This article was downloaded by: [University of Calgary] On: 30 March 2015, At: 14:57 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Performance Enhancement in Physical Medicine and Rehabilitation Philip R. Appel Ph.D.
a
a
National Rehabilitation Hospital , USA Published online: 21 Sep 2011.
To cite this article: Philip R. Appel Ph.D. (1992) Performance Enhancement in Physical Medicine and Rehabilitation, American Journal of Clinical Hypnosis, 35:1, 11-19, DOI: 10.1080/00029157.1992.10402978 To link to this article: http://dx.doi.org/10.1080/00029157.1992.10402978
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
AMERICAN JOURNAL OF CLINICAL HYPNOSIS VOLUME
35,
NUMBER
1,
JULY
1992
Performance Enhancement in Physical Medicine and Rehabilitation
Downloaded by [University of Calgary] at 14:57 30 March 2015
Philip R. Appel National Rehabilitation Hospital
Performance enhancement or mental practice is the "symbolic rehearsal of a physical activity without any gross muscular movements" to facilitate skill acquisition and to increase performance in the production of that physical activity. Performance-enhancement interventions have been well known in the area of sports psychology and medicine. However, clinical applications in physical medicine and rehabilitation have not flourished to the same extent, though the demand for improved physical performance and the acquisition of various motor skills are as important. In this paper I will describe how hypnosis can potentiate mental practice, present a model of mental practice to enhance performance, and describe how to help patients access an ideal performance state of consciousness.
Wright (1960), Martin (1983), Crasilneck and Hall (1985), and I (1990) have argued that hypnosis is a valuable tool in rehabilitation because it can facilitate both psychological change and physical change. Manganiello (1986) and Holroyd (1989) reported on the use of hypnosis to assist motor recovery of stroke patients, and I (1990) reported on increased range of motion and improved coordination during activities of daily living with a juvenile rheumatoid arthritis patient. Many authors have written about hypnotic interForreprintswriteto Philip R. Appel,Ph.D., Assistant Directorof Psychology, National Rehabilitation Hospital, 102 Irving Street NW, Washington, DC 20010. Received April 10, 1991; revised December 26, 1991;acceptedFebruary 26, 1992.
ventions to enhance the performance and outcome of physical tasks and objectives; these techniques and approaches have been called variously "neuromuscularre-education" (Shires, Peters, & Krout, 1954), "neuromotor facilitation" (Garver, 1977), "hypnotically hallucinated physical therapy" (McCord, 1966), and "mental practice" (Warner & McNeill, 1988). In the psychology literature, such techniques have traditionally been subsumed under "mental practice." The enhancement of physical activity through mental practice has been well documented and researched through the last 2 decades (Richardson, 1967a, 1967b; Jeffrey 1976; Feltz & Landers, 1983; Woolfolk, Murphy, Gottesfeld, & Aitken, 1985; Ungerleider, Golding, Porter, & Foster, 1989). "Mental practice" was first 11
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12
APPEL
defined by Richardson as "the symbolic rehearsal activity of a physical activity in the absence of any gross muscular movements" (1967a, p. 95). Essentially, in mental practice, the subject is asked to rehearse a physical activity cognitively through imagery, experiencing each element of the task in sequence as if he were really engaged in that activity. Clinical applications of mental practice in physical medicine and rehabilitation have not flourished to the same extent as applications of mental practice to sports psychology and medicine, though in rehabilitation the demand for improved physical performance and acquisition of various motor skills is as important. Enhancing performance is accomplished either through covert rehearsal of the rehabilitation activity or through the development of an ideal performance state of consciousness in which the patient can approach any activity with the cognitive and emotional factors necessary to perform that activity. In this paper I describe how hypnosis potentiates mental practice, present a model of mental practice to enhance performance, and describe how to help patients access an ideal performance state of consciousness. Potentiating Mental Practice Dennis (1985) stated "for an image to serve an efficient function in mental practice, it should possess at least three properties ... vividness ... controllability ... and exactness of reference ...." (pp. 8s9s). Holroyd (1987, 1989) suggested that hypnosis allows subjects to experience imagery more vividly and allows them to control their inner experiences more readily, changes attention and awareness, and increases suggestibility. Thus, mental practice can be enhanced by having subjects engage in hypnotically mediated im-
agery. Epstein (1980) and Suinn (1983) argued that the perspective of the images may influence the outcome of physical activity, and they state that internal imagery (feeling oneself do), as opposed to external imagery (seeing oneself do), enhances physical performance. Ryan and Simons (1982) found that subjects who could image kinesthetically were superior to subjects who could image visually in their performance of a balancing task, and both groups were superior to those who could not image at all. They concluded that using vivid imagery during the process of mental rehearsal is important for the enhancement of motor performance and that facilitating the subject's ability to experience the imagery kinesthetically can make a critical difference in the outcome of the performance. Dennis (1985) reviewed experiments that examined the combination of mental practice and physical practice and found that the combination produced significantly higher effects than physical practice alone. Applying these findings to rehabilitation suggested that if mental practice accompanied physical and occupational therapy, patients would benefit and would attain theirrehabilitation goals more readily. Woolfolk et al. (1985) found that when athletes imagined the outcome of athletic performance before engaging in the activity, their performance of the activity was more successful than if they had just engaged in brief mental rehearsal. Thus, including imaging the outcome as part of a mental practice protocol is as essential as the activity of practicing the activity itself. A Model for Rehabilitation The first task in helping patients per-
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PERFORMANCE ENCHANCEMENT IN PHYSICAL MEDICINE
