the treatment of patients with Parkinson’s disease.5′ Perry, Jones, Thomas,60 using the Rolf method as an integrative treatment for children with cerebral palsy, demonstrated improved mobility in certain subjects. The efficacy of this treatment seemed dependent on the child’s level of motor plasticity.
This clinical commentary and case study examined the philosophical assumptions, constitutive principles, and assessment taxonomies that underlie holistic treatment intervention. A successful case study was presented involving a patient afflicted with amyotrophic lateral sclerosis who had balance and mobility dysfunctions. Through the design and implementation of a holistic manual and movement protocol (Rolf Method), this case illustrated the differences between the dualistic and mechanistic assumptions of conventional corrective intervention and the non-dualistic assumptions of holistic intervention. Drawing on the insights of phenomenology, cognitive science, and biology, the holistic perspective views the person as a unified psychobio-logical being oriented in lived space and time. If a person becomes dysfunctional at any level of his being, faulty patterns of somatic alignment and movement and distorted patterns of thought will typically manifest. Therefore, when selecting, designing, and implementing treatment interventions, the holistic practitioner must always consider the whole person, his way of orienting and his embodied way of living in the world.
1. Maitland, J. Spacious Bodv: Explorations in Somatic Ontoloay. Berkeley, CA: North Atlantic Books; 1995.
2. Cottingham, J.T; Maitland, J. “A ThreeParadigm Treatment Model Using SoftTissue Mobilization and Guided Movement-Awareness Techniques for a Patientwith Chronic Low Back Pain: A Case Study”. J Orthoo. Sports Phys. Ther.1997; 26: 155-167.
3. Dennett, D. Consciousness Explained. Boston, MA: Little, Brown and Co.; 1991.
4. Lakoff, G.; Johnson, M. Philosophy in the Flesh: The Embodied Mind and its Challenge to Western Thought. New York,NY: Basic Books; 1999.
5. Varela, J.; Thompson, E.; Rosch, E.l- life* -0 LA #S. *soand Human Experience. Cambridge, MA: MIT Press; 1991.
6. Damasio, A.R. Descartes’ Error. New York, NY: Avon Books; 1994.
7. Capra, F. The Web of Life: A New Scientific Understanding of Living Systems. New York, NY: Doubleday;1996.
8. Merleau-Ponty, M. Phenomenoloav of Perception. London: Routledge and Kegan Paul; 1962.
9. Dillon, M.C. Merleau-Pontv’s Ontology, 2nd edition. Evanston, IL: Northwestern University Press; 1997.
10. Pinker, S. How the Mind Works. New York, NY: W.W. Norton and Co; 1997.
11. Dennett, D. Darwin’s Dangerous Idea: Evolution and the Meanings of Life. New York, NY: Simon and Schuster; 1996.
12. Mayr, E. Toward A New Philosophy of$ioloay: Observations of an Evolutionist. Cambridge, MA: Harvard University Press; 1988.
13. Goodwin, B. How the Leopard Changed its Spots: The Evolution of Complexity. New York, NY; Charles Scribner’s Sons; 1994.
14. Kauffman, S. At Home in the Universe: The Search for the Laws of SelfOrganization and Complexity. New York, NY: Oxford University Press; 1995.
15. Bortoft, H. The Wholeness of Nature: Goethe’s Wav toward a Science of Conscious Participation in Nature. Hudson, NY: Lindisfarne Press; 1996.
16. Maturana, H.R.; Varela, FJ. The Tree of Knowledge. Boston, MA: Shambala; 1987.
17. Tauber, A.I. The Immune Self: Theory of Metaphor? Cambridge: Cambridge University Press; 1994.
18. Crook, J.H. The Evolution of Consciousness. Oxford: Oxford University Press; 1980.
19. Honderich, T. The Oxford Companion to Philosoohy. New York, N.Y.: Oxford University Press; 1995.
20. Maitland, J. “Radical Somatics and Philosophical Counseling”. Invited paper presented at the Annual Meetings of the Eastern Division of the American Philosophical Association, Washington, DC, December 29, 1998.
22. Maitland, J.; Sultan, J. “Definition and Principles of Rolfing”. Rolf Lines. 1992; 20(2).
23. Frank, K.; McHose, C. “The Evolutionary Sequence: A Model for an Integrative Approach to Movement Study”. Roll: Lines. 1998; 26(3): 37-41.
24. Gajdosik, R.L.; Albert, C.R.; Mitman, J.J. “Influence of Hamstring Length on Standing Position and Flexion Range of Motion of the Pelvic Angle, Lumbar Angle, and Thoracic Angle.” J. Orthop. Sports Phys. Ther. 1994; 20: 213-219.
25. Cottingham, J.T “Effects of Soft Tissue Mobilization on Pelvic Inclination Angle, Lumbar Lordosis, and Parasympathetic Tone”. Presented at the National Center of Medical Rehabilitation Research of the National Institute of Health, Bethesda, MD, March 19th, 1992.
26. Oschman, J.L. Readinas on the Scientific Basis of Bodywork. Dover, NH: N.O.R.A.; 1997.
27. Podsiadlo, D.; Richardson, S. “The Timed ‘Up and Go’: A Test of Basic Functional Mobility for Frail Elderly Persons”. J. Am. Geriatr. Soc. 1991; 39: 142-148.
28. Di Fabio, R.P.; Emasithi, A. “Aging and the Mechanisms Underlying Head and Postural Control during Voluntary Motion”. Phys. The(. 1997; 77: 458-475.
29. Becker, R.O. The Body Electric: Electromagnetism and the Foundation of LIg. New York, NY: William Morrow and Co.; 1985.
