DARCY A. UMPHRED, PT, PhD, FAPTA, CAROL M. DAVIS, DPT, EdD, MS, FAPTA and MARY LOU GALANTINO, PT, PhD, MSCE After reading this chapter the student or therapist will be able to: 1. Differentiate the four historical to modern worldviews of health care delivery. 2. Analyze how complementary and alternative-based health care practices overlap with allopathic traditional medical models and movement diagnoses. 3. Analyze how mind, body, and spiritual interactions have the potential to lead to health, healing, and quality of life. 4. Compare and contrast the various therapeutic models discussed and identify similarities and differences between these and the traditions of Western medicine, OT and PT practice, and the International Classification of Functioning, Disability and Health (ICF) World Health Organization (WHO) model. 5. Appreciate the role of complementary and alternative approaches in the examination and intervention of individuals with movement-based problems as a result of neurological disorders. 6. Use evidence-based practice to measure outcomes in body system functions, functional activities, and life participation. The use of complementary and alternative methods (CAMs) in the treatment of patients with neurological disorders and resultant movement problems is evolving into common practice. Clinicians and patients/clients are seeking nontraditional approaches to relieve signs and symptoms of neurological diseases, syndromes, and movement disorders as well as to attempt to alter the progression of diseases of the central nervous system (CNS) through unconventional movement therapies and manual therapeutic approaches. It is important that professionals working within a traditional rehabilitation environment understand the principles and practices of complementary, alternative, and even transdisciplinary approaches to the treatment of movement problems because many of these therapeutic approaches are being proposed as options in the management of body system problems and restrictions in daily life activities and independence resulting from neurological problems. The clinician needs to be cautious in the application of these treatment modalities. We do not want to accept alternative therapies as intervention solutions without significant evidenced-based research substantiating the use of these approaches. The reader must also be reminded that evidence comes from effectiveness, and many complementary approaches have established effectiveness.1 Looking at the evolution of health care throughout the world over hundreds and even thousands of years, general categories or worldviews have developed that best categorize philosophy of management of individuals with health care issues and their respective rationales for practice. In the following paragraphs a further discussion of these four worldviews will help the reader identify how the practice of health care today still fits within the second worldview but has begun to fractionate into the third worldview as linear research based on two variables does not explain the multiple variables involved both in disease or pathology and in recovery of function. In their book The Second Medical Revolution, Laurence Foss and Kenneth Rothenberg described levels of academic learning as being three tiered.2,3 Starting at the top, the third tier comprises the applied studies and subjects for therapists, such as therapeutic exercise and electrotherapy. The second tier is the pure sciences on which these subjects are founded, such as anatomy, chemistry, physiology, and biology. The first tier is the “assumption of reality” (day-to-day observations) on which the pure sciences are based. This first tier consists of the basic assumptions found in “worldviews” today. Different worldviews yield different scientific bases, whether pure or applied. Alternative approaches used in medicine and rehabilitation are well established in “premodern” and “postmodern” worldviews. This is in contrast to the “modern worldview” customarily taught in current Western medical training. To present these methods in overview, it would be helpful to discuss these worldviews and how physical therapy (PT) and occupational therapy (OT) may fit into the scheme. Essentially, there are four worldviews4: the premodern, modern, “fracturing or splintering,” and postmodern views. The first worldview developed during prehistoric times and lasted until the sixteenth century. This is called the premodern view. In this perspective, time is cyclical rather than linear. In other words, it was believed that the sun, the moon, and the stars circle around the earth, the tides ebb and rise cyclically, and the seasons circle back again and again, using the same patterns each time, connecting with “deep time.” Deep time is compared with profane time. Profane time is tangible, as in the time it takes rice to boil; or visible, as in the sundial; or sensible, as in the heartbeat. In deep time such perceptions are suspended, profane time stands still, and one becomes a part of time. It is in deep time that premodern man finds reality. Infused