A Manual Therapist's Guide to Movement. Teaching Motor Skills to the Orthopedic Patient

385 Pages·2006·15.322 MB·English

by  Gordon Browne, BSC (Auth.)

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First published 2006
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Foreword
AManual Therapist’s Guide to Movementis a book for those discovery model. The patient is asked to explore a new focus
who want to know more about human movement and of movement by attending to altered kinesthetic cues during a
how to influence it. In his analyses of postural alignment, motor desired action. The patient is then carefully guided to compare
control and muscle balance, Gordon Browne presents the first and observe whether the new focus leads to improved adapta-
part of his published work on the trunk and lower limbs. A tion during the desired function activity.
second volume is planned to cover the cervical spine, tem- In this system, evaluation is not performed separately from
poromandibular joint, upper limbs and autonomic balance. the learning process. The therapist constantly observes and
Written for physical therapists in clinical practice who are inter- adapts stimuli in order for the student to maximally explore
ested in exploring a new exercise paradigm, this excellent book and adapt new motor patterns during a particular lesson; to
is a triumph of orderly thought and presentation. It suggests experience a sense of success or the novelty of discovery. Eval-
that for physical therapy to continue to grow as a profession, uation and progress notes record the conditions that facilitate
traditional therapeutic exercise and strictly quantifiable goals learning for this person; the key auditory, visual, kinesthetic,
need to make room for new exercise and treatment paradigms and/or movement cues that maximize functional performance
that focus on integration, self-awareness, quality and coordi- of a desired task, illustrating in each unique case the neuro-
nation of movement rather than on isolated movements and plasticity of the central nervous system.
compartmentalized exercises featuring straight lines, cardinal The author of this first volume has produced a text that
planes and rote repetition. focuses on the functional movements that underlie every action
Modern manual therapy has a rich and colorful heritage. As that we participate in on a day-to-day basis. As physical thera-
a profession, it has tenaciously held to the value of manual pists, we have learned to focus on the components of move-
treatment for disorders of structure and function. Gordon ment that are limited by injury – range of motion, strength and
Browne, with his extensive background in both manual therapy somatosensory functions. A review of physical therapy litera-
and the Feldenkrais Method, presents a unique system of ture documents a gradual shift toward movement as its own
therapy that has grown out of creative observation and consis- entity. Physical measurements of joint motion and force pro-
tent, independent development. duction remain important, but new efforts address other com-
When the Feldenkrais Method is applied to patients in phys- ponents – motor control, balance, somatosensory awareness,
ical therapy and rehabilitation, the therapist takes on the role movement error detection, sensory effect of somatic injury etc.
of teacher, facilitator and guide. The intention of the therapist – that allow us to perform our daily and recreational activities
is to guide the individual using verbal, visual and kinesthetic at the level we wish. This serves as the basis for determining
information. Rather than first evaluating the patient and then well-organized function and success in treatment...
treating with soft tissue techniques and strengthening or range achieving full range of motion or strength is no longer the final
of motion exercises, the patient is ‘invited to learn’ using the goal of treatment.
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A Manual Therapist’s Guide to Movement
One element of functional exercise brought out in Browne’s related with needed self-awareness and movement skills. The
work that is worthy of consideration is the idea of ‘integrated’ organizing principle for this chapter is the way the foot inter-
versus ‘isolated’ movement patterns. Whereas most machine- acts with the ground...and how the foot functions as an
based exercises isolate motion to a particular joint, effectively extension of and in concert with the pelvis, hips and knees.
training a muscle in one plane, functional exercises tend to be Gordon Browne is to be congratulated for this presentation
multi-planar, since true functional movements occur in a tri- of his outstanding approach to exercise and movement therapy.
planar fashion. He has taken the best scientific evidence available in manual
After the initial background chapters covering key concepts, therapy, integrated it with the Feldenkrais Method and applied
trunk organization and the function of the legs, the text then it to clinical practice. Embracing the Feldenkrais methodology
addresses the spinal and pelvic muscles and their potential to and manual therapy has finally been achieved by Mr. Browne’s
stabilize the spinal column. There is significant biomechanical work.
