Norwegian Psychomotor Physiotherapy (day 2)

27/09/2016

“Kirsten Ekerholt is van 17 tot en met 18 oktober in Leuven/Kortenberg en geeft een tweedaagse workshop.
U bent van harte uitgenodigd op deze tweedaagse workshop.

De workshopdagen gaan door op campus Kortenberg en starten beiden om 9u30  en duren tot 16u30.
(AVC, zaal 1, Leuvensesteenweg 517, 3070 Kortenberg).

In de bijlage vindt u meer informatie omtrent deze workshop.
Om alle kosten te kunnen dekken, vragen wij u om een kleine bijdrage van 60 EUR voor de 2 dagen (lunch is inbegrepen)

Voor meer informatie over deze workshop en om u aan te melden, kunt u contact opnemen met: Beeleke Bredero  (beeleke.bredero@kuleuven.be)”


Kirsten Ekerholt1 and Anne Gretland2

Norwegian Psychomotor Physiotherapy

A brief introduction

Historical background

Norwegian psychomotor physiotherapy (NPMP) has its origin in a joint clinical work carried out by physiotherapist Aadel Bülow-Hansen and psychiatrist Trygve Braatøy from 1947 until the sudden death of Braatøy in 1953. Bülow-Hansen had worked with patients with orthopedic problems for 20 years when she met Braatøy, who was specialized in psychoanalysis (Bülow-Hansen, 1982; Thornquist and Bunkan, 1991). Together, Bülow-Hansen and Braatøy developed a physiotherapeutic method to complement the psychoanalytic treatment of neurotic patients. They saw muscular tensions, breathing and emotions as interdependent factors mutually influencing one another, and their physiotherapeutic approach aimed at helping the patient to recognize and change habitual muscular tensions involved in the regulation and inhibition of emotional experiences (Heller, 2007; Thornquist and Bunkan, 1991). The idea of the body and emotions being closely related as described by Braatøy (1947, 1948), was new and strange to professionals at that time. Nevertheless, the practice-based theory explained why patients could react emotionally in physiotherapy, and paved the way for the evolution of a specific physiotherapeutic approach. From initially being regarded as a way of treating neurotic patients, NPMP now has a wide range of usage in every part of the health services, including psychiatric hospitals and outpatient clinics. As the method has developed, it has gradually evolved into an independent physiotherapeutic approach, originally called the Braatøy-Bülow- Hansen therapy or just Aadel Bülow-Hansen’s physiotherapy (Øvreberg and Andersen, 1986). However, the official designation used in Norwegian legal documents and in official health care since 1973 is Psychomotor Physiotherapy. To distinguish this specific physiotherapeutic tradition from relaxing therapies called

1 The main traditional sources additional to Braatøy’s writings are the experience-based books of Thornquist and Bunkan (1991[1986]), Øvreberg and Andersen (2003 [1986]) and Bunkan, Radøy and Thornquist (ed.) (1982). Here, we have supplied with research literature, based on video studies of natural practice.

2 For convenience, we use the pronouns “he” talking about the patient and “she“ for the physiotherapist. “psychomotor therapy” throughout Europe, the term now used internationally is Norwegian Psychomotor Physiotherapy (NPMP) (Bunkan, 2010).

Core features of NPMP

Examination, assessments and treatment in NPMP NPMP consists of practice-driven comprehension of the body, its functions and dysfunctions, and a specialized practical mode of assessing and treating patients, derived from experience3. NPMP conceptualizes a reciprocal relationship between bodily phenomena such as restrictions of movement, muscular tension and autonomous (dys-) functions on one hand, and regulation and restriction of emotions on the other. The PT should draw attention to the patient’s circumstances of life in deliberations about whether he should be treated or not, and eventually how he should be treated4. Whatever problem the patient presents, the psychomotor PT does not look for symptoms and clinical signs in the traditional biomedical sense. Local clinical signs must be put into the context of the body as a whole and the bodily function and dysfunctions should be assessed relative to the patient’s life experiences and current situation (Thornquist, 2006; Thornquist and Bunkan, 1991; Øvreberg and Andersen, 1986).