in this thinking is that life and death, the earth and the sky, are mysterious or mystical. In other words, they contain truth beyond human comprehension. This is a hard perspective for many to grasp, yet the role of the scientist is to be a passive observer. Numbers were used to describe observed events, such as the days between the circling of the sun and the moon, and the number of hours between the ebb and high tide, but “there was no widespread assumption in the western world that natural processes in general had any intrinsic relation to numbers, to mathematics.”5 In other words, in Western science, these perspectives were not tangible, visible, or sensible…and so, historically, science moved on. The second worldview, which began with Copernicus, is known as the modern worldview. It is the one with which the majority of the Western population would be most familiar and feel at home. In this view time is linear, progressing from start to finish. “The world is a rational, predictable, clockwork universe. Every bit of it can be predicted if you know one part of it. Purpose in life is to describe, generalize, predict, and control. Human beings are fairly mechanistic, separate, discrete entities from the rest of the universe.”4 Worldview 4, postmodern, is complex, integrated, and nonlinear. It is about self-organizing and self-regulating systems, looking for patterns, and knowing that a small variation in the pattern can produce large changes. Time is a dimension, interwoven with the dimensions of space. Time and space can change, expand or shrink, speed up and slow down. Rituals are an important means for creating order. The whole is greater than the sum of the parts, and “we know and yet don’t know.” Worldview 4 has a lot of similarities with worldview 1. The pure sciences that arise from this worldview include systems theory, quantum physics, cybernetics, string theory, and fractal mathematics, which in turn affect many other fields of study, such as meteorology, ecology, business and economics, medicine, theology, movement science, and computer science, to name but a few. Research parameters, technology, and interpretation differ significantly from the assumptions of worldview 2 because scientific description is no longer considered purely objective, but rather epistemology (the view from which knowledge is gathered) is becoming “an integral part of every scientific theory.”6 Western medicine has begun to shift from the second worldview into the third worldview because a total linear approach to explain efficacy has not proven inclusive and cannot always explain why individuals do and do not recover from disease or pathology or the functional loss they produced. The professions of PT and OT have run into the same dilemma as Western medicine and are also making similar shifts. The incorporation of alternative or complementary approaches that take into consideration the mind, body, and spirit is becoming more acceptable as colleagues embrace the shift in thought process. Change will come. The rate and the depth of that change will depend on the openness of all of us to accepting different research methodology and outcomes while still embracing those linear research models of today that we believe lead to efficacy or evidence-based practice. The roots of Western medicine extend back to Hippocrates, 400 bc, who provided a holistic picture of the state of health, writing that “Health depends upon a state of equilibrium among the various internal factors which govern the operations of the body and the mind, the equilibrium in turn is reached only when man lives in harmony with his external environment” (p. 23).2 The basic assumption in this perspective is that health depended on a balance with mind-body and nature or the environment, and disease was a disturbance of this balance. Preserving the balance was the priority for the practitioner. Three means were used to ascertain the characteristics of an illness: a dialogue with the patient, observational assessment of the patient’s appearance, and palpation of the soft tissues and pulses. The most important component of this approach was considered the dialogue with the patient/client. It was believed that the “meaning” of the illness to the patient/client, and his or her attitude and expectations were valuable diagnostic and prognostic factors. This coincides closely with the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model accepted by rehabilitation professionals around the world.7 Descartes largely initiated the shift from a preservative approach for mind-body-environment integrity to the conventional curative thinking found in medicine today. He conceptualized reality as having two separate domains, one the body or matter, the other the mind. “The body is a machine,” said Descartes, “so built up and composed of nerves, muscles, veins, blood and skin, that though there were no mind in it at all, it would not cease to have the same [functions]” (p. 32).2 His ideas were closely tied to newtonian physics, which conceives the universe as a harmonious and well ordered machine. These concepts gave rise to the view that matter and nature were separate from humans, and thus one could observe without affecting what was being observed. The physician, then, could have complete objectivity when assessing the patient. The patient could be viewed as a biological organism whose function was reducible to interrelating physical parts. 