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The Case Study Method

Pages: 64-68
Year: 2012
IASI - International Association for Structural Integration

IASI Yearbook 2012

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Pedro Prado, PhD, Certified Advanced Rolfer™ and Rolf Movement® Practitioner of Sao Paulo, Brazil, is a member of the Advanced and Movement Faculties of the Rolf Institute of Structural Integration®. In 1981, he became the first Certified Rolfer™ from Brazil and brought the work to Latin America. He was a founding member of Brazil’s regional Rolfing® association, Associação Brasileira de Rolfing/Brazilian Rolfing Association (ABR). He is a clinical psychologist and a former professor of Somatic Psychology at the Catholic University of Sao Paulo. Currently, he is exploring the psychobiological dimension of SI in his practice, teaching, and research. He has developed extensive clinical and teaching protocols to both track and evaluate SI process outcomes, and to enhance awareness of the psychobiological perspective. These protocols include Quality of Life assessments made according to World Health Organization methods. His pioneering research, which correlates SI with improved quality of life, has been published as part of his doctoral dissertation. He created the Ida P. Rolf Library of Structural Integration, a Virtual Library, where one can find complete collections of articles from six SI publications, as well as other academic pieces. Since 1998, he has been a practitioner of Peter Levine’s Somatic Experiencing (SE) and is now an SE Instructor. He has developed a method called Structural Stretches that draws upon the principles and wisdom of both SI and SE.

Introduction

Structural Integration is a broad field, and we now have multiple schools that honor this work with a common heritage and an individualized inquiry; practitioners from these schools have been working to legitimize this work, which is derived from Dr. Rolf, in the scientific field. Recent developments in understanding the nature and behavior of fascia have helped us all to deepen our understanding of how and why it is that structural integration works. The following is an article that relates the effort being carried out in Brazil by the ABR. We hope that it can encourage many other schools and fellow practitioners to investigate and write about what their particular approach to structural integration is producing. Not only do our commonalities need to be recorded, but also our special differences deserve highlighting. In the following studies, investigations have been carried out according to the approaches that are specific to the Rolf Institute® and its members in Brazil. I’m sure that as more of us investigate and write, our identity and differences will be perceived more clearly, which will help further the creative spirit that is inherent to the practice of structural integration.

[The following article first appeared in Structural Integration: The Journal of the Rolf Institute®, Vol. 39, No. 2, December 2011.]

Science is a collective activity (1) in which, with creativity and discipline, researchers investigate and build upon the existing material, establish parameters of inquiry, and document and share their work. In 2006, I presented a study using

NAPER (2) questionnaires to verify and demonstrate the psychobiological aspect inherent in Rolfing® structural integration. The data, gathered from the viewpoints of both clients and practitioners, made the psychobiological aspect concrete. It was a tentative opening of the field of inquiry, and the start of an arduous task of creating documentation tools for our empirical studies. The continued development and refinement of the questionnaires became a collective task spanning several years, in which the NAPER practitioners created the documentation protocols we now use in clinical practice. We also began using the WHOQOL-BREF questionnaires, a psychometrically valid tool for assessment of the subjective experience of quality of life across multiple dimensions of being. (3) The key point is that here in Brazil the growth of our science so far has been a collective activity in which at least 35 practitioners plus a great many students have participated.

Now, five years later, our initial investment has paid off. This kind of exercise in clinical retrospection is beginning to be incorporated into the curriculum for Rolfing® training through the case study method:

a pedagogical tool that asks students to reflect upon the activity and to present—at particular stages of the training and of their processes with class clients— descriptions of the clinical experience and its outcome. At the end of the final phase of training (Unit 3), students must make presentations of their cases. This requires and trains students to look back on what they have done, to think about it, and to talk about it. At a higher level, the exercise permits investigation of specific questions and problems—the resolutions of which will empower us to clarify the value of Rolfing in the many ways it can, as an instrument of health and personal development, ameliorate the human condition. We have a collective need to answer these questions, as well as to gain some control over the variables inherent in clinical practice.

In its latest initiative in furtherance of these goals, ABR (Brazilian Rolfing Association), in partnership with Centro Universitario Italo Brasileiro (Unitalo) created a postgraduate program for Rolfing SI, and those who complete it are awarded the equivalent of a master’s degree. The program is open to students in the last stage of their professional certification training (Unit 3), as well as to practicing professionals. Participants take university courses in scientific methodology and pedagogy, and finally apply this learning to execution of formal case studies on the process of a class client or client in a practitioner’s clinical practice. We recently graduated our first class, which began in 2010 and consisted of 13 participants—seven already-certified practitioners and six students in the final phase of their professional certification training.