Trial-treatment: a dynamic, intersubjective perception of body relationships

In NPMP, the original clinical examination is termed a trial-treatment due to its interactive and dynamic aspects. The diagnostic enterprise in NPMP is to seek information about the total flexibility of the body and the patient’s changeability. Schematic, the trial treatment is divided into sections as follows. From an introductory verbal dialogue, the encounter goes on to a comprehensive examination of the whole body. The patient is examined in various bodily positions (standing, sitting, lying both supine and prone on a treatment table, and then standing again). The examination ends up with a concluding talk on the experiences they had during the session. The therapist and patient usually also consider whether the patients should continue with the therapy or not, and if yes – the PT informs about the treatment, such as usually being a time-consuming process and that she aims for gradual changes. During all sub-assessments, the PT observes the patient’s movements, spontaneous ones and those he was instructed to perform, as well as body’s posture, respiration, autonomic and motoric reactions. The PT moves the patient in particular ways, and she palpates the skin and muscles all over the patient’s body, all the time having the focus on the interplay between respiration, muscular tensions, posture and movement (Thornquist, 1990). During the examination, the PT raises questions verbally, as well as by means of her hands. The exchanges between the PT and the patient are mainly grounded in the latter's immediate bodily reactions, often used as a starting point for short verbal dialogues. “Can you let your head slide gently forwards?” -“Do you feel you are holding back?” –“Do you normally feel you have difficulty in freeing your head?” Such questions give the PT an insight into how the patient usually uses his body, and whether he is aware of what is happening in and to his body (Thornquist, 1990). With her hands, the PT can gently invite the patient to exceed the initial range of movement to observe his responses to these challenges to his spontaneous limits. The PT can directly call the patient’s attention to his bodily potentials, such as letting go of tension, ask him to follow impulses to move, to express himself etc. (Thornquist and Bunkan, 1991). The patient’s responses to and experiences of a gentle play on his limits supply important information to the PT

about the patient’s potentials for change. Most of the time, the patient and the PT are close to each other, the PT using hands- on techniques. Thus, interaction is embedded in the clinical encounter, and dependent on the perception of signs through various senses, including vision and hearing, as well as sense of touch and pressure, movement and position (Thornquist, 2006). Bülow-Hansen emphasized the importance of the physiotherapist being sensitive to the patient’s reactions, to see, listen, and last, but not least – feel. “What physiotherapists must train is their intuition”, she claimed, rejecting measurements of bodily phenomena as sources of relevant and information (Øvreberg and Andersen, 1986:7).

Even if a schematic progress is proscribed, the examination, as well as any treatment plan should be individualized, adjusted to the actual situation and the patient’s precondition (Thornquist and Bunkan, 1991, Øvreberg and Andersen, 1986).

Theoretical frames of reference in NPMP

Theoretical frames influence what is regarded as clinically relevant information, as well as interpretation of signs and words, and in the end – how the patient’s problems are defined as “something to act on” to the professional. Originally, Bülow-Hansen’s physiotherapeutic techniques and her intuition combined with Braatøy’s psychoanalytic knowledge and interest for the somatic aspect in psychiatry, created this therapeutic approach (Bunkan, 1982, p. 24). From the mid-1970s, the theoretical development of NPMP mainly followed the psychoanalytical heritage given by Braatøy (cf. Bunkan, 1982; Bulow-Hansen, 1982; Monsen, 1989). In assessing function, Thornquist (2006) found that the PTs were first and foremost emotionally and individually oriented, and not concerned with the socially and culturally informed and informing body. Symptoms and the state of the body were interpreted in a context of the body as an expression and regulator of the person’s emotional life; as a kind of mirror of yesterday’s life. The PT distinguished between function and dysfunction, i.e. between desirable and undesirable conditions, based on the interrelationship between local conditions and the general state of the body, and by comparing the patients’ experiences expressed verbally and bodily (ibid). From the 1990’s, Merleau-Ponty’s phenomenology of perception has been a vital reflective source for researchers in the field of NPMP (Dragesund and Råheim, 2008; Ekerholt and Bergland 2004; 2006; 2008; Gretland 2007; Thornquist 1990, 1991, 2001a, 2001b, 2006, 2012; Øien , Iversen & Stensland, 2007). Following Merleau- Ponty’s theory, Thornquist emphasizes the embodied nature of human subjects, maintaining that the body is social by nature. Conceiving human beings as embodied and experiencing social agents has also led psychomotor PTs to empirically based social science research illuminating relationships between objective social conditions and events and different forms of embodiment and agency as well as health problems (cf. Gretland, 2007; Thornquist, 1991, 1995, 2001a, 2001b, 2006). In parallel to theoretical elaboration of the social nature of the body and its clinical relevance for understanding health problems, Thornquist’s studies (op. cit) of clinical practice in NPMP has highlighted the former implicit dimensions of NPMP – e.g. the relational aspects of clinical work as well as it’s relevance to the patient’s health- and participation. Information in clinical encounters results from an interactive and interpretative process, where both parties contribute to an evolution of information on the patient’s problem, his resources and his ability to change. Whether the main communicative channel is talk or bodily interaction, the trial treatment can be seen as a semi-structured dialogue, allowing both parties to participate in a creative process opening for intersubjectivity (Thornquist 1990, 2006).

