Benefits, indications, and precautions.

Hippotherapy and THR are perceived 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, allows for variations in speed and cadence, and triggers neuromuscular responses through the stimulation of postural reflex mechanisms. Research has demonstrated that the pelvic motion trajectories and displacement amplitudes are similar in walking and riding; while there can be significant variation due to the different horses used, this variation does not cause significant alterations in the movement patterns generated. 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. ^, Vestibular, proprioceptive, tactile, and visual sensory inputs are incorporated during a hippotherapy session.

Hippotherapy is indicated for neuromuscular conditions. These conditions are 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). ^,

Common conditions that may benefit from hippotherapy and THR include autism spectrum disorder, cerebral palsy (CP), developmental delay, genetic syndromes, learning disabilities, sensory integrational disorders, speech-language disorders, traumatic brain injury (TBI), and cerebral vascular accidents. 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. ^,

Contraindications for the use of hippotherapy or THR include excessive hip adductor or internal rotator tone accompanied by potential hip subluxation or dislocation. Similarly, lack of head control (in large children or adults), pressure sores, spinal instability, extreme aggressive behavior, or anxiety around animals are also contraindicated. ^,

Regulations.

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 use the designation Hippotherapy Clinical Specialist (HPCS). An entry-level certification has also been available since 2014, with the designation of American Hippotherapy Certificated Therapist (AHCB) Hippotherapy Certified Therapist; this requires 1 year of professional practice (2000 hours), completion of AHA Level I and II skills courses, and 25 hours of hippotherapy practice.

American Physical Therapy Association recognizes hippotherapy as a treatment tool to address impairments and functional limitations in patients with neuromusculoskeletal dysfunction. APTA recommends that PT sessions that incorporate hippotherapy be billed as neuromuscular education, therapeutic exercise, gait training, or therapeutic activities based on the treatments completed. The American Occupational Therapy Association (AOTA) also recognizes hippotherapy as an interventional tool, which can be billed as neuromuscular education, therapeutic exercise, therapeutic activities, or self-care management training. The American Speech and Hearing Association (ASHA) recognizes hippotherapy as a treatment tool, which can be billed as speech-language therapy (individual or group), treatment of swallowing dysfunction and/or oral function for feeding, and therapeutic intervention for cognitive function.

Evidence and clinical implications.

Research and studies concerning the use of hippotherapy and THR have expanded in recent years. Research has primarily focused on children diagnosed with CP but has expanded to include conditions such as multiple sclerosis (MS), autism spectrum disorder, attention-deficit/hyperactivity disorder, psychological disorders, TBI, and stroke. In addition to the large number of articles focusing on the pediatric population, the literature has expanded to include research into the benefits of hippotherapy and THR for the adult and geriatric populations.

One systematic review investigating the use of hippotherapy and THR for children with CP 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. A systematic review and meta-analysis reported that short-duration hippotherapy (8 to 10 minutes of riding time) significantly reduced asymmetrical activity of the hip adductor muscles and improved postural control in children with spastic CP. Another meta-analysis found that postural control and balance were improved in children with CP after hippotherapy and THR interventions. A systematic review by Whalen and colleagues suggests that large randomized controlled trials that utilize specific and well-defined protocols are needed to provide stronger evidence for the use of hippotherapy and THR; however, the current evidence appears to support the positive effects of these interventions on gross motor function in children with CP. 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.

Studies have supported that hippotherapy can improve postural stability in individuals with MS and can assist in treatment of balance disorders. ^, A systematic review by Bronson and colleagues found that hippotherapy has a positive effect on balance and enhances quality of life for individuals with MS; individuals with primary progressive MS demonstrated the greatest improvement in balance, as compared with other subtypes, assessed with the Berg Balance Scale (BBS).

Hippotherapy has been shown to reduce lower-extremity spasticity in patients with spinal cord injury (SCI). For individuals with hemiparetic stroke, hippotherapy, combined with conventional treatment, helped improve lower extremity motor control, independent ambulation, and gait speed and cadence; individuals treated with hippotherapy had improved normalization of gait as compared with a control group.

A randomized controlled trial, conducted by de Araújo and colleagues , used a sample of convenience to investigate the effect of hippotherapy on functional mobility, muscle strength, and balance in a group of elderly participants. The Timed Up and Go (TUG) was used to assess functional mobility, the 30-second Chair Stand Test (30CST) was used to assess lower extremity muscle strength, and the BBS was used to assess balance. After the 8-week intervention, improvements were found in muscle strength and balance in the group that participated in the hippotherapy intervention. A systematic review by Hilliere and colleagues (2018) investigated eight studies about hippotherapy and simulated horse riding for older adults. The results suggested that hippotherapy may lead to improvements in balance, mobility, gait ability, and muscle strength; there was also potential for hormonal and cerebral activity changes with the use of hippotherapy (Hilliere, 2018). The use of horse simulators for riding contributed only to physical fitness and muscular activity changes (Hilliere, 2018).

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. A systematic review evaluated 33 studies involving children and adolescents with autism; hippotherapy and THR demonstrated improvements in behavior, social interaction, positive emotions, motor skills, and communication for children and adolescents diagnosed with autism. A systematic review by O’Haire suggests that the research supporting the use of animal-assisted interventions, including hippotherapy and THR, for individuals with autism is promising, but further research with substantial methodological rigor is required; preliminary research suggests the potential benefits of increased social interaction and communication and reduced problem behaviors, autistic severity, and stress.

While the methodological rigor in many studies involving hippotherapy and THR is lacking, the results remain promising for a wide variety of conditions. Hippotherapy and THR are effective in the areas of gross motor function, balance, symmetry, postural control, muscle strength, gait normalization, communication, behavior, and social interaction. Continued research in hippotherapy and THR using larger, randomized controlled studies with well-defined protocols to 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.

Development of the Feldenkrais method.

Moshe Feldenkrais, a boy in Palestine, 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 George Gurdjieff. He also studied psychology, progressive relaxation, bioenergetics, and the hypnosis methods of Milton Erickson. Also, he was familiar with the physiological concepts 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).

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 were able to 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.

Background theory—dynamical systems theory.

For Feldenkrais, learning was an organic process in which cognitive and somatic aspects were completely integrated. Presented first in 1949, this idea prefigured our current sense of dynamic systems functioning of the brain and body. The learning experience 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. This interactive cycle of action and perception has been described well by the motor learning model proposed by Newell.

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 colleagues 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.” 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 Whiting 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 both within the human organism as well as participation within the external world. This suggests that a home exercise program should not be strictly proscribed, but patients should be encouraged to experiment with movement and be guided in that process by the therapist. In the Feldenkrais method, this discovery and perceptual learning process are explicit.

