Saturday, 4 July 2009

What use is 'physical therapy'?

Further reminder, if reminder be needed

I have just stumbled upon the following passage.

It might prove of interest or even practical use to those involved in the continuing arguments with backwoodsmen and backwoodswomen about relative efficacy and 'proof' of physical therapy (physiotherapy) and Conductive Education.

Physical therapy, along with orthopedic surgery, has been the mainstay of the rehabilitation management of cerebral palsy for decades. Pediatric therapy has a clear and important role in helping children and their families cope more effectively with the disability through education, advocacy, functional training, and recommendations for adjunctive devices or therapies to optimize function. What is less clear is the extent to which physical therapy can alter the motor prognosis or make a clinically significant change in the level of disability or degree of participation for any given child. Traditional therapy approaches have been shown for the most part to be marginally beneficial and demand serious reconsideration by those who still advocate them.

Those wishing to make serious use of this (authoritative) judgement will have to follow it up for themselves, through the usual source engines, through the Internet and library facilities.

Demiano, D. L. (2006) Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy, Physical Therapy, vol. 86, no 11, pp. 1534-1540

Authoritative? Diane Demiano was subsequently elected President of the American Academy of Cerebral Palsy and Developmental Medicine.

If you like this statement of hers you will probably love what she has said about 'Bobath':

Sutton, A. (2008) CE: a lesson from Bobath, Conductive World, 2 January


  1. I know this paper very well Andrew. For me it is a reminder that Conductive Education is not really in a much better situation ! It is not yet clear to what extent CE can make significant evidence based change in the level of disability, activity or degree of participation for any given child. We can very soon find ourselves under the same demand as stated by damiano, that CE have been shown for the most part to be marginally beneficial and demand serious reconsideration by those who still advocate it.
    I think we are already in this stage...

  2. I'll go with all that, Rony. I think that CE and physio are in much the same boat. There has been no radical reconceptualisaon of what it is that they are doing, without which they are neither in a position for a proper dialogue with the outside world of the sort or level necessary for them to develop as serious players.

    I cannot speak for physiotherapy, except to note that it comprises a numerically vaste number of people, with a considerable infra-structure that can throw up people like Ms Demiano who might just come up with the goods to ensure survival in some form when push realy comes to shove.

    And CE? Tiny, with its 'flat' professional hierarchy (foot soldiers, almost all), little/no institutional development, virtually no professional writing, no apparent capacity for public avocacy of its position, few/no allies... one could go one but already, I think, few would offer good odds for its survival in other than vestigeal ways.

    You write of CE as being 'shown for the most part to be marginally beneficial... demand[ing] serious reconsideration by those who still advocate it. I think we are already in this stage...'

    Yes, that's the stage that I am entering.

    I do not consider this to be a despairing position, rather one of refreshing reconsideration as I begin to accept that the 'conductive movement' as it now stands is unlikely to have much to contribute to its own salvation. Indeed, it is now an important part of its own problem.

    I know that I am not the first to come to this view, by a long chalk. I have to admit that I have rather held out against it...

    So, I now beginning to wonder not so much how one might go about saving Conductive Education as is and begin to consider instead what might be salvaged from the wreckage to help build something new, to follow a shipwreck that just might have been avoidable...

  3. That's an nteresting point (reffering to your last paragraph). Reinterpreting CE into a more measurable construct?
    I believe that in the current era where EBP rules, we should obey, by findind the way to measure our achievements. Unless we find the way, we shall very soon be in a dep trouble. Ofcourse there is the problem of standards of practice which are so varied. I beleive there no two places in the conductive world which meet the same standards

  4. First, I want to comment on about Rony’s measuring and standards.

    Are there any two of anything that offer similar products that meet the same standard,. why do you use this supermarket and not that, use this bank and not the other, why is it that people fly to this country and not the other for an operation or treatment, or eat in this Greek restaurant and not the other, or buy clothes from this designer and not the other?

    Perhaps because in their opinion and maybe in the opinion of others one is of a higher standard than the other.

    People are different so all centres offering CE will be different, people have different abilities some conductors received high grades some low (who ever asks, no one asked me in my life!)

    Some centres are/were run by academics or professionals, some centres are run by businessmen, some by housewives, some by salesmen, some by conductors.

    Are we going to say that all centres, before they can employ conductors, have to have an academic or professional leading them? Or is it better to have a businessman and a older conductors working together? Or should it be a parent initiative?

    Who decides? Who is in control?


    PS I decided to google “EBP”, evidence based practise.

