A Case Study

The Potential Benefits of Integrating Neuro Linguistic Programming with Physiotherapy for Patient Confidence and Functional Outcomes: a case study

Ann Parkinson – 2013

Time To Be: Lincoln Neuro Physio & Holistic Therapies, At South Lincoln Physiotherapy & Sports Injuries Clinic, North Hykeham, Lincoln

Abstract

Objectives:  To highlight the potential benefits of using NLP techniques and principles within physiotherapy to improve functional outcomes and overall health and well-being.

Design: Case study.

Setting:  Private practice, North Hykeham Lincoln.

Participant:  13 year old boy with cerebral palsy.

Intervention:  Two sessions of neuro linguistic programming as adjunct to physiotherapy.

Main outcome measures: No formal measures used.  The objective physical marker was co-ordination measured subjectively by therapist observation of co-ordination and efficiency of movement in lateral weight transfer in sitting along the plinth.  The psychological markers were determination and confidence, which were based on therapist observations and subjective information from child and mother.

Results:  Showed NLP combined with the physiotherapy treatment of a 13 year old child with cerebral palsy seemed to improve co-ordination, confidence and self-awareness.  Prior to the treatment the child did not talk about himself or express what he wanted, after the interventions the factors mentioned above improved along with him talking about himself and what he wanted as part of his immediate and long term future.

Conclusion:  This study supports the need for further research into the use and benefits of NLP in the health arena.  There is currently no good quality research that supports the use of NLP.  The results of this case study also suggest NLP may be beneficial in improving physical factors such as co-ordination as well as psychological factors like motivation and self-awareness.

Introduction

There is no clear date when NLP came into existence nor is there a universally accepted definition of NLP.  NLP has been said to be an integration of cybernetics, psychophysiology, linguistics, and information services (Steinbach 1984).  It is said to have been founded by John Grinder, a linguistics professor, and Richard Bandler, a mathematician, in the 1970’s.  They studied and modelled the most effective therapists of their time: Fritz Perls (psychotherapist), Virginia Satir (family therapist), and Milton Erikson (hypnotherapist), (Walter et al 2003).  They discovered patterns in language, that clients had a preference for sensory predicates, for example visual or kinaesthetic predicates, and observed when these were matched by the therapists it was beneficial (Steinbach 1984).   Following this they discovered eye accessing cues, movement of the eyes in a certain direction when remembering or thinking in pictures, feelings, words, or talking to oneself. (Steinbach 1984).  Bandler and Grinder followed different paths in the 1980’s and Grinder developed New Code NLP, between 1982 and 1987, with Judith DeLozier (Grimley, 2013).  New code NLP focused on the wisdom on the unconscious mind to drive the change and bring it to the conscious mind, it was influenced by the work of Gregory Bateson (Grimley, 2013).  Robert Dilts has also been part of the development of NLP since the original work of Bandler and Grinder, as well as contributing to NLP literature and NLP training.

Breaking the name down reflects its meaning: neuro relates to the way the brain processes information and the effect of this on our physiology, including how we interpret the world through the five senses; linguistic relates to the language we use and how verbal and non-verbal language affects our experiences; and programming relates to how we do what we do specifically in terms of our patterns of thinking, behaviour and emotions.  NLP is about understanding thinking on a conscious and unconscious level, specifically how we individually mentally represent the knowledge of what we know and how we do what we do, it is the study of excellence (Knight, 2009).

‘NLP is known as the study of subjective experience, and how we can achieve excellence in any area of life’ (Everden & Bayliss 2008).

NLP can facilitate changes in thinking and or behaviour which have been identified by the patient/client to be unhelpful for them.   A widely recognised therapy aimed at behaviour change is cognitive behavioural therapy (CBT), this works with the conscious mind.  One crucial aspect of NLP is that it targets the unconscious mind, this is important as it is the highest percentage of the mind.  The unconscious mind holds everything that a person has experienced, all thoughts, feelings and emotions that are not in the conscious mind as well as automatic body functions such as digestion and heart rate.  Various psychologists have been particularly interested in the link between behaviour, psychopathology and the unconscious mind, including Alfred Alder and Carl Jeung.  Grimley (2013) states that the simple meta programmes of NLP are largely based on Carl Jung’s work.

