This series of 11 lessons took place over 2 and one half months. I will not describe the individual lessons in much detail in favor of expressing my thinking over a longer period of time. I am also using this case study to discuss a process that didn’t work out as I had intended, and to describe my response and change in strategy as a result.
Professor S. suffered a stroke about five years ago. He was unconscious for a week and lost the feeling in his right arm and leg. He also suffered from limited peripheral vision to the right and could not see the right side of his body (hemianopsia). After three and a half months, he had regained the ability to walk without a cane. He had been living quite well until approximately two and a half years prior to our lessons, when he fell during physical therapy and broke the head of his right femur. Following his injury he had a hip replacement and since then had experienced considerable difficulty with walking. Stairs and uneven terrain became especially difficult for him. He received three FI’s from a colleague two years ago, but stopped coming because he was terrified of climbing the stairs to her practice. At that time, I was practicing one day a week in a room without stairs. He had a prescription from his doctor for twelve FIs and so he came to see me.
Professor S. came to his appointment accompanied by his partner Ms. B. who drove and helped him get around. She asked if she could stay in the room during the lesson. Perhaps she wanted to make sure there would be no more accidents. I asked him what he was interested in and what he hoped would come out of the FI’s. He reported that the previous FI’s had been very helpful, but he didn’t want to climb the stairs. He further explained that he hoped to improve his ability to walk, especially during the upcoming summer holidays. I had observed him as he came in to my office; he seemed to have a difficult time maneuvering and needed much help from his partner. Based on my assessment, I decided to have him lie down on his back, which he said was the most comfortable position for him, so I could start with some simple movements, including lifting his shoulders and rolling his head. As I lifted his arms and brought them to his forehead, he began to breathe more deeply and seemed to relax a bit.
I went to his feet and wanted to push through them to compare the feeling of connection through his skeleton on both sides. His right side was much less responsive than the left. I asked him if he noticed any differences and he said he couldn’t. I noticed that didn’t seem very interested in the process. I continued with the lesson and when finished, he got up and appeared to move around more easily. He also said he enjoyed the lesson.
Professor S. reported that he hadn’t noticed any changes during the week, but wanted to continue with FIs. He seemed quite resigned and uninterested nonetheless. I worked with the idea of his right side and leg being able to bear weight more easily. I had him bend his knee slightly while I was holding his leg and gently push against my resistance. Again, I didn’t feel like he was very interested in the lesson, but he said it was relaxing and enjoyable.
Before he arrived, I had decided to ask him if he felt he was receiving some benefit from the lessons. Although he couldn’t say what was benefiting him, he wanted to continue. Ms. B. piped in and said she hoped that he could walk more easily so that they could walk together in the mountains. “Werner please, I’d like to be able to go walking with you.” She seemed more interested than he was and I suspected that he was coming to please her, and not because he really wanted to walk better. I wondered if it was worth continuing and said so, but they both expressed a desire to continue. I said we could try a few more lessons and see if there were any improvements. I continued with the idea of pushing through his legs and asked him to roll his head a bit to one side and the other while I gently pushed through his feet. I also concentrated on seeing if he could access more kinesthetic sensation on his right side (which was not in his field of vision) through light patting on his arm, leg, and the right side of his chest.
Ms. B. reported that he had been taking her hand more (instead of the cane) when they went walking. She seemed to think this was a sign of progress. She also said he was looking around and appearing more interested in the environment. After hearing her observations, I had him lie on his right side and used rolling movements; my intention was for him to fill out more of the sensation of his right side as well as begin to roll his chest opposite his pelvis in order to explore the possibility of contralateral movement in walking.
Professor S. seemed more alert and interested today. I felt it would be good for him to work on transferring weight from side to side as well as lengthening and shortening of the sides of his torso to facilitate this function. I had him begin by sitting on the table (he was past the phase where he just wanted to lie down) and lifting one side of his pelvis and then the other. I then had him lie on his back and continued with the theme of weight shifting by pushing through his legs. After finishing that part, I had him come up to a sitting position and walk back and forward with his pelvis a little. I explained that doing so would require him to use lateral flexion and slight rotation, which he would need later on for walking.
Two weeks passed before the next lesson because Professor S. and Ms. B. had been traveling to art galleries in Germany. Ms. B. reported that he was walking much better and faster. To begin our session, I had him lie prone and use the artificial floor with his knee bent. I had him feel me moving his feet in various orientations and then asked him to mimic what I was doing. Towards the end of the lesson, he mentioned that he was indeed interested in eventually walking without a cane. eventually. He also said he missed dancing. I suggested that he experiment with shifting his weight side to side in rhythm to music while sitting. I thought it might be more pleasurable and interesting for him and possibly stimulate some kinesthetic memories from dancing. He agreed that this was a good idea and said he would try it out. At this point I felt like we were making some good progress and he seemed very motivated and interested.
When my client came into my studio and sat down, he again seemed less interested and motivated. He hadn’t tried “dancing” either. Ms. B. sat and read the newspaper quietly. I had him hold his knees with his hands and shift his weight on his back by rolling a bit side-to-side. I thought the trauma of falling might be interfering with his progress, but when I mentioned it, he didn’t seem interested in considering the possibility. I suggested that he consider using two hiking poles when walking to give him more balance and to encourage the contralateral pattern in walking. Again, he seemed passive and uninterested.
Professor S. seemed a little more motivated during at this visit, so I worked with him sitting on the table. I had him slide one knee forward and then the other, feeling the differences. I wanted to continue simulating contralateral movements and had him push his left arm and right knee forward against me and visa versa. I varied this theme by having him use small firm rollers as poles while sitting, pressing one foot in to the floor and pushing down on the opposite roller.