form mental practice activities is to deal with any pain and discomfort that the patients are experiencing. Pain and discomfort will not only affect the patients' concentration but also can lead to patients making negative attributions about self and/orthe rehabilitation regimen. Woolfolk et al. (1985) found that"... the effects of preperformance mental activity can serve either to degrade or to enhance performance." (p.192) When patients learn how to create their own feelings of comfort this leads to feelings of adequacy and mastery , which begin to mitigate ruminations about not being able to learn what is needed for successful rehabilitation. Learning how to become comfortable can be accomplished readily through hypnosis and by using a variety of hypnoanalgesic techniques. Mental practice with external imagery should be used first, and it can be employed as a deepening technique once patients are in a hypnotic state. I give patients the suggestion to imagine seeing themselves in the therapy area performing their rehabilitation exercises as their therapists told them to. It is imperative to know what goals the physical or occupational therapist has for the patient and what performance difficulties the patient may be having. Knowledge of the patient goals permits specific suggestions to be made as to what should be imaged. For example, patients learning to stand with prostheses must learn not only to have balance but also to have structural alignment so knees, hips, and shoulders are all aligned. I ask them to visualize having perfect postural alignment easily and skillfully. Once they report having visualized themselves performing the activity, I suggest that they look critically at the image of themselves, noting whatever instructions the physical therapist has given them, and
13
compare those instructions with the image seen. I then suggest to the patients that they correct whatever is necessary in their images until it is the way their physical therapist wants them to perform. After the external imagery segment is performed, I prepare patients for internal imagery. Throughout this segment of mental practice I find it useful to give various suggestions, such as "with each exhalation the images will become more vivid ... as the images become more vivid you feel yourself relaxing ... as you see yourself doing 'X' perfectly you will feel more comfortable and competent and skillful." The shift from external to internal imagery can have the effect of further deepening the trance, and various deepening suggestions also can be given during this transition time. However, now I give a suggestion to experience and to image kinesthetically the projected self. I suggest that the patients experience performing the activity, the movements in sequence, in a masterful and skillful way. I further suggest that the kinesthetic aspects of the imagery become more vivid, and give further suggestions for deepening the trance and ego strengthening. I then suggest that mental practice be performed daily to augment the learning of rehabilitation goals. I instruct patients to begin each training session with the very procedures they had previously learned and in the order they had learned them. This practice will reinforce the patients making themselves comfortable and attending to themselves before they begin their mental practice of the skills leading up to their functional goals. By engaging in this practice the consciousness is concentrated and the likelihood of negative thinking intruding on the practice is fairly diminished. The constant repetition of the images with the association and the pair-
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14
ing of relaxation serve to desensitize the patient to any anxieties associated with the rehabilitation regimen. Once patients have begun to perform the activity successfully (in the therapy area and/or nursing unit), I prepare them for reentry into the community. I construct a hierarchy of simple to complex familiar environments and have the patients practice covertly the activity in these settings. For example, I might have the patients initially begin covertly rehearsing the activity within their home, then on the street outside their home, then at a friend's house, at a favorite store, on public transportation, and so on. I have the patients construct the hierarchy with me, then, as with systematic desensitization, I have them, while in a trance state, perform mental practice of the activity in successive environments of the hierarchy. Again, the strategy is to use external imagery, followed by internal imagery. This mental practice activity facilitates the diminishment of anticipatory anxiety associated with leaving the hospital and going back into the community. In addition, it enables the patients to imagine experiencing the successful outcome of the rehabilitation experience while still in the protected hospital environment. As such, this model incorporates a successful reentry, outcomeoriented, covert mental experience as part of the protocol.
Case Example The patient was a 65-year-old, widowed, high-school-educated, AfricanAmerican female. She was admitted to the hospital with a diagnosis of status post bilateral-below-the-knee amputations secondary to a long history of severe peripheral vascular disease and insulin-dependent diabetes mellitus. The patient's mental status upon ad-
APPEL
mission was within normal limits; there was no evidence of any gross deficits of higher cognitive functioning, nor was there any evidence of psychopathology. At a treatment team conference the therapists reported that the patient had begun to appear depressed over her slow rate of progress. The patient (while in the physical therapy gym) had noticed other amputees ambulating with their prostheses and had begun to become despondent about her ability to learn to ambulate. As she became despondent, her performance began to deteriorate. Because of the change in the patient's psychological state and its effect on her rehabilitation, I decided to treat her using performance-enhancement techniques. When the patient's mood shifted, she began to focus more on the discomfort and pain in her stump. The first task became alleviating her discomfort so she could tolerate her temporary prosthesis. I taught her self-hypnosis by using a combination of relaxation, breathing, and imagery techniques. I then taught her a pain-control technique that used imagery and self-suggestion. I gave her a suggestion to imagine being in a safe and comfortable place in which there was a magical, healing pool nearby to which she could go and soak her residual limbs. I gave her further suggestions for the water to be cool, refreshing, and smelling like spearmint and that the longer she soaked her legs, the more she would notice how refreshingly cool and numb they would become. She was given the suggestion that she could imagine putting on her prostheses and then notice how comfortable her legs felt. I also gave her ego-strengthening suggestions that allowed her to experience herself in control and being masterful. I then suggested to her that she could practice her self-hypnosis several times daily;
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PERFORMANCE ENCHANCEMENT IN PHYSICAL MEDICINE
