Integrating Manual and Movement Therapy with Philosophical Counseling for Treatment of a Patient with Amyotrophic Lateral Sclerosis: A Case Study that Explores the Principles of Holistic Intervention

John T. Cottingham is a physical therapist and a certified Advanced Rolfing Practitioner at Christie Clinic Association in Champaign, Ill. He has conducted investigations into alternative manual and movement techniques for the last 20 years and has published several related articles. He is the author of Healing Through Touch: A History and a Review of the Physiological Evidence. Jeffrey Maitland, formerly an associate professor of philosophy at Purdue University, is Director of Academic Affairs and a senior instructor at the Rolf Institute, Philosophical Counselor and Consultant, and Board Certified Diplomat in the American Academy of Pain Management. He is author of Spacious Body: Explorations in Somatic Ontology and forthcoming, Spinal Manipulation Made Simple. He practices in Scottsdale, Ariz.
Author
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Pages: 119-127
Year: 2000
Others publications and sources

Others publications and sources

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John T. Cottingham is a physical therapist and a certified Advanced Rolfing Practitioner at Christie Clinic Association in Champaign, Ill. He has conducted investigations into alternative manual and movement techniques for the last 20 years and has published several related articles. He is the author of Healing Through Touch: A History and a Review of the Physiological Evidence. Jeffrey Maitland, formerly an associate professor of philosophy at Purdue University, is Director of Academic Affairs and a senior instructor at the Rolf Institute, Philosophical Counselor and Consultant, and Board Certified Diplomat in the American Academy of Pain Management. He is author of Spacious Body: Explorations in Somatic Ontology and forthcoming, Spinal Manipulation Made Simple. He practices in Scottsdale, Ariz.

Amyotrophic lateral sclerosis or ALS (Lou Gehrig’s disease) is a progressive degenerative disease of the central nervous system that involves the motor neurons.(1,2) Amyotrophic lateral sclerosis (ALS) is also the most frequently occurring motor neuron disease among adults. The common early symptoms of ALS are weakness in the arm, leg, and bulbar musculature (ie, the muscles of swallowing and speech). The muscle weakness usually progresses to include serious impairment of balance, mobility, swallowing, -speech, and breathing. The disease does not usually affect sensory systems, mental abilities, or autonomic functions.(1,3) The most frequent cause of death is from breathing complications.

Many manual and movement therapy protocols for ALS and other motor neuron diseases are based on corrective paradigm treatment-that is, they consist of exercises, stretches, and manipulative-movement techniques designed to treat regional problems symptom by symptom.(4,5) Philosophically, corrective interventions are based on the mechanistic assumption of Cartesian dualism-where the body is considered a soft machine and the mind is a ghost-like entity that inhabits it.(4,6-8) Consequently, this form of treatment may not account for how the corrective strategies impact the whole person.

Holistic paradigm approaches, in contrast, are based philosophically on a nondualistic view of “mind” and “body”-where thought and soma are considered 2 aspects of the same unitary living being.(4,5) Although a functional distinction can be drawn between body and worldview (mind), how one lives his worldview is not separate from how he lives his body. Thus both the worldview and the somatic aspects of a patient’s orientation must be addressed in holistic manual-movement protocols for motor neuron and other neurological disorders.

FIVE HOLISTIC PRINCIPLES OF INTERVENTION

Maitland and Sultan(9,10) have proposed 5 constitutive principles that underlie holistic manipulative-movement treatment: adaptability, support, palintonic, continuity, and closure (Figure 1). A constitutive principle is defined as a fundamental rule from which a chain of reasoning proceeds.(9,10) These principles define the parameters of intervention and the conditions for optimal human activity.

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FIGURE 1. Holistic Third Paradigm Intervention: The Principles of Intervention and Associated Assessment Taxonomies

The adaptability principle

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

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 worldview.