30. Cottingham, J.T.; Porges, S.W.; Richmond, K. “Shifts in Pelvic Inclination Angle and Parasympathetic Tone Produced by Rolfing Soft Tissue Manipulation”. Phvs. Theta 1988; 68: 1364-1370.
31. Levine, P.A. Waking the Tiger – Healing Trauma. Berkeley, CA: North Atlantic Books; 1997.
32. Maitland, J. “Creative Performance: The Art of Life”. Research in Phenomenology. 1980; 10: 278-303.
33. Lahav, R.; Tillmanns, M. Essays on Philosophical Counseling. Lanham, MD: University Press of America; 1995.
34. Domholdt, E. Physical Therapy Research: Principles and Applicationg. Philadelphia, PA: W.B. Saunders Co; 1993.
35. Basmajian, J.V; Nyberg, R. Rational Manual Therapy. Baltimore, MD: Williams and Wilkens; 1993.
36. Mitsumoto, H.; Chad, D.A.; Pioro, E.K. Amyotrophic Lateral Sclerosis. Philadelphia, PA: F.A. Davis Co; 1998.
37. DalBello-Haas V; Kloos, A.D.; Mitsumota, H. “Physical Therapy for a Patient through Six Stages of Amyotrophic Lateral Sclerosis”. Phys. Thee. 1998; 78: 1312-1324.
38. Andres, PL.; Hedlund, W.; Finison, L.; et al. “Quantitative Motor Assessment in Amyotrophic Lateral Sclerosis”. Neurology. 1986; 36: 937-941.
39. Schor, R.H.; Kearney, R.E.; Dieringer, N. “Reflex Stabilization of the Head”. In: Peterson, B.W.; Richmond, FJ., eds. Control of Head Movement. Oxford, United Kingdom: Oxford University Press; 1988: 141-166.
40. Garrett, T.R.; Youdas, J.W.; Madson, T.J. “Reliability of Measuring Forward Head Posture in a Clinical Setting”. L Orthoo. Sports Phvs. Ther. 1993; 17: 155160.
41. Porges, S.W. “Orienting in a Defensive World: Mammalian Modifications of our Evolutionary Heritage. A Polyvagal Theory”. Psychophvsioloay. 1995; 32: 301-318.
42. Byrne, E.A.; Fleg, J.L.; Vaitkevicius, P.V.; et al. “Role of Aerobic Capacity and Body Mass Index in the Age-Associated Decline in Heart Rate Variability”. Journal of Applied Physioloay. 1996; 81: 743-750.
43. Kendall, FP; McCreary, E.K. Muscles, Testing and Function, ed. 3. Baltimore, MD: Williams and Wilkins; 1983.
44. Rothstein, J.M. “Measurement and Clinical Practice: Theory and Application”. In: Rothstein, J.M., ed., Measurement in Physical Therapy. New York, NY: Churchill Livingstone Inc.; 1985.
45. Jones, F.P. “Method for Changing Stereotyped Response Patterns by the Inhibition of Certain Postural Sets”. Psychological Rev. 1965; 72: 196-214.
46. Schleip. R. “Primary Reflexes and Structural Typology”. Rolf Lines. 1993; 21(4): 37-47.
47. Cottingham, J.T. Healing through Touch: A History and a Review of the Physiological Evidence. Boulder, CO: Rolf Institute; 1985.
48. Newton, A.C. “Basic Concepts in the Theory of Hubert Godard”. Rolf Lines 1995; 23(2): 32-43.
49. Bond, M. Rolfing Movement Integration: A Self-Help Approach to Balancing the Body. Rochester, VT Healing Arts Press; 1993.
50. Rolf, I.P. “Structural Integration: A Contribution to the Understanding of Stress”. Confinia Psychiatric a. 1973; 16(2): 69-79.
51. Rolf, I.P. Rolfina: The Integration of Human Structures. Santa Monica, CA: Dennis-Landman Publications; 1977.
52. Stevens, C. “The Development of the Alexander Technique and Evidence for its Effects”. British J. of Ther. and Rehab. 1995; 2: 621-626.
53. Cottingham, J.T.; Porges, S.W.; Richmond, K. “Shifts in Pelvic Inclination Angle and Parasympathetic Tone Produced by Rolfing Soft Tissue Manipulation”. Phys. Ther. 1988; 68: 1364-1370.
54. Solit, M. “Study in Structural Dynamics”. J. Am. Osteopath. Assoc. 1962; 62: 30-40.
55. Norkin, C.C.: White, D.J. Measure-rent of Joint Motion: A Guide to GoniomW. Philadelphia, PA: F.A. Davis Co; 1988.
56. Grossman, P.; Svebak, S. “Respiratory Sinus Arrhythmia as an Index of Parasympathetic Cardiac Control during Active Coping”. Psvchophysiol. 1987; 24: 228-235.
57. Porges, S.W. “Autonomic Regulation and Attention”. In: B.A. Campell, H. Hayne, and R. Richardson, eds. Attention and Information Processing in Infants and Adults. Hillsdale, NJ: Lawrence Erlbaum Associates; 1992: 201-223.
58. Lukoff, D.; Edwards, D.; Miller, M. “The Case Study as a Scientific Method for Researching Alternative Therapies”. Altern. Ther. Health Med. 1998; 4(2): 4452.
59. Cottingham, J.T. “The Use of ManualMovement Techniques for the Treatment of Patients with Balance Problems”. Presented at the Rolf Institute Faculty Meeting, Boulder, CO, Jan. 10th, 1998.
60. Perry, J.; Jones, M.H.; Thomas, L. “Functional Evaluation of Rolfing in Cerebral Palsy”. Dev. Med. Child Neurol. 1981; 23: 717-729.