A Mind-Body-Spirit Approach to Rehabilitation: Selected Modalities for Practical Integration - An Overview for Physical Therapists

1. Introduction
2. Becoming an Instrument of Healing
3. Selected Touch Therapies
4. Exercise and Movement
5. Imagery
6. Conclusion

Introduction

Healing can occur in many ways, on many levels, and in many dimensions. Therapists can complement care by the nature of their presence, the environment they create, and the interventions they choose, while being guided in each moment by their patients' needs and responses.

Becoming an Instrument of Healing

There are three key behaviors to master in becoming a more holistic practitioner – presence, unknowing, and listening.

1. Presence

Presence is the process of outlining a therapeutic relationship with patients by focusing on the wholeness of each moment with them. A distinction must be made between actively being with them and being strictly present in the physical sense. A deeper level of being with a patient should be sought and maintained, along with an effort to sustain this relationship with the patient at each successive moment.

• Physical presence is "body to body", where the therapist uses the skills of seeing, examining, touching, doing, and hearing, using physicality with the patient.
  
  
• Psychological presence is "mind to mind", where the therapist employs listening skills in order to help, comfort, and support, while communicating, empathizing, and accepting without judgment.
  
  
• Therapeutic presence is "spirit to spirit" and relates to the use of every resource with the patient, including those of the body, mind, emotion, and spirit. This kind of presence is used to center, meditate, and connect with the patient.

Barriers to presence are common, and they hinder the process of connecting with the patient. These barriers include fear, preoccupation, distractions, impatience, and lack of openness. Health practitioners will often say, "I don't have time to be 'present' for the patient," but presence doesn't require extra time -- it's just a way of approaching a patient and caring for him/her. It's important to remember that much time may be saved in the long run if the therapist makes an effort to connect personally with the patient. A bond of trust is formed, and it opens the lines of honest communication; this results in a less problematic experience.

2. Unknowing: "Beginners Mind"

When a physician has experienced many different cases throughout his/her career, it becomes second nature to judge a patient's diagnosis, condition, or experience without actually focusing on the patient as a person. However, it is important to approach things with a tabula rasa for each patient in order to empathize with them – since they have never been through the experience, it is easier to lead them through it with a fresh, new perspective.

3. Listening

There is a difference between hearing someone and listening to someone (i.e. connecting to the meaning behind the words heard). For example, if a patient says, "I'm fine", it is not enough to merely accept those words to be true. It is important to look at how the patient is moving, how they're holding themselves, their facial expressions, their tone of voice, etc. This kind of observation (sometimes referred to as active listening) may provide a sense that the patient is holding something back. It might be wise to present a follow up question such as, "you say you're fine, but you don't really look like or sound like you're fine today -- what's going on?" Once the patient knows that their physician is very interested, they might share their honest feelings about their situation.

Some tips for listening include:

• Maintaining focus
• Setting aside the need to fix, answer, or correct
• Interrupting as little as possible
• Hearing the journey, relationships, and meanings in the story
• Listening with all senses

Selected Touch Therapies

Touch therapies include a broad range of techniques that a practitioner uses to restore optimal functionality to the patient, in which the hands are on - or near - the body.

For most conditions, there is something available within the broad range of touch therapy that can be of benefit to someone. It is important to note, however, that even if it's appropriate in terms of the condition or diagnosis, the patient must be open and interested in trying it. If not, its use as a good modality is irrelevant.

1. Somatic and musculoskeletal

These therapies encompass all "therapeutic massages", such as Swedish massage, myofascial release, neuromuscular therapy, and lymphatic massage/drainage.

2. Eastern/energy/point-based

These methods involve the stimulation of sensory "points" in the body in order to increase circulation and relaxation. Examples of these therapies include acupressure, Amma, Jin Shin Jyitsu, Shiatsu, Tui Na, reflexology, Reiki, Therapeutic Touch, and Polarity therapy.

3. Manipulative therapies

Intensive, hand-on therapies, these are used mainly for body manipulation or adjustment. Examples of these techniques include Chiropractic and Osteopathic.

4. Other holistic therapies related to touch

• Alexander technique: an instruction of simple methods to direct the body into an easy upright posture in any situation, improving balance and coordination, as well as posture.
  
  
• Feldenkrais®: gentle movements to increase body awareness, range of motion, flexibility, and coordination. Also known as "movement re-education", Feldenkrais brings attention to movements of the body that are normally taken for granted.
  