The palintonic principle

The palintonic principle is derived from the Greek word meaning “unity in opposition” (literally, “stretched back and forth”(4)). Palintonic harmony describes the somatic and perceptual geometry of spatial order that is apparent in the body as it approaches integration. Frank and McHose(11) have described this palintonic “unity of opposites” as graceful, economic movement, where the person has the sense of 2 directions: “a sense of accepting gravity in the body; …and a sense of orientation to the space around oneself….”

The continuity principle

The continuity principle recognizes that restrictions at 1 level of human activity will be reflected at all other levels.

The closure principle

The closure principle recognizes that when the patient has achieved the highest level of somatic and perceptual integration available treatment should be terminated.

FOUR TAXONOMIES OF HOLISTIC ASSESSMENT

Maitland(9,10) also defined 4 holistic taxonomy outcome measures that can be assessed and reassessed over the course of treatment: structural, functional, energetic, and psychobiological orientation (Figure 1). These taxonomies are like classificatory lenses that assist in the evaluation of problem areas associated with the 5 holistic principles. This analysis in turn helps the practitioner address the following clinical questions: What do I . do first? What do I do next?, and When am I finished?

The structural taxonomy

The structural taxonomy involves the assessment of biomechanical and geometric body alignment. This taxonomy may be operationalized as segmental postural position(12,13) or, geometrically, as computerized topography.(14)

The functional taxonomy

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 balancetests and rating scales.(15,16)

The energetic taxonomy

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 micro-currents that are transmitted through connective tissue network.(14,17) Autonomic activity, as operationalized by heart rate variability, has also been used as a measure of the energetic taxonomy(18,19)

The psychobiological orientation taxonomy

The psychobiological orientation taxonomy refers to what is traditionally termed mind and includes worldview(20,21) as one of its taxons. This taxonomy includes the bodys’ self-sensing ability, the perceptual-emotional orientation of the patient in regard to how he views his movement, his self-image, and his place in the world. The worldview taxon can be operationalized through self-reports and rating inventories.(22)

The case report that follows describes a patient diagnosed with ALS who had balance and mobility deficits. This case study illustrates a holistic treatment design based on the above proposed holistic intervention principles and assessment taxonomies. This protocol uses manual-movement techniques (Rolf Method) integrated with philosophical counseling. The patient was selected from the author’s (JTC) physical therapy practice.

Case Report

A 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 1.5 years ago, Travis was diagnosed with ALS, noninherited type. Over the last month he reported falling 3 times, all in a forward direction. Travis reported losing his breath easily and having trouble swallowing certain foods like meat. He also had difficulties with fine coordinated activities such as buttoning shirts and tying a necktie. Travis had prior physical therapy involving a corrective protocol of exercises for balance, strengthening, and stretching. He also had a respiratory consult for the use of a Bipap external intermittent positive pressure breathing device.(1) Travis lives with his wife. Several years ago he developed an interest in Christian contemplative prayer.

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 the arms.(1,3) 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 hyper-reflexes.

Examination and Assessment

Balance Assessment. 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 1 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 somato sensory (tactile) and vestibular input when visual information was removed. In the second test, when the visual information was removed again and the somato sensory 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 with ALS.(3,23)

Holistic Assessment of Postural Alignment and Movement. From the integrative level of assessment, Travis’ overall standing posture and gait were examined. The practitioner focused on identifying problems involving postural misalignments and faulty movement that 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 was given additional support by manual muscle testing that found the extensors were, overall, weaker then the flexors.(24) From a lateral view Travis exhibited an alignment pattern in which the head and neck were forward on the shoulders and torso, the shoulders protracted, the trunk slightly flexed at the waist, and the knees and hips also flexed. Jones(25) first compared this pattern to the posture associated with the startle reflex.(26) Increased sympathetic tone has also purportedly been linked to the startle reflex with a reciprocal decrease in parasympathetic tone. (18,26)

Even more interesting were the observations of Travis’ alignment pattern just before he initiated movement-what Godard(27) has called pre-movement. Just prior to initiating a sitting to standing movement, he shortened his sitting posture by (1) increasing the backward bending at the head-neck level (atlanto occipital 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.(5) Figure 2A shows a lateral view of this pre-movement posture. This shortened head-neck torso alignment remained 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.