‘…Jeung concluded that harmony between the conscious and unconscious is the most significant task for the individual and society to achieve’ (Gallo, 2005:4).

NLP encourages creativity by the practitioner and the client by working with the unconscious mind, the creative right hemisphere of the brain can be considered to be the gateway to the unconscious mind.  The principles of NLP techniques can be adapted for, respecting the uniqueness of every individual.  One way of targeting the unconscious mind is with stories including fables, NLP encourages this with the use of metaphors.  With metaphors the conscious mind is listening for content whilst the unconscious mind is listening for patterns, themes, or relationships that link to a situation (Grimley, 2013).

‘The conscious mind responds to the challenge of the metaphor by finding a unique solution that fits the listeners experience and needs’ (Knight, 2009:101).

NLP could stimulate neuroplasticity in neural pathways and synapses in response to behaviour change, sensory stimuli, and conscious and unconscious thought processes.  It is likely that NLP will activate and modify connections in some of the limbic system, including the hippocampus which is involved in conscious memory function and the amygdala which is involved in unconscious memory and a variety of emotional responses.

‘…the personality or the “self” can be seen as a function of synaptic configurations: “patterns of interconnectivity between neurons in the brain”…’(LeDoux 2002 cited in Gallo 2005:10).

The NLP presuppositions include: the mind and body are part of one system; the map is not the territory; the meaning of communication is the response you get; a person’s behaviour is not who they are it is the best choice they have available to them at a specific moment in time; every behaviour is potentially communication; every behaviour is generated by positive intention; we all have all the necessary resources; there is no failure only feedback (Grimley 2013).  One that may be considered particularly relevant to this case study is the presupposition that mind and body are one, it asserts that one does not function without the other.

‘Any occurrence in one part of the cybernetic system (such as the human being) will necessarily affect all other parts of that system in some way…’ (Dilts cited in Steinbach 1984:148).

‘The map is not the territory’, the map refers to an individual’s internal representation of the world and that the territory is not the actual world itself.  Maps hold beliefs and values as well as sensory representations of the world based on our experiences.  We interact with the world moment by moment through our five senses, then filter and represent our interpretations using sensory representations, in a way that is unique for each individual.  Our experiences of a specific moment or context can be broken down into submodalities: visual, kinaesthetic , auditory, olfactory, gustatory, auditory digital (self talk).  These specific sensory elements, join together to form the quality of the representations we store, such as the colour and size of a picture of a memory or specific event.  NLP proposes that, rather than our experiences directly affecting us, it is the way we individually represent our experiences that influence how our thoughts affect us. Therefore by changing some of the submodalities of a specific representation of an event in time the effect on us is changed.

‘…When we react to a memory we are reacting not to the direct experience but to the way we store that memory in our mind.  Managing the distinctions in our thinking gives us the ability to influence and change the nature of our memories, so that we can store them in a way that results in us feeling the way we want to feel’ (Knight, 2009:27).

The mental, physical and emotional aspects of a person at a given moment in time influence how they react to the environment, both externally and internally.  This is termed as their ‘state’ within NLP terminology, and state affects the outcome.   Grimley (2013) states that when we are in the most helpful state it enables the resources of the unconscious mind to be accessed.  The most appropriate state facilitates the best outcome, similarly the least helpful state usually leads to the least helpful outcome.

‘Anxiety can reduce the patient’s ability to hear information and respond during a consultation’ (Mason, 2010:25).

NLP is able to help a person change their response to their environment, enabling them to maintain the most helpful state, such as being calm or energetic, and achieve the greatest potential for success in that specific moment or task.  It proposes breathing is the key to changing or maintaining a particular state, breathing is a catalyst to move to the desired state, for example from an anxious to a calm state.  Grimley (2013) states the best way to change your state is to change your physiology and that the most effective way to do this is through modulation of your breathing.