literature describing the role of various anatomical components Darlene Hertling
on stability but until recently this is not the case concerning
the muscles.1–7Specific movement lessons focus on reactivating
the deep intrinsic stabilizers such as the transverse abdominis, 1. Hodges PW. Core stability exercise in chronic low back pain.
internal obliques, multifidus, quadratus lumborum, gluteus Orthop Clin N Am 2003;34:245–54.
medius/maximus and latissimus dorsi. These functional core 2. Hodges PW, Richardson C. Inefficient muscular stabilization of the
exercises train stability patterns in movement and positions lumbar spine associated with low back pain. A motor control eval-
uation of transversus abdominis function. Spine 1996;21:2640–50.
similar those of daily life, recreation and sport or occupational
3. McGill SM. Mechanics and pathomechanics of muscles acting
demands.
on the lumbar spine. In Oatis C: Kinesiology: The Mechanics and
Manual resistance is used to faciliate awareness of various
Pathomechanic of Human Movement. Philadelphia, Lippincott,
extension, flexion and lateral stresses. Resistance is used as an
Williams & Wilkins; 2004: 563–7.
evaluation tool to allow the therapist to assess the patient’s 4. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for
global muscular responsiveness and recruitment as well as inter- Spinal Segmental Stabilisaton in Low Back Pain. Scientific Basis and
segmental stability. The patient is observed and monitored Clinical Approach. Edinburgh, Churchill Livingstone; 1999.
through kinesthetic feedback to determine if the spine, pelvic 5. Richardson C, Jull G, Hides J. A new clinical model of muscle dys-
girdle and lower limbs are well positioned and maintained in function linked to the disturbance of spinal stability: Implications
balanced alignment. Browne’s text synthesizes very well the for treatment of low back pain. In: Twomey LT, Taylor JR, eds.
Physical Therapy of Low Back, 3rd edn. New York, Churchill
available information about dynamic stabilization of the spinal
Livingstone; 2000: 249–67.
column and the role of the pelvic girdle, hip and lower limbs,
6. Richardson C, Hodges P, Hides J. Therapeutic Exercise for
which play a major part in spinal stabilization and functional
Lumbopelvic Stabilization: A Motor Control Approach for Treat-
movement.
ment and Prevention of Low Back Pain, 2nd edn; 2004.
The last chapter in this volume focuses on specific lessons 7. Richardson CA, Snijders, CJ, Hides JA, et al. The relationship
to facilitate lower extremity function, balance and efficiency. between transversus muscle, sacroiliac joint mechanics and LBP:
Categories of lower extremity stressors are discussed and cor- Spine 2002;27:399–405.
viii
Preface
When the early anatomists first started opening up and dinal plane movement and relative to a fixed and stable point,
peering inside human bodies with the intention of a particular vision of human movement and exercise was des-
describing and recording what makes us tick, they made a tined to come into being.
fateful decision. They began describing things relative to car- Fast-forward to the early twentieth century and the advent
dinal planes. They divided the body into X, Y and Z axes and of modern exercise principles. Armed with an accumulation of
created the coronal, sagittal and transverse planes. They could precise anatomical knowledge, modern scientific exercise was
then describe with written or verbal language exactly where a predictably designed around stretching or strengthening of
particular vein, nerve or muscle was relative to another by using individual muscles performed in cardinal planes. Destiny was
the terms medial/lateral, anterior/posterior or superior/infe- fulfilled, and we have come to find ourselves under the influ-
rior. That way, they had a commonly accepted way of com- ence of a somewhat mechanistic vision of human movement
municating their findings with one another. and exercise, never suspecting there could be another way of
Naturally, when they began describing human movement, looking at things.