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Unlike the results found from the static postural analysis and manual muscle testing, the posterior spinal extensors appeared to dominate over the anterior flexors during pre-movement and the execution of basic movements. Travis’ observed movement pattern is in sharp contrast to the configuration of holistic motion. According to Bond,(28) 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 (Figure 2B).

Taxonomy Outcome Assessments. Travis’ initial evaluation was completed by assessing the following 4 taxonomy outcome measures:

(1) Structural assessment: forward head posture. Excessive forward head alignment may be linked to balance deficits in patients with neurological pathologies. (16,23) Since the head’s position appears to serve as a “reference” for upright posture in gravity, slight adjustments in head alignment could make the difference between standing and falling for a patient.(16) To quantify the patient’s excessive forward head posture, we selected Garrett’s(29) cervical range of motion (CROM) instrument as a structural taxonomy assessment. The CROM instrument has showed good intratester and intertester reliabilities.(29) Travis sat erect in a straight back 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. 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 (23.5 cm). For reference, a group of patients diagnosed with orthopedic disorders showed a mean (X) forward head posture of 17.0 cm and a standard deviation (SD) of 1.8.(29)

(2) Functional assessment: 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.(15) This test has demonstrated high interrater and intrarater reliabilities, as well as good validity for measuring balance and mobility in older adults.(15,16) Travis sat comfortably erect in the same chair. He was instructed to stand up, walk 3 meters to a wall, turn around, and walk back to the chair and sit down. The practitioner timed this activity with a stop watch to the nearest tenth of a second. Podsiadlo and Richardson(15) proposed that test scores of <20 seconds indicate reasonable balance and mobility; scores between 20 to 30 seconds indicate some balance and mobility problems; scores of >30 seconds indicate serious balance and mobility problems. Travis’ score was 32.7 seconds.

(3) Energetic assessment: parasympathetic activity (vagal tone).Somatic therapists have long contended that releasing stored autonomic “charge” can be elicited or “discharged” through appropriate manual and movement methods. Levine(19) has recently tied repressed traumatic life experiences to “frozen” and disassociated autonomic states of high sympathetic arousal and a reciprocal decrease in parasympathetic “nurturing” activity. To assess the patient’s energetic taxonomy, a measurement of parasympathetic activity, vagal tone, was selected.(30,31) 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 measure of parasympathetic activity(30,31) Travis was positioned in a supine position with electrodes placed on the ventral surface 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 to 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 a X=4.8 and SD=1.2.(31)

(4) Worldview assessment: self-reports. To assess the worldview taxon, the patient’s self-reports 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 the world.(9,21) Travis expressed a dissociated concern about his recent falls and his difficulty in performing daily activities: “My body is not doing what I want; it’s no longer mine.”

Analysis

As noted, Travis had already received a corrective protocol of balance exercises and stretches from another physical therapist. Since this corrective approach was not successful in increasing mobility/balance and since Travis’ conflicted somatic and worldview problems might be interfering with further corrective strategies, the clinician chose to implement a holistic approach.(5)

Several problem issues related to the holistic principles became evident from the initial evaluation. Travis’ tendency to fall forward could be first viewed as a palintonic balance problem between the extensors and 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 (Figure 2A). This spinal extensor pattern may be a compensatory response to his fear of falling forward.

The 4 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.(23) The functional assessment, Timed Up and Go, suggested serious deficiencies in balance and functional mobility.(15) 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.(9) The energetic assessment of decreased vagal tone (parasympathetic activity) also lends credence to the significance of the adaptability and support deficits.(5,9) 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 in immobility/disassociation responses correlated with high sympathetic arousal.(19) Finally, the support/adaptability issues are further reflected in Travis’ worldview-self-reports.