Our understanding of how experience and learning restructure almost all areas of the CNS is expanding rapidly. A large focus of current thinking in rehabilitation is how to translate neuroplasticity concepts into more effective techniques for rehabilitation. 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.

Approaches to the Feldenkrais method.

The two approaches to facilitating learning created by Feldenkrais, ATM and FI, are similar in terms of principle and process, although they differ in practice. They are essentially two methods for communicating a sensory experience that the patient 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 forces acting on the system from inside or outside the body. 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 patient progressively approaches functional movements that she or he desires to perform.

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 patient 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 patient’s foot and ask the patient 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 patient and is left to emerge in the patient’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.

In ATM the practitioner verbally provides suggestions for movements for a patient to explore and asks the patient to focus on the sensory outcomes throughout the body. Thus the patient introduces the experimental forces into his or her own system with the intention of understanding how the body as a whole responds. The underlying idea, however, is the same. In my practice, FI is used to assess body image and capacity for movement and as a form of communication when patients do not understand how a force might act on the body or when the patient is unable to produce a range of movements that we might desire to explore. An example might be in a case where spasticity prevents fine discrimination in both sensory and motor realms.

In practice with an individual patient, 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, a functional activity important to the patient, and so on. ATM is a verbal process in which patients 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 each of them as individuals. Because ATM is under the active control of the patient, this method is often a more effective tool in reestablishing voluntary control.

Note: A case study on the Feldenkrais method can be found in the online resources associated with this text.

Evidence of effectiveness.

In a review of studies of evidence-based studies of effectiveness up to 2004, Stephens and Miller divided the literature into four different areas: pain management, postural and motor control, functional mobility, and psychological and quality-of-life impact. These categories still hold with more studies being done since in the areas of pain and posture, mobility, and balance, especially in the geriatric population. A growing amount of the literature is in the randomized, control trial format. That literature (through 2015) has been reviewed by Hillier and Worley, including meta-analysis for outcomes, effect sizes, and biases.

The theory underlying the Feldenkrais method predicts that there should be changes in perception of the body or body image. Elgelid 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 colleagues 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. Bitter and colleagues found significant improvements in dexterity compared with a control group following a single ATM lesson. Stephens and colleagues have shown that ability to image movement is improved in people post stroke 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 BBS. In a qualitative study, Connors and colleagues made a compelling argument that ATM lessons are based on principles of motor learning and therefore the general literature in an important point of reference.

Breathing.

Faulty breath patterns can be associated with complaints of pain and movement dysfunction. Pilates movements create an environment where breath facilitates improved air exchange, breath capacity, and posture. During Pilates exercise, breathing is used to facilitate stability and mobility of the spine and extremities. Because of the movement of the rib cage on the thoracic spine, inhalation can promote spinal extension while exhalation can promote spinal flexion. Breath may or may not facilitate movement based on where the breath is occurring. If accessory breath occurs while attempting spine extension, it would not have a positive movement on the spine articulating into extension. It is then important to realize that the direction of movement in the ribs facilitated by breath determines whether breath facilitates movement or not. Similarly, breath may assist with stability of the spine through the coordinated contraction of the diaphragm and the lower abdominal muscles, both of which attach to the lumbar spine and pelvis. ^,

Trunk control and axial elongation.

Core control is the optimal recruitment of the trunk musculature required to perform a given task in relation to the anticipated load. The transversus abdominis, internal abdominal obliques, external abdominal obliques, multifidi, erector spinae, diaphragm, and pelvic floor muscles are key organizational muscles that work together during the movement in healthy individuals. Motor control studies indicate that the coordinated, subthreshold contraction of these local and global stabilization muscles modulate the level of spinal stability required to safely perform activities of daily living (ADLs).

Axial elongation is the proper alignment of the head, spine, and pelvis that provides optimal joint spacing during movement. Correct joint spacing avoids working or resting at the end of range, which can place undue stress on the inert and contractile structures of the trunk and extremities. ^, Through emphasis on axial elongation of the spine and maintaining appropriate joint spacing, soft tissue surrounding the joint can move more freely, and the risk of injury can be minimized. Recent discussion has challenged the Pilates approach to trunk control and has passed through the fitness and rehabilitation fixation on core control, where the assumption is that the stronger the core muscles, the healthier the spine. Research has been leaning away from this paradigm to one of motor control and efficiency. Though Pilates uses the trunk musculature and coactivation to successfully perform the vast repertoire of exercises, the focus is on efficiency and spontaneous contractions of the trunk musculature based on the anticipated load and the amount of intraabdominal pressure required in that moment.

Mobility.

Spine mobility allows for the distribution of movement throughout the cervical, thoracic, and lumbar spine. This principle can also be thought of where distribution of movement equals distribution of force. It has been suggested that repetitive movement at a hypermobile spinal segment may result in microtrauma or macrotrauma. Hypermobility is often a result of a lack of movement in a neighboring segment or joint. Pilates exercise attempts to facilitate a change in movement strategy during functional tasks and distribute the forces through other motion segments. Patients are trained to distribute movement in the spine over a greater number of spinal segments, thereby decreasing potentially harmful forces at the hypermobile segment. The ability to segmentally move the spine decreases unwanted stress and shear of the spinal segments and increases the efficiency and fluidity of movement. The clinical findings of decreased low back pain because of Pilates exercise may be due to changed strategy that reduces the stress afforded to the pathological segment(s).

Efficiency of movement.

Efficiency of movement is the minimization of unnecessary muscle contractions that tend to interfere with healthy movement. The excessive recruitment of antagonist muscles is obstructive and significantly increases the amount of energy required to perform a task. ^, This principle can be applied to functional movement skills as well as performance skills. Inefficient motor recruitment can often be recognized by the amount of tension or faulty posture in the head, face, neck, and shoulder girdle, in relation to the thoracic spine and trunk.

Alignment and weight bearing of extremities.

Alignment and posture are concepts often incorporated in the field of rehabilitation. The Pilates principle of alignment refers to the most energy-efficient posture (static or dynamic) of the body for a given task. Proper postural organization can significantly decrease energy expenditure during daily activities by improving mechanical advantage. ^, Faulty alignment in the extremities and the spine can be a source of decreased range of motion, loss of joint congruency, early fatigue of muscle groups, or abnormal stresses on inert structures and may potentially cause degeneration and injury. ^,

Pilates provides a closed chain environment that facilitates compression and decompression forces on the axial skeleton and extremities through a full range of motion. Adjusting the spring resistance or patient’s orientation to gravity can alter the amount of load. The ability to regulate load based on an individual’s physiological limits, set by age or pathological condition, allows practitioners to more safely and effectively stress the skeletal and soft tissue systems. Theoretically, these forces can help stimulate osteoblastic activity and provide nutrition to a larger surface area of the joint and its surrounding connective tissue.