they turned again to the concept of the cardinal plane. Move- This vision has been one where the legs move on a station-
ments of one bone relative to a stationary neighboring bone in ary pelvis, instead of one in which the legs manage the pelvis
the coronal plane became flexion/extension, movements in the from their grip on a stationary ground. This vision has been
sagittal plane became abduction/adduction, and movements in one where the arm and shoulder girdle move relative to an
the transverse plane became internal/external rotation. This immobile chest and torso, instead of one in which the arms and
idea of movement in cardinal planes, and the corollary princi- head move synergistically with movements of the pelvis and
ple of fixed origin and movable insertion, has subtly but com- torso. This robotic view emphasizes a fixed origin and a mobile
pletely colored how we have viewed movement and exercise insertion, and has the extremities moving in cardinal planes
ever since. relative to an immobile pelvis and torso like a plastic Barbie
Once movement was described in cardinal planes, the next doll. It localizes, isolates and compartmentalizes the body,
logical step would have been to ask which muscles moved and it has strongly influenced the way that we as physical ther-
which bones in what cardinal planes. The infraspinatus exter- apists think of exercise, which is from an objective/scientific
nally rotates the shoulder joint in a transverse plane; the quadri- perspective.
ceps extends the knee joint in a coronal plane; the gluteus We have based our physical therapy exercise paradigm on
medius abducts the hip joint in a sagittal plane. And so on it logic. What muscle needs to be stretched or strengthened for
went, until over time we came to know exactly which muscles this particular orthopedic or movement problem? What cardi-
were responsible for what cardinal plane movements. Once nal plane movement does this muscle perform? What exercise
movement was described this way and a language had been can I prescribe that makes that muscle work in that plane and
constructed that described muscular function relative to car- against scientifically dosed progressive resistance? With this type
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A Manual Therapist’s Guide to Movement
of circular thinking, we have constructed an entire therapeutic in movement and posture regulation, we will need to start
exercise paradigm with some unspoken but shaky assumptions. finding ways to bring proprioceptive self-awareness and
We assume that by making the infraspinatus stronger that it improved body self-image into our exercise prescription, to
will then automatically kick in at the appropriate time, with the make it less mechanistic and more organic.
appropriate amount of force and for an appropriate period of Fortunately, exercise paradigms already exist that show
time to do its job of controlling arthrokinematic movement of promise in fulfilling these requirements. Tai chi, the
the glenohumeral joint and reducing impingement stresses Feldenkrais Method® and yoga are examples of exercise
on the shoulder. We assume that making the vastus medialis systems designed not scientifically but by accumulated propri-
stronger will make the patella track more accurately. We assume oceptive experience. These systems could be described as
hip flexor stretches will reduce anterior pelvic tilt and relieve subjective/proprioceptive and, with modifications, have vast
back pain, and that strengthening the lower trapezii makes us untapped potential for physical therapists and others who are
reach forward better. interested in advancing their understanding of human move-
We are making an assumption that strengthening or stretch- ment and how to best influence that movement in their
ing exercises will improve a given motor skill...but do they students.
really? How do we know our student is still using his new The purpose of this book is to provide a bridge between the
strength or flexibility appropriately? Isn’t there a less circuitous two visions of movement and exercise, the objective/scien-
route we can take to improve clinically relevant motor skills – tific/isolationist view and the subjective/proprioceptive/inte-
one that teaches an integrated movement skill in a way that grative view. This book advocates using modifications of these
doesn’t first disintegrate or atomize a movement? I suggest we proprioceptively based movement systems in therapeutic exer-
just turn the whole equation on end and teach our students cise, but leaves the spiritual/mystical trappings inherent to
how to progressively improve a particular motor skill, then these systems for another forum and explains the science
assume that the appropriate muscles will be stretched or behind the movement. It analyzes the muscular components of
strengthened along the way! a particular prescribed movement and relates it to clinical and
It is certainly simpler and cleaner to think of one muscle functional relevance and to specific tissue strain or pathology.
group controlling one direction within one joint, with one Primarily, it is written for practicing physical therapists with
bone fixed and one bone moving. Studies based on these obser- an orthopedic clientele who are looking for new and improved
vations are much simpler to set up and to replicate. Exercises ways of facilitating better movement or postural quality in their
based on these assumptions are easier for you to teach and students. It is a book that challenges some of the assumptions
easier for your students to learn, but may lack the complexity we have always made about movement and exercise, and artic-
or specificity required to make it stick in real life. Reality has ulates an alternative vision of human movement and how to
a way of making things less tidy and increasing the degree of influence it. Rather than figuring out which muscles to exer-
difficulty. cise in order to influence a motor skill, we will be figuring out
The reality is that the human body moves in incredibly how to exercise particular motor skills and common synergis-
complex patterns, many of which are imbalanced and ineffi- tic patterns of movement that will in turn influence certain
cient and which can lead to a host of musculoskeletal miseries. muscles.