1. Disease or dysfunction is a “deviation from the norm of measurable biological parameters” (p. 23).2 A patient/client is a biological organism whose dysfunction is reduced to the identified deviations. Treatments or procedures are then used to cure or at least improve the deviations, which in turn improves the biological condition. 2. Objectivity provides the basis for diagnosis or assessment and the subsequent rationale for treatment. Patients’/clients’ descriptions of what they are experiencing and the clinician’s observation are considered “subjective” and not given as great a value as the “objective” findings, such as laboratory or other measured tests. 3. Eventually biomedicine can address virtually all medical problems at least adequately, if not fully, through more knowledge and research. It goes without saying that the biomedical model has produced stunning and tremendous accomplishments. Yet its restriction to physical causes of disease, in light of diseases and dysfunctions that are more widely recognized as having multiple causes, is creating a search for other answers. More of the public and some physicians and other health professionals are turning to alternative forms of intervention and healing. As stated in Life magazine in September 1996, “Why have alternative therapies in this country started to migrate from the margins to the center? One reason is that as allopathic medicine, a term commonly used to describe western techniques, becomes better at what it can do well, its limitations become more conspicuous. Allopathy is clearly superb at dealing with trauma and bacterial infections. It is far less successful with asthma, chronic pain and autoimmune diseases.”8 One of the tenets of dynamical systems theory, as noted in the journal of the American Physical Therapy Association (APTA) in 1990, is that “biological organisms are complex, multidimensional, cooperative systems. No one subsystem has logical priority for organizing the behavior of the system” (p. 770).9 The nervous system, then, is no longer a dominant subsystem with neurological patients. Rather, it is part of a self-organizing system that has multiple subsystems such as arousal, gravity, learning style, body weight, center of gravity, cardiovascular function, and so on. “No one subsystem contains the instructions for [an action]. . . . The behavior of the system is instead an emergent property of the interaction of multiple subsystems” (p. 771) (see Chapters 4 and 5).9 Added to these developments was the emergence in the 1980s of a new field of therapy intervention: vestibular habilitation for posture and balance, which is multisystem and multifunctional and inherently demands the use of motor control and learning principles and understanding of the mechanism of neuroplasticity and interactive systems theories. Systems concepts are used for both balance and the task-oriented approach, the concept being that “movement emerges from an interaction between the individual, the task, and the environment”10 (see Chapters 11 through 17 and 19 through 31). Orthopedic, or manual, PT appears to be firmly committed to the biomedical model, yet there is interest found in “being holistic,” and treatment and exercise approaches are continually being developed that endeavor, to various degrees, to work with movement and function in a broader and more integrated manner (see Chapter 18). Further changes will be experienced when a critical mass of the population turns fully, in all aspects of personhood, to “worldview 4,” which, again, has great similarities to worldview 1. A big difference, though, is that at this time in history, we have scientific methods for understanding our nonlinear, complex, evolving, multidimensional, multilevel, continually interacting, irreducible world. Through systems theory we can handle, with sophistication, this multitude of complex detail, by working with its “sweeping simplicity and order in overall design.”3 Throughout the twenty-first century, as the growth of worldview 4 continues to evolve on many levels and in many fields of endeavor, it is entirely possible that it and its sciences will indeed replace, and not simply complement, worldview 2. And from there, the future has yet to be conceptualized and belongs to future students willing to venture beyond what is comfortable to best meet the health care needs of a world society. Approaches to patient management that do not fall within a traditional allopathic medical model are often considered alternative or complementary. Although many of these therapeutic approaches have not been able to show effectiveness or efficacy in totality as an approach to medical management, neither has Western medicine. Although the