    I found it only related to clinical stuff in hospitals, huge centres with lots of resources. Some of the questions being asked are very similar to those conductors ask all day in the observations they make, others are not.

    I don’t see how universal “standards” and EPB apply to what I do or to the work of a lot of conductors around the world.

  5. Andrew, I think it is time for me to stop reading your gloom-and-doom blogs and comments! They make me feel really despondent and I see the time when I shalll have to leave my lovely flat because there is no more interest in CE and I will be earning my money as a cashier in Lidl, or maybe even in Morrison’s back in England.

    I wonder how many of the people who read the despondency in the conversation between you and Rony are conductors, working alone with time and knowledge only to do the work and not the other stuff that is so much needed.

    And i wonder if reading your words actually does anything to make them get up and fight, or makes them like me think whether it’s really worth getting exhausted every week if the whole thing worldwide is collapsing around our ears anyway?

    There are not enough people like you and Rony and involved in CE and those there are are widely dispersed and working in completely different directions.


  6. It is conductors like you, Susie, who will help CE to sutvive. You may not have the time or energy to do the things that Andrew and Rony talk about, but you do write about and share what you do. I think that must help in promoting CE and helping others to understand exactly 'what is it you do?'. Ignorance of what it is and what it can do is a large part of the problem at all levels.

  7. Susie,
    I am well aware of the fact that conductive education around the world does not and will not meet the same standarts, still, standards should be formulated and than, services will be judged according to the standard. When you chose a physcian , your decision is based upon the unquestionable assumption that the he meets basic standards according to the requirements of his profession. It is only than that you can prefer one doctor on the other, but that is alraedy because of the 'art' and not neccesraly the 'science' of his work.
    Do we truly know what are the common standarts of a conductor? Do we share the same standarts around the world? Do our training relates and socialize the students with regard to these standarts? How do we control this process?
    Without this system of quality assurance we shll run into a Chaos. I think we are already evidencing a Chaos. CE is being literally abused in many ways and places and nobody seems to care. Yes, when I employ a conductor, I want to be sure that he meets all the standards of his profession. I shall than prefer one conductor on the other according to other criterions like experience, creativity, personality, reccomendations etc.What are these standards?Why do we avoid confronting them? What are we afraid of?Why are we so passive and not struggle? it is a 'to be or not to be' struggle.Unfortunately i don't see a real, empowered, solid and motivated leadership to steer this boat. We shall not sink very soon Susie, we can float for a while, for a long while, but floating is a survival mechanism and not a developmental one.
    And yes, as Gill reacted, you are doing your part in an impressive way. I am not a conductor, and reading your Blog and others who are devoted to this way of documentation, you enable me to be part of a constant reflection on what CE is. You are active, and you would have a great impact on others if they were active as well, and at list read your thoughts and insights.I can imagine a whole international virtual conference on CE, based on Blogs like yours, I think thee Blogs are a compulsory reading materials for students in CE. But agin, how do we dicide which Blog is worthy?These stadards again ...Yes, it can't be ingnored or we shall be

    and to you Andrew, can you explore more about:
    '... build something new' ?

  8. Susie

    I do not intend to spread despondency through what you call my ‘doom and gloom’ and indeed I suspect that tour own personal business model, as described in your blog, will ensure your continued employment as a conductor or the rest of a long career (which is something that one might say about the career intentions of many conductors).

    It is not the essence of Conductive Education, nor the ability of this essence to find new and productive manifestations around the world, that I consider vulnerable in the continuing world economic crisis.

    What I regard at risk (doomed may be a better word0 are the practices and structure in Conductive Education the ideas and the attitudes that date from a professional generation ago, or further back still, and a certain lack of flexibility that often goes wit these. It is institutions predicated upon these that will fade away, not creative, personal enterprises like yours.

    And as for ‘doom and gloom’, I would consider it imprudent to think about any aspect of Conductive Education over, say, the next five years without recognition that the world is in flux, mega-flux. Even though we cannot know how things will turn out, it would be foolish in the extreme to make plans that do not incorporate the high probability that any plans made will have to be open to major modification.

    I do not regard this as particularly doom and gloomy. I restrict what I write (deliberately) to economics, possible one of the least of or problems. In doing so I take a general y cautious, middle of the road position, and wait to modify this in the light of how things shape up. I avoid the really frightening things, like the dreaded warming, a six-metre rise in sea level, the Volswanderung that comes fro these, all already under way… Then there are the unavoidable the political-social effects of these, plus pandemics, nuclear proliferation…

    Me, I shall stick with my five-year horizon and keep looking on the bright side. So should you.