These learned patterns of movement and posture are uniquely This alternative vision of therapeutic exercise is not a quick
constructed by each individual and consist of the coordinated and easy study. The subject matter is immense and intricate.
and simultaneous action of many different bones and joints, On the other hand, the huge scope and complexity of these
powered by the synergistic contraction of a body-wide series of proprioceptive systems also means that there is a huge poten-
muscles and controlled by some omnipotent (though not tial for use in treating a wide variety of musculoskeletal injuries
usually omniscient) wizard in the CNS. or other movement-related conditions. So, if you are feeling a
If we acknowledge the reality of synergistic patterns of bit adventurous and have an inquisitive mind, dig into your
movement, we will need to start updating our exercise para- Guide and have a safe and interesting journey.
digm from isolation to integration...to emphasize stretching
or strengthening an entire pattern of movement, and to take Maple Valley G.B.
into account the relationship of individual parts to the inte- Washington 2006
grated whole. If we acknowledge the pivotal role the CNS plays
x
Acknowledgements
As always when advancing human knowledge, we all stand for the content and ideas of this book, and I would like to
on the shoulders of others. I would like to express my thank him for his help. My mother put in yeoman’s duty in
gratitude and appreciation to my orthopedic/musculoskeletal combing through this tome three times to make editorial
instructor in physical therapy school, Darlene Hertling, who corrections, and I want to add a thank you for the work she
sparked an interest in orthopedics early on in my PT career. did on the book to my thanks to her and my father for giving
I would like to commend the genius of Moshe Feldenkrais me life.
and thank him for his insight into the marvelous design that is Finally, I would like to thank my family. My kids, Morgan
the human body. My thanks go to Anat Baniel and other train- and Derek, provided much of the inspiration for this book.
ers in the Feldenkrais Method for continuing the work of Dr Watching them grow up and develop their motor skills gave
Feldenkrais after his death, and for making this knowledge me insights into movement and learning that later became
available to me and to thousands of others. some of the main themes of this book. My wife Julie, who is a
I would like to acknowledge the incredible depth, quality Feldenkrais Practitioner and a Physical Therapists’ Assistant,
and variety of movement experiences that have been developed, has helped me every step of the way, from initial concept
taught and passed on through many generations by the prac- through outline to final changes. I want to thank her for steer-
titioners of Tai Chi, yoga and other eastern movement tradi- ing me back in the right direction a number of times, for being
tions. I thank those nameless masters who have kept these a rock of unwavering support when I got discouraged, and for
traditions alive through changing times. sacrificing her needs to give me the time I needed to complete
My friend and colleague, Israel Sostrin, helped immensely this project.
with the research and was a valuable early sounding board
xi
E
N
O

R
E
T
P
Introduction to
A
H
C
motor learning
Chapter outline 3. We don’t want to teach mere stimulus and response behav-
ior, but to mold our students into lean, mean and self-
regulating motor planning machines.
1. Pathokinesiology. What happens when movement goes bad? 4. Puzzle analogy – teach a process rather than imitation and
2. HJ Hislop coined the term pathokinesiology and called repetition.
it the distinguishing clinical science of physical therapy.