Movement integration.

Many forms of rehabilitation focus on treating limitations of anatomical structures and neglect the neuromuscular reeducation required to learn to regain the motor control necessary to perform a complex task. Pilates provides a more holistic approach by emphasizing the synthesis of mind (motor control) and body (physical strength and flexibility) to achieve fluid movement. Mobility, control, and coordination of the extremities with the trunk and the trunk with the extremities are examined and trained through motor learning and repetition of practice. In addition to the physical and mental capacity to complete a task, the environment in which a task is performed can greatly affect the success of movement organization. ^, Pilates provides an environment that can be modified on the basis of a patient’s impairments and limitations, providing a safe, successful, and pain-free movement experience.

Carpal tunnel syndrome.

Physical and occupational therapists treat carpal tunnel syndrome (CTS), an upper-limb neuropathy caused by compression of the median nerve. Symptoms involve numbness, tingling, and pain from repetitive movements that respond to a variety of treatments. ^, Two studies specifically explored the use of yoga to treat subjects with CTS. A yoga trial with 42 individuals tested the effectiveness of a yoga regimen on CTS symptoms. Those in the experimental yoga group were given 11 postures designed to stretch and strengthen the upper limbs, along with relaxation techniques, twice a week for 8 weeks at a local geriatric center. A control group was given wrist splints or no treatment at all. Significant improvements in grip strength, pain reduction, and Phalen sign were noted. However, no statistically significant change was recorded in sleep improvement, Tinel sign, or median nerve conduction; however, improvements were noted in pain and function 4 weeks later. A second study investigated the impact of yoga in patients with osteoarthritis. Twenty-six participants performed a 1-hour yoga session each week for 8 weeks with reported significant improvement in joint and hand pain during activity. Larger randomized clinical trials could provide definitive evidence for patients with CTS.

The specific use of YOGA when dealing with movement problems caused by brain problems arising from specific medical diagnosis can be found on line and should be integrated with specific chapters dealing with those movement problems.

Stroke and hemiparesis.

Strokes are the primary cause of adult disability in the United States and Europe, with 4.7 million individuals in the United States living with the sequelae of stroke. Extreme difficulties encountered while performing simple movements result in a sedentary lifestyle in this population, and resultant muscle atrophy further potentiates fall risk.

A pilot study with four subjects observed the impact of yoga as a treatment for impairments post-stroke. Baseline measurements included the BBS, Timed Movement Battery (TMB), and SIS version 2.0. Three of the four participants had statistically improved BBS scores indicating improved balance, improved self-selected speed on the TMB indicating enhanced ability to perform everyday tasks, and positive changes in quality of life based on the SIS.

Other factors may have affected the outcome of this pilot study, including differing adherence to the home exercise program with varying participation levels, degree of impairment, and fear of pain, which reduce participation with certain asanas. Those who adhered to the program witnessed more improvement than those who did not follow it as closely. Yoga appears to have some level of positive impact on function in post-stroke patients, and a recent systematic review of eight clinical trials was done on the effects of yoga after a stroke for improvement of balance. Many stroke survivors have a least some degree of difficulty with balance, which can then affect all areas of daily living activities. The current research is not consistent with the duration or the type of yoga practice that should be performed, as studies varied based on the regions they were done. The exact reasons that yoga is beneficial in this population are unknown. It is hypothesized that it helps improve proprioception through posture, movement, and breathing techniques, but the protocol for treatment needs to be better defined.

Multiple sclerosis.

Individuals with MS can suffer from virtually any neuropathy, fatigue, ataxia, and chronic or acute pain. In addition, cognitive, digestive, visual, and speech problems may also occur. Although there is no cure for MS, patients have life expectancies similar to those unaffected by the disease, and yoga may be an option to manage the various impairments encountered through the years. ^, It is interesting to note that 65% of those diagnosed with MS use some CAM, with yoga being the most popular. Perhaps the best study to date was a 6-month study that compared Iyengar yoga and exercise interventions. Participants underwent multiple cognitive assessment tests such as the Stroop Color and Word Test and the Cambridge Neuropsychological Test Automated Battery to test reaction times in performance of certain tasks that are difficult for individuals with MS. These tests measure attention and visual and auditory abilities to determine the impact of cognitive abilities. Alertness, mood, fatigue, and quality of life were also measured using the Profile of Mood States (POMS), the SF-36, electroencephalography, and physical activities such as a timed walk. Of those who completed the study, both the exercise and yoga intervention groups had greater quality of life based on data from self-assessment forms (SF-36), a reported increase in vitality and energy, and a decrease in fatigue.

Research exploring the use of yoga for MS is promising, and while the evidence for mind-body medicine in MS is limited, they are safe and may provide a nonpharmacological benefit for MS symptoms. ^,

Epilepsy.

Yoga, as well as other mind-body practices, has shown promise in helping control seizures. One yoga meditation trial reported a 62% decrease in seizure occurrence at 3 months, 86% at 6 months, and 40% of the subjects becoming seizure free. ^, The patients in this study had hyperventilation-related epilepsy caused by anxiety, so the meditation and controlled breathing exercises along with the asanas may have led to a better understanding of how the subjects could control their diaphragm and experience relaxation, resulting in the high success rates. In this study, electroencephalographic data recorded a large shift in frequency from 0 to 8 Hz to 8 to 20 Hz, with an increase in A-band power and a decrease in D-band power. These results showed improvement in control and power of breathing. Yogic meditation regulates the limbic system, providing better control over endocrine secretions and lowering the chance of over-firing neurons. Another investigation tested the use of yogic meditation for 1 year versus a control of no meditation in patients with drug-resistant epilepsy. Data showed significant differences between the experimental and control groups, with the experimental group having significantly lower seizure activity over the observation period.

Efficacy of a yoga meditation protocol (YMP) as an adjunctive treatment in patients with drug-resistant chronic epilepsy was a trial based on the frequency of complex partial seizures, which was assessed after 3, 6, and 12 months. Participants sat in a relaxed position with legs crossed (sukhasana) and focused on deep, slow, controlled breathing ( pranayama ) for 5 to 7 minutes, followed by silent meditation. Patients were instructed to perform YMP daily for 20 minutes in the morning and evening at home and at supervised sessions. Individuals with greater than or equal to a 50% reduction in the rate of monthly seizures were classified as responders, whereas patients with less than this percentage in seizure reduction were classified as nonresponders. After the first 3 months, there was a reduction in the frequency of seizures in all but one patient. Fourteen patients continued the YMP for 6 months or more and were tested again. Of these, six were seizure free for a 3-month period, and three were seizure free for 6 months. The authors of this study concluded that yoga was cost-effective with less adverse events with drug-resistant forms of epilepsy.