My own role in the program is two-fold. First, I am the program coordinator. Second, Unitalo requires each Scientific Methodology student to have a sponsor to help the student design and execute the case study, and I served as the sponsor for all 13 of our participants. In that role, I attended the Scientific Methodology class, as well as the supervision workshops in which we worked with the Scientific Methodology instructor to determine how to apply the general theoretical concepts in the Rolfing context. I also advised each student in person and by e-mail as necessary. To me, it is especially rich and gratifying to have the opportunity to expand the students’ universe in the theoretical realm, as well as to guide their thinking towards a scientific attitude when assisting them with their case studies.

These case studies our postgraduate program requires are far more extensive than those required in the Rolf Institute’s basic certification training. The student researches a specific problem by engaging

potentially useful theories, raising questions, developing hypotheses, and seeking methods to investigate them; and then the student presents and discusses the outcomes according to accepted scientific parameters.

The case study is both a method of investigation and the investigation itself. In both scope and level of effort required, the postgraduate program case studies are comparable to any other master’s thesis.

Besides being a philosophy, a professional practice and a calling, Rolfing SI is also a science—and science is no simple task. The scientific investigation of Rolfing raises particularly thorny questions: because Rolfing is premised upon and practiced through an integrative paradigm, it eludes the classical approaches and experimental methods focused on cause and effect.

It is not easy to perceive simultaneously the multiple aspects of an entire phenomenon, nor is it easy to find the language to articulate one’s multidimensional perception and experience.

Despite this obstacle, in order to advance the conceptualization and elucidation of the work—and thereby, ultimately, to advance the work itself—we must determine how and in what context to best investigate and document its results. What’s more, although we have abundant empirical evidence of the work’s efficacy, to date this evidence has no real repository: It has not been collected and recorded systematically, nor, for the most part, has it been aggregated, indexed or published. The small quantity of data currently available is a base too ephemeral on which to evolve and demonstrate the efficacy of our work. It provides neither an adequate context for further investigation nor a common language for further discussion. For our research to advance, we need more of it, somewhere to put it, and a vocabulary to talk about it.

The multi-dimensional and holistic attributes that give the work its conceptual richness present at the same time the chief obstacle to investigation of its results.

What we need is a scientific approach consistent with our paradigm. The segmentation of reality and isolation of phenomena, often used for controlling multiple variables, in our context poses the risk of losing the whole, of overlooking the most essential attribute of the work. Paradoxically, it is the essential holism of the work that poses the greatest challenge to its investigation. As these 13 case studies show, their authors have accepted the challenge. Each found a focus, defined a theme, and investigated a problem; and from this focus, observed correlations among the multiple dimensions of Rolfing and its taxonomies of access (structural, functional, psychobiological, and energetic).

The researchers—all of whom administered to single clients 10 structural sessions, and some of whom added movement integration sessions as well—chose a variety of themes and perspectives, from how Rolfing affects aches and pains, to features Rolfing shares with psychoanalysis. Clients studied included men and women of all ages, in pain seeking relief, or pain-free and seeking a better quality of life. While some of the studies focus on the physical dimension, others concern the psychobiological or energetic, and still others the functional. While many of them evaluate quality of life and others measure symptoms or objective physiological phenomena, most record the clients’ multidimensional experience.

Several researchers evaluated how the holistic approach of a Rolfing series could affect chronic aches and pains, including adhesive capsulitis, low back and cervical pain, and plantar fasciitis. Not only was pain reduced and function improved, but the clients’ quality of life was measurably improved across various dimensions of being beyond the physical. One studied a client with both temporomandibular dysfunction and plantar fasciitis. He found that by contextualizing the local pathologies in terms of their relationship to posture and considering them as multiple aspects of the same system, SI’s holistic, global approach addressed and ameliorated both. Plus, the client’s function and self-esteem both improved.

Another researcher who focused on temporomandibular dysfunctions studied two clients to assess whether posture and balance improvements from SI could contribute to the treatment of TMJ disorders and malocclusion. The clients underwent orthodontic evaluation before, during, and after the treatment series. The case study verified that the postural changes correlated with objective changes in craniometry and Rocabado analysis; and that the clients’ perceived balance improvements correlated with objective changes in computerized baropodometry, stabilometry and statokinesiometry.

  • One of the clients, who had been in severe pain prior to her series, experienced a 30% pain reduction (Visual Analog Scale [VAS] assessment, see note 6).