each time she practiced it she would become more skillful, the periods of comfort would increase in length, and upon awakening from her trance state she would continue to feel comfortable and relaxed. This technique worked well for her and she experienced relief for several hours at a time. The next stage of intervention consisted of having her perform mental practice of standing on both prostheses in a balanced manner, with good posture, incorporating all the suggestions and instructions that her physical therapist had been giving her. Suggestions for mastery, skill, competence, and self-appreciation accompanied all imaginal tasks. I instructed the patient to begin her hypnotic routine by going to her imaginal safe place where she could relax and then proceed to the pool where she would experience the healing, numbing waters (deepening through kinesthetic imagery and achievement of control over pain and discomfort). When she experienced numbness in her residual limbs, I instructed her to imagine putting on her prostheses and to experience how comfortable that could be. I then gave her the suggestion to imagine seeing herself in the physical therapy gym, walking between the parallel bars in the manner that her physical therapist had been instructing her. I suggested that she could correct the image of herself walking until it was just perfect for her. When she signaled that she was satisfied with the image of herself walking, I suggested that she merge with the external image of herself and that she experience herself walking in the way and manner that she had seen it (that she could feel her prostheses, could feel lightly the parallel bars beneath her palms, see the gym, etc.). When she learned the sequence of external imagery followed by internal imag-
15
ery, I directed her to perform her mental practice of gait training between the parallel bars in the physical therapy gym. When she was able to perform her mental practice sufficiently, co-treatment with her physical therapist was initiated. During one of the physical therapy sessions, before actual practice of her ambulation skills, I asked her to go into a hypnotic trance and mentally rehearse what she was about to do ("psyching-up" strategy). This also had the effect of concentrating her attention and relaxing her so any anticipatory anxiety about her physical therapy would be diminished. I instructed the physical therapist in future sessions to create time for the patient to practice her selfhypnosis as a prelude to therapy and to encourage the patient to rehearse what they were doing through mental practice. Further hypnotic sessions for performance enhancement then focused on ambulating in the following hierarchical situations: the physical therapy gym excepting the parallel bars, the nursing unit, her home, a friend's house, her favorite store, and a supermarket. After approximately one week, the patient's mood and actual physical performance increased significantly by self-report and team observation. At the end of 2 weeks her physical therapist noted that she was ambulating with her prostheses more skillfully and was feeling very confident. When she was discharged she had learned to control her discomfort, had significantly increased her sense of self-esteem and self-efficacy, and had acquired the skills necessary for ambulation with bilateral prostheses. Ideal-Performance States Another type of performance-enhancement intervention is helping a patient
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retrieve existing mental and emotional resources that aren't being used in the performance of some task. The technique consists of creating a cognitive/affective mood state by integrating the cognitive and affective components of memories of past successful experiences that embody particular traits or characteristics that patients have identified will make them be successful again. The patients are then taught how to access those mood states when required. Once that ideal performance state of consciousness has been crafted, the patients are helped through future pacing to experience those difficult circumstances or situations with which they have been struggling. The future pacing is accomplished in an imaginal way while the patients are in their "ideal-performance" state of mind. In its most basic form, the intervention is reminding the individual of who he is and restoring a sense of adequacy and competency. The last part of the intervention consists of facilitating patients' in-vivo performance of the activity that was future paced.
Case Example Patient was a 57-year-old Caucasian female with 13 years of education; she had a primary diagnosis of neuro-sarcoidosis with cervical myelopathy accompanied by quadraparesis and was admitted for inpatient rehabilitation to achieve independence in wheelchair ambulation and in activities of daily living at the wheelchair level. This was the third admission for the patient, and she was in a moderate state of denial concerning the severity and permanence of her condition. As she was not willing to engage in traditional psychotherapeutic exploration of her feelings about her illness and disabilities and because she was very motivated for rehabili-
APPEL
tation, a "performance-enhancement" approach to intervention was used to establish rapport and to build a relationship until the patient was ready to deal with realities of her illness. In addition, it would help her to confront the reality of the moment; she would have to admit to what she could not do, or how she could not perform certain activities, and to state what she wanted to do better. Once there was that tacit admission, we would work together to help her improve her performance on those abilities that she did not possess. Part of the patient's problem in performing many activities was that she was not intentional or thoughtful about what she did. She was basically reflexive, on automatic pilot, and attempted to accomplish activities without paying attention to what modifications and effort were needed to accomplish a particular task. Part of her concentration problems stemmed from anxiety in the form of obsessive ruminations and fears about performance and her capabilities when she was confronted with a task. The first step in the intervention was to have her identify three separate times in her life that she felt were examples of outstanding performance. Once the events were identified, I explored them with her for what behaviors, attitudes, and moods were present that combined to create that psychological state that led to that ideal performance. For example, the patient talked about having once water-skied in the late fall in the cold ocean at night. The important characteristics of that experience were that, as she didn't want to fall, she was very precise and careful in what she did and that she thought through everything. Another example that she felt represented ideal performance was a particular
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PERFORMANCE ENCHANCEMENT IN PHYSICAL MEDICINE
sale that she made in her business. The salient aspects of that experience were remaining calm, having insight, being able to finesse the competing needs of the individuals involved, having a good sense of timing, and being able to use humor. The third event was a memory of a rehabilitation experience in a former hospitalization in which she had walked for 40 feet. The salient aspects of that experience were that she had to think about every step, she could not be casual about what she was doing, and she was able to think appropriately about everything she was doing. I engaged her in a discussion about what kinesthetic signal she would like to create for herself so she could "trigger" what would become her "ideal performance state." She decided to use her tongue pressed against the back of the lower front teeth as her "trigger." I then hypnotized her, helped her to relax, and gave her a suggestion that she could remember event number one; as she began to recall that event she could begin to reexperience it as if it were happening again. I gave her further suggestions that as she exhaled, the experience would become more vivid and that she could begin to feel the emotions, thoughts, and sensations of that time as if it were occurring right then. When she was in the midst of the experience, I asked her to place her tongue against her lower teeth and to keep it there (pairing stimulus). After allowing some time to pass and after giving suggestions for reexperiencing the mastery, the skill, and what ever elements had previously been identified, I asked her to release the "trigger" and shift her awareness to a neutral stimulus, her breathing. I suggested that she could relax even more deeply and asked her to recall the second event, shifting her attention