evidence-based method of medicine is the accepted term for identifying outcome measures by reliable and valid instrumentations and interventions, there is controversy within the literature as to the validity of evidence-based medicine.8–16 Personally, I have been a patient for the last two decades with interactive health issues that medical practitioners cannot explain. I have been told by at least seven excellent medical specialists that, when looking at their specific area of specialization, they have never seen the specific system problem that my body system presented. Thus, not knowing what it is, each doctor does not know specifically how to treat the problem. Medical doctors know there is some genetic basis and understand the specific system problem from a descriptive perspective, but cannot explain how and why the system problems interact. Thus a syndrome exists without a medical diagnosis. My medical case was submitted to the National Institutes of Health (NIH) as a potential syndrome for which they might find a diagnosis. NIH returned the case saying they do not have the ability to determine the diagnosis because it is much too complex. Doctors have had to stretch beyond their comfort zone to help me and work with me in order for me to remain on this plane we call life. Kerri Sowers, USEF National Paraequestrian Classifier At the 1952 Helsinki Olympic Games, a Danish dressage rider named Liz Hartel won the silver medal and inspired a renewed interest in the field of hippotherapy and therapeutic horseback riding (THR). Liz used horseback riding as a form of rehabilitation to aid her recovery from poliomyelitis, which left her lower extremities paralyzed.17,18 The use of horses in therapy to improve physical and mental health has its founding roots in Greek culture. The term hippotherapy originated from the Greek word hippos, meaning “horse.”19 The renewed interest in hippotherapy and THR grew first in Europe and was especially popular throughout England. In 1969, the North American Riding for the Handicapped Association (NARHA) was founded; this organization established standards for the developing THR centers in the United States.17–20 Recent studies conducted in North America show that approximately 90% of children with disabilities participate in THR programs, and the remaining 10% participate in hippotherapy sessions.21 It is crucial to understand the differences between hippotherapy and THR, as both programs are commonly offered at the same facility and are often mistakenly thought to accomplish the same goals. The American Hippotherapy Association (AHA) defines hippotherapy as “a term that refers to the movement of the horse as a tool by physical therapists, occupational therapists and speech-language pathologists to address impairments, functional limitations and disabilities in patients with neuromuscular dysfunction. Hippotherapy is used as part of an integrated treatment program to achieve functional outcomes.”20 During hippotherapy, the horse is used as a modality or treatment tool; the therapist and his or her assistants control the horse in order to effect a change in the patient/client. In contrast, THR teaches the client specific riding skills that allow the rider control of the horse’s movement; the focus is on teaching horseback riding skills to riders with disabilities. AHA attempts to clarify the difference by stating that hippotherapy “treatment takes place in a controlled environment where graded sensory input can elicit appropriate adaptive responses from the client. Specific riding skills are not taught as in therapeutic riding but rather, a foundation is established to improve neurological function and sensory processing.”20 Hippotherapy and THR are felt to be beneficial because the equine walk provides a multidirectional input resulting in movement responses that closely mimic the movement of the pelvis during the normal human gait. The movement is both rhythmic and repetitive and allows for variations in speed and cadence. In hippotherapy the horse is used as a dynamic base of support (BOS) to assist in improving trunk control, postural stability, core strength, and righting reactions to improve balance.22 Vestibular, proprioceptive, tactile, and visual sensory inputs are incorporated during a hippotherapy session. As stated by the AHA, “the effects of equine movement on postural control, sensory systems and motor planning can be used to facilitate coordination and timing, grading of responses, respiratory control, sensory integration skills and attentional skills.”22 Hippotherapy is indicated for neuromuscular conditions characterized by reduced gross motor skills, decreased mobility, abnormal muscle tone, impaired balance responses, poor motor planning, decreased body awareness, impaired coordination, postural instability or asymmetry, sensory integration deficits, impaired communication, and limbic system dysfunction (impaired arousal or attention skills).18,22,23 Common conditions that may benefit from hippotherapy and THR include autism spectrum disorder, cerebral palsy, developmental