Others investigated whether Rolfing could be useful in the management of chronic diseases. One case study showed that Rolfing, as one component of a multidisciplinary approach, allowed the client to manage bipolar disorder better and experience a higher quality of life. Both the psychotherapist’s and the client’s reports confirmed the improvement. The other case study showed that Rolfing improved the quality of life for a client with multiple sclerosis, this being confirmed not only through the WHOQOL questionnaire, but also through another QOL questionnaire validated specifically for MS patients. (5)

Posture and awareness of the Rolfing line were the subjects of two more case studies. In one study, the client’s postural improvement and heightened body awareness allowed greater congruence between her attitudes and her behavior, which led to a significant improvement in perceived quality of life, especially in the physical, psychological and social dimensions.

In the other study, the client’s heightened awareness and perception of her line correlated with reduced psychobiological symptoms and increased sense of well being; and along with better stability, she reported greater structural, emotional and spiritual balance.

One researcher chose to study the benefits of Rolfing for a professional aerial acrobat, and in particular, how postural changes and heightened body awareness altered her body concepts, movement, and structural organization. Photos documented postural improvements; and in questionnaires and interviews, the client reported changes in body image and attitude, which allowed her to perform with freer movement and less bodily stress, and to feel her movement “from within.”

Another researcher, having observed that many who seek somatic therapies lack a sense that certain body parts belong to them, explored in the context of Rolfing the psychoanalytic concept of autotomy, coined by Sándor Ferenczi, which refers to our tendency, for reasons of survival, to cleave off from the whole certain experiences or aspects of being; i.e., the tendency to reject the part that is in a state of tension. The client’s questionnaire responses indicated that Rolfing facilitated, in addition to structural and emotional benefits, recognition and reintegration of body parts into the client’s image of the whole self. The researcher concluded that psychoanalytic concepts like autotomy contribute to a richer understanding of relationships among various dimensions of being, and therefore advance the understanding of our work.

Finally, one researcher used case studies of two clients who sought to learn more about their physical conditions and to improve posture and function to explore the relationship between Rolfing and therapeutic process in light of the psychoanalytic theory and practice of Sándor Ferenczi and Fabio Landa. The researcher concluded that Rolfing is indeed a therapeutic process: Like psychoanalysis, Rolfing is an event between two persons and there can be no Rolfing by oneself. For Rolfing to be therapeutic, both practitioner and client must participate in the relationship as co-responsible agents; and, it is effective because it is a two-person therapeutic process—not because the practitioner applies any particular technique.

Our colleagues grappled with questions of methodology as well. We can analyze data with both quantitative and qualitative measures. Various case studies in this group share several metrics for outcome measurement, such as photos to assess posture; the VAS to assess pain (6); the WHOQOL to assess the client’s perceived quality of life; and the NAPER questionnaires (or their precursors and successors) to elicit reports of multidimensional phenomena from various perspectives (practitioner, client, and the relationship between them). Having common tools with which to measure results is essential to building a coherent and intelligible body of literature.

With these case studies, we are taking a step forward, making gradual but definite progress on the methodological questions intrinsic to working in a holistic paradigm. The participants’ analysis and discussion of the clinical outcomes of their studies show that each considered multiple aspects of being human together as they related to Rolfing; i.e., each case study was conceived and executed with a holistic, multidimensional perspective. For example, the participants:

  • Related multiple symptoms to each
  • Observed correlation among multiple perspectives, such as structure and function or the various components of quality of
  • Discussed clinical outcomes in terms of correlation among multiple perspectives, such as the correlation of reduced physical pain with improved emotional state or quality of life, or how the integration of a physical part into the body image and how that relates to the person’s sense of self in

Thus, at the same time the participants employed impeccable scientific methodology, they displayed an embodied holistic attitude, one congruent with the philosophical stance and conception of the human being that are fundamental to Rolfing. Put another way, these researchers walked their talk; they showed by example that science and holism can coexist, that there can indeed be a science regarding a holistic activity.

It is the scientific attitude which not only lights the way, but above all takes the first step, lays the first stone, on the path to finding and using scientific methods that respect the philosophical paradigm that Rolfing posits. Our experience shows that we can and should gradually develop more varied and precise instruments to yield even better qualitative descriptions. Still, what’s important is that when we see a path, we will have access to it. And our practice will nourish future practices. We hope this example might inspire some of you also to join those practitioners pioneering the research of Rolfing.

The program participants and the topics of their inquiries are listed below. The full case studies are available (in Portuguese, with abstracts in English) at the Ida P. Rolf Virtual Library for Structural Integration (7); at the ABR’s library; and at Uniitalo Library’s special collection of postgraduate program papers.

 

Alfeu Ruggi, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “The effects of Rolfing® SI and its holistic approach on chronic adhesive capsulitis.”