17
and concentration onto that experience so again it would be as if she were reliving that time. In the midst of the experience, I asked her to "fire the trigger," and I gave her suggestions for deepening, such as "each time you exhale you can really begin to feel and sense where you were and what was happening; ... with each exhalation the experience becomes more and more vivid." I also gave her ego-strengthening suggestions for mastery, skill, and competence. Upon completion of reexperiencing this event with associated mental and emotional resources that she could have access to, I asked her to release the "trigger" and then guided her to a neutral transitional state again. The same procedure was followed for the third event. Upon completion of the reliving and remembering of all three events, I shifted the patient's attention to a neutral stimulus and invited her to relax even more deeply. I instructed her to "fire her trigger"; gave her ego-strengthening suggestions for mastery, skill, and competence; and reminded her that she possessed the attributes previously identified. For example: "Even now as you exhale, and feel your tongue against your teeth, you can realize that you are a woman who can be very precise and careful in what you do and that you really can think through everything you need to do. Even as you touch yourself now in this special way, you can feel your calmness and observe how it increases. You can have more insight into who you are, recognizing that you are capable of finessing the outcome of complicated situations, and as you exhale you can really begin to appreciate your own natural sense of timing that allows you to do so many things in so many creative and intentional ways ...." Following the synthesis of the experi-
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APPEL
ence and the suggestions, I gave the patient the further posthypnotic suggestions that "whenever you fire your trigger you will begin to experience this ideal performance state, and whenever you do this you will be able to accomplish whatever task you are engaged in with "timing, precision, insight, carefulness, ...." I then brought her out of hypnosis and distracted her in conversation. I chose a wheelchair push-up as her in-vivo practice test for the effectiveness of the intervention. I asked her to fire her trigger and to perform a pressure release for her buttocks by doing a wheelchair push-up. The patient was moderately obese and she had been having trouble in physically performing this activity; she would get quite anxious at the thought of doing it. By triggering her posthypnotic suggestion to go into an ideal performance state, she concentrated her attention, concentration, and will in such a manner that her imagination was aligned with the task, and she was able to perform her wheelchair push-up quite well. As the patient began to use this technique during her hospital stay, the rehabilitation team noted that she began to become more intentional and concentrated upon her rehabilitation tasks and that her anxiety was diminishing. Over time as she began to recall that she was a person with a history and various capabilities, she became better able to tolerate her disabilities, because she had other positive aspects of herself and of her life that were being reflected back to her. Discussion I have discussed the use of hypnotically facilitated mental practice to assist patients with enhancing their performance in the rehabilitation setting, and I have
presented a clinical model. The model integrates from the mental practice literature those features of mental practice that are effective. Thus, internal and external imagery are used, as well as having the patient experience a successful outcome. Most notably the model combines physical practice and mental practice. Finally, hypnosis is used to potentiate the experience and to make it more vivid and controllable. In addition, a way to help patients access mental and emotional resources to help them perform some task is also presented. However, clinical anecdotal experiences must be backed up by experimental investigation to prove the efficacy of this approach and to determine which patients would best benefit from it. It is not enough just to assume that techniques developed to assist athletes in their attainment of quality performance can be used with physical medicine and rehabilitation patients.
References Appel, P. R. (1990). Clinical applications of hypnosis in the physical medicine and rehabilitation setting: Three case reports. American Journal of Clinical Hypnosis, 33,85-93. Crasilneck, H. B. & Hall, J. A. (1985). Clinical hypnosis principles and applications, (2nd ed.). Orlando: Grone & Stratton. Dennis, M. (1985). Visual imagery and the use of mental practice in the development of motor skills. Canadian Journal of Applied Sport Sciences, 10(4), 4s-16s. Epstein, M. L. (1980). The relationship of mental imagery and mental rehearsal to performance of a motor task. Journal of Sport Psychology, 2.211-220. Feltz, D. L. & Landers, D. M. (1983). The effects of mental practice on motor skills learning and performance: A meta analysis. Journal ofSport Psychology, 5,25-57. Garver, R. B., (1977). The enhancement of human performance with hypnosis through
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neuromotor facilitation and control arousal level. American Journal of Clinical Hypnosis, 19,177-181. Holroyd, J. (1987) How hypnosis may potentiate psychotherapy. American Journal of Clinical Hypnosis, 29, 194-200. Holroyd, J. (1989) Hypnotherapy with a stroke patient. International Journal of Clinical and Experimental Hypnosis, 37,120-127. Jeffrey, R. W. (1976) The influence of symbolic and motor rehearsal in observational learning. Journal ofResearch in Personality, 10, 116-127. Manganiello, A. J. (1986). Hypnotherapy in the rehabilitation of a stroke victim: A case study. American Journal ofClinical Hypnosis, 29, 64-68. Martin, J. (1983). Hypnosis is also useful in rehabilitation therapy.Journal ofthe American Medical Association, 249, 153-618. McCord, H., (1966). Hypnotically hallucinated physical therapy with a multiple sclerosis patient. American Journal of Clinical Hypnosis, 8, 313-314. Richardson, A. (1967a). Mental practice: A review and discussion (part I). The Research Quarterly, 38, 95-107. Richardson, A. (1967b). Mental practice: A review and discussion (part II). The Research Quarterly, 38, 263-273.