Human immunodeficiency virus.

A pilot study examined the use of a yoga intervention for individuals with human immunodeficiency virus (HIV) infection who experienced pain and anxiety. Results indicated a decrease in pain and anxiety symptoms and a reduction in amount of pain medication after an 8-week yoga program.

Another study examined the effect of yoga practice that included breathing, movement, and meditation techniques for 47 participants with HIV disease. Positive changes were noted in the Mental Health Index (MHI) and general physical health on the Medical Outcomes Study HIV Health Survey (MOS-HIV). The Daily Stress Inventory showed a decrease in stress after the yoga program and improvements in activities of daily living were reported. Finally, the impact of Iyengar yoga for 1 month may reduce depression and improve immunity in individuals living with HIV disease.

Fear of falling and insufficient balance.

A 12-week yoga practice for adults aged above 65 years with fear of falling and balance problems included sessions of yoga asanas and breathing exercises in sitting and standing. Fear of falling was measured using the Illinois Fear of Falling Measure, and balance was captured with the BBS before and after the yoga intervention. Results showed a 6% decrease in fear of falling, 4% increase in static balance, and 34% increase in lower-body flexibility. Our chair yoga study showed a reduction of fear of falling and improvements in the Short Physical Performance Battery in seniors above the age of 65 years who received previous physical therapy interventions for a fall. Another observational study explored the effect of yoga on balance, fear of falling, and quality of life in 26 postmenopausal and osteoporotic women aged 55 years and above. Results of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) and a neuromuscular test battery revealed improvements in all aspects of the QUALEFFO for the yoga participants as well as improved ability to stand on one leg and improved perception of general health.

There is also research that states yoga can help improve balance in patients with Parkinson disease, while also improving anxiety, depression, and overall quality of life. There were only two studies that were examined, so more research is needed in this area.

Conclusion.

Available data on the use of yoga as a therapeutic intervention for people with various neurological disorders are promising. Most studies have small sample sizes but do show trends toward improved function and reduced impairments. In general, yoga can assist in the establishment of the mind-body connection and awareness of self for individuals with neurological challenges. Greater self-awareness may explain why patients report improvements in quality of life, improved ability to better manage their disease, and a deeper understanding of their own bodies. Relaxation that results from yogic meditation fosters stress management and may improve the outlook on long-term management of neurological conditions. Yoga may serve as an adjunct to traditional exercise and can be adapted for elderly patients who are unable to perform strenuous exercise. Yoga may be modified to accommodate patients with almost any physical or cognitive disability, and potentially provide mental enhancement, which can create a significant relaxation effect. Further research is needed to further explore specific effects of yoga practice in neurological populations.

Assumptions.

There are four assumptions that form the foundation for TT as an intervention that can facilitate healing and health. The first assumption, described by Delores Krieger, RN, PhD, the developer of TT, is that the body is an open energy system. The open system allows energy, often referred to as subtle energy , to flow within and through the body. This flow allows for a dynamic interface with the environment. The second assumption suggests that individuals are bilaterally symmetrical, so that the right and left and front and back mirror each other. This symmetry allows for a balanced energy flow. The third assumption is that an imbalance or an irregular flow of subtle energy is associated with physiological impairments, illness, and disease. The fourth assumption is that the body can initiate and achieve a process of self-healing through manipulation of biofields and restoration of subtle energy balance and flow.

The concept of internal and external subtle energies and their relationship to health and illness can be found in many whole medical systems, such as Ayurveda, traditional Chinese medicine, and Navajo medicine. More specifically, the assumptions of TT described by Krieger have their roots in the ancient concepts of prana and chakras. ^, Prana, which is coined chi or qi in other systems of medicine, is the universal life force or energy that circulates through the universe and all living things. Chakras are the centrally aligned energy centers that are able to receive, transform, and send prana throughout the body. A blockage, interruption, void, or imbalance of prana is thought to exist when there is pathology or disease. Restoration of an individual’s energy flow and balance is important for self-healing and health.

Krieger, along with her colleague Dora Kunz, investigated the phenomenon and characteristics of people known as “healers” and concluded that healers possess a heightened sensitivity to their patients’ states of health and being and are able to effect change through intention and energy. Through her description of sensing and effecting change in an individual’s energy or biofield, Krieger has elucidated a four-step process that defines TT as a distinct therapeutic intervention different from other energy-based therapies such as Reiki and Healing Touch.

Procedure.

TT is often performed with the patient or patient fully dressed and sitting. Despite the name, TT can be administered without actually touching the patient because TT practitioners are able to sense and manipulate the patient’s subtle energies from a distance of 2 or more inches away from the patient’s body. The first step in the TT process is called centering. During centering, practitioners center their consciousness so that a state of integration and quiet can be achieved. From the state of centeredness, practitioners initiate the assessment step by placing their hands 2 to 3 inches from the patient’s head and slowly moving their hands down the patient’s body, noting the patient’s biofield. Practitioners may perceive the patient’s energy as hot or cold, or sense that a patient’s energy is blocked in a particular area. Perceived disturbances in a biofield suggest that the practitioner should return to that area later in the process.

Krieger has described the next step in the TT process as “unruffling the field.” To unruffle the field, TT practitioners sweep away bound up or congested energy, which allows the patient’s energy field to become open and unrestricted. Opening the energy field sets the stage for the final step of the TT process. During the final step, TT practitioners direct and modulate the transfer and flow of energy so that the patient’s energy fields can achieve balance and symmetry and healing can occur. Krieger points out that TT does not “cure” people of their diseases. Rather, she suggests that TT can have positive effects on energy fields and the flow of energy, and that these effects create an environment in which the patient’s own self-healing processes can be optimized. ^, Sessions usually take 20 to 30 minutes, but TT practitioners have reported that frail patients and children can benefit from as little as 5 to 8 minutes of TT; other patients may require 60 minutes of TT to achieve a state of relative energy balance.

Scientific literature.

The application of TT for people with neurological diseases and disorders has not been widely investigated in the scientific literature. Researchers have, however, investigated the efficacy of TT for the reduction of anxiety and pain in a variety of patient populations and disruptive behaviors in people with dementia and Alzheimer disease (AD).

Anxiety.

Anxiety is a general term associated with nervousness, fear, apprehension, and worrying. An anxiety disorder differs from feelings of anxiety associated with a specific event and is characterized by an irrational dread of everyday situations or excessive and long-standing anxiousness regarding nonspecific events and objects.