Pathology creates movement dysfunction, and vice versa. Factors influencing motor learning
3. Moshe Feldenkrais was a scientist and martial artist. Injured
1. Early childhood development
knee and learned to use/move again through observation
and mimicking movement of others, especially children. • Developmental sequence implications. Let your stu-
dents develop at their own pace. Allow progressive
4. We as movement professionals need to know both objec-
acquisition of motor skills instead of expecting imme-
tive and subjective movement...it is through subjective
diate emergence of a finished product. Allowance of
criteria that we make motor decisions.
approximations. Start your students at a place where
5. Movement is behavior, learned and shaped by individual
they can be successful, so they don’t get frustrated.
experience. We who are seeking to change the way
Progress them on as they learn, so they don’t get bored.
someone moves need to be able to converse in the lan-
• The Goldilocks effect. Give your student choices, even
guage of movement.
deliberately wrong ones. By allowing them to decide
6. Proprioception is the internal body awareness sense that
between an array of choices, we are helping our stu-
tells us where we are in relation to gravity, where bones
dents improve their proprioceptive listening skills,
are relative to each other, about the direction of move-
problem-solving abilities and decision-making, and
ment of bones, about where the physiological end range
they will become much better self-regulators. They
of a joint is, and about muscular effort.
will also be able to apply those skills to other func-
tions and be able to modify the basic patterns you’ve
taught to fit varied circumstances.
Exercise for motor control purposes
• Developmental mistakes and imbalances. Early child-
1. How can we better use exercise to improve neuromuscu- hood learning blends into lifelong movement and
loskeletal function or performance? postural patterns. The seeds of our destruction are
2. We can speak broadly of three categories of motor behav- sown early on. Rule of Holes: when in a hole, stop
ior: gross motor, postural and arthrokinematic. digging.
3
A Manual Therapist’s Guide to Movement
2. Injuries cal practice who are interested in exploring a new exercise para-
• Avoidance. Local and distal synergists: ankle sprain digm. This exercise paradigm features whole-body integrated
movements rather than isolated movement of a part. It stresses
inhibits gluteals.
the importance of being proprioceptively self-aware, and
• Compensation. Someplace else works more or moves
explains how to train your patients in acquiring that awareness.
more.
It makes our exercise functionally relevant by basing move-
• Tendency of avoidance and compensation patterns to ments around real life or developmentally based functions.
habituate and perpetuate. Need to address the local These exercises are designed to be informational, to make you
and distal functional and muscular imbalances that are a better teacher of motor skills and your patient a better kines-
the unrecognized detritus of injury. thetic learner.
• Self-inflicted wounds. Many injuries are insidious, The movements described in this book are sophisticated
created by what we habitually do. Inefficiencies, facilitation techniques designed to influence more efficient/less
imbalances and invariance. damaging movement and postural patterns. On completion
of this book, you will be able to apply this material to ortho-
3. Cultural/emotional factors
pedic rehabilitation (spinal and extremity joints, tendons,
• People choose to move or hold themselves a certain way
muscles), to neurological rehabilitation (stroke, multiple scle-
not because of either developmental reasons or injury
rosis, cerebral palsy) and to performance enhancement (run
but because of subjective factors such as communication
faster, jump higher and throw farther).
style, chronic emotional states or acculturation.
Although it is not an anatomy or kinesiology book, some
• We are not psychotherapists: be careful about dispensing knowledge of anatomy on the part of the reader is assumed;
advice outside of your scope of practice, but be aware of keep an anatomy reference close if you are a bit hazy. Because
culture/emotion when working with movement disorders. this is a book on movement, you will need to get off your duff
4. Performance enhancement and out of your chair. You will be learning to move your own
body to experience the techniques you will be teaching.
• Another reason people move the way they do – a
Although you will learn a lot by reading, you will learn a lot
deliberate attempt to move in new or improved ways.
more about human movement by feeling human movement
• Important component of peak performance is neural firsthand.
orchestration. How accurate are the proprioceptive We will start with an overview of movement. Why do we
signals coming from your performing body, how good move or carry ourselves the way we do? Why do different
and how fast are performance decisions made based people move so differently? What is the consequence of injury
on that information and how accurate are the motor on normal movement? What other influences beside injury and
signals that are sent back in reply? early development affect the way we move? What are some
• How can we get someone to practice and perform strategies for teaching new or regaining lost movement skills?
perfectly without interference or drag from inefficient We will discuss exercise in Chapter 2, and how we might
or imbalanced subroutines? use it as a vehicle for influencing efficient gross motor move-
ment, postural control and intra-articular stability. How can we
Imbalances define ideal or efficient movement? Why do we need to make
exercise look more like real life, developmental or performance
1. Structural imbalances, muscle imbalances, functional activity? What makes exercise informative to the central nervous
imbalances are facets of the same gem, peas in the same system? How do we stimulate proprioceptive self-awareness?