delay, genetic syndromes, learning disabilities, sensory integrational disorders, speech-language disorders, traumatic brain injury (TBI), and cerebral vascular accidents.22 There have been a multitude of suggested therapeutic benefits from hippotherapy and THR, which affect many body systems. Suggested physical benefits include improvements in endurance, symmetry, and body awareness; development of trunk and postural control; improvements in head righting and equilibrium responses; normalization of muscle tone; mobilization of the pelvis, lumbar spine, and hip joints; and improved sensory awareness. Suggested cognitive, social, and emotional benefits include improvement in self-esteem, confidence, interaction with others, concentration, attention span, and communication skills.18,19,24 Contraindications for the use of hippotherapy or THR include excessive hip adductor or internal rotator tone accompanied by potential hip subluxation or dislocation, lack of head control (in large children or adults), pressure sores, spinal instability, or anxiety around animals.18,24 AHA offers a Clinical Specialty Certification for therapists demonstrating advanced knowledge and experience in the practice of hippotherapy. Physical therapists, occupational therapists, and speech-language pathologists must have been practicing in their profession for 3 years (6000 hours) and have had 100 hours of hippotherapy practice within the 3 years prior to application. Certification is valid for 5 years; once applicants pass a multiple choice test they are entitled to used the designation HPCS.22,25 Research and studies concerning the use of hippotherapy and THR are limited but expanding. At the time of publication of this text, there have been no large, well designed, randomized controlled trials investigating the use of hippotherapy or THR. There have been several fair-quality randomized controlled trials and many nonrandomized trials that do support the use of hippotherapy in children with cerebral palsy. One systematic review investigating the use of hippotherapy and THR found improved gross motor function; normalization of pelvic motion; improvements in weight shifting, postural and equilibrium responses, muscle control, and joint stability; improved recovery from perturbations; and improved dynamic postural stabilization.21 Studies have supported that hippotherapy can improve postural stability in individuals with multiple sclerosis (MS) and can assist in treatment of balance disorders.26,27 Hippotherapy has also been shown to reduce lower-extremity spasticity in patients with spinal cord injury.28 Support for hippotherapy has been shown by improvements in the areas of muscle symmetry, gross motor function (as measured by valid and reliable tools), energy expenditure, and postural control. Researchers suggest that hippotherapy will lead to improved head righting and equilibrium reactions and dynamic postural control, normalization of abnormal muscle tone or symmetry, improved muscle control, and better endurance. In addition, hippotherapy has the potential to contribute to psychosocial well-being and improved motivation by allowing interaction and acceptance with another living being and the opportunity to be mobile while astride the horse; being positioned high up on a horse gives the child the chance to be at eye level with his or her peers, and the fun of riding encourages participation and enjoyment of the therapy sessions. Continued research into hippotherapy and THR using larger, randomized controlled studies that investigate specific outcomes and account for the variations within a variety of neuromusculoskeletal conditions will be necessary to conclusively determine all potential benefits that exist. The Feldenkrais method is about learning the following: I do not treat patients. I give lessons to help people learn about themselves. Learning comes from the experience. I tell them stories [and give them experiences of movement] because I believe learning is the most important thing for a human being” (p. 117).29 [parentheses added by the author]. As a boy in Palestine, Moshe Feldenkrais developed a method of hand-to-hand combat that was used by settlers for self-defense. Later, as a student in Paris where he trained in physics at the Sorbonne, he studied judo and became the first person in Europe to receive a black belt. When he injured his knee playing soccer, he relearned pain-free walking on his own. Later he studied with F. M. Alexander, Elsa Gindler, and Gurdieff. He also studied psychology, progressive relaxation, bioenergetics, and the hypnosis methods of Milton Erickson. And he was familiar with the physiology of his day: Sherrington, Magnus, Fulton, and Schilder. With this background, Feldenkrais developed two approaches to facilitating learning that are now known as Awareness Through Movement (ATM) and Functional Integration (FI).30 Feldenkrais was ultimately interested in the development of human potential. He saw that, although all people encounter trauma and difficulty in their lives, those who are most successful develop