Robinson and colleagues performed a systematic review of the effect of TT on symptoms related to anxiety disorders but were unable to identify any studies in which subjects met the definition of anxiety disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or the International Classification of Diseases (ICD-10). In all of the studies of TT and anxiety included in the review, Robinson and colleagues noted that pretest anxiety was measured in all subjects, but these subjects did not have “anxiety disorder” as their primary diagnosis. This systematic review helps show that individuals with neurological disorders and other medical diagnoses may not be diagnosed with an anxiety disorder but may experience some anxiety as they face the challenges of their condition.

Several researchers have investigated the effect of TT in different patient populations, such as those with severe burns, cardiovascular diagnoses, ^, and breast cancer. ^, Turner and colleagues found that for hospitalized patients with severe burns, TT was associated with a reduction in anxiety with no adverse effects. Quinn and Heidt investigated the application of TT in people with cardiovascular conditions and determined that compared with sham TT, subjects who received TT reported significant reductions in anxiety on the State-Trait Anxiety Inventory (STAI). Women with breast cancer were studied by Samarel and colleagues and Frank and colleagues. Samarel and colleagues found that women who received 10 minutes of TT and 20 minutes of dialogue before surgery reported significantly lower preoperative anxiety than women who received quiet sitting and dialogue, but no differences in anxiety were observed postoperatively. Frank and colleagues found that TT was helpful for reducing restlessness, fear, and nervousness in women who were scheduled to undergo a stereotactic core biopsy (SCB) but that the results were similar between the TT group and the sham TT group.

The application of TT with older adults has been reported by Simington and Laing and Lin and Taylor. Both research studies found that older subjects who received TT had significant postintervention reductions of anxiety as measured by the STAI. In the study by Simington and Laing, TT was paired with a backrub in the experimental group. The control group received just a backrub. In the study by Lin, TT was compared with sham TT. For inpatients with psychiatric diagnoses, TT was compared with sham TT and relaxation therapy. The researchers found that TT was more effective than sham TT but not more effective than relaxation therapy for reducing anxiety in this population.

A review of the TT literature and anxiety suggests that TT’s efficacy for reducing anxiety is inconclusive. Several researchers have reported benefits of TT, yet others have found no effects when comparing use of TT with a control group or with use in patients with another condition. Reasons for the inconclusive results may be differences in the criteria for anxiety and variability in the measurement instruments. Other reasons may include research design issues such as assignment methods, blinding, and the frequency and duration of the TT intervention and comparison conditions.

Pain.

Pain is strongly linked to anxiety and is associated with depression, anger, and fear. Pain also has physiological effects, including increased heart and respiration rates, and, when chronic, can result in structural changes in the brain. Pain can interfere with the ability to participate in physical rehabilitation and impair ability to function efficiently and effectively. Nonpharmacological methods for managing pain have the potential for assisting patients in their rehabilitation and achievement of functional independence without adverse effects. Investigations of TT for pain associated with neurological conditions are extremely limited. In a case report of a subject with long-standing phantom limb pain, Leskowitz found that TT was effective in reducing the subject’s pain from an 8 to 10 out of 10 on a visual analog scale (VAS) to a 0 in one session. Self-administered TT was then able to maintain pain at a 0 to 1 on a VAS, in which 10 is the maximum intensity. Before TT, medication, stress management, hypnosis, transcutaneous electrical nerve stimulation (TENS), and ultrasound had been successful in temporarily reducing the subject’s pain to 6 to 8, but long-term pain management with these approaches was inadequate.

TT was investigated in subjects with chronic pain associated with fibromyalgia syndrome and CTS. Denison found no significant improvement on the Short-Form McGill Pain Questionnaire (SF-MPQ), VAS, or Fibromyalgia Health Assessment Questionnaire (FHAQ) after subjects received 6 weekly sessions of TT. TT and sham TT groups both demonstrated immediate significant improvement in median motor nerve distal latencies, pain scores, and relaxation scores; however, there were no significant differences between the two groups on any of the outcome measures.

Other researchers have investigated the use of TT for pain management with older adults ^, and people with cancer, ^{, , ,} osteoarthritis, ^, headache, postoperative pain, ^, burns, and various chronic pain complaints.

In older adults, pain from a range of sources was reduced by 38% with TT, and chronic musculoskeletal pain was significantly reduced following three 20 minute sessions of TT compared with sham TT and usual control groups, although no long-term measurement of pain reduction was conducted. Musculoskeletal pain due to osteoarthritis was also significantly reduced with 6 weekly sessions of TT. ^,

Giasson and Bouchard found that after each session of TT, people with terminal cancer reported improved well-being, which included a reduction in pain, compared with individuals in the control group. In a randomly controlled trial (RCT), including 90 patients with cancer undergoing chemotherapy, Aghabati and colleagues found that five 30 minutes of TT significantly helped reduce pain and fatigue immediately following the session compared with those who received either standard care or sham TT. However, in a study of women with breast cancer, a session of TT had no effect on reducing their pain or anxiety when undergoing a stereotactic core breast biopsy.

When utilized postsurgically, TT has been demonstrated to be effective in reducing pain when compared with a usual care group in two studies. ^, However, in a study that compared TT with sham TT and the standard intervention of narcotic analgesic, there were no significant differences in reports of pain. Nevertheless, TT may have decreased the patients’ need for analgesic medication.

The results of studies that have included TT and measures of pain suggest that TT may be helpful in managing pain that arises from many different conditions. There are, however, inconsistencies across the studies that raise questions about both significant and insignificant findings. Inclusion of a control group, use of sham TT, sample size, measurement instruments, and the duration and frequency of TT are factors related to the studies’ validity that limit the ability to draw firm conclusions about the efficacy of TT for reducing pain. There is also a scarcity of information about the long-term effects of TT.

Disruptive behaviors.

TT has been investigated for its effect on disruptive behaviors in people with AD and dementia. Although most patients with neurological conditions do not typically manifest AD, alterations in cognitive functioning and behavior are often observed. Studies using a within-subject design and the Brief Agitation Rating Scale (BARS) have found that TT provided twice a day for 5 to 7 minutes was beneficial for reducing overall agitation and behaviors of vocalization, pacing, and restlessness in people with dementia. ^, When applied in the same way in a RCT, TT was found to be helpful for significantly decreasing overall behavioral symptoms of dementia, including restlessness and vocalizations, when compared with usual care and sham TT groups. In people with AD, results of an RCT that compared TT to sham TT and usual care suggest that 30 to 40 minutes TT over 5 days can be helpful in reducing physical nonaggressive behaviors but had no effect on physically aggressive and verbally agitated behaviors.