pod, layers in the same onion. How do we improve our students’ motor planning decision-
• Factors in imbalance creation. Childhood develop- making abilities?
ment, injuries, culture, occupation and emotion. The In Chapter 3 we will be exploring more primitive global
usual suspects. movement patterns and focusing on the relationships among
• Left/right imbalances normal. Asymmetrical child- the head, spine and pelvis – trunk control. We will use this
chapter and the next to introduce concepts of ideal movement
hood development, handedness. Advantages in bomb-
and general teaching principles: what to teach and how to teach
proof roll or ability to throw a spear accurately.
it. You will also start actively participating at this point by
• Left/right imbalances contribute to asymmetrical
getting on the ground and mimicking early childhood move-
tissue strain and musculoskeletal pain syndromes.
ments. How do the pelvis and head cooperate in balance func-
Absolute mirrorimage as a clinical goal is unrealistic.
tions and in orientation from prone? How are the upper and
Soften the asymmetry, improve efficiency and improve
lower extremities organized at this stage? What are the impli-
awareness of pattern.
cations for influencing more mature movements? Why is it
important to exercise outside of cardinal planes and in posi-
Overview of motor learning tions other than the vertical?
Chapter 4 continues with head-to-tail relationships in more
mature functions: transitions and orientation from vertical.
This book is for those who want to know more about human How does a baby with limited use of arms or legs roll over, or
movement and how to influence it. What can we do when good get from point A to point B? How can we use orientation or
movement goes bad? It is written for physical therapists in clini- transitional movements to facilitate improved function in
4
Introduction to Motor Learning
people with cervical strain, low back pain or hemiplegia? How Pathokinesiology
can we teach the importance of coordinating head, spine and
pelvis in fun and progressively challenging ways? We will intro-
duce differentiated patterns of movement in this chapter, and My perspective in approaching this question of how to facili-
will use overlapping functional necessities to create multidirec- tate ideal movement derives from my background in both
tional differentiated movements. medicine and movement. I teach movement and postural skills
In Chapter 5 we begin to explore the role of the legs in as a clinician working with various movement disorders. Ever
movement and posture. How do the biases and imbalances of since I was a kid I have been fascinated with movement and
the legs contribute to postural and movement dysfunction the acquisition of motor skills. Initially, this interest manifested
of the torso and spine? How do these biases contribute to itself in games, sports and martial arts practice. With high
injury or performance drag? What are strategies for teaching school graduation looming, I started looking for a job where
powerful and balanced pelvic, back and lower extremity I could use my (not good enough to be a professional athlete)
movements? movement skills.
What is the importance of hip and pelvic organization in I learned about the profession of physical therapy (PT) and
unidirectional or bilaterally reciprocating athletic skills? This decided that PT school would be able to answer the questions
chapter is focused mainly on achieving lower torso and lower I had about movement: how is movement organized and
extremity musculature balance, strength and flexibility, and on regulated, what is ideal movement, and how to improve move-
facilitating a cooperative use of the opposite side hip extensors ment skills in someone else? After PT school and a couple of
and flexors in a basic and crucial piece of the movement puzzle: years in practice, I realized that my questions were still not
the pelvic force couple. answered. I had learned a lot about anatomy, physiology,
In Chapter 6 we will focus more specifically on low back pathology, neurology and how to work with the components
pain and lumbar stabilization. What are specific categories of of movement (muscles, joints, ligaments, bones), but my fun-
movement and postural stressors for the back? How can we get damental questions were left unanswered.
our students to recognize these stressors in real life? How can Whereas physical therapy/medicine/science addressed quan-
we teach the physical and proprioceptive skills needed on the tifiable questions about specific body parts, I was left with ques-
part of the back pain sufferer to stabilize against these stress- tions about quality of movement and the integration of those
ors? How can we blend intra-articular or segmental stability parts with the whole. I wanted to know what makes a move-
with pelvic stability? What is the role of the legs in stabilizing ment good or bad, but couldn’t find these answers in a purely
the pelvis and lower back, or moving the pelvis adequately scientific framework where the emphasis is so geared toward
enough that the back doesn’t have to continue to move too quantification.
