Twelve long months of sophisticated OT and PT designed to restore function to the hand showed limited results. Goodman's physiatrist and rehab team told him to accept the fact that he might never play his beloved game again.
That's when Goodman began treatment with Sandy Burkart, PhD, PT, certified Feldenkrais practitioner (CFP), who came at the problem from a different angle.
"We were able to capture the hand's function through movement patterns in the trunk, cervical spine, head and eyes that were associated with a golf swing," said Dr. Burkart. "His functional retraining program began with postural retraining coupled with muscular tone reduction techniques on his uninvolved side, and the facilitation of selected movements on the involved side. Essentially, these movements bypassed the damaged areas of the brain and provided an opportunity for his central nervous system to use pathways away from the damaged site in his brain," he said.
Dr. Burkart likens the unusual methods he used with Goodman to current research into constraint-induced movement therapy for people who have had a stroke, which trains the uninvolved side of the body. "We relaxed the uninvolved side so that it basically did nothing except be quiet," he said. "I then went to work on the involved, spastic side, decreasing the tone in the spastic muscles by selectively facilitating the extensors or antagonists of the spastic muscles. As I tried that with Norman, first one finger moved, then two, three, and soon the hand was opening and closing.
"Norman plays 18 holes now with his wife and friends," Dr. Burkart continued. "He dropped an eight-foot putt the first time he went out. He still has a lot of sensory motor neglect in the arm and hand, but at least he's able to golf with his wife and friends and to do the things he wants to. It's a whole new life for him."
This cutting edge approach to integrating all aspects of motor control and motor learning makes up the basic tenets of the Feldenkrais Method, an education-based approach to movement and sensory accompaniment that even today remains largely misunderstood and is often met with a raised eyebrow.
Does This Really Work?
Dr. Burkart was skeptical, too, at first. So before he attended his first certification session, he practiced a gymnastic planche (a maneuver in which the body is supported on the hands, the elbows are tucked into the stomach, and the entire body is horizontal to the floor) for one-and-a-half intense hours per day, three days a week, for six weeks. Despite being able to do the planche in college—when he was 19 years old and weighed 128 pounds—the 45-year-old, 170-pound Dr. Burkart just couldn't do it.
After returning home after two months of Feldenkrais training, though, he performed the move the first time he tried it. Now 58, Dr. Burkart says he can do the planche anytime he wants.
"That was a real eye-opener for me," he said. "I was able to objectively measure the effectiveness of this approach on my own movement pattern recovery. And what it demonstrated was that the basic motor programs necessary to perform that move were still there; it was just a matter of accessing them. I started to question whether they could be similarly accessed in patients with chronic RSD, spinal pain and fibromyalgia, patients with stroke, the elderly and others in order to improve the efficiency of the movements in these individuals."
Brian Hauswirth, PT, has a similar story. He took the certification training 20 years ago to improve his own motor function, but found that going through the certification has made him a better therapist as well. Hauswirth began combining Feldenkrais principles with his expertise in functional orthopedics to his patients at Integrating Function Physical Therapy, Larkspur, CA. He witnessed such success that he now spends a large part of his time making other therapists aware of the power this system holds. Since 1985, he has taught the Feldenkrais Method—along with the management of soft tissue dysfunction, joint mobilization and exercise training—to audiences through the Institute of Physical Art.
He admited that while explaining the often roundabout precepts that make up the teachings, he must tread lightly.
"Feldenkrais is not especially prescriptive, and can deal in generalities," he said. "If we're dealing with a repetitive stress disorder of the hand, for instance, most therapists think mid-forearm and below. When I start talking about the breathing, stance, pelvic movements and habits that contribute to that disorder, it can be radically different than what they're used to. You have to introduce it slowly, or you'll lose them."
But Hauswirth stresses that once PTs and OTs are exposed to the method, many realize its potential and pursue education in the method on their own.
Alternative No More
So if the benefits are there, why is the Feldenkrais Method still considered controversial in many circles, and why is it often mistakenly referred to as an "alternative technique?"
Perhaps being named after a single individual carries a subtle cultish connotation. Perhaps the high degree of artists, musicians, actors and dancers looking to improve their performance through the method place it on the fringes of traditional rehabilitative therapy.
"Books on Feldenkrais tend to be a bit poetic and esoteric," Hauswirth conceded, adding that early lecturers—trained in anatomy, physiology, mechanics and movement sciences, but not physical therapy—may not have articulated the abstract philosophies in a way that PTs could understand. "Physical therapists, who might be more used to a regimented, step-by-step style of prescriptive treatment, might find it a bit difficult to relate to."
Whatever the reason, Feldenkrais has yet to enjoy the mainstream support given to other, more established treatments. Feldenkrais practitioners see this as strange, pointing out that it is a method founded on the principles of physics, anatomy and hard-core empirical science. Dr. Osa Jackson pioneered the introduction of Feldenkrais into the mainstream of neurological practice, especially in treatment of geriatric patients. So the method has been written about and presented in an objective manner to rehab practitioners for more than 10 years. Many clinicians recognize the importance of the method but realize that the training is long and is based on experiential learning strategies, Dr. Burkart said.