  
• Rolfing® or Structural Integration: a technique to establish a structurally sound way for the body to relate to the effects of gravity, including manipulation and integration of muscles for improved balance and symmetry.
  
  
• Trager: an application of rhythmic rocking or shaking movements to aid relaxation, optimize energy, and loosen restrictions in the joints. This technique encompasses both applied and self-motivated exercises.

Exercise and Movement

It is easy to theorize that a patient with musculoskeletal conditions or limitations - especially where pain or a decrease in mobility is involved - would benefit from a limited amount of intentional movement. However, certain movements can decrease pain and increase mobility in the long run, especially for arthritic patients.

1. Pilates

The goal of Pilates is to strengthen the core (abdominal and lower back) region. Training the core muscles around the spine can help treat chronic low back pain while decreasing stress, depression, and anxiety.

2. Tai Chi

In Tai Chi, the body is extended and relaxed through a coordinated sequence of movements. This exercise technique can be used as a weight bearing exercise, and - like all weight bearing exercises - it has the ability to potentially stimulate bone growth, strengthen connective tissues, and increase overall strength, flexibility, and range of motion in the joints. Tai Chi has also been shown to improve balance and decrease the risk of falls. As a result, older adults in particular can realize the benefits.

3. Other techniques of rehabilitative movements

Yoga can also be very helpful for stretching, strengthening, and relaxation, as it incorporates breath work, which is good for centering and stress reduction. Hospital for Special Surgery also offers PACE (People with Arthritis Can Exercise) class, developed by the Arthritis Foundation as a series of exercises designed specifically for people with arthritis to help them continue to work within and around the limitations on their mobility.

Imagery

Imagery is useful in overcoming stress and pressure by focusing on pleasant thoughts and imagined places or feelings. By calling upon internal experiences of memories, dreams, fantasies, inner perceptions, and visions, it is possible to connect the body to the mind and spirit and provoke a state of relaxation.

A great healing modality on a number of levels (physically, emotionally, and spiritually), imagery can be used for calming, relaxation, pain control, healing, connecting, and increasing awareness and consciousness.

Examples of Imagery used by practitioners:

• Guided: Guided imagery involves following direction from an outside source. This could include a one-on-one session or a pre-recorded voice directing the subject. This type of imagery is the best place to start for beginners, but like meditation (or any of the other methods), this technique requires practice.
  
  
• Biologic: This technique is used to imaginatively create a biologically and physiologically accurate visual representation of natural healing functions in the body. For example, in one case study, a patient created a vision of white knights on horses with spears, representing their T-cells, fight their cancer cells. In another case, a patient imagined Pac-Man (representing their white cells) attacking and "eating" their tumor cells. This type of imagery should be performed with a practitioner working with the patient to ensure that their manufactured images are biologically and physiologically sound.
  
  
• Rehearsal: This method is a type of mental coercion in which the mind convinces the body that it is healing. (Many people do this automatically without being conscious of it.) A patient will use this method to visualize their healing at various stages, from intermediate recuperation to complete recovery. For example, a patient might envision having a procedure done with minimal pain or side effects. In a therapy context, rehearsal could be used for a patient who may be in the early stages of their healing or recovery, and who might be having a difficult time. In this technique, it is important to visualize and anticipate the healing process beforehand.
  
  
• End state: Although similar to the rehearsal technique, the end state technique requires that the patient visualize and focus on complete recovery as the end result, as opposed to concentrating on the healing process itself.

Conclusion

Many rehabilitative approaches can very easily be integrated into a traditional model of care. The techniques discussed in this article are not alternatives to contemporary treatment; rather, they can be considered to be complementary or holistic supplements to existing treatments. This comprehensive approach provides patients with more individualized options, producing a more optimal result in the patient's outcome and improving the patient-therapist relationship along the way.

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Gina Kearney is a Holistic Nurse Practitioner and site manager at HSS' unique center for Integrative Care. In addition to earning her RN degree from Bowling Green University, she also holds a Masters in Nursing from the Yale University School of Nursing. She is a certified Reflexologist and Reiki Master and is one of only a handful of nurses in NY State certified as Holistic Nurse Practitioners. Gina recently presented her project: "Shift Happens-Overcoming Resistance to Create an Integrative Care Center" at the Integrative Medicine for Healthcare Organizations conference in Phoenix, Arizona, in February 2005.

Summary prepared by Mike Elvin

posted 6/8/2005