In this case study I hope to illustrate how engaging the use of hands in space and in the environment can elicit the freedom of movement and perhaps even voice.

A six year boy I see, ‘Theo’ who has a severe form of cerebral palsy is kept in a wheelchair for most of his waking time. When I met him he spent most of his time on an iPad with a touch screen on his lap, and was able to swipe with his index finger for screen interactivity. Theo was unable to raise his head, to interact visually with people when they were in his vicinity, and had no verbal skills. The only vocalization I heard was him crying.

We may be familiar with the movements of the hand, but the link to expression and communication is profound. It is summed up beautifully in the book The Hand by neurologist Frank R. Wilson: ‘somewhere between 18 months and two years... the eruption of mobility gesture and verbalism(are) an incomparable moment in human cognitive life and in the genesis of human consciousness.’

My priority was to find a way Theo could move from what seemed like permanent flexion and activate his extensors. Then when I came to visit he would lift his head and stare me in the eyes. Once he was able to raise himself, we could play with the use of the hands. We spent a long time enabling his capacity to grasp objects, cross the midline, and contact between the left and right hand. We did this with Aboriginal clap sticks. We gurgled and laughed together. As we worked he would begin to verbalise, in his own way, his interpretations of his experience. I don’t know if it had anything to do with the rhythm of the sticks, his hands or whether he was going to get there anyway. Whether this was coincidental is not clear to me.

The confluence of gesture and speech is quite specific according to Dr Susan Goldin-Meadow. In her book "Hearing Gesture: How Our Hands Help Us To Think", she suggests that the movement and gesture of the hands and the rhythmic pattern is a key mechanism that launch the process for human language acquisition. This was certainly my interpretation of Theo’s increased ability to babble with me. His language may not have had specific meaning to me, but it certainly did to him.

The other day when I saw Theo at school his hands were in splints to differentiate the use of the thumb, which is chronically flexed. I removed them and placed him on his belly. He had forgotten how to raise himself and collapsed on the ground. Here's how we got him to do it himself: just by showing him he could weight bear. He was able then to use his hands push down and so to lift his head up high to see the world. If we were to think of an Awareness Through Movement lesson that fit the work we did it may be the Active Dominant Hand, exploring the opening and closing of the hand in various positions. We then put it into practice, in relation to the physical world of the school floor. With Theo those positions were all about engaging with the world. In this context the use of the hands were an essential part of this small boy being able to organize his own weight shift, but more importantly to organize his self-image as an individual with capacity in the world.

My work with Alison elucidates how the hand can be a conduit to other parts of the body. The freeing of the movement of the hand can enable the rest of the body to be without pain.

Alison is an academic, who sits at the computer a lot, and fits into the main demographic of people who get frozen shoulders: women over 40.

There’s that beautiful Awareness Through Movement lesson called the Bell Hand, but in a one on one session I also make it available as the ‘ball hand’. At the conclusion of a range of movement strategies, the take-home exercise is quietly rolling the hand on a tennis ball, in specific ways we sneak up on the shoulder without directly working on it (at least to start with). It’s fun and not painful. If we work with pain, we’ll be telling the body that it needs to protect itself, and that just means limited action. If we work without pain, we feel free to learn to move differently.

So what did we do to get there? Unlike some other lessons where we focus more on the whole movement patterns of the person, this time we focused on the movement of the hand, and implicitly the arm, and shoulder. Any endeavours, at least in the beginning to work in the symptomatic area, were useless. This is a classic strategy of working distally and integrating to a proximal action in order to influence the self- image.

Within six sessions Alison was able to reach above her head. I must confess some of my colleagues did not believe this could be possible.

Here’s what Moshe Feldenkrais has to say on it: "functional integration turns to the oldest element of our sensory system – touch, the feelings of pull and pressure; the warmth of the hand, its caressing stroke. The person becomes absorbed in sensing the diminishing muscular tonus, the deepening and the regularity of breathing, abdominal ease, and improved circulation in the expanding skin. The person senses his most primitive, consciously forgotten patterns and recalls the well-being of a growing child."

Alison’s take home exercise was to quietly roll the ball, enabling pronation, and supination, flexion and extension. Every joint in the hand is woken.
And more. Her self is enabled.

This case study demonstrates how small integrative actions can the affect the disjuncture between desire and ability.

Emma is a professional cellist who described her fourth finger on her left hand as weak. She had tried various exercises to increase its strength, but it continued to inhibit her playing. I watched her playing and it was clear the finger was dystonic.

Dystonia is an imbalance of muscle firing (too much tone or too little) resulting in stiffening, involuntary movements, and inability to control the movements. Her finger was responding with reduced rapidity and visibly shaking while she tried to reach to press to the string.

Dr. Nancy Byl, PhD, PT, Professor and Chair of the Department of Physical Therapy and Rehabilitation Science at the University of California at San Francisco trained several monkeys to work for their supper by making them do repetitive hand movements. After several months they became increasingly reluctant to use their hands and showed signs of stiffness, clumsiness and pain. She believes that the monkeys lost their ability to identify which finger was which, that their brains were unable to make the distinction or map the fine finger action.

So it was with curiousity that I gave Emma a Functional Integration lesson, while she was sitting, her left hand in my hands. We explored the movement of her hand in various ways, including the detail of finding a way where each fingertip easily came to the thumb. More, it was finding out what action could be elicited through the nervous system to engage different organisation of the tiny joints, tendons, muscles and skin. It’s rather like the lesson Surgeon’s Hands, but in Functional Integration format, and with only the one hand.

Byl subsequently developed the Practical Guidelines for Sensory and Selective Sensory Motor Training which have as the primary goal the restoration of the somatosensory representation of the hand and normal fine motor control.

Three main ways she recommends are:
1. Identify everything about the surface of the instrument, eyes closed
2. Reflect back to the time when the hand was working normally
3. Constantly remind [yourself] how easy it was to do the task, how warm the hand felt, how each individual digit felt absolutely controlled...and how coordinated the hand felt.

We did not specifically follow any of the actions suggested in Byl’s guidelines, but I suspect simply sitting in the context of playing the instrument, before and after, fulfilled them.

I’ll let Emma describe the result: ‘Margaret worked with me for only a short time, yet my finger, and my hand in general, feels massively stronger and somehow more whole. The subtlety of (the) work goes far deeper than any other treatment I have had. The difference to my playing is profound. I have more vigour in my hand, all fingers work evenly and, most importantly, I am now able to fully express my musical desires.’