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Ryan, E. D. & Simons, J. (1982). Efficacy of mental imagery in enhancing mental rehearsal of motor skills. Journal of Sport Psychology, 4, 41-51. Shires, E. B., Peters, J. J., & Krout, R. M. (1954). Hypnosis in neuromuscular re-education. U.S. Armed Forces Medical Journal, V, 1519-1523. Suinn, R. M. (1983). Imagery and sports. InA. A. Sheikh (Ed.) Imagery: Current theory, research and application. New York: Wiley & Sons. Ungerleider, S., Golding, J. M., Porter, K., & Foster, J.(1989). An exploratory examination of cognitive strategies used by master track and field athletes. Sport Psychologist, 3, 245-253. Warner, L. & McNeil, M. E. (1988). Mental imagery and its potential for physical therapy. Physical Therapy, 68, 516-521. Woolfolk, R. L., Murphy, S. M., Gottesfeld, D., & Aitken D. (1985). Effects of mental rehearsal of task motor activity and mental depiction of task outcome on motor skill performance. Journal of Sport Psychology, 7,191-197. Wright, M. E. (1960). Hypnosis and rehabilitation. Rehabilitation Literature, 21,.212.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Performance Enhancement in Physical Medicine and Rehabilitation Philip R. Appel Ph.D.
a
a
National Rehabilitation Hospital , USA Published online: 21 Sep 2011.
To cite this article: Philip R. Appel Ph.D. (1992) Performance Enhancement in Physical Medicine and Rehabilitation, American Journal of Clinical Hypnosis, 35:1, 11-19, DOI: 10.1080/00029157.1992.10402978 To link to this article: http://dx.doi.org/10.1080/00029157.1992.10402978
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
AMERICAN JOURNAL OF CLINICAL HYPNOSIS VOLUME
35,
NUMBER
1,
JULY
1992
Performance Enhancement in Physical Medicine and Rehabilitation
Downloaded by [University of Calgary] at 14:57 30 March 2015
Philip R. Appel National Rehabilitation Hospital
Performance enhancement or mental practice is the "symbolic rehearsal of a physical activity without any gross muscular movements" to facilitate skill acquisition and to increase performance in the production of that physical activity. Performance-enhancement interventions have been well known in the area of sports psychology and medicine. However, clinical applications in physical medicine and rehabilitation have not flourished to the same extent, though the demand for improved physical performance and the acquisition of various motor skills are as important. In this paper I will describe how hypnosis can potentiate mental practice, present a model of mental practice to enhance performance, and describe how to help patients access an ideal performance state of consciousness.
Wright (1960), Martin (1983), Crasilneck and Hall (1985), and I (1990) have argued that hypnosis is a valuable tool in rehabilitation because it can facilitate both psychological change and physical change. Manganiello (1986) and Holroyd (1989) reported on the use of hypnosis to assist motor recovery of stroke patients, and I (1990) reported on increased range of motion and improved coordination during activities of daily living with a juvenile rheumatoid arthritis patient. Many authors have written about hypnotic interForreprintswriteto Philip R. Appel,Ph.D., Assistant Directorof Psychology, National Rehabilitation Hospital, 102 Irving Street NW, Washington, DC 20010. Received April 10, 1991; revised December 26, 1991;acceptedFebruary 26, 1992.
ventions to enhance the performance and outcome of physical tasks and objectives; these techniques and approaches have been called variously "neuromuscularre-education" (Shires, Peters, & Krout, 1954), "neuromotor facilitation" (Garver, 1977), "hypnotically hallucinated physical therapy" (McCord, 1966), and "mental practice" (Warner & McNeill, 1988). In the psychology literature, such techniques have traditionally been subsumed under "mental practice." The enhancement of physical activity through mental practice has been well documented and researched through the last 2 decades (Richardson, 1967a, 1967b; Jeffrey 1976; Feltz & Landers, 1983; Woolfolk, Murphy, Gottesfeld, & Aitken, 1985; Ungerleider, Golding, Porter, & Foster, 1989). "Mental practice" was first 11
Downloaded by [University of Calgary] at 14:57 30 March 2015
12
APPEL
defined by Richardson as "the symbolic rehearsal activity of a physical activity in the absence of any gross muscular movements" (1967a, p. 95). Essentially, in mental practice, the subject is asked to rehearse a physical activity cognitively through imagery, experiencing each element of the task in sequence as if he were really engaged in that activity. Clinical applications of mental practice in physical medicine and rehabilitation have not flourished to the same extent as applications of mental practice to sports psychology and medicine, though in rehabilitation the demand for improved physical performance and acquisition of various motor skills is as important. Enhancing performance is accomplished either through covert rehearsal of the rehabilitation activity or through the development of an ideal performance state of consciousness in which the patient can approach any activity with the cognitive and emotional factors necessary to perform that activity. In this paper I describe how hypnosis potentiates mental practice, present a model of mental practice to enhance performance, and describe how to help patients access an ideal performance state of consciousness. Potentiating Mental Practice Dennis (1985) stated "for an image to serve an efficient function in mental practice, it should possess at least three properties ... vividness ... controllability ... and exactness of reference ...." (pp. 8s9s). Holroyd (1987, 1989) suggested that hypnosis allows subjects to experience imagery more vividly and allows them to control their inner experiences more readily, changes attention and awareness, and increases suggestibility. Thus, mental practice can be enhanced by having subjects engage in hypnotically mediated im-
agery. Epstein (1980) and Suinn (1983) argued that the perspective of the images may influence the outcome of physical activity, and they state that internal imagery (feeling oneself do), as opposed to external imagery (seeing oneself do), enhances physical performance. Ryan and Simons (1982) found that subjects who could image kinesthetically were superior to subjects who could image visually in their performance of a balancing task, and both groups were superior to those who could not image at all. They concluded that using vivid imagery during the process of mental rehearsal is important for the enhancement of motor performance and that facilitating the subject's ability to experience the imagery kinesthetically can make a critical difference in the outcome of the performance. Dennis (1985) reviewed experiments that examined the combination of mental practice and physical practice and found that the combination produced significantly higher effects than physical practice alone. Applying these findings to rehabilitation suggested that if mental practice accompanied physical and occupational therapy, patients would benefit and would attain theirrehabilitation goals more readily. Woolfolk et al. (1985) found that when athletes imagined the outcome of athletic performance before engaging in the activity, their performance of the activity was more successful than if they had just engaged in brief mental rehearsal. Thus, including imaging the outcome as part of a mental practice protocol is as essential as the activity of practicing the activity itself. A Model for Rehabilitation The first task in helping patients per-