Studies ^{, ,} have provided some preliminary evidence for TT’s potential use for modifying at least some forms of disruptive behaviors. Additional studies need to be conducted to determine the effect of frequency and dose of TT on the duration of quelling undesirable behaviors. Application of TT to people with post-TBI or other conditions who exhibit agitated behaviors needs to be investigated.

Conclusion.

As a noninvasive, nonpharmacological intervention, TT may be helpful to patients with AD or dementia who demonstrate disruptive behaviors and people with pain or anxiety. Research that investigates the mechanism by which TT may alleviate pain and the physiological changes that may occur with TT will advance the acceptance of TT as a useful modality and suggest patient diagnoses that might benefit from the incorporation of TT into a rehabilitation plan of care.

Structure of the craniosacral system.

The anatomy of the craniosacral system includes a water-tight compartment formed by the dura mater, the cerebrospinal fluid (CSF) within this compartment, the inflow and outflow systems that regulate the quantity and pressure of the bones to which the dura mater attaches, the joints or sutures that interconnect these bones, and other bones not anatomically connected to the dura mater. The bones of the cranium and the second and third cervical vertebrae, the sacrum, and the coccyx are also included in the structures of the craniosacral system. ^, In combination with the message sent to the patient through the intentional touch of the therapist is the corrective work that is done on a basic physiological level by gentle hands-on manipulations applied both directly and indirectly to the craniosacral system. The semiclosed hydraulic system includes the dural sleeves, which invest the spinal nerve roots outside the vertebral canal as far as the intervertebral foramina, and the caudal end of the dural tube, which ultimately becomes the cauda equina and blends with the coccygeal periosteum. The fluid within the semiclosed hydraulic system is CSF. The inflow and outflow of CSF are regulated by the choroid plexuses within the brain’s ventricular system and arachnoid granulation bodies, respectively. CSF outflow is not rhythmically interrupted, but its rate may be adjusted by intracranial membrane tension patterns, which are broadcast primarily by the falx cerebri and tentorium cerebelli to the anterior end of the straight venous sinus, where an aggregation of arachnoid granulation bodies is located. This concentration of arachnoid granulation bodies is known to affect venous backpressure, which has an effect on the rate of reabsorption of CSF into the blood-vascular system.

Technique.

The therapist, after mobilization of bony restrictions, focuses on the correction of abnormal dural membrane restrictions, perceived CSF activities, and energy patterns and fluctuations as they relate to the craniosacral system. It is during this time that the patient often moves from a phase of being corrected and having obstacles removed to a phase of self-healing, with the therapist serving as a facilitator of the process. The tenets of CST include the concept that the dura mater within the vertebral canal (dural tube) has the freedom to glide up and down within that canal for a range of 0.5 to 2.0 cm. This movement is allowed by the slackness and directionality of the dural sleeves as they depart the dural tube and attach to the intertransverse foramina of the spinal column.

A basic assumption in CST, as it has evolved, is that the patient’s body contains the necessary information for the discovery of the cause of any health problem. The treatment relies primarily on hands-on evaluation and treatment. The hands-on contact is tender and supportive. It is accompanied by a sincere intention to assist the patient in any way that is possible. In short, the therapist serves primarily as a facilitator of the patient’s own healing processes. The rapport that develops during the patient-therapist interaction lends itself powerfully to the positive therapeutic effect that many patients experience.

Western medicine imparts a therapeutic modality for curative measures, whereas CST fosters facilitation, wherein the patient directs the treatment session. The inherent participation of the patient through CST promotes a holistic approach to healing. Conventional medical diagnosis will usually be more closely related to what the therapist views as the result rather than the cause. For example, the therapist would search for a cause of strabismus within the intracranial membrane system and the motor control system of the eyes, rather than considering the strabismus as a diagnosed condition to be corrected by surgery. The cause of strabismus can be found as an abnormal tension pattern in the tentorium cerebelli. The therapist then searches for the cause of the abnormal tentorial tension pattern. Quite often, these tension patterns are referred from the occiput or from the low back or the pelvis. If this is the case, the CST “diagnosis” would be intracranial membranous strain of the tentorium cerebelli as a result of occipital or low back or pelvic dysfunction, individually or severally, resulting in secondary motor dysfunction of the eyes (strabismus). The therapist would focus on the sacrum, the pelvis, the occiput, and then the tentorium cerebelli. Correct evaluation and treatment would be signified by a “spontaneous correction” of the strabismus.

Somatoemotional release is a technique that involves the bodily, and usually conscious, reexperiencing of episodes, the energies for which have been stored in the totality of body tissues. A powerful emotional content is typically connected with this technique, and it has proved to be extremely effective in cases of severe posttraumatic stress disorder. It was tested through qualitative research with a group of six Vietnam veterans in 1993. It proved to be successful in all six of these patients. ^{, , ,}

Outcomes.

Objective responses to CST are based on the removal of obstructions to smooth and easy physiological motions of the patient’s body, the absence of energy cysts, the free movement of the dural tube in the spinal or vertebral canal and the rate and quality of the craniosacral rhythm, the absence of pressing responses during the somatoemotional release process, and statements from the deeper levels of consciousness through dialogue with various images encountered in the session that “all is well.” ^{, ,}

Subjectively, patients report an increased sense of well-being, improved sleep patterns, reduced manifestation of stress, reduction in or disappearance of pain, increased energy levels, and fewer episodes of transitory illness. How long it takes to achieve these results is extremely variable and dependent on the complexity of the layers of adaptation, the defense mechanism, and the level of spiritual evolution of the patient.

Use in treatment intervention.

CST is useful as a primary treatment modality and as an adjunct to a wide variety of visceral dysfunctions. It works well to balance autonomic function, specifically reducing sympathetic nervous tonus. It has proved beneficial in chronic headache problems, temporomandibular joint problems, whiplash sequelae, and chronic pain syndromes. We have used it as an intensive treatment for people rehabilitating from head injuries, craniotomies, spinal cord injuries, post-stroke syndromes, transient ischemic attacks, seizure disorders, and a wide variety of rare brain and spinal cord dysfunctions. Little positive effect has been reported in people with amyotrophic lateral sclerosis. However, some remarkable success has been seen in patients with MS.

CST has been used extensively and effectively in a great number of children with spastic CP, seizure disorders, Down syndrome, and a wide variety of motor system disorders, including problems with the oculomotor system, learning disabilities, attention deficit disorder, speech problems, childhood allergies, and autonomic dysfunction. CST seems to be safe in preterm infants and has cost-effective outcomes. We have used CST for people living with HIV disease who have peripheral neuropathy and other chronic musculoskeletal and neurological problems. Pain management techniques can be used by the therapist and also taught to the family members to implement for a home program. Future studies addressing the interaction of the immune system with the craniosacral system would be helpful in elucidating the neuroendocrine response to this technique.