  9. PS To Susie

    Sorry, I see that I misspelled ‘Volkswanderung’.

  10. Gill,

    I wholly concur. There is a potentially bright future for Conductive Education, and this will be only enhanced by conductors whose practice not only continues to burn bright but is also described, analysed and shared to create a real discourse around Conductive Education.

    The other side of this coin is of course that, if conductors do not do this to a critical degree, then it will be left to others, and other forces to the shape that future. In effect conductors may have permitted themselves to be written out of the plot.

    I suspect that some would consider that this is already happening.

  11. Rony

    This question of 'standards' is such a tricky one and I am very aware that there are likely sophisticated formulations about this in all sorts of fields of human endeavour, against which anything that I can say will sound incredibly naïve.

    Over on Norman Perrin’s blog I have puzzled over standards for the processes of innovation. Here you make me puzzle over it in a different way.

    What is a ‘conductor?’ you ask. At the present state of the art, this is surely a matter or criteria rather than of standards, of quality rather than quantities.

    Behind this question looms a further, more basic criterial one, that old favourite, ‘What is Conductive Education?’ And behind that towers the great unasked, ‘What is conduction?’?

    ‘How is this to be decided?’ you ask. The world of CE, you say, has no mechanisms, no leadership, no apparent will to stand up and fight. I would be hard-put to find evidence to pit against any of this. I shall try and answer your question for you in the light of present circumstances.

    Either nothing will be decided and Conductive Education will continue, at most, as the sum of ever further dispersed individual efforts. Or outside bodies will step in and make the decision on your behalf, with Conductive Education, its forms and standards decided by people who know nothing about it but, worse, believe that they do.

    It is perhaps just a mite too early to call yet (though this may seem different with the advantage of hindsight), but as far as the institutional structure of Conductive Education is concerned, at least as we have come to know it over recent years, its time may indeed be up.

    As as I wrote above, however, this may not be the case of the essence of the system embodied in its practitioners.

    Unfortunately, this essence will one day die with its practitioners if a new structure is not built out of the wreckage to carry Conductive Education forward. I think that you asked me what I meant by this.

    I’m working on it! I do hope that others are too.


  12. Rony,
    I do not think conductors who are doing the job they learnt to do are afraid of anything certainly not of “standards”. Many of them struggle everyday to do the work they believe in, often against great odds and I believe they are far from passive. We are out here, the very small isolated spots on a map, passionately struggling to practise our craft as we learnt it.

    I still do not agree that we can or indeed need to be setting Conductive Education standards for the benefit of the development of Conductive Education. Standard setting the world over in different professions is done for financial purposes, for the purpose of raising money, finding sponsorship and not directly for the development of the cause.

    I also do not agree that all doctors are of the same standard throughout the world. As there are a great many more places to train doctors than there are to train conductors, then the difference in standards between doctors should be much greater than between conductors.

    Health services know this and a medical qualification in country A does not always qualify you to work as a doctor in country B. The same goes for therapists, nurses, teachers, all sorts...

    If I weren't self-employed, and very choosey about the work that I accept, people could assess me constantly as having inconsistent standards, because in some workplaces I would be pressured to do work in ways that I do not consider good practice, while in others I am given a free hand.

    I know that conductors are driven crazy, for example when they work in a place where the "management" dictates how they work, how groups are set up, how many hours the children work, etc .

    As you say, Andrew; it is a question of establishing what is conductive education first.

    Again the question "Who decides?"

    Conductive Education at one time was what a very small number of people saw in the 1980s and before at the Petö Institute.

    Then it turned into something else, as soon as the first conductor stepped into another country. The first ones who went were no longer part of a team and they were working with a child in a family, so no group. Was that Conductive Education, or upbringing? It depended on the pressure that the parents put on the conductor to do something different, and on how creative and confident the conductor was.

    Then Conductive Education turned into small groups chosen by parents who then bought in conductors, Then larger centres opened and tried to create what they thought they had seen at the PAI.

    After 20 years of being involved in Conductive Education I am still telling people "You can't do it”
    You can do Conductive Education anywhere, in the street, on the beach, on the moon, in England, Timbuctoo or Greece. You can even do it without speaking the language of the land that you are in. But you can only do PAI Conductive Education at the PAI."

    Each country, each town, each village, each family, each language, needs something different.

    Perhaps the best thing to do is like you say, Andrew, to define what is a conductor and above all what is conduction, and then the conductor has to decide what kind of conduction is needed in that specific instance.

    This is no easier than setting standards, but perhaps more beneficial.

