Several months ago, I read a blog post by The Manual Therapist about continuing education. He emphasized how beneficial any course could be, meaning that if you can take even 1 thing from the course and apply it regularly to your practice, the course was worth it. I took this concept to heart this weekend.
Several months ago, I was offered a free spot in the course Clinical Strategies for the Restoration of Posture, Balance, and Gait. In an orthopaedic setting, we regularly see people with these impairments. Even though I would have preferred a topic that was more orthopaedic- or manual-based, I would not shy away from a free opportunity to gain some skills at restoring those common impairments.
I was talking with the instructor before the class began and he mentioned how he used to be a manual therapist but no longer does any segmental mobility testing. With me completing an orthopaedic residency with an emphasis on manual therapy, obviously I became a little wary. I figured I would continue to listen during the lecture, of course, as potentially there would be some explanation as to how he performs his exams. The lecture started off reviewing some of the founders of physical therapy and their contributions. I noticed there was a large emphasis on Neuro-Developmental Treatment (NDT). Given my affinity for the Selective Functional Movement Assessment (SFMA), I was definitely interested in learning more about using the developmental sequence in my treatment and assessment techniques. It turned out the instructor was teaching us about the Feldenkrais Method. The technique focuses on relaxing the body and "resetting the nervous system." This is done by using repeated movements, recalling past experiences connect to current impairments, retraining breathing and how eye-sight effects movement throughout the body. There is much more to the theory, but these are some of the areas highlighted by our instructor. When I was in physical therapy school, we learned about NDT techniques such as Bobath, of which I was extremely resistant towards at the time due to the lack of high-level evidence and mechanical reasoning. I could tell at the beginning of the lecture that I was a developing some resistance towards the content, similar to that which I had for Bobath-esque content, so I had to remind myself to keep an open mind and look for some gems to use in the clinic.
As I stated earlier, there were a variety of treatment and assessment techniques demonstrated in the course. The instructor started off how he starts off treatments for his own patients - with a relaxation technique. He places the patient in supine with towel rolls under the knees, supporting the lateral side of the ankles for hip control, under the elbows and in the the hands. The goal is to lower the tone throughout the body. I can see this being beneficial for any patients that show resistance towards manual therapy and are easily tensed up. It is from this state, the instructor stated, that the nervous system is allowed to "reset." Unfortunately, the course felt more like a clinician trying to show us a "bag of tricks" to use related to the Feldenkrais Method, as opposed to truly learning the school of thought. We then proceeded to review some postural training methods. I actually found they could be useful for quite a few patients. For example, have the patient slouch and test should strength. Follow that up with re-testing in proper posture. It is likely that the patient will notice a significant change in strength. Another significant component of treatment under this method is core re-training. This includes the diaphragm, multifidi, pelvic floor, and transversus abdominus. A big focus was placed on teaching diaphragmatic breathing, followed by training techniques for the other 3 components of the core. These muscles are trained progressively from supine to standing - something most orthopaedic physical therapists do already. Another interesting topic that we discussed was the relation of eye movement to cervical motion. If you place your hands on your upper cervical vertebrae posteriorly and simply look in various directions, you will feel movement under your hands. Whether that is true spinal motion or cervical muscle tensioning does not necessarily matter as it clearly plays a role in the cervical spine. I have actually seen it used for METs of the upper cervical spine before.
As you can see, there was some use to the course as it pertains to incorporating material into my examination and plan of care with various patients. However, I had a difficult time grasping the concepts of Feldenkrais Method. I questioned the examiner frequently on topics, such as why he though he could ignore segmental mobility, why he thought stretching was never appropriate, and the contradictory nature of some of his explanations. He would try and cite studies to justify his techniques, but there was no true relation to the actual Feldenkrais Method. There were interesting anecdotal examples of using a past experience like dancing to help a stroke patient walk without impaired gait (the patient competed in dance when younger) or a person unable to speak relearn how to participate in conversation by singing (she sang regularly when younger). While the instructor was unable to convince me that sufficient research existed to show the effectiveness of the technique, I am unable to prove that it doesn't work. It's possible that an entire school of thought cannot be taught in a 1-day course and I must either learn more about it or see it in action, before I make any official opinion of the course. Nevertheless, I definitely was able to find several pieces I will be able to incorporate into my practice regularly, making it worthwhile. Perhaps, when my traditional methods of treatment are not working, especially when significant psychosocial involvement is present, I will incorporate some of what I learned this weekend in order to trial it.
James Heafner DPT, Chris Fox DPT, and Brian Schwabe DPT, CSCS are recent graduates of Saint Louis University's Program in Physical Therapy.