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form mental practice activities is to deal with any pain and discomfort that the patients are experiencing. Pain and discomfort will not only affect the patients' concentration but also can lead to patients making negative attributions about self and/orthe rehabilitation regimen. Woolfolk et al. (1985) found that"... the effects of preperformance mental activity can serve either to degrade or to enhance performance." (p.192) When patients learn how to create their own feelings of comfort this leads to feelings of adequacy and mastery , which begin to mitigate ruminations about not being able to learn what is needed for successful rehabilitation. Learning how to become comfortable can be accomplished readily through hypnosis and by using a variety of hypnoanalgesic techniques. Mental practice with external imagery should be used first, and it can be employed as a deepening technique once patients are in a hypnotic state. I give patients the suggestion to imagine seeing themselves in the therapy area performing their rehabilitation exercises as their therapists told them to. It is imperative to know what goals the physical or occupational therapist has for the patient and what performance difficulties the patient may be having. Knowledge of the patient goals permits specific suggestions to be made as to what should be imaged. For example, patients learning to stand with prostheses must learn not only to have balance but also to have structural alignment so knees, hips, and shoulders are all aligned. I ask them to visualize having perfect postural alignment easily and skillfully. Once they report having visualized themselves performing the activity, I suggest that they look critically at the image of themselves, noting whatever instructions the physical therapist has given them, and
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compare those instructions with the image seen. I then suggest to the patients that they correct whatever is necessary in their images until it is the way their physical therapist wants them to perform. After the external imagery segment is performed, I prepare patients for internal imagery. Throughout this segment of mental practice I find it useful to give various suggestions, such as "with each exhalation the images will become more vivid ... as the images become more vivid you feel yourself relaxing ... as you see yourself doing 'X' perfectly you will feel more comfortable and competent and skillful." The shift from external to internal imagery can have the effect of further deepening the trance, and various deepening suggestions also can be given during this transition time. However, now I give a suggestion to experience and to image kinesthetically the projected self. I suggest that the patients experience performing the activity, the movements in sequence, in a masterful and skillful way. I further suggest that the kinesthetic aspects of the imagery become more vivid, and give further suggestions for deepening the trance and ego strengthening. I then suggest that mental practice be performed daily to augment the learning of rehabilitation goals. I instruct patients to begin each training session with the very procedures they had previously learned and in the order they had learned them. This practice will reinforce the patients making themselves comfortable and attending to themselves before they begin their mental practice of the skills leading up to their functional goals. By engaging in this practice the consciousness is concentrated and the likelihood of negative thinking intruding on the practice is fairly diminished. The constant repetition of the images with the association and the pair-
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ing of relaxation serve to desensitize the patient to any anxieties associated with the rehabilitation regimen. Once patients have begun to perform the activity successfully (in the therapy area and/or nursing unit), I prepare them for reentry into the community. I construct a hierarchy of simple to complex familiar environments and have the patients practice covertly the activity in these settings. For example, I might have the patients initially begin covertly rehearsing the activity within their home, then on the street outside their home, then at a friend's house, at a favorite store, on public transportation, and so on. I have the patients construct the hierarchy with me, then, as with systematic desensitization, I have them, while in a trance state, perform mental practice of the activity in successive environments of the hierarchy. Again, the strategy is to use external imagery, followed by internal imagery. This mental practice activity facilitates the diminishment of anticipatory anxiety associated with leaving the hospital and going back into the community. In addition, it enables the patients to imagine experiencing the successful outcome of the rehabilitation experience while still in the protected hospital environment. As such, this model incorporates a successful reentry, outcomeoriented, covert mental experience as part of the protocol.
Case Example The patient was a 65-year-old, widowed, high-school-educated, AfricanAmerican female. She was admitted to the hospital with a diagnosis of status post bilateral-below-the-knee amputations secondary to a long history of severe peripheral vascular disease and insulin-dependent diabetes mellitus. The patient's mental status upon ad-
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mission was within normal limits; there was no evidence of any gross deficits of higher cognitive functioning, nor was there any evidence of psychopathology. At a treatment team conference the therapists reported that the patient had begun to appear depressed over her slow rate of progress. The patient (while in the physical therapy gym) had noticed other amputees ambulating with their prostheses and had begun to become despondent about her ability to learn to ambulate. As she became despondent, her performance began to deteriorate. Because of the change in the patient's psychological state and its effect on her rehabilitation, I decided to treat her using performance-enhancement techniques. When the patient's mood shifted, she began to focus more on the discomfort and pain in her stump. The first task became alleviating her discomfort so she could tolerate her temporary prosthesis. I taught her self-hypnosis by using a combination of relaxation, breathing, and imagery techniques. I then taught her a pain-control technique that used imagery and self-suggestion. I gave her a suggestion to imagine being in a safe and comfortable place in which there was a magical, healing pool nearby to which she could go and soak her residual limbs. I gave her further suggestions for the water to be cool, refreshing, and smelling like spearmint and that the longer she soaked her legs, the more she would notice how refreshingly cool and numb they would become. She was given the suggestion that she could imagine putting on her prostheses and then notice how comfortable her legs felt. I also gave her ego-strengthening suggestions that allowed her to experience herself in control and being masterful. I then suggested to her that she could practice her self-hypnosis several times daily;