Clinical experiences also suggest that CST is a powerful evaluative and treatment modality for patients with vertigo who have not responded well to or have not found relief from traditional medical treatments. CST has been found to be an effective means for treating lower urinary tract symptoms and improving quality of life in patients with MS. Osseous, dural membrane, and fascial restrictions leading to asymmetrical temporal bone movement and, hence, vertigo are some of the dysfunctions of the craniosacral system. More clinical trials are necessary to verify that CST is an effective treatment as well as to determine the full range of symptoms for which CST is beneficial.

Recent studies have found an impact of CST on chronic pain pain, including fibromyalgia. CST improved quality of life in this population, reducing the perception of pain and fatigue and improving night rest and mood with an increase in physical function.

CST along with other osteopathic techniques to treat chronic lateral epicondylitis as opposed to treating it with traditional orthopedic techniques revealed increased strength and decreased pain for both osteopathic and orthopedic groups. The assumption is that osteopathic techniques such as CST can be successful in treating chronic lateral epicondylitis; however, future studies will need to isolate CST to ultimately reveal its efficacy in treatment for this problem.

To date, there have been several studies refuting the value of CST. One example is in The Scientific Review of Alternative Medicine. According to this group of researchers, interexaminer reliability among CST practitioners is zero. Other studies suggest that the sutures that CST practitioners are attempting to mobilize are fused in the adult population; therefore the techniques are ineffective. Future studies are necessary for CST to achieve recognition as a valid and reliable treatment option.

Training.

The prerequisites for training in CST by the Upledger Institute are quite simple. It is believed that any kind of therapist who has a license to see and treat patients/clients might find CST, in its more basic form, a useful adjunct to practice.

There are six levels of training within the series that are required before one can enroll in the advanced-level workshops. The workshops are all 4 or 5 days in length and are about evenly divided between academic work and hands-on supervised practice. The training program is designed to develop the sense of touch, motion, and energy perception slightly before the academic material is presented.

A certification process was established in 1995, along with an International Association of Healthcare Practitioners, of which the American CST Association is a subdivision. The American CST Association, a nonprofit organization, was founded by a group of therapists and concerned laypersons in 1994, and the stated objectives are to bring CST into public awareness, to enhance networking among practitioners who use CST, and develop a certification program that will result in the recognition of CST as a specialty for people who are licensed as health care practitioners in other fields.

Contemporary American Indian health care and traditional healing: North and South American Indian or indigenous perspectives.

In a report to NIH, Alternative Medicine: Expanding Medical Horizons, the Lakota (a Sioux people) were cited for the use of healing ceremonies by specialists who are essentially shamanic in their approach to treatment. To understand American Indian medicine ways, one cannot rely solely on written accounts. Although written ethnographical studies may provide a wealth of descriptive data, it is best to talk to authoritative sources personally. Professionals interested in learning more about traditional approaches to help and heal should contact any one of the federally recognized tribal headquarters and the tribally sponsored American Indian colleges and universities for more specific information. Many colleges conduct summer courses on Lakota culture and philosophy that are open to non–American Indians as well as American Indians interested in learning the culture. Readers wanting to know more about the cultural and linguistic revitalization with the Lakota and Dakota people are urged to visit the website for the Lakota Language Consortium.

Today, many of the old American Indian healing traditions are experiencing a renaissance and are beginning to be viewed with a renewed sense of respect and credibility as an alternative and complement to more invasive or secular Western medical models of treatment. For example, on the Cheyenne River Sioux Reservation at Eagle Butte, South Dakota, the tribe has incorporated traditional methods and approaches to a variety of social service programs, including services for at-risk youth and care for people with alcoholism, which is viewed as a problem with social, emotional, physical, and spiritual dimensions. ^{, , ,} A survey of Urban Indian Health Organizations revealed that 100% of the responding program utilized some kind of traditional healing in their behavioral health services. American Indian veterans utilize traditional healing methods to relieve the symptoms of posttraumatic stress disorder. These traditional methods include the inipi , or purification ceremony (popularly called the “sweat lodge”), the hanblecaya , or pipe fast (often called the “vision quest”), and the wiwang wacipi , or the Sundance. The inclusion of these ceremonies within the treatment process has collectively been called the “Red Road approach.” ^{, ,}

A number of medical facilities on various reservations include medicine men as consultants on a formal and informal basis, ^, and the use of traditional ceremonies in health care settings is encouraged and respected. Where the ceremonial burning of sage (a common medicinal herb burned for purification) had been discouraged in the past, hospital staff report increased acceptance of this practice and now arrange appropriate space for traditional ceremonial practices both within the health care facility and outside on hospital grounds. ^, One Lakota friend commented on his recent hospitalization at an allopathic hospital. He was visited by a medicine man that placed a bundle of sage under his pillow. This made him feel better and showed how simple cooperation among allopathic medicine, health care practices, and alternative, complementary health care practices can be.

A lakota centric perspective on health.

A traditional American Indian perspective on health care and medicine begins with the spiritual reality of the human being who is part of all creation and dependent on creation. Traditional understanding views human beings as intimately related to plants and all other creations in the natural world that sustain life. Reality is not linear; it is circular. Everything is connected to everything else. Good and bad, sickness and health, and physician and patient are not separate processes, they are all related aspects and part of the whole. For the Lakotas and other traditional American Indian people, there is no split or dualism in reality or creation. This traditional view challenges the intervention model and offers a prevention model as the starting place for social health and assistance. The emphasis from a Lakota-centric view is on building up the immune system and seeing the important role of the community in promoting good health care and well-being, a cultural emphasis often overlooked in conventional health care practices.

Traditional Lakota values of health and well-being emphasize the participation of the family in the healing process, including the extended family and the larger kinship community, to bring about good health to the individual. The health of the individual is connected to the health of the community, so there is an important tribal dimension to this understanding. For traditional Lakota people, the health and healing process are not impersonal but highly personalized and individualized around specific needs. The roles of medicine practitioners are multidimensional and include those of healer, counselor, politician, and priest.

Another important contribution of the Native American perspective on health is that it provides a rich topology of spirit. The human creation, like all creations, is a spirit being composed of multilayered aspects of spirit. “Spirit” here is not some supernatural reality outside the human being but an intrinsic dimension of everything that is, including the human creation (person). To speak of human beings is to speak of spiritual reality. For traditional American Indians, medical treatment or any kind of social, human, or mental health service is first and foremost a spiritual endeavor.