Part of the problem might just be the profession's youth. Feldenkrais is a relatively new area of study; the first professional training program took place in Israel in 1968. The brainchild of Moshe Feldenkrais, DSc, an Israeli physicist, mechanical engineer and educator, the Feldenkrais Method is rooted in education rather than correction. Dr. Feldenkrais began applying his mastery of movement patterns and experience in martial arts and human physiology to heal his own crippled knee. Dr. Feldenkrais realized that by modifying inefficient patterns of movement, he could train himself to walk in a new, pain-free way. Before long, the principles were being applied to children with CP and physical deformities, patients with stroke and others. A certification program began in 1991.
"He was in many ways ahead of his time in understanding the principles of motor control and motor learning that we are only starting to understand today through a theoretical standpoint," Dr. Burkart said. "The science-based, empirical way of looking at movement variations is an excellent contribution to the therapeutic methods PTs use every day."
Analysis of the Method
The Feldenkrais Method begins with identifying and altering restricting movement patterns that have been learned since birth, and habituated over time. These movement patterns, from placing food into our mouth to walking to brushing our teeth, develop throughout our lives and make us unique.
Breaking down these limiting patterns is the first step toward abandoning them, and substituting them with healthier, more efficient movement habits. What follows is an awareness of one's own flexibility and coordination, and an improvement in everyday function.
A central philosophy around which Feldenkrais is built involves treatment that improves function instead of symptoms.
"I've seen tennis players with shoulder problems because they're not inhaling properly and opening up the trunk," Hauswirth illustrates. "So the shoulder takes the brunt of the stress. Now, we can try injecting the shoulder, friction massage or a myriad of options to treat the shoulder symptomatically, but the underlying cause will still be there, leading to problems. Of course, in the age of the 'quick fix' this is not an easy thing to do, but in my opinion it is the far superior approach."
Hauswirth will study and break down a patient's "red light" posture (closed and flexed as a reaction to fear) and "green light" posture (excited with tight back muscles as a fight-or-flight reaction), which can lead to a host of structural dysfunctions.
"Part of the methodology addresses how the whole body and mind work, whereas traditional therapy might be more compartmentalized," Hauswirth said. "And what's powerful is that the same philosophy applies to everyone from 85-year-old stroke patients to Olympic athletes."
He added that many elite athletes, musicians, dancers and others who are highly aware of their movement patterns recognize that they could improve, and see Hauswirth to help them do it. A Feldenkrais practitioner might avoid many common strengthening exercises if they have no functional applications in the everyday mechanical needs of the body.
Adding the Method to the PT Repertoire
The Feldenkrais Method is broken down into two general components: Awareness Through Movement (ATM), non-contact group classes designed to raise awareness of one's own movement patterns, and Functional Integration (FI), one-on-one manual lessons that capitalize on the lessons described in ATM.
Because Hauswirth is limited by the amount of time he can spend with a patient, much of his in-clinic time as a PT involves treating the many conditions he sees with a blend of prescriptive PT and hands-on FI methods. Condensed ATM teachings often form the basis of his prescribed home programs. He will also familiarize patients with community Feldenkrais classes if they wish.
And while it's true that a Feldenkrais practitioner starts fresh with each client, identifying and breaking down movement patterns learned since birth, Hauswirth does not have to re-invent the wheel every time.
"After you've been incorporating these techniques over time, you start to notice what works in a certain scenario," he said. "It's not cookbook therapy, but there can be some regularity to it, and I'll often come across conditions in which I follow a strictly traditional PT rehab protocol."
Dr. Burkart agreed that the 800-hour certification program has enhanced his ability to treat his most difficult patients. This awareness has given him the ability to analyze the movement and motor control strategies people have developed as they come into his office for the first time. His next step is to discover whether these patterns need to be broken, and if so, how to go about doing it. "For instance, if these habits were produced as a reaction to pain, then we need to work on reducing the pain first in order to make these movements more efficient," he explained.
After completing his certification training, Dr. Burkart focused his energy on examining the results of the method in their purest sense, without any biases.
"I was looking at this method very seriously in relation to the outcomes of my most difficult patients," he said, adding that treating these patients free of charge removed the constraints of money and number of visits. "I was interested only in determining whether I could produce a significant, measurable change in these patients."
Dr. Burkart feels strongly about the answer that his clinical interventions showed him. And even though his colleagues in the PT arena might still look on Feldenkrais as alternative, he prefers to look at it as complementary.
"The bottom line becomes whether Feldenkrais training and certification has made me a better practitioner," he said. "I would say that without a doubt, my level of competence with acute, chronic, neurologic, geriatric and post-surgical patients has been greatly improved. I am a better practitioner as a result of the integration of Feldenkrais into my practice," he said.