new, adaptive behaviors to overcome those difficulties. He proposed that a type of learning that reconnected the brain to the control of the musculoskeletal system would be the most effective way to approach this problem of adaptation. His initial thinking in this area is set out in his first book, Body and Mature Behavior: A Study of Anxiety, Sex, Gravitation, and Learning.31 For Feldenkrais, learning was an organic process in which cognitive and somatic aspects were completely integrated and interactive. Presented first in 1949, this idea prefigured our current sense of dynamic systems functioning of the brain and body.32 The learning should proceed at its own pace in an individualized way following the learner’s intention and guided by the learner’s perception that the performance of the task, movements of the body, and interaction with the environment become easier.31 This interactive cycle of action and perception has been described well by the motor learning model proposed by Newell.33 Learning is a complex process with overlays from the intention of the learner, interference from environmental distraction, misperception of the task and the body, desire related to self-image, fear of injury, or incorrect performance. Thus it is possible to learn poorly, incorrectly, or in such a way as to interfere with performance and not improve it. This kind of process has been suggested by Byl and co-workers34 as the underlying cause of focal dystonia. One of the definitions Feldenkrais gave for learning took this process into account: “Learning is the acquisition of the skill to inhibit parasitic action (components of the action unrelated to the intention behind an action but resulting from a secondary intention) and the ability to direct clear motivations as a result of self-knowledge.”31 An adult engaged in learning to walk again after a stroke with a fear-related reluctance to bear weight on the involved limb would be an example of such a secondary intention. The process of learning proposed by Feldenkrais is one of discovery. The outcome desired is one of increased awareness. Vereijken and Whiting35 have proposed that discovery learning, in which learners are free to explore any range of solutions in learning to perform a task in any way that they want, is as effective as or more effective than any formal approach to motor learning involving controlled schedules of practice or feedback. This process of discovery has the added dimension of allowing learners to focus on the perceptual understanding of the body/task/environment as a component of the learning process. In the Feldenkrais method this discovery and perceptual learning process is explicit. Our understanding of how experience and learning restructure almost all areas of the CNS is expanding rapidly.36 A large focus of current thinking in rehabilitation is how to translate neuroplasticity concepts into more effective techniques for rehabilitation.37–39 The method developed by Feldenkrais and practiced by people around the world who are trained in this method is clearly explained by these new principles, creating new approaches to rehabilitation. The two approaches to facilitating learning created by Feldenkrais, ATM and FI, are similar in principle and process although they differ in practice. They are essentially two methods for communicating a sensory experience that the client can consider and act on. The first requirement of the process is to create an environment that is comfortable, safe, and conducive to learning, whether the learner is being moved passively or creating the movement experience voluntarily. The second requirement is that the amount of effort associated with making the movements be reduced greatly so that it is possible to make fine discriminations about the effects of force acting on the system from outside, from inside, or both. The goal is to develop a rich understanding of changes throughout the system produced by small perturbations. This understanding becomes the basis for creating new solutions to movement problems as the client progressively approaches functional movements that she or he desires to perform.40 In FI the practitioner will manually introduce small perturbations into the learner’s system after placing the learner into a safe position closely approximating some desired activity to be learned. Here the practitioner is providing the force inputs and the client is asked to attend to the changes created in response to the perturbation. For example, the practitioner might press gently into the bottom of the client’s foot and ask the client to notice where in the body movement and pressure are felt as a result. This will be repeated a number of times and then some other forces or movements will be introduced. The guiding idea for the practitioner might be to build sensory experiences in the body that are associated with a particular movement, such as rolling. This goal is rarely explicitly expressed to the client and is left to emerge in the client’s understanding of the experience: “Oh, now I am rolling,” or “This feels like