The principles of association and dissociation are key aspects of NLP and crucial to helping someone change their response to their environment and sensory stimuli.  Association relates to when an individual feels present in an event or moment feeling all the emotions, hearing what is going on around them and seeing things through their own eyes.  Dissociation relates to when an individual is seeing themselves in an event or in the moment, as if an observer, detaching them from their emotions.   Association is useful when it is beneficial for an individual to feel all that is associated with their state in a certain situation or specific moment.  Dissociation is useful when a person needs to step away from the emotions attached to a situation or specific moment, to give a sense of perspective or to create distance from the experience.

It is well understood that therapeutic alliance or therapeutic bond between the therapist and patient is important in improving health and well-being, and in helping patients achieve their goals.

‘The evidence has shown that a good therapeutic alliance can positively influence treatment outcomes such as improvements in symptoms and health status and satisfaction with care’ (Hall et al cited in Pinto, 2012:77).

Rapport is an important aspect of the therapeutic alliance, as is trust and empathy (Pinto et al 2012).  Rapport is the ability to relate to others in a way which creates trust and understanding, when people are in rapport it is said they are on the same ‘wavelength’.  It can be said to be a state of unconscious responsiveness which is based on mutual trust and respect.

‘Rapport is maintained superficially on the conscious, verbal level, and truly rooted in the unconscious verbal plane’ (Luban, 2010:22).

In building rapport NLP considers it important that aspects, such as tone of voice, speed and type of language, match the style of the person you are communicating with.  This can enhance the quality of the two way rapport process and can help it to be built quickly.  If there are a lot of mismatches, such as in body language, use of voice, choice of language, then the mutual trust and understanding are unlikely to reach a level that encourages rehabilitation.

‘If we can match-or-mirror-some or all of the patient’s body language and non-verbal cues we can create an environment of trust and understanding’ (Mclean, 2008:141).

Effective communication is a vital element of building and maintaining rapport and the therapeutic alliance.    It is well known that effective communication does not rely on what is said so much as how it is said and the non-verbal aspects of the communication (Luban 2010).    Research has shown that good communication is comprised of 7% words, 28% tone of voice and 55% body language and non-verbal cues (Mclean 2008).  When patients believe in the advice they have been given it may help them adhere to the rehab or engage with it more fully (Fuertes et al in Pinto et al 2012).

‘Language and behaviour used when interacting with patients can help or hinder the healing process…’ (Mason, 2010:25).

Language, non-verbal and verbal, is an important part of NLP.  As we experience the world around us we distort, delete and generalise things based on our preferred sensory systems and current map of the world, which includes our beliefs and values (Knight 2009).  When this is identified as unhelpful by an individual it can be challenged with language, specifically using Meta language.  The ‘Meta Model’ targets the analytical and logical left hemisphere, engaging the conscious mind (Grimley, 2013).  Meta language enables such as beliefs about specific opinions to be uncovered, such as a belief about what being independent means, and then the belief can be challenged and changed for a more helpful belief or beliefs.  The ‘Milton Model’ is the other language model in NLP and this is language which is hypnotic and artfully vague to engage the unconscious mind.  Milton language bypasses the resistance of the conscious mind to activate the more holistic right hemisphere of the brain, engaging the unconscious mind (Grimley, 2013).

Steinbach (1984) states that NLP can be used to help with problems ranging from psychological to complex organic ones, however this is not supported with research.  As the research to-date is empirical, some of which is over 30 years old, it could be questioned as to whether NLP should be continued to be used.  There is no quality supporting evidence for or against the use of NLP.  However, there is supporting empirical evidence so it would be acceptable for practitioners to continue to apply its principles until quality research supports or discounts its proposed benefits.

