Alissa's Progress using Feldenkrais:
First I would like to discuss what we think our daughter, Alissa, is getting out of Feldenkrais and why we think it is working for her. Then we would like to talk about what we think are some of the limitations of Feldenkrais and other existing treatment modalities.
We were introduced to Feldenkrais by Ester Thelen, a member of our scientific advisory board and one of the leading scientists applying "Dynamic Systems Theory" to the development of children with developmental delay. To give a you quick review of "Dynamic Systems Theory", it is the leading theory to explain how humans develop motor skills. "Dynamic Systems Theory" describes the human as an open, self-organizing, thermodynamic system. In this case "Open" means that humans develop by interacting with their environment, as opposed to having their future determined by genetic programming. Self-organizing, means that common patterns such as learning to walk, can develop among all humans independently. Finally, human development must follow the basic laws of thermodynamics in that we try to optimize for minimal energy solutions.
One of the most interesting concepts of the theory for me is the idea that the brain is only one of many "system components" in human development. It is certainly a critical component but it holds no higher role in development than several other very important components such as environment, physical structure of the body, etc. An example of how a healthy brain can still produce an unhealthy child can be found in documented cases of children being neglected in war torn orphanages. In this case a healthy brain and a deprived environment produces abnormal development.
Another example of open, self-organizing, thermodynamic systems in nature can be found in weather systems. Under certain predictable and reproducible circumstances, weather systems can self organize and take on very recognizable characteristics. The best example of this the Tornado. If we think of the human in terms of this analogy then we can begin to understand how most humans develop very similar motor skills and why kids with brain injuries also tend to develop with similar motor deficiencies. Normal human motor skills develop spontaneously in the early years of life and because most humans all face a very similar set of system parameters, motor skills thus tend to develop in a very similar pattern. In fact, "Dynamic Systems Theory" says that unless the parameters change, all humans will find the optimal solution to the physical equation of motion that minimizes energy. An example of this is the fact that all humans develop the same basic walking pattern. As a rule, humans do not hop or gallop. The reason for this is that hopping and galloping may be great for Kangaroos and Horses, however for the human biped, walking is the most energy efficient equation of motion.
With this background, we can now begin to understand why kids with brain injuries develop abnormal motor patterns. Effectively the initial injury to the brain causes a change to the normal set of parameters that are critical to human development. The injured child still follows all the same laws as described above and therefore still optimizes the system for minimal energy output. Unfortunately the optimal solution results in the familiar set of abnormal movement patterns commonly known as Cerebral Palsy.
So how does Feldenkrais fit in? Moshe Feldenkrais, was an Israeli physicist who developed the methodology. He was not aware of "Dynamics Systems Theory" but being a physicist the practice of his methodology almost perfectly describes the predictions of the theory. Fundamentally it is a methodology to maximize ones awareness of movement. It is used widely by athletes and musicians. To treat children with disabilities, the methodology relies on the fact that the initial brain injury is limiting the variation of movement that is seen is an uninjured child. Feldenkrais, allows the child to experience the variation of movement. By definition, Feldenkrais defines the term Spasticity simply as a lack of variation of movement. They treat Spasticity by helping their patients to feel what is like to move in other ways. They believe that self-awareness of the alternative motions is the key to functional movement and to improvement of Spasticity. This is in direct contrast to other methods, such as patterning, that rely on passive movement. Feldenkrais argues that passive patterning, on children that are not structurally ready, will not create new neural pathways and may even lead to increased Spasticity. This seems to correlate to reports that we are receiving from parents that have spent many years on the IHAP intensive program and have children that have developed increased rigidity and structural issues. Feldenkrais also does not place nearly the emphasis on repetition and intensity as other programs such as the IAHP. This is because, although practice is important in the learning process, the actual point of learning often occurs very quickly. A good analogy is learning how to ride a bike. Learning the skill seems to just hit you all at once. You go from a feeling of wobbly discomfort to smooth balance almost like turning on a light switch. Training wheels allow a child to feel what is like to balance on two wheels but prevent scabbed knees in the learning phase. Feldenkrais hopes to be the training wheels for kids with brain injury. Feldenkrais seeks to provide the child with a few experiences of very high quality movement with the hopes that during one of those movements the desired movement pattern will take root in the brain through the brain’s natural plasticity. This desired movement pattern gives the child slightly more variation of movement and slowly allows the child to transition from abnormal functional patterns to more desirable patterns.
We saw this scenario happen with Alissa during her first series of treatments from Anat. When we brought Alissa to see Anat at 18 months she was anxious to begin sitting on her own. She had mastered the ability to sit independently at about 16 months and was trying hard sit-up on her own. Full credit needs to go to Alissa’s NDT trained therapists that had helped her achieve the massive goal of sitting independently, however her rigidity in her left leg and right arm was preventing her from initiating the needed sequence of movement to transition from supine to sitting. Anat, worked with Alissa for five one hour sessions. By the fifth lesson, Alissa had mastered the movement patterns necessary to transition to a sit, but her strength did not allow her to do it unassisted. With-in a month she had gained the strength needed and she had mastered the ability to sit on her own! We are confident that Alissa would have gained this functional skill with-out Feldenkrais, however we feel that Anat helped Alissa to gain this skill much faster. In that same five session series, Anat helped Alissa to begin combat crawling as well. Needless to say, we were impressed, as were our regular therapists.