much? How can we facilitate low back stability without creat- I wanted to be able to do something besides tinkering with
ing whole-body rigidity? the parts: I wanted to be able to understand and influence the
We wrap up Volume 1 in Chapter 7, with a focus on the coordination of the whole. Knowledge about range of move-
lower extremities. What are the common movement strategies ment, arthrokinematics, tensile strength, collagen properties,
we can use for cerebrovascular accident (CVA), hip joint neural pathways and force vector analysis of a muscle contrac-
replacement or ankle sprain? What muscle imbalances are con- tion is useful, but incomplete.
tributing to foot pronation, genu valgus or tibial rotation? How I realized that physical therapy could not be based solely on
does hip musculature bias influence patellar tracking? How can hard science, but needed to acknowledge that when working
we start closed kinetic chain exercise with the person having a with people we are engaging in a bit of psychology: we are
fresh total knee replacement short of fully bearing weight working with peoples’ behavior. It is this question of motor
through a fully weightbearing foot? behavior, how people come to behave the way they do, why
What associative movements could we do to facilitate they stick with the behavior even in the presence of negative
stronger ankle dorsiflexion and a reduction of foot drop? consequences, and how to positively influence that behavior
How can we safely and progressively teach knee stability in that led me to explore a discipline outside of the physical
cutting or in changing directions? How can we use exercise therapy field.
designed to balance the foot on the floor for refining foot, I am a Feldenkrais Practitioner® in addition to being a
ankle, knee and lumbar stabilization or to enhance athletic physical therapist, and I understand the advantages of each.
prowess? This means that I can blend the countless experiential hours
A discussion of cervical injury and dysfunction, shoulder spent exploring complex movement patterns with my medical
girdle imbalances and myofascial syndromes, neurological reha- training and knowledge of anatomy to provide a unique per-
bilitation of the upper extremity and upper extremity repetitive spective. I have learned to use movement for medicine, and
strain or trauma-induced injuries will be covered in Volume 2. would like to share some of what I have learned with a larger
Examples include whiplash injuries, headaches, impingement community of my peers.
syndromes, upper extremity postsurgical rehabilitation, tennis
elbow and carpal tunnel syndrome. This will also include dis-
cussions of stroke rehabilitation and athletic enhancement of Feldenkrais background
the upper extremities. We will also be exploring lip, tongue
and jaw movements in the chapter on vegetative function, Moshe Feldenkrais was a Russian-born Israeli, trained as a
along with breathing, pelvic floor movements and strategies for physicist and a mechanical engineer, who was also one of the
facilitating autonomic balance. earliest Europeans to earn a black belt in judo. The story goes
5
A Manual Therapist’s Guide to Movement
that he injured his knee playing soccer in the 1950s and that Perhaps we could ask the question another way. Instead of
his doctors wanted to fuse it. Instead, he applied his knowl- asking whether the Feldenkrais Method is a valid therapeutic
edge of physics, mechanics and the balance/movement skills tool, we could ask about the concepts and principles articulated
learned in judo to his own rehabilitation. and demonstrated throughout the work, and whether those
He began to explore movements on his own, with an concepts and principles could be applied in a clinical setting.