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each time she practiced it she would become more skillful, the periods of comfort would increase in length, and upon awakening from her trance state she would continue to feel comfortable and relaxed. This technique worked well for her and she experienced relief for several hours at a time. The next stage of intervention consisted of having her perform mental practice of standing on both prostheses in a balanced manner, with good posture, incorporating all the suggestions and instructions that her physical therapist had been giving her. Suggestions for mastery, skill, competence, and self-appreciation accompanied all imaginal tasks. I instructed the patient to begin her hypnotic routine by going to her imaginal safe place where she could relax and then proceed to the pool where she would experience the healing, numbing waters (deepening through kinesthetic imagery and achievement of control over pain and discomfort). When she experienced numbness in her residual limbs, I instructed her to imagine putting on her prostheses and to experience how comfortable that could be. I then gave her the suggestion to imagine seeing herself in the physical therapy gym, walking between the parallel bars in the manner that her physical therapist had been instructing her. I suggested that she could correct the image of herself walking until it was just perfect for her. When she signaled that she was satisfied with the image of herself walking, I suggested that she merge with the external image of herself and that she experience herself walking in the way and manner that she had seen it (that she could feel her prostheses, could feel lightly the parallel bars beneath her palms, see the gym, etc.). When she learned the sequence of external imagery followed by internal imag-
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ery, I directed her to perform her mental practice of gait training between the parallel bars in the physical therapy gym. When she was able to perform her mental practice sufficiently, co-treatment with her physical therapist was initiated. During one of the physical therapy sessions, before actual practice of her ambulation skills, I asked her to go into a hypnotic trance and mentally rehearse what she was about to do ("psyching-up" strategy). This also had the effect of concentrating her attention and relaxing her so any anticipatory anxiety about her physical therapy would be diminished. I instructed the physical therapist in future sessions to create time for the patient to practice her selfhypnosis as a prelude to therapy and to encourage the patient to rehearse what they were doing through mental practice. Further hypnotic sessions for performance enhancement then focused on ambulating in the following hierarchical situations: the physical therapy gym excepting the parallel bars, the nursing unit, her home, a friend's house, her favorite store, and a supermarket. After approximately one week, the patient's mood and actual physical performance increased significantly by self-report and team observation. At the end of 2 weeks her physical therapist noted that she was ambulating with her prostheses more skillfully and was feeling very confident. When she was discharged she had learned to control her discomfort, had significantly increased her sense of self-esteem and self-efficacy, and had acquired the skills necessary for ambulation with bilateral prostheses. Ideal-Performance States Another type of performance-enhancement intervention is helping a patient
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retrieve existing mental and emotional resources that aren't being used in the performance of some task. The technique consists of creating a cognitive/affective mood state by integrating the cognitive and affective components of memories of past successful experiences that embody particular traits or characteristics that patients have identified will make them be successful again. The patients are then taught how to access those mood states when required. Once that ideal performance state of consciousness has been crafted, the patients are helped through future pacing to experience those difficult circumstances or situations with which they have been struggling. The future pacing is accomplished in an imaginal way while the patients are in their "ideal-performance" state of mind. In its most basic form, the intervention is reminding the individual of who he is and restoring a sense of adequacy and competency. The last part of the intervention consists of facilitating patients' in-vivo performance of the activity that was future paced.
Case Example Patient was a 57-year-old Caucasian female with 13 years of education; she had a primary diagnosis of neuro-sarcoidosis with cervical myelopathy accompanied by quadraparesis and was admitted for inpatient rehabilitation to achieve independence in wheelchair ambulation and in activities of daily living at the wheelchair level. This was the third admission for the patient, and she was in a moderate state of denial concerning the severity and permanence of her condition. As she was not willing to engage in traditional psychotherapeutic exploration of her feelings about her illness and disabilities and because she was very motivated for rehabili-
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tation, a "performance-enhancement" approach to intervention was used to establish rapport and to build a relationship until the patient was ready to deal with realities of her illness. In addition, it would help her to confront the reality of the moment; she would have to admit to what she could not do, or how she could not perform certain activities, and to state what she wanted to do better. Once there was that tacit admission, we would work together to help her improve her performance on those abilities that she did not possess. Part of the patient's problem in performing many activities was that she was not intentional or thoughtful about what she did. She was basically reflexive, on automatic pilot, and attempted to accomplish activities without paying attention to what modifications and effort were needed to accomplish a particular task. Part of her concentration problems stemmed from anxiety in the form of obsessive ruminations and fears about performance and her capabilities when she was confronted with a task. The first step in the intervention was to have her identify three separate times in her life that she felt were examples of outstanding performance. Once the events were identified, I explored them with her for what behaviors, attitudes, and moods were present that combined to create that psychological state that led to that ideal performance. For example, the patient talked about having once water-skied in the late fall in the cold ocean at night. The important characteristics of that experience were that, as she didn't want to fall, she was very precise and careful in what she did and that she thought through everything. Another example that she felt represented ideal performance was a particular