rolling to me.” Also there is no strict expectation by the practitioner about what specific movement might emerge. Thus it is possible to create novel and unexpected outcomes of how a particular task might be best performed by this particular person at this time. This allows for a process of assessment that is continually evolving as the intervention is unfolding.40 In practice with an individual client, it is common to move back and forth between ATM and FI during the same session. The session is usually focused on the development of understanding and performing a specific function: turning, rolling, standing, stepping, and so on. ATM is a verbal process in which clients perform their own movements; thus a practitioner can work with many individuals simultaneously. At the same time individuals within the learning group are free to respond differently from one another in ways that may be appropriate only for them as individuals.41 Because ATM is under the active control of the client, this method is often a more effective tool in reestablishing voluntary control (Case Study 39-1). The theory underlying the Feldenkrais method predicts that there should be changes in perception of the body or body image. Although there have not been a lot of studies in this area, there are several that support this prediction. Elgelid42 reported positive changes in body perception, as evaluated by the semantic differentiation scale in a group of four subjects after a series of ATM lessons. Dunn and colleagues43 reported that subjects who had had a unilateral sensory imagery ATM lesson perceived their experimental sides to be longer and lighter and demonstrated increased forward flexion on that side, linking the changes in perception to changes in motor control. Batson and co-workers44 have shown that ability to image movement is improved in people poststroke after a series of ATM lessons, and furthermore that there is a high positive correlation between the Movement Imagery Questionnaire (MIQ) score and improvements in balance assessed by the Berg Balance Scale. There is not a lot of literature evaluating the efficacy of the Feldenkrais method in general and even less specifically for people with neurological diagnoses, as a result of the complexity of the problems and the multiple system involvement of the individuals. Evidence-based studies on effectiveness are more easily identified. In a review, Stephens and Miller40 divided the literature into four different areas: pain management, postural and motor control, functional mobility, and psychological and quality-of-life impact. Much of the literature is in case report format. A small amount of the literature is controlled study format, with some of that using randomized control groups. The work on pain management suggests that the Feldenkrais method may be especially effective in treating pain that is biomechanical in origin. This concept may be applied to work with pain in patients with neurological diagnoses, especially pain caused by biomechanical malalignment. No research has been done in this area with neurological patients. Hall and colleagues45 found improvements in balance (Berg Balance Scale [BBS]), mobility (Timed Up-and-Go Test [TUG]), functional activity (Frenchay, Short Form 36 [SF-36]), and vitality (SF-36) in a large group of elderly women compared with control subjects as a result of a 16-week ATM intervention. These results have been confirmed by Vrantsidis and colleagues46 and Connors,47 also using ATM with a group of elderly women. In the areas of psychological and quality-of-life impact, Kerr and colleagues48 have shown decrease in state anxiety in subjects who participated in ATM lessons, and Laumer and colleagues,49 working with young women with eating disorders, have demonstrated positive changes in self-concept, self-confidence, and behavior resulting from participation in ATM lessons. Many of these findings are beginning to be reproduced in clinical populations with neurological diagnoses. Most of the studies to date have been done with people with MS. Colleagues are beginning to look at ATM effectiveness in patients after a stroke (cerebrovascular accident [CVA]).
Complementary and alternative therapies: beyond traditional approaches to intervention in neurological diseases and movement disorders
Historical perspective
Alternative models and philosophical approaches
Movement therapy approaches
Equine-assisted therapy
Introduction to hippotherapy and therapeutic riding.
Benefits, indications, and precautions.
Regulations.
Evidence and clinical implications.
Feldenkrais method of somatic education
Development of the feldenkrais method.
Background theory—dynamical systems theory.
Approaches to feldenkrais method.
Evidence of effectiveness.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Complementary and alternative therapies: beyond traditional approaches to intervention in neurological diseases and movement disorders
Only gold members can continue reading. Log In or Register a > to continue
![](https://clinicalpub.com/wp-content/uploads/2023/09/banner1.png)