emphasis on feeling and paying attention to those movements. Concepts of even distribution of movement, proportional use
He watched people as they moved, especially children and of synergistic muscles, conservation of energy/reduction of
infants. He mimicked movements from early childhood and effort and skeletal/tensigrity weightbearing might be codified
discovered certain principles of movement...among which and adapted by our profession. (Tensigrity is a term coined by
was the realization that there are certain recurring patterns of Buckminster Fuller. He invented the geodesic dome, a design
movement that can be influenced most efficiently by teaching used in some oddball buildings and in backpacking tents. Ten-
whole-body patterns of movement. sigrity refers to the ability of a structure to hold its shape not
He then started working with other people who came to through the vertical compression of columns, but by the
him with their movement problems and developed a way of tension created by the connections between nonvertical rigid
manually guiding movement that he called Functional Inte- structures. It owes its integrity to the tension between the
gration®. As more and more people came to him for help, he parts, hence the name. Because a skeleton has no vertical bones
needed to find a way of being able to work with many people and contacting surfaces are not level, a true skeletal weight-
at the same time. He then developed the movement/exercise bearing structure is not possible. I use the term skeletal weight-
portion of his work, called Awareness Through Movement®, and bearing as a descriptive term that matches the proprioceptive
began teaching large group classes. sensation of bearing weight effortlessly. In reality, the skeleton
Over the next few decades he continued to develop and and its interconnecting ligament and fascial system is closer in
refine a huge body of knowledge that is both experiential and kind to a tensigrity structure.)
analytical, the Feldenkrais Method®. He led training programs The principles of exercising our students with whole-body
in Israel and the US until his death in 1983. His early students patterns of movement rather than with isolated muscles or
and graduates from his training programs continued his work joints, linking our exercise to meaningful functional outcomes
and are in turn running training programs in this method and emphasizing proprioceptive self-awareness, should not be
today. There are professional training programs, entailing 8 controversial. Teaching techniques such as training the
weeks of training a year for 4 years, throughout North America, same pattern of movement in many different positions, varying
Europe and Israel. I attended my professional training in north- speed and functional intension, applying constraints, allowing
ern California from 1990 through 1994, and was trained by approximations, reprising developmental movements, and
Anat Baniel. exercising in reciprocating patterns might be adopted by our
Dr Feldenkrais wrote several books and articles about his profession and be used to greatly benefit our students.
work, as have his students. I have included a sampling of these Try taking a fresh look at this method and what it has to
writings in the references section at the end of the chapter.1–18 offer, as well as other movement disciplines such as yoga,
Other books and articles, as well as audio and videotapes of various dance methods or martial arts. There is a wealth of
other Awareness Through Movement lessons, can be found by knowledge in these disciplines that is wreathed in mysticism
looking on the Internet. Go to www.feldenkrais.com for infor- and obscured by cloudy, flowery or generalized language.
mation about training programs, how to find a local practi- What knowledge can we mine from these sources? What is
tioner, and general information about the Method. For articles, there in what these methods teach or how they teach it that is
books and tapes, go to www.feldenkraisresources.com. consistent with what we know today through movement
There are also some research articles in the medical litera- science?
ture that investigate the effectiveness of the Feldenkrais
Method on various rehabilitation scenarios. Some of these arti- A call to purpose
cles find merit and promise in the method,19–33 but others
don’t.34,35I’m not sure one can even gauge the effectiveness of During my training I found an article, a call to arms for the
the method itself given the relative paucity of research available physical therapy profession, which resonated with my belief
to date and the subjective nature of the work itself. The work that knowledge about movement is central to our work. In
is too broad, too open to interpretation and too dependent on 1975, in the tenth Mary McMillan Lecture, HJ Hislop pro-
the skill and knowledge of the individual practitioner or prac- posed that: ‘pathokinesiology is the distinguishing clinical
titioners doing the teaching for that particular study. What is science of physical therapy.’36,37 Pathokinesiology is literally the
being taught and how is it being taught? study of damaged or damaging movement. This includes the
Are we saying the Feldenkrais Method is bodywork, and do limp that follows a sprained ankle and the shoulder subluxa-
we study results from hands-on functional integration? Are we tion that follows a stroke. It includes the difficulty the child
saying that it is exercise, and do we study results from randomly with cerebral palsy, the grandmother with a hip joint replace-
selected awareness through movement lessons taught in a ment and the veteran with a below-knee amputation have in
group setting? Are we saying that the Feldenkrais Method is standing and walking. It includes the way joint surfaces move
some exercise/coaching hybrid, and do we study results from relative to each other and the way fascial planes interact. The
a series of specific awareness through movement lessons taught common denominator here is movement: what is wrong with
one on one to a specific individual? it, what are the consequences of that movement in terms of
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