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sale that she made in her business. The salient aspects of that experience were remaining calm, having insight, being able to finesse the competing needs of the individuals involved, having a good sense of timing, and being able to use humor. The third event was a memory of a rehabilitation experience in a former hospitalization in which she had walked for 40 feet. The salient aspects of that experience were that she had to think about every step, she could not be casual about what she was doing, and she was able to think appropriately about everything she was doing. I engaged her in a discussion about what kinesthetic signal she would like to create for herself so she could "trigger" what would become her "ideal performance state." She decided to use her tongue pressed against the back of the lower front teeth as her "trigger." I then hypnotized her, helped her to relax, and gave her a suggestion that she could remember event number one; as she began to recall that event she could begin to reexperience it as if it were happening again. I gave her further suggestions that as she exhaled, the experience would become more vivid and that she could begin to feel the emotions, thoughts, and sensations of that time as if it were occurring right then. When she was in the midst of the experience, I asked her to place her tongue against her lower teeth and to keep it there (pairing stimulus). After allowing some time to pass and after giving suggestions for reexperiencing the mastery, the skill, and what ever elements had previously been identified, I asked her to release the "trigger" and shift her awareness to a neutral stimulus, her breathing. I suggested that she could relax even more deeply and asked her to recall the second event, shifting her attention
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and concentration onto that experience so again it would be as if she were reliving that time. In the midst of the experience, I asked her to "fire the trigger," and I gave her suggestions for deepening, such as "each time you exhale you can really begin to feel and sense where you were and what was happening; ... with each exhalation the experience becomes more and more vivid." I also gave her ego-strengthening suggestions for mastery, skill, and competence. Upon completion of reexperiencing this event with associated mental and emotional resources that she could have access to, I asked her to release the "trigger" and then guided her to a neutral transitional state again. The same procedure was followed for the third event. Upon completion of the reliving and remembering of all three events, I shifted the patient's attention to a neutral stimulus and invited her to relax even more deeply. I instructed her to "fire her trigger"; gave her ego-strengthening suggestions for mastery, skill, and competence; and reminded her that she possessed the attributes previously identified. For example: "Even now as you exhale, and feel your tongue against your teeth, you can realize that you are a woman who can be very precise and careful in what you do and that you really can think through everything you need to do. Even as you touch yourself now in this special way, you can feel your calmness and observe how it increases. You can have more insight into who you are, recognizing that you are capable of finessing the outcome of complicated situations, and as you exhale you can really begin to appreciate your own natural sense of timing that allows you to do so many things in so many creative and intentional ways ...." Following the synthesis of the experi-
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ence and the suggestions, I gave the patient the further posthypnotic suggestions that "whenever you fire your trigger you will begin to experience this ideal performance state, and whenever you do this you will be able to accomplish whatever task you are engaged in with "timing, precision, insight, carefulness, ...." I then brought her out of hypnosis and distracted her in conversation. I chose a wheelchair push-up as her in-vivo practice test for the effectiveness of the intervention. I asked her to fire her trigger and to perform a pressure release for her buttocks by doing a wheelchair push-up. The patient was moderately obese and she had been having trouble in physically performing this activity; she would get quite anxious at the thought of doing it. By triggering her posthypnotic suggestion to go into an ideal performance state, she concentrated her attention, concentration, and will in such a manner that her imagination was aligned with the task, and she was able to perform her wheelchair push-up quite well. As the patient began to use this technique during her hospital stay, the rehabilitation team noted that she began to become more intentional and concentrated upon her rehabilitation tasks and that her anxiety was diminishing. Over time as she began to recall that she was a person with a history and various capabilities, she became better able to tolerate her disabilities, because she had other positive aspects of herself and of her life that were being reflected back to her. Discussion I have discussed the use of hypnotically facilitated mental practice to assist patients with enhancing their performance in the rehabilitation setting, and I have
presented a clinical model. The model integrates from the mental practice literature those features of mental practice that are effective. Thus, internal and external imagery are used, as well as having the patient experience a successful outcome. Most notably the model combines physical practice and mental practice. Finally, hypnosis is used to potentiate the experience and to make it more vivid and controllable. In addition, a way to help patients access mental and emotional resources to help them perform some task is also presented. However, clinical anecdotal experiences must be backed up by experimental investigation to prove the efficacy of this approach and to determine which patients would best benefit from it. It is not enough just to assume that techniques developed to assist athletes in their attainment of quality performance can be used with physical medicine and rehabilitation patients.
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neuromotor facilitation and control arousal level. American Journal of Clinical Hypnosis, 19,177-181. Holroyd, J. (1987) How hypnosis may potentiate psychotherapy. American Journal of Clinical Hypnosis, 29, 194-200. Holroyd, J. (1989) Hypnotherapy with a stroke patient. International Journal of Clinical and Experimental Hypnosis, 37,120-127. Jeffrey, R. W. (1976) The influence of symbolic and motor rehearsal in observational learning. Journal ofResearch in Personality, 10, 116-127. Manganiello, A. J. (1986). Hypnotherapy in the rehabilitation of a stroke victim: A case study. American Journal ofClinical Hypnosis, 29, 64-68. Martin, J. (1983). Hypnosis is also useful in rehabilitation therapy.Journal ofthe American Medical Association, 249, 153-618. McCord, H., (1966). Hypnotically hallucinated physical therapy with a multiple sclerosis patient. American Journal of Clinical Hypnosis, 8, 313-314. Richardson, A. (1967a). Mental practice: A review and discussion (part I). The Research Quarterly, 38, 95-107. Richardson, A. (1967b). Mental practice: A review and discussion (part II). The Research Quarterly, 38, 263-273.
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Ryan, E. D. & Simons, J. (1982). Efficacy of mental imagery in enhancing mental rehearsal of motor skills. Journal of Sport Psychology, 4, 41-51. Shires, E. B., Peters, J. J., & Krout, R. M. (1954). Hypnosis in neuromuscular re-education. U.S. Armed Forces Medical Journal, V, 1519-1523. Suinn, R. M. (1983). Imagery and sports. InA. A. Sheikh (Ed.) Imagery: Current theory, research and application. New York: Wiley & Sons. Ungerleider, S., Golding, J. M., Porter, K., & Foster, J.(1989). An exploratory examination of cognitive strategies used by master track and field athletes. Sport Psychologist, 3, 245-253. Warner, L. & McNeil, M. E. (1988). Mental imagery and its potential for physical therapy. Physical Therapy, 68, 516-521. Woolfolk, R. L., Murphy, S. M., Gottesfeld, D., & Aitken D. (1985). Effects of mental rehearsal of task motor activity and mental depiction of task outcome on motor skill performance. Journal of Sport Psychology, 7,191-197. Wright, M. E. (1960). Hypnosis and rehabilitation. Rehabilitation Literature, 21,.212.