Literature Review

A literature search was conducted using Ahmed, BNI, Cinahl, Embase, Health Business Elite, HMIC, Medline (from Pubmed) and PsychInfo databases.  The key words used were stroke and NLP, NLP and cerebral palsy, NLP and physical rehab, NLP and physiotherapy, NLP & balance, NLP & Gait, NLP & confidence, NLP & motivation, psychology and physical rehab.  The use of these key terms showed that there are no previous studies that combine NLP and physical rehabilitation or physiotherapy.  A wider less specific search was also conducted using NLP restricted to being within the title, 310 results found, and neuro linguistic programming found 13 results.  When searching within title and text the former found 3375 and the latter 1059.  Of the articles found none class as actual evidence, the majority were descriptive articles, one was a case study and two were literature reviews, and some were irrelevant.

One literature review by Witowski (2010) reviewed empirical evidence sourced from the NLP database.  It also states that Bandler and Grinder failed to test their empirical evidence and continued to the stage of implementing their claims which is likely to be the case as there is no existing quality evidence for the use of NLP.  Although this article claims there is no supporting evidence for NLP this in itself cannot be classed as evidence for not supporting its use due to the quality of the research reviewed.  The other literature review by Sturt et al (2012) concluded that their review of the literature supported the fact that NLP research is limited in both quantity and quality.

‘Limited experimental research has been undertaken into the use of NLP to influence health outcomes and there is little evidence that NLP interventions improve health outcomes based on poor quality studies across heterogeneous conditions and populations’ (Sturt et al, 2012:758).

The purpose of this case study was to ascertain if NLP affects both psychological and physical factors and if it improves overall health and well-being.   In addition to this it aimed to highlight if further quality research into this area is warranted.

Case Study

The case study is a child with Cerebral Palsy (CP) thus it is appropriate to provide a brief background of this neurological condition.  CP can be described as a disorder of movement and posture resulting from a non-progressive lesion or developmental abnormality in the immature brain (Campbell et al, 2006).  It is a wide ranging disorder which causes a variety of symptoms involving one or more limbs and commonly the trunk, due to the disruption and in-coordination of voluntary motor function (Campbell et al, 2006).  It can be classified according to the type of impairment: spastic, dyskinetic/athetoid, ataxic, and hypotonic, and also its distribution: monoplegia, diplegia, hemiplegia and quadriplegia (Campbell et al, 2006).  Common problems associated with CP include abnormal tone, movement problems, postural abnormalities, bone/joint deformities, muscle weakness, balance problems, decreased trunk and postural control, epilepsy, visual and auditory problems, learning difficulties and perceptual problems.  NLP is not commonly included within the management of cerebral palsy, as is the case with other physical conditions.

Methodology

The patient in this case study is Sam, a 13 year old boy; he was 12 when he was initially assessed in June 2012.  He has diplegic cerebral palsy, initially diagnosed as a quadrapelgic and was re-diagnosed around age 7.  He is a twin and was born at 26 weeks gestation, both had to be resuscitated, his twin was not affected.  He had a specialist chair until approximately age 4, only being able to sit unaided in the last few years and relax his arms for approximately the last 5 years.

Sam was having private physiotherapy for approximately 6 months before NLP was integrated into treatment sessions.  It was made clear to Sam and his mother that NLP is not a physiotherapy treatment and, also, at the time of initial use (December 2012 and January 2013), the therapist was a student NLP Practitioner.  Since this time the therapist has qualified as an NLP practitioner and continues to integrate NLP into treatment sessions as appropriate.  Parental and patient consent were obtained for writing this case report and permission has been given for Sam’s first name to be used.

At the initial appointment Sam’s mum advised that Sam uses a stander and gaiters, mobilises with a walker and anterior foot othoses (AFO’s) short distances with supervision of 1.  Botox had been stopped as it was having little or no effect.  Sam’s mum stated she felt Sam to be capable of doing more than he was doing.  The therapist observed evidence to support this during treatment sessions.  It appeared that Sam’s ability was being hindered by his decreased self-awareness, decreased concentration, and decreased trust in his own abilities, alongside physical deficits.  Sam would talk about many different things during each appointment, distracting his attention from himself.  When asked about himself, such as how his legs were feeling, he would distract from this by looking at his mum or change the subject.  His mum also advised Sam doesn’t answer questions about he wants to do in the future.  The therapist felt that NLP could help get to the root cause of these issues and change them to be more helpful for Sam.