Patients experiences

Several studies explore patient’s experiences. Many patients find the clinical body examination in NPMP and its potential for activating knowledge and insight through bodily experience to be highly useful. The consultation may be of great value to both parties as a starting point for further cooperation (Thornquist, 1995). To become aware of and familiar with their habits and ways of reacting can be extremely useful for understanding their own situation (Ekerholt and Bergland, 2004). By taking patients' experiences seriously (including bodily ones), examinations can involve a search for meaning. Cooperation in the process conveys the message that the patient is a central contributor to the diagnostic process, someone who could to a certain extent function as his own “therapist” (Ekerholt, 2011; Ekerholt and Bergland, 2006; Thornquist, 2006). The bodily communication in massage and the movements in NPMP are important in increasing the individual’s awareness and understanding of the body reactions, connected to a new understanding of oneself. The massage in particular also helped the patients to increase their ability to differentiate their sensations more particularly and to develop an understanding of both the emotional and physical aspects of bodily reactions (Dragesund and Råheim, 2008; Ekerholt and Bergland, 2006; 2008; Øien, Iversen and Stensland 2007; Øien, Råheim, Iversen and Steihaug, 2009). The orientation on the lived body and signs that can be observed, rather than the symptoms, together with a time schedule that allows communicative reciprocity, are essential factors allowing inter-subjectivity on several communicative layers to grow from a bodily base (Thornquist, 1995).

Therapeutic aims

The theoretical reorientation described above has allowed an extension of therapeutic issues in NPMP. From originally being restricted to the enhancement of bodily and emotional functioning (“free stretching, free respiration, free feelings”), the understanding of the connection between bodily functioning and social life has increased. Therapeutic aims could then be related to issues as bringing nuances to bodily functioning in time and space, to sense, respect and mark personal borders, to be confident with and be able to express feelings and to mentalize (Biguet, 2012; Ekerholt, Schau, Mathismoen and Bergland, 2014; Gretland, 2007, 2009; Sternberg, 2010; Thornquist, 2010).

Quantitative body examinations derived from NPMP

From the original body examination, i.e. the trial treatment in NPMP, four main quantitative body examinations have been developed; The Resource Oriented Body Examination (ROBE), The Comprehensive Body Examination (CBE), Global Physiotherapeutic Muscle Examination (GPM) and The Global Physiotherapy Examination (GPE-52) (Bunkan. Ljunggren, Opjordsmoen, Friis and Moen, 2004). The purpose of the development of these examinations was to fulfil the needs for obtaining information concerning the patient’s potential for improvement and to define the appropriate level of intervention. The intension was also to objectify the outcome of physiotherapy and to study body features in groups of patients (Breitve, Hynninen and Kvåle,2010; Bunkan, Opjordsmoen, Moen, Ljunggren and Friis, 1999; Bunkan, Opjordsmoen, Moen, Ljunggren and Friis, 2001; Bunkan, Moen, Opjordsmoen, Ljunggren and Friis, 2002; Friis, Bunkan, Opjordsmoen, Moen, and Ljunggren, (2002); Friis, Kvåle, Opjordsmoen,and Bunkan, 2012; Heløe, Heiberg and Krogstad, 1980; Kvåle, Ellertsen, and Skouen, 2001; Kvåle, Wilhelmsen and Fiske, 2008; Meurle-Hallberg and Armelius, 2006; Meurle-Hallberg, Armelius, and von Koch, 2004; Sundsvold, Vaglum and Denstad, 1982).

Education: From master apprentice learning to master’s degree.

Education in NPMP was administered by the Association of Norwegian Physiotherapists from 1960 to 1994.Training in NPMP was primarily oriented towards method, providing extensive instruction in specific examination and treatment methods. This, in turn, instilled confidence and security in the students as the therapists learned about tools which are useful to deal with patients suffering from complex ailments such as ‘‘myalgia’’, ‘‘dorsalgia’’ and so on (Thornquist, 2006). Clinical training and practical supervision may be helpful to students who are learning how to act in certain situations and to handle problems in ways that do not provoke insecurity. However, the programme neither encouraged the critical reflection that is commonplace in academic traditions (Thornquist, 2006), nor provided the qualifications required by today's professionals. Since 1994, education in NPMP was included in Postgraduate Education in Psychosomatic and Psychiatric Physiotherapy at Oslo University College of Applied Sciences. Today, education in NPMP is offered at Oslo and Akershus University College of Applied Sciences, and UiT The arctic University of Norway (Tromsø). Education at the level of a master’s degree is required for recognition in the special competence of NPMP in Norway.

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