So why did it work so well? A few things, Alissa was ready to master those movement patterns. She was age appropriate, had adequate strength, and she was internally motivated. The only thing holding her back was that her limitations of movement caused by her rigidity had not allowed her to experience and thus develop the appropriate motor plans for those complex movements. Anat, provided her with that learning opportunity and she responded. I emphasize the word ‘learning’. Anat does not see herself as a therapist, but rather as a teacher.
One of the lessons that Anat taught us as parents was not to be too supportive of Alissa. She observed that Alissa needed to be more self-motivated as opposed to always responding to mommy or daddy’s words of encouragement. She gave Alissa the time and space to decide what she wanted to do, then she followed on that lead helping her with the correct patterns to achieve that goal. Self-motivation is one of the tenants of learning.
Another area that Anat feels strongly about is that you should not push a child to do things that they are not physically, structurally and mentally ready to do. For example, Alissa is now 19 months old. She has a strong desire to stand erect and try to walk. However, she is far from achieving that on her own structurally. Her heal cords have become very tight and her ankles are very week. Therefore, when she is put into a supported stand her feet roll inward severely. Some of our therapists and orthopedist are anxious to get Alissa standing as soon as possible. Their proposal is to use botox to weaken the rigid muscles causing the toe pointing, to use casting to stretch the tight heal cord, then to place Alissa in a standing position to allow static proprioceptive signals to be sent to the brain. The hope is that in the short period that the botox is in effect, the brain will create the appropriate neural loops between the muscles and joints and that as the botox wears off, the old rigidity will be reduced. This is a valid approach developed based on good science. Unfortunately, this approach has several things working against it. From a "Dynamics Systems Theory" perspective the introduction of botox and casting is a new parameter in the system. Also, both act to weaken the muscles. Because of this, the likely hood of the desired movement pattern becoming dominant over the established pattern is reduced.
Feldenkrais takes the conservative approach. In Alissa’s case they are urging us to allow Alissa to develop subtle but important movement patterns that will eventually build on one another and eventually allow Alissa to have the structural and physical capability to be ready to stand on her own. In my mind, it is the correct approach but a slightly dangerous approach. On of the key aspects of "Dynamics Systems Theory" is that with time, existing movement patterns become more and more dominant in the brain. In addition, with time, structural deformities caused by abnormal movement patterns also begin to play a larger role. One of the limitations of Feldenkrais is that it can not reverse structural deformities. If a child or adult with structural deformities comes to a Feldenkrais practitioner, the practitioner will help the person to move most effectively given the physical limitations of the deformity.
For Alissa, it will be a balancing act to see if the slow progression of subtle improvements can keep the rigidity and deformities from getting worse. So far it seems that we are winning the race. The same therapists that pointed out Alissa’s tight heal cords are now telling us that Alissa’s heal cords are loosening and at the very least are not getting any worse. We will keep a close watch on this area and will act quickly to prevent the physical deformity from getting worse.
Another therapy that offers a unique approach to this scenario is the Adeli Suit promoted by the Euromeds Co of Poland. The Adeli Suit is essentially a suit worn over the body, with elastic bands that mimic the major muscle groups. The tension in the elastic bands can be adjusted to offset the highest tone muscles without weakening the muscles like botox. In addition, the suit allows full movement of the muscles and thus actually allows strengthening of the muscles as well as dynamic proprioceptive input. Euromeds has produced a small amount of self-generated statistics, which seem to support that this method works very well given the correct conditions of the patient. From my analysis of the Euromeds program this specific application of the Adeli Suit is truly beneficial. However, the program in general appears to be modeled after the IAHP program with passive patterning and intensity being major components and thus these aspects of the program are not in sync with "Dynamics Systems Theory". Thus the combination of correct alignment via the structural support of the suit, along with the dynamic proprioceptive input of exercising with the suit on creates a winning combination.
Returning to the limitations of Feldenkrais, the approach relies on the hope that enough variation of movement can be introduced early enough in a child’s development to allow the brain’s natural plasticity to overcome the effects of the initial injury. When I put the specific question of the limitations of Feldenkrais to Anat she responded with a reply of the limitation being one of the student and not one of the method. My observation is that although Feldenkrais can produce fantastic results it is extremely dependent on the skills of the practitioner. Get the wrong teacher and the best student will suffer. In addition, Feldenkrais is very conservative. It relies on the subtle improvements slowly overcoming severe neural injury. In some cases I am certain that the effects of the injury will dominate and the result will be improved functionality but still severe disability.
So that leaves me still searching for the therapeutic approach with enough robustness to fully overcome the devastating effects of the initial injury. Techniques such as NDT, Feldenkrais, the IAHP approach, the NACD approach, the Euromed approach, Conductive Education, and Constraint Induced Therapy all draw their partial success on the proven fact that the brain is extremely plastic.
So if re-generation is not the answer and re-organization therapies have limitations, does that mean that the current approaches can only take a brain injured child so far? I believe the answer is yes and the data supports it. Every study that we have read, every parent that we have talked to, every young adult that has been through all the therapies has clearly shown the limitations of the existing treatments. Thus our search is to find the next evolution of approach that will take Alissa further than the current approaches allow.