The practitioner chose to first work with the support and adaptability problems 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 5 sessions over a period of 12 weeks. Session length was approximately 45 to 55 minutes. The 4 taxonomy outcome measurements (forward head posture, Timed Up and Go, vagal tone, and patient selfreports) were assessed after each treatment session and also at 3 voluntary follow-up testings. Figures 3, 4, and 5 summarize the results. The somatic treatment protocol for this patient was based on the Rolf Method of soft tissue manipulation and movement integration.(32.33) Rolf’s system is a form of manipulation-movement education that focuses on the whole person’s organization in gravity. Aspects of Alexander’s method were also incorporated 34 These techniques have been described elsewhere.(5,l8,35,36)

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Weeks After Initial Evaluation

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Treatment Sessions 1-3. The soft tissue intervention focused on support and adaptability problems found in the lower extremities, pelvis, breathing diaphragm, spine, A-O joints, and upper extremities. Soft tissue manipulation was applied to the interoseous membrane between the fibula/tibia and the radius/ulna, the hamstring attachments on the pelvis, the lateral hip rotator muscles, the iliopsoas musculature, the pelvic floor musculature, the diaphragm, the cervical muscles of the suboccipital triangle, and the back extensor muscles.

In the latter portions of the first 3 sessions, guided movement awareness techniques were employed to address 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 “embraces the space” around him. In the second and third sessions, when the therapist’s tactile and verbal guidance were present, Travis clearly shifted his premovement and movement execution patterns (Figure 2A, B). If, however, the clinician’s assistance was removed, he reverted to his faulty postural/movement patterns outlined in the initial evaluation.

The taxonomy assessments obtained after the first 3 sessions also support these movement and postural observations. The structural (forward head posture), functional (Timed Up and Go), and energetic (vagal tone) measurements were essentially unchanged from their initial evaluation levels (Figures 3, 4, and 5). From the practitioner’s analysis, Travis seemed to have the somatic ability by late in the second treatment session to support and adapt to a higher level of palintonic balance and to occupy a more integrative spatial orientation. Yet he appeared to have difficulty in adopting and supporting the worldview necessary to occupy this new orientation in space. Since Travis expressed a dualistic and alienated worldview, the practitioner, at this time in treatment, chose to 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? After the second treatment Travis’ alienation between self and afflicted body was evident in his reply 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?”

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 significantly transformed, but this time the changes were independent of the therapist’s guidance. The spine lengthened during the preparation and execution of basic movements (Figure 2B). Concurrently, his forward head-neck alignment moved superior and back over the shoulder girdle while he executed a more fluid, quicker movement sequence.

The taxonomy outcome measures also reflected this transformational shift (Figures 3, 4, and 5). Travis’ forward head posture was reduced and his balance-mobility test time was decreased from the initial evaluation. The sympathetic discharge described above was also reflected by a large reciprocal increase in parasympathetic vagal tone (ie, increased “relaxation response”).(19) Travis’ own words equally portray a dramatic shift from a dualistic and alienated worldview to one of a nondualistic 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.

To allow further reassessment of the 4 taxonomy outcome measurements, Travis voluntarily returned for a first followup assessment a week after the fourth session (6 weeks after the initial evaluation) and for a second followup visit (12 weeks after the initial evaluation). At both testings Travis arrived at 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 similar levels to the fourth session testings (Figures 3, 4, and 5). Travis reported improved balance/mobility in terms of walking, stair climbing, and transfers.

Two weeks after the second followup assessment (14 weeks after the initial evaluation), Travis called and stated the he had fallen. He reported having trouble catching his breath and difficulty swallowing. A fifth session was scheduled for the next day. Travis arrived in a wheelchair with his wheeled walker and was 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 were also recommended to assist his wife in the daily care of Travis. 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. Both forward head posture and Timed Up and Go test had dramatically increased (Figures 3 and 4). Vagal tone, however, remained essentially unchanged (Figure 5). From the worldview perspective, Travis stated that he was trying 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 3 weeks.

On arrival for his last follow-up assessment (17 weeks after the initial evaluation) Travis, wearing a neck brace, appeared noticeably weaker and fatigued as he sat flexed forward in his wheelchair. 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 and 4). His vagal tone level again exhibited little change (Figure 5). Travis’ last selfreport eloquently expressed his transformed worldview: “It’s frightening, but then I remember that [in Christ] I am both the eternal witness of my pain and the one who is suffering it.”