  13. Norman asked at the end of his blog how can” I measure and evidence the value of an individual's life story ?”. I have often wondered something similar, how do you measure individual development, individual learning at the individuals own pace due to individual difficulties? How do you quantify this and then where do you even start to find a control group for that? Fact is that Conductive Education only got this far because parents, spouses and participants themselves see a value in what we do. Today alone I had a mom saying to me that in the week her daughter attended our conductive summer camp she has made greater improvements then through physio she received for a year. How do you quantify this one? And if you cannot, is it worth less?

    I am not saying its impossible, just very tricky. However, one of the conductors I know came up with a measuring system that would help to quantify the way we write our reports, however that system is not perfect or complete yet. But I guess there are more of this half-finished (or even finished) attempts somewhere floating around the CE world and maybe sharing it would help to finish it. Anyone willing or able to share???

    I agree we need something to help quantifying the success stories we have and a common measuring system might be an idea to quality control CE (if this is even possible- who would decide??).
    Maybe a general used website where you can log in and type in your participants aims, achievements, some kind of time frame and maybe even how the aims got achieved might be the way to go.

    I know that the RDI (relationship development intervention) –program uses something like this. If I remember right, the parents as well as the therapist have access to the kids’ information, as RDI is more a parent training program then actually working hands on with the kid. The parents post videos and the therapist then comments on it (pretty much a Dina new age approach). The founders of RDI made the effort of writing down most(if not all) social and emotional stepping stones and breakdowns of it. This way the therapist fills out what has been achieved and the table shows you what the next aim is concluding out of this. I know it will have to be very complex for CE, especially as you can break down so many stepping stones into so many different parts, but its an idea. I guess this way, over a certain period of time, you could make some quantitative data out of it (in respect of the privacy act etc.).

    ‘Obeying’ any rules must be done with caution. Though out the past, different institutions and individuals have jumped through hoops to get CE paid for; sometimes to make it fit therapeutic interventions and more rarely educational ones. (Btw my current work visa says I work as a physio). Some research set out to prove it fits in one or the other and added more to the confusion. I am a believer in adapting CE, but more to make CE meaningful in the life of my participants.

    Hope this is useful at all.


    PS. Andrew I do not think that conductive education can survive without the conductors input. Yes, I believe the parents can become conductive parents to their own child. I do believe that non-conductors can be great advocates (like yourself) for conductive education. However, conductors without hands-on experience (needs to have preferable ongoing hand-on experience) are no real conductors. Conductive Education without having someone knowing the conduction of it, is no Conductive Education.

  14. Jo Lebeer MD PhD, University of Antwerp,BESaturday, 11 July 2009 at 22:14:00 BST

    Interesting discussion. I am particularly concerned that CE has been classified by the AACP (American Academy of CErebral Palsy) as "insufficiently evidence based" and therefore not recommendable treatment, which puts CE along the same (poor evidence based) line as NDT such as Bobath and Vojta. Gone are the 20th century paradigms (in the eyes of the academics). On the EACD 5Eur. academy of Childhood Disability) conference in Monaco, then AACP president Charlotte Butler placed CE amongst the list of quackeries. In the EACD Barcelona conference, I had a talk on "the dilemma between inclusive education and activation", where I presented, as an example, the inspiring results obtained in a small CE+inclusion project in Hengelo, NL, as well as referring to Rony Schenker's and Roby O'Sheas positive results in this respect; after the talk, I received a comment "it's a pity that you mentioned CE examples, because CE is not an evidence based therapy". However, listening afterward to Elisabeth Bower's talk on Collaborative Goal Setting, I had a feeling of "old wine in new barrels"; the idea of functional and goal oriented treatment seems to be the 21st century approach; the underlying philosophy has been advocated long ago by... Andras Petö, who, however, is not cited by E. Bower. Strikingly, Maria Hari's chapter in the "academic bible" on CP therapy, Management of motor disorders of children with cerebral palsy, London: McKeithPress, has been replaced by Elisabeth Bower's chapter on collaborative goal setting. Equally, when you carefully read Diane Damiano's article on Activity, Activity, Activity, this is precisely what CE also advocates, right from the beginning. It has been the cornerstone of CE. So, don't throw away this cornerstone, but Damiano (and Rony Shenker) are right that we need more research to measure the effect of activity. Why is it that CE people never present research results in the EACD or AACP conferences? It is difficult to prove any effect of any therapy in the field of pediatric rehabilitation systems. I tried to explain this in my article "Towards an ecology of rehabilitation: Methodology issues in evaluating intervention, in Conductive Education Occasional Papers, N° 9".

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