Ayahuasca: A spiritual pathway to consciousness and healing.

Traditional Indian people of South America have similar and yet distinctive traditions of health and healing where the rain forest provides the pharmacopoeia of medicinal plants, bark, herbs, and vines. Of course, the forest itself is viewed as a powerful source of spiritual healing. In 2004, a study in the Tambopata River area of the southeastern Peruvian Amazon (through the Amazon Center for Environmental Education and Research), Voss had an opportunity to meet with various shamans, their patients, and public health care representatives at a local community center where the regional public school and health care station are located. It is interesting to note that all members of the health care staff rotate, making visits to the area community members, including both indigenous traditional people, who mainly live dispersed through the forest (Amazon), and mestizo or mixed-blood settlers, many of whose families have lived in the river settlements since the mid-1970s. Both indigenous natives and mestizo settlers seek assistance from the shaman, the curanderos, and the health station outpost, staffed by nurses and a visiting physician. The South American indigenous community Prue who visited the Tambopata River region of the southeast Peruvian Amazon used both herbal remedies and spirit-calling ceremonies, often incorporating the use of forest tobacco and other vegetation gathered from the forest as a means of purification. The use of ayahuasca, a concoction or tea made from various plants, tree bark, and vines gathered from the forest, is administered to both patient and shaman and is a common shamanic practice throughout Amazonia, according to the shamans I interviewed. A detailed description of an ayahuasca ceremony is reported by Salak, providing a fascinating participant observer’s experience of an ayahuasca ceremony. A brief audio-video capture of the beginning of an ayahuasca ceremony may be viewed at www. nationalgeographic.com/adventure . Clinical applications of ayahuasca are being studied by Jacques Mabit, Director del Centro de Rehabilitacion de Toxicomanos (Rehabilitation and Detoxification Center) at the Takiwasi Center, Peru. Mabit combines the traditional use of ayahuasca and psychotherapy techniques and holistic methods (consciousness expansion methods such as fasting, hyperventilation, and nonaddictive plants) mainly for the treatment of coca paste addictions. The center is funded by the French government. Conventional allopathic medicines are not used, except in unusual circumstances.

Riba and colleagues published their neuropsychobiology study on the effects of ayahuasca. Hence traditional medicine has captured both the imagination and the attention of medical science.

Physical detoxification is accomplished through the use of medicinal plants. Conventional Peruvian approaches to addiction treatment are based on prison or military models, which have raised human rights concerns among health care workers. All studies on the clinical use of ayahuasca have European or South American sponsorship, and most have been published in Spanish.

History.

Acupuncture as it is practiced in the United States is a huge conglomerate of different styles of acupuncture coming from China, Japan, Korea, Thailand, Vietnam, and Western Europe. The styles differ radically depending on who is doing the acupuncture, where he or she learned it, and how much individuality has been instilled into the practice. Within this discussion, the similarities among practices are described, followed by an in-depth analysis of the style that Kauffman used.

Acupuncture is one of the five categories that make up Chinese medicine. The other four are herbal medicine, diet and nutrition, exercise, and massage. Acupuncture is a healing method that tunes a human being. Just as a piano tuner tunes a piano or one tunes a guitar or an auto mechanic does a tune-up on a car, it is possible to tune a human being. After this process, or intervention, is done, the body-mind functions more efficiently in a balanced, harmonious fashion. As a result, the aches and pains often are eliminated and illnesses and diseases reversed. Acupuncture can be used by itself and, even better, in combination with other holistic and traditional Western medical methods.

Methods.

Acupuncture involves the use of tiny needles made of stainless steel, their diameter two or three times the width of a human hair, sharpened by a diamond. These needles are put into particular points on the surface of the body. There are at least a thousand of these points all over the human body. ^, They have a lower electrical potential compared with the surrounding skin, as is evidenced by a galvanometer. These points are also known as acupuncture points , acupressure points , trigger points , and perhaps by other names as well. These points are about 1 mm in diameter and are located pretty much in the same place for everyone, according to bony landmarks, skin landmarks, and anatomical structures such as nipples, umbilicus, fingernails and toenails, eyes, ears, nose and mouth, and so on. The points can be found with practice by the trained finger of the practitioner. There are electrical instruments that can help locate these points, but their reliability has not been established. Needles are put into these acupuncture points, and after being inserted, the needles are turned either clockwise or counterclockwise one revolution. They are either taken out immediately or left in for a period of time, depending on the individual patient’s imbalance and illness.

Examination and evaluation.

Deciding where to insert the needles is really the key and the most difficult and important part of acupuncture diagnosis. This is where styles of acupuncture come into play. There is a spectrum of acupuncture styles or methods that ranges from completely symptomatic to perfectly holistic, just as there is in traditional Western medicine. The symptomatic methods involve simply putting needles into acupuncture points at anatomical sites that are specifically related to symptoms. For example, for shoulder pain, or arthritis or bursitis, an acupuncturist using a symptomatic method would select acupuncture points that are in or around the shoulder area. Headache would be treated with needles in the head area. ^, Constipation would be treated with needles in the belly area. Hemorrhoids would be treated with needles around the anus and coccygeal area. This method pays little attention to where the constitutional imbalance exists within each person. An opposite philosophy, which is called holistic acupuncture , treats the underlying constitutional imbalance within the person. Described earlier, such imbalances are considered the vulnerable, or weak, links in the chain in each human being—the part that always gives out first because it is not as strong or disease resistant as the rest of the body-mind. The type of acupuncture Kauffman used is a holistic form. Specifically, it is called five-element acupuncture. It is based on the Law of Five Elements, which is a law of nature that comes from Chinese philosophy and is one of the basic foundations of Chinese medicine. It is sometimes known as the Five Phases and is considered the most holistic form of acupuncture available.

The law of five elements.

The Law of Five Elements states that there are five elements in nature (fire, earth, metal, water, and wood) and that these elements all relate to one another in a particular fashion ( Fig. 39.5 ). The diagram in Fig. 39.5 shows an outer creative cycle (known as Shen ) that goes in a clockwise fashion and demonstrates that fire creates earth, earth creates metal, metal creates water, water creates wood, and wood creates fire again. Also, a star-shaped control, or destructive, cycle (known as K’o ) shows that fire destroys or controls metal, metal does the same to wood, wood to earth, earth to water, and water to fire. These two cycles, the creative and destructive cycles, are necessary to keep balance in nature. These five elements are also found in human beings because the body is composed of elements that come from nature and return to nature when the body dies. The emotions and feelings in our personality align themselves with these same elements ( Fig. 39.6 ).

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