Goals were set at the first appointment with Sam: to use walker more, to play wheelchair basketball and his mum’s goal was to decrease hamstring tightness.  Over the next 3-4 months, prior to using NLP, several goals were added which included for Sam to be more independent and to go into his own room in April 2013.  Sam was not keen to talk about himself, which was thought to possibly relate to his decreased confidence and self-awareness, and needed encouragement to focus on what he wished to be able to do.

Prior to the integration of NLP into Sam’s treatment, treatment had been a combination of myofascial release to lower limbs, stretches, reaching out of base of support with trunk facilitation, initiation of sit to stand to lift bottom from plinth with quadriceps facilitation, throwing and catching ball with adductor inhibition, facilitation of lateral weight transfer along the plinth, teaching stretches to Sam’s mother, devising a home exercise programme, education and advice.  The latter three elements were to improve Sam’s mothers confidence in completing the stretches to help maintain and improve hamstring length, and to build a more effective self-management plan to be carried out by both Sam and his mother.

NLP was first used with Sam in December 2012; this was his 7th month of treatment.  This was not a planned intervention and occurred due to therapists observations of Sam when using the mirror for lateral weight transfer along the couch.  Observations related specifically to concentration and self-awareness impacting co-ordination of movement.  The NLP principles of association and dissociation were used (see the introduction for discussion of these principals).  This involved using the mirror with dissociated language and not using the mirror with associated language.  Use of dissociation was important especially initially to disengage Sam from his emotions so he could see why he was distracting himself from focusing on himself and his treatment.  Association was important to enable to Sam to engage with the emotions that were more helpful for him.  Through discussion in this way it was discovered that Sam had two conflicting parts, one part of him found exercises boring and the other wanted to do them, understanding them to be important.  We all have two conflicting parts at times, when it could be said we are in two minds about something, often daily, for example when getting up to do exercise before work in the morning part of the person may be eager to do this and part may wish to stay in bed.

‘The human condition is structured by opposing voices…Freud’s Superego, Ego and Id and Berne’s Adult and Child…’ (Steinhouse, 2010:170).

To reach an effective outcome there needs to be negotiation between the conflicting parts to reach a solution, such as 10 more minutes in bed and reduce the exercises so both parts are happy.   In Sam’s treatment the two conflicting parts were integrated to form one strong part using the NLP visual squash technique which is also known as inner conflict resolution.     After identification of two conflicting parts the visual squash steps facilitate communication between the patient’s conscious and unconscious minds, firstly to discover what each part is trying to do for them, this is termed the intent of the part.  Secondly, negotiation between the two parts takes place, to reach a solution.  The final part of the visual squash is to change the two parts, who have agreed how they can work together, into one part, thus resolving the previous conflict (see steps of the visual squash in table one).

Before completing this session Sam was asked if there was anything else stopping him helping himself more, again the mirror was used along with appropriate association and dissociation.  Sam stated ‘he doesn’t want to walk’ and when asked why he stated ‘because his legs will get tired’.  Sam was using dissociated language and the mirror which enabled him to remain distanced from any attached emotions.  At this point associated language was used to discover if Sam felt it was ok for his legs to get tired and to associate with everything relating to walking.  The use of associated language by the therapist encouraged Sam to talk about himself in the first person.  The therapist then asked Sam if he wanted to walk he stated ‘yes’.  Sam was tired at this point so it was agreed to work with this next time.