DISCUSSION

For about a 2-month period, Travis exhibited a remarkable improvement in balance and functional mobility. Specifically, he demonstrated improvements in head-neck alignment, speed, balance, and coordination of basic movements as demonstrated by the structural and functional taxonomy assessments and the practitioner’s visual analysis. For that 2-month span, he was functionally and structurally improved despite his degenerating motor neuron condition.

However, by the fifth session (14th week after the initial assessment) and as evidenced by his functional and structural taxonomy measures, Travis’ balance, mobility, and forward head posture had suddenly regressed to below pre-treatment levels. The most plausible explanation is that the degree of motor neuron damage had finally reached a critical level and had become an insurmountable somatic limitation for Travis to overcome. Sudden losses of balance/mobility skills are commonly reported in the ALS literature.(1-3)

Although the functional and structural taxonomy assessments after the fifth and final session had reverted to below pretreatment levels, Travis’ autonomic activity remained remarkably unchanged since the increased shift noted after the fourth treatment assessment. This enhanced vagal tone, like the transformed worldview evident in his fourth session self-report, remained through the final follow-up assessment taken 17 weeks after the initial evaluation. The provocative continuity between 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 neural functions.(30,37,38)

Ontological Transformations

The practitioner chose to first address the holistic principle issues associated with support and adaptability because these problems were apparently undermining Travis’ ability to accommodate to a higher level of palintonic balance. The somatic aspect of this conflict was first approached by identifying dysfunctions in Travis’ postural alignment and movement patterns. In the second and third treatment sessions the application of soft tissue manipulation and guided movement-awareness 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 dysfunctions alone as the therapist first suspected. In his words, “I want to get this … ‘ [movement activity] done with so I can forget this decaying body.”

Since Travis’ functional abilities were also being compromised by his worldview, the practitioner decided to pursue philosophical counseling as an intervention. In the early treatment sessions Travis began to ponder the ontological question, posed by the clinician, of who is the observer of the suffering and who is it that 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 faulty patterns. As Travis stated, “My body needs your guidance; it can’t move 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 bidirectional 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 2-month span was a “most precious and important time” for himself and his wife.

About 1 week after these statements were made, Travis experienced a sudden loss of balance/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 self expanded beyond his dualistic boundaries. He said, “At times it’s the most God-awful 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’.”

Clinical Implications

Whether holistic somatic protocols emphasizing worldview shifts would produce similar results for other patients with motor neuron disease (or other neurological impairments) is beyond the scope of a single case study design and must await further research.(39) In other case studies, we found some success in applying such integrative methods for mild stroke and mild Parkinson’s disease.(40) Perry et al(41) using the Rolf method as a holistic treatment for children with cerebral palsy, showed improved mobility in certain patients.

SUMMARY

A patient (Travis) suffering from ALS received a holistic principle-based protocol that combined manual-movement techniques with philosophical counseling. After 4 sessions, he exhibited a remarkable improvement in head-neck alignment, balance/ mobility, autonomic activity, and worldview for, a 2-month span. These changes occurred only after his worldview underwent a shift from a dualistic split of mind and body to a nondualistic orientation. After this 2-month period of improvement, Travis’ structural alignment and balance/mobility suddenly deteriorated rapidly. Yet, his enhanced worldview and autonomic tone continued through a final follow-up taken 17 weeks after the initial evaluation.

Acknowledgments

The research was performed at Christie Clinic Association (Rantoul Branch), Rantoul, IL This research was supported in part from a start up grant from the Rolf Institute and in-kind matching funds from the Christie Clinic Association. The authors thank biologist, Bruno U’dine, Parma University, Italy, for his untiring support and efforts in pointing us toward the relevant biological research and theory. Thanks also to Sheila Hayes at the Eleanor and Lou Gehrig ALS/MDA Research Center for her technical assistance. Special thanks to Mary Rose Cottingham for editing this manuscript into a seamless whole.

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