This lesson was a turning point in our work together. When Ms. B dropped off Professor S., she said needed to do some shopping and would come back in an hour. After she left, Professor S. seemed more communicative and open with me. I decided to ask him the question that had been nagging me since the second lesson. “Was he really interested in walking more?” He answered that he wasn’t really interested in walking anymore. When the weather was nice, he felt obligated to go walking, but actually he would really prefer reading his art books in his study. “There is was so much to be read,” and he told me that he had walked so much in his lifetime that he didn’t feel the need to continue. He had never owned a car in his life (in fact Ms. B’s Mercedes was the first car he’d ever really ridden in so much) and had regularly walked an hour downhill to the train station to go to work, and then back up after work. He had hiked all over the Swiss mountains and enjoyed walking very much, but now he felt he had had enough. He also admitted that he was coming in order to placate his partner.
Ok, so my suspicions were confirmed; where do we go from here? I sensed that he appreciated being able to tell me that he didn’t care about walking so much. I felt as if we understood each other and could communicate better. I asked him how we could use the remaining three lessons to his benefit. He replied, “I would like to walk with you outside behind the building just once without the cane, that’s all.” Behind the building, there was a small black top parking lot surrounded by walls and bushes, which probably offered him a sense of security. I wasn’t sure why he wanted to do this, but now he seemed really sincere and interested now and I was relieved to have had this discussion. Because this conversation had taken up most of the lesson time, I described what I thought would be necessary for him to walk outside and explained my plan. He seemed quite happy with the my idea and we ended the lesson with some review of side bending and weight-shifting sitting on the table.
Ms. B. dropped off Professor S. again and left. He appeared animated and interested, saying he was looking forward to walking. I had him face the wall and sidestep along using his hands for balance and support. I thought this would be a safe way to practice shifting weight from one leg to the next. After doing this a few times, I noticed that he held his shoulders very still, even rigid, and that his rigidity appeared to be hindering his ability to transfer weight from one leg to the next. While he lay on his back, I lifted his shoulder blades from underneath; then I had him turn his head with the shoulder in the opposite direction of the shoulder I was lifting. When this movement became clearer and easier, I had him first lengthen his left arm towards the ceiling and then his right. I asked him to look with his eyes to the right and left. Because looking to the right was difficult for him, I suggested that he imagine looking to the right. This time he said he could feel the difference between his right and left sides. He got back up and we worked on breathing while sidestepping along the wall. After a rest, he wanted to try walking around the table without his cane; I walked behind him with my arms near his sides for safety. He said he was quite pleased and was enjoying himself. After making the appointment for next week he said, “next week we’ll walk outside.”
When Professor S. arrived, Ms. B. dropped him off and didn’t even come into the room. His mood seemed light and alert. He said he was looking forward to our little walk outside. I had him review sidestepping along the walls in the room. When this movement felt comfortable, he rested sitting on the table. He told me about his research in color theory, and said that he had published an article in an art journal. When he was ready again, I suggested that he slowly walk backwards with me around the table. I felt it would benefit him to experience more awareness in his feet and ankles and less in his visual perception. Because he knew that the floor was completely smooth, he would not have to worry about tripping over anything. By walking backwards, he would be able to set his heels fully onto the floor and feel the sense of weight in his ankle and foot as he shifted weight in preparation for the next step. Slowly, carefully, he began as I guided him around the room. As this movement became more familiar, his arms and shoulders softened; I mentioned to him that he could now pay attention to his breathing. He realized that he was stopped his breathing when he transferred his weight towards his right leg and foot. After a rest, I suggested he take smaller steps and coordinate his exhalation with the beginning of weight shifting. This breathing pattern seemed to work and he said he felt more secure now going onto his right foot. While he was resting, he said he felt ready to go outside. So off we went.
Once we were outside, he stopped and looked around, surveying the little parking lot for any irregularities. When he was satisfied that the surface was smooth he gave me his cane. I stood behind him and lightly placed my hands on his pelvis for security. He began to take a step forward but seemed very tentative and tensed up his shoulders. We stopped and I gave him his cane back so he could rest. He said that, indeed, his fear of falling was interfering with his walking, but he was determined to try again. He gave me the cane and we started again. This time he relaxed his shoulders and breathed out as he shifted his weight. After a few steps, his gait became more fluid and secure. He asked me to take my hands away from his pelvis, but to stay behind him. We continued like this for some time, walking around and around. He then said that he had had enough and we went back inside. He was beaming and seemed very pleased with himself. He told me that he was very grateful for this opportunity and didn’t feel he needed to come for the twelfth lesson. We said our goodbyes and Ms. B. picked him up. About two weeks later I received a package in the mail from Professor S. He had sent me a copy of the art journal with his article and a letter thanking me for the lessons.
In conclusion, I was reminded of just how important a student’s motivation is to the effectiveness of the lessons. Although I think the first eight lessons were useful in preparation for walking, they would have been much more productive if I had initiated the discussion of whether or not he really wanted walk much earlier. Unfortunately, I was not sure how to do this when Ms. B. was present. Since then, I am as thorough as I can be when interviewing a new student in the first lesson. With the help of communication courses, I have developed strategies to sound out what the expected outcome of our work together should be and what is expected of me. I find communication especially useful when someone comes in because his or her spouse or partner says he/she should come in. Additionally, I engage the students much earlier with short ATM sequences and questions about what they are feeling and sensing.
info [at] hartmanntarr [dot] ch john [dot] tarr [at] dynamicmusician [dot] com
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