At his next appointment in January 2013 a metaphor and a visual squash were used.  The metaphor was written by the therapist and was based on some aspects from the childrens nursery rhyme Humpty Dumpty.  The aim of the communication with Sam’s unconscious mind was for him to use his imagination and pass the message, that he could trust his legs and wouldn’t fall, to his conscious mind.   Following the metaphor, hamstring length and posture supine were assessed and myofascial release treatment used.  Lateral weight transfer along the plinth was checked with prompts to use the mirror in front of him and to move both his legs to the side before moving his bottom.

Visual squash technique was used for the two conflicting parts Sam had identified at the previous session, being wanting to walk and not wanting to walk.  After placing the parts in his hands, dissociation, based on particular facial expressions and body language it was deemed not to be helpful for Sam to have his eyes closed.  These were specific and sometimes minimal changes, for example a slight down turn of the mouth which in previous physio treatment sessions had been correlated to when Sam is unsure about something.  This is known as calibration in NLP, specific physical changes are correlated to a specific state and checked with the person to ensure that what they are feeling, for example motivated, is correlated to the correct physical reaction.  When asked to open his eyes he was automatically using the mirror which was in front of him so the therapist invited him to imagine placing one part in the mirror and one part on the couch, so that he remained dissociated and could interact with the parts as if he was an observer.  The therapist asked Sam what each part wanted for him.   The intent behind a specific behaviour could be, for example, to protect from such as failure.  In this case, for part one it was to be more independent, more like his family, and help out more; for part two, not wanting to be more independent, not wanting to help out more, wanting to stay in his chair to rest as he felt walking was hard work and would damage his legs.    The next stage was asking if the two parts were ready to work together, negotiation, Sam stated they were.  However, the therapist observed the reaction did not fit to a positive one, based on calibration, and on Sam’s negative response to asking whether there was something they could share to do this.  The therapist asked Sam what they needed to be able to work together, he stated they needed to meet sometime to talk about being more independent.   As there was no agreement for the two parts to work together at this stage and Sam had stated they needed to meet to have a conversation, further intentions were elicited for the two parts.  Part two felt he didn’t want to be more independent as he would have to go out on his own and was scared to do so, highlighting that fear was the thing that was stopping Sam and causing the two parts to conflict.   On asking Sam if part one could share anything with part two so he would not be scared to go out on his own he stated (looking in the mirror) he needs to understand why it is important to be more independent.  Sam automatically started a conversation between the two parts, he was using a different tone of voice for each part and he was also looking between the mirror and the couch.  This was taken to be the meeting Sam had mentioned, of the two parts needing to discuss being independent, earlier in the session and would be classed as sharing resources in the visual squash steps.  Sam confirmed part two was less scared now and that he (part two) now understood why being independent was important.  The therapist asked if there was anything else they needed to share or if they were ready to work together, Sam stated they were ready.  On asking Sam to lift his hands and sit and see what happened it wasn’t long before he moved his hands together and interlocked his fingers; the therapist reinforced the integration by telling Sam that there was now one strong part that would help him walk better.  Association was used to enable Sam to bring his hands to his chest and feel all the emotions linked to wanting to be able to walk.  The change was tested for how walking would be in the future.

 

Table one: Visual Squash/Resolution of Inner Conflict

  • The patient identifies two conflicting parts of themselves.  The practitioner asks them to place hands palm up on their legs.
  • The patient chooses which hand represents each part and imagines placing each part in the corresponding hand (dissociation).
  • The patient focuses on each part in turn and chooses a name for each
  • The patient focuses on each part and creates a representation for each in terms of submodalities, such as what it looks or feels like.
  • The patient focuses on each part in turn, asking the positive intentions.  The practitioner uses the names of each part when instructing to do this and asks after each one if there is a bigger or higher intention for each.
  • Ask if the intentions are similar.
  • Ask if the parts are willing to help each other and work together.
  • Ask each part of they have a resource they are willing to share with the other to help them work together.  If not return to eliciting intention stage and repeat steps.
  • Ask them to share their resources to create one new combined resource
  • Ask the patient to lift hands and face them together and to allow them to move their hands together in their own time (integration of parts).
  • Use of language to reinforce integration and now have one strong part.  Patient to bring hands to chest to integrate positive intentions back to heart if they wish to.
  • Ask if they can think of a future situation where the new resource will be helpful (future pace)

(Steinhouse, 2010 167-170, Dexter & Dexter 2012 module 3).