Ana Maria Gilioli, Certified Rolfer,™ Rolf Movement® Practitioner, “The effects of Rolfing® SI and its holistic approach on chronic low back pain in an elderly client.”

Cornélia Rossi, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “Rolfing® SI as one component of a multidisciplinary approach to the treatment of bipolar disorder.”

Hulda Bretones, Certified Advanced Rolfer™, Rolf Movement® Practitioner, “The process of Rolfing® SI as a therapeutic relationship between two people.”

José Henrique Bronze, Certified Rolfer,™ Rolf Movement® Practitioner, “Rolfing® SI both ameliorates symptoms and enhances quality of life for a client suffering from the correlated conditions of temporomandibular dysfunction and plantar fasciitis.”

Marcela Nascimento, Certified Rolfer,™ Rolf Movement® Practitioner, “Effects of postural changes and enhanced body awareness from Rolfing® SI on the body image and structural and functional organization of a professional acrobatic artist.”

Maria Helena Orlando, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “Rolfing® SI as an agent of integration among posture, behavior and quality of life.”

Maria Lucila Freitas, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “How perception of the Rolfing® SI line enhances well being.”

Marcia Cintra, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “Applying by analogy the psychoanalytic concept of autotomy in the practice of Rolfing® SI.”

Mariana Moretto, Certified Rolfer,™ Rolf Movement® Practitioner, “The effects of Rolfing® SI and its holistic approach on idiopathic low back pain.”

Marina Mattar, Certified Rolfer,™ Rolf Movement® Practitioner, “Rolfing® SI enhances quality of life for a client suffering from cervical and lumbar pain.”

Monica Caspari, Certified Advanced Rolfer,™ Rolf Movement® Practitioner, “The contribution of Rolfing® SI to the treatment of temporomandibular disorders.”

Taissa Rebouças, Certified Rolfer,™ Rolf Movement® Practitioner, “Rolfing® SI enhances quality of life for a multiple sclerosis patient.”

Endnotes

  1. Prado, (2007). The making of a science of Rolfing: From an individual path to a collective activity. Structural

Integration: The Journal of the Rolf Institute, 35(4), 22-25.

  1. Prado, , “Documentation for Clinical Practice and Research,” available at www.iprlibrary.com <blocked::http:// www.iprlibrary.com/> or pedroprado.com. br. Note: NAPER is the Brazilian acronym for Núcleo de Atendimento, PesquisaEducação em Integração Estrutural Rolfing®, which translates from Portuguese as The Center for Rolfing®Structural Integration Treatment, Research, and Education.
  2. Prado, , (2010). Does Rolfing® SI enhance quality of life?: A pilot study. Structural Integration: The Journal of the Rolf Institute, 38(2), 43-47. Note: WHO QOL is the Quality of Life index established by the World Health Organization.
  3. Craniometry, which is a radiographic technique, has various At the University of Sao Paulo, they measure both sides of the face and take the average between the two, whereas Rocabado analysis measures the posture of the head in relation to the posture of the neck. Stabilometry is an objective method for the quantitative study of postural equilibrium, which has been shown to correlate with functional instability of the ankle joint. Statokinesiometry is an objective assessment of vestibular function, and is used to evaluate postural stability. Baropodometry is an objective assessment of pressure on the sole of the foot in standing, and is used to evaluate weight distribution between the two feet and within different regions of the foot.
  4. This scale is the DEFU (Determinacao Funcional da Qualdidade de Vida de Pacientes com Escclerose Multipla).
  5. The VAS is a subjective psychometric response scale often used to measure the experience of Subjects specify their pain levels by indicating positions along a continuous line between two end-points.
  6. The Ida Rolf Library of Structural Integration (www.iprlibrary.com or www.pedroprado.com.br) was built to advance the theory and practice of SI by facilitating access to the intellectual product of the Structural Integration community, encouraging study and research, and inspiring visitors to contribute to the literature of our young science. This virtual library now includes nearly complete collections of the substantive articles originally published in six periodicals devoted to SI, as well as a growing collection of academic papers, theses and other individual works of interest.

 

Quantity of articles

23 Academic

129 Bulletin of Structural Integration

45 IASI Yearbook of Structural Integration

32 Notes on Structural Integration

14 Other publications

398 Rolf Lines

88 Rolfing Brazil

331 Structural Integration: The Journal of the Rolf Institute

 

This online library is in constant evolution with more material being gradually added. We hope that in the near future we will have the complete collection of IASI Yearbooks and the material that has been produced in past years from all other structural integration schools.

 

Acknowledgement: Special thanks to Heidi Massa, Certified Advanced Rolfer, for her collaboration on the conception and preparation of this piece.

The Case Study Method

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