 

Results

After using the visual squash, the second time, Sam was using the mirror for lateral weight transfer without prompts and his lower limb co-ordination was better (see table two for comparison of physical and psychological aspects before and after the use of NLP).  After the first session of integrating NLP with physiotherapy, Sam’s mum advised that he was asking to walk more, instead of crawling, in the house and that he was asking to go in his stander more.  She reported both of these aspects to be unusual for him.  He had also asked his mum to hold him to see if he could stand himself, rather than his usual practice of putting his arms out towards his mum for her to stand him up, furthermore, his mum reported, he was taking more of his own weight when doing so.

On asking Sam what he thought of the story (metaphor), he stated ‘I have taken some of the ideas from Humpty Dumpty and stored them in here for me’ (he pointed to his head).  Sam stated the story to be a bit like the one he knew about Humpty Dumpty.  This association, between the original story and the metaphor, was derived from communication between the conscious and unconscious minds.  The therapist stated the story, to be similar but not the same as the story he knew.  Sam made further links to story of Humpty Dumpty he had heard as a child stating him to be clumsy, the therapist confirmed that that Humpty Dumpty was clumsy but that this Humpty was clever.  This was a way of passing to Sam’s unconscious and conscious minds that he was clever, with the aim of helping with his confidence.

The therapist asked Sam how he felt, he stated more able to walk and that he could be more able bodied.  Sam stated he would like his own house in the future.  Sam’s mum prompted him to tell the therapist about his bedroom.  The therapist was already aware Sam was due to go into his own room in April, this was one of his goals.  Sam hadn’t felt able to go in his own room prior to using NLP; he stated he now felt he could do this.  At the end of the session Sam automatically moved himself sideways along the couch towards his wheelchair, he would usually have put his hands in the air from where he was sitting to be assisted to stand and step to his chair.

 

Table Two: Physical and Psychological Factors Before and After NLP

 

Physical Before NLP Psychological Before NLP
Decreased co-ordination in lateral weight transfer along the couch of trunk, lower limbs and upper limbs.

Decreased weight bearing through upper limbs hindering lifting bottom.

Prompting needed to use visual feedback to improve quality and ease of lateral weight transfer.

Not keen to practise functional transfers at home.

Decreased motivation.

Decreased self-awareness.

Decreased responsibility for self.

Decreased trust in self.

Decreased focus on lateral weight transfer.

Not talking about wishes for future.

Physical After NLP Psychological After NLP
Increased co-ordination in lateral weight transfer along the couch of trunk, lower limbs and upper limbs.

Increased weight bearing through upper limbs enabling to effectively lift bottom.

Using mirror for visual feedback as and when needed automatically.

Mum reported practising toilet transfers at home (Sam had not wanted to do this and co-ordination was not good enough prior to NLP).

Practising lateral weight transfer along sofa and bed at home and Sam and his mum reported improvements.

Increased motivation.

Increased self-awareness.

Increased responsibility for self.

Increased trust in self.

Increased focus on task of lateral weight transfer.

Talking about wishes for future.

 

Following the second session of NLP, Sam’s mum stated she had noticed his legs were completely straight on one occasion when he as asleep.  Sam’s mum reported they had in the past, at times, gone straight in his sleep but bend up again and never go fully straight, stating this to be the best she had seen them.  She advised Sam to be asking to walk more and have his stretchers on (help stretch his legs at night) and that she is seeing ‘little sparks he is learning a few more things’.  The therapist noted all of the factors in table one to carry over and continue to improve in subsequent treatment sessions.

Discussion

This case study shows that NLP may be beneficial when used within physiotherapy and that it may improve both psychological and physical factors.  This in turn can improve overall health and well-being.  In the absence of previous research, the results of this case study cannot be related to any other results.  There is, however, a variety of published literature which shows the links between mind and body.  One body of literature surrounds psychoneuroimmunology, this studies the interactions between the nervous and immune systems, specifically in terms of if they are led by behaviour and psychological traits and states (Cohen & Herbert 1996).  Pert (1997) found that the same neural receptors exist not only in the mind but also throughout the body, thus the chemicals released from our thoughts and emotions are received throughout the body.  Neurotransmitters, the messengers of the nervous system effect the nervous system, the mind and the body, in other words the whole being.

‘Now our much more sophisticated understanding of the systems of neurotransmitters, which are involved in regulating the continuous interaction between our thought processes, our physiological functioning and our immune system, allow us to understand how language can affect health’ (Blake, 2006:13).

Lipton (2005) proposes that thoughts, as the minds energy, affect biological and physiological aspects.  This suggests that some memory is stored in the mind and some in the body, so it makes sense to combine physical and psychological treatments.

Usually the visual squash is done content free, which means not discussing a problem in-depth, however Sam was automatically using content so this was continued and kept specific using Meta language.  His automatic use of content could be because of his usual preference to not to talk about himself consciously.  His mum had previously advised me that they do not really know what Sam wants because he usually avoids answering when asked what he wants.

One of the benefits of case study research is that it enables a small scale study to be conducted in depth which can help to understand complex inter-relationships.  Case studies use a single sample so the results cannot be generalised.  The limitations of this research are related to it being a single case and no formal outcome measures were used for the changes in the physical and psychological factors, making the results subjective.  The gross motor function measure (GMFM) and the Paediatric Evaluation of Disability Inventory (PEDI) are widely used with children with cerebral palsy and are said to be complementary to one another (Engelen et al 2007).  However neither were appropriate for Sam, the PEDI is used for children from 6 months to 7.5 years and only the last two sections of the GMFM would have been relevant.  Health related quality of life is important as this considers physical and cognitive function, social aspects along with how the patient feels about their functional abilities.  The TNO-AZL Child Quality of Life (TACQOL) questionnaire was developed for children aged 6-15 years to measure health related quality of life in children.  There is both a parent and child form, in a study by Erik et al (1999) the parent and child responses were only moderately correlated thus their feelings and judgements about the child’s health related quality of life differed.  Although no specific outcome measure was suitable for psychological aspects the therapist discussed both the parent and child’s feelings relating to function.

‘…both parents’ and children’s opinions may be valuable in evaluating treatment effects, it seems best to obtain both parents’ and children’s evaluations whenever possible’ (Erik et al, 1999:192).

The Functional Independence Measure (FIM) could have been used as it assesses physical ability at home, including activities of daily living, and in the community.  In this case the FIM would have shown a change from supervision to modified setup following the two sessions which included NLP for transfers at home.  None of these outcome measures consider the quality and efficiency of the movement or psychological factors such as confidence and motivation in a specific task.  All of which are important parts that add together to form part of quality of life.

Ideally some physio assessment would have been done prior to reading the metaphor, and after, to assess if the NLP techniques used had different effects on physical factors in isolation.  In paediatric physiotherapy the timing of assessment and treatment and the approach used is guided mainly by the child to enable them to fully engage with the rehabilitation process.  On this occasion the therapist deemed it to be most beneficial to read the story prior to the physio assessment due to the level of enthusiasm Sam displayed suggesting he would fully engage with the metaphor.

Conclusion

This case report shows NLP seemed to be beneficial for confidence, self-awareness and functional outcomes.  To the writer’s knowledge, based on journal searches, it is the first documented integration of physio and NLP techniques.  The mind and body are one, one does not function without the other; this case study beautifully illustrates how mind and body are united.   It shows how integrating treatment of mind and body can help achieve outcomes and improves overall health and well-being.  This case report highlights the need for more structured research using the best outcome measures to ascertain whether physio alone, NLP alone, or physio combined with NLP achieve better physical outcomes and overall health and well-being.

 

 

 

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