Conductive education

John is relearning how to walk. He takes a step forward, saying, "I put my weight on my left foot, I step with my right foot. One, two, three, four, five." John has experienced mobility problems since his stroke five years ago. For the last two years, he has been attending the National Institute of Conductive Education (NICE) in Birmingham, United Kingdom, for conductive education sessions. "His walking has been getting better and better since he started here," John's dad says. "Conductive education has made a big difference to both our lives." Yet there has been little research into the effectiveness of conductive education, and there is a lack of awareness of conductive education among health professionals.

What exactly is conductive education?

Melanie Brown, director of conductive rehabilitation services at NICE explains, "Conductive education is an educational approach to habilitation and rehabilitation for adults and children with motor disorders." Motor disorders arise in people when damage to the central nervous system affects the person's ability to control movement, for example, in cerebral palsy, dyspraxia, multiple sclerosis, stroke, Parkinson's disease, or following head injury. Conductive education teaches adults and children with motor disorders how to achieve control over bodily movements and coordination. People also learn skills to solve movement problems experienced in personal and social situations.

History

Conductive education originates from the work of Austrian-Hungarian physician András Petõ. Petõ developed his ideas while working with adults and children with motor disorders in Budapest, Hungary, after the second world war. Petõ believed problems of bodily control and coordination were not an inevitable consequence of motor disorders. He thought people with motor disorders could learn how to use their bodies more effectively to solve movement problems encountered in daily activities, giving them more independence and dignity. Petõ suggested gaining control over movements and coordination was not a medical but an educational matter.¹

Petõ's work was written about in some German and English journals in the 1960s and 1970s, but the iron curtain limited dissemination of his ideas. When he died in 1967, another physician, Mária Hári, who had worked with Petõ since she was a medical student, continued to develop conductive education at the Petõ Institute, Budapest.

A medical model?

Conductive education has its critics, however. It has been criticised as working within a medical model of disability. The medical model decrees that a person's functional impairments, such as walking difficulties, lead directly to their restricted opportunities in society, that is, their disability. In his article in the BMJ, Michael Oliver argues that conductive education is based on this model, requiring the individual to adapt to society.² He sees this as oppressive, and argues for alternative approaches under the social model of disability. The social model views disability as a social construct--people with functional impairments have restricted opportunities because society does not cater for their needs. For example, if a person has walking difficulties and uses a wheelchair, it is the lack of wheelchair accessibility (such as ramps) that restricts their opportunities to participate in society. Functional impairments such as walking difficulties do not necessarily have to lead to exclusion from society. Oliver suggests that removal of societal barriers should form an alternative to conductive education.²

Conductive education can empower people with motor disorders

Another argument suggests that conductive education is not oppressive, as it offers people with disabilities the opportunity to make their bodies work for them, and achieve greater control over their own lives.³ Conductive education is actually empowering, as people work to achieve personally formulated goals.

This idea is central to conductive education--people learn best when they have something they want to learn and people identify goals important to them. Brenda attends the adult stroke group sessions at NICE. She says, "I wanted to learn to turn over in bed by myself so I didn't have to keep waking my husband for help."

Using conductors

"Conductors" help people to achieve their goals and they have to understand motor disorders, how these manifest, and how this affects people's lives. The conductors teach how to plan and carry out movements to achieve a self defined goal. One of the conductors at NICE explained, "The goal is broken down into a series of tasks to learn." In Brenda's case, learning to grasp with an outstretched arm was a fundamental task to learn. As time goes by, the tasks become increasingly complex and demanding. The ultimate aim is to teach people how to assimilate different basic movements to solve problems they encounter in their lives.¹

Conductors usually practice with groups of people. Brenda explained, "I learn things from the others in my group. We support each other. And it helps my husband to talk to other families." Indeed, conductors offer support and advice for families and carers. "The conductors showed me how to help Brenda do things for herself," Brenda's husband says.

Rhythmical intention

Rhythmical intention is important in conductive education. The conductor defines the task, for example, raising one arm. The group repeats the task, saying, "I raise my right arm." This is "intention," and focuses the attention on body position, which allows the person to imagine, plan, and implement the movement.¹ The group then carries out the intended movement while counting from one to five. Counting provides rhythm and control over speed of the movement. Rhythmical intention may also promote development of speech abilities.¹

People also learn to check and adjust the position of their body. A woman with multiple sclerosis recently thought that the multiple sclerosis was affecting her legs. Her conductor explained that it was actually affecting her trunk; her legs were shaking because of her inability to find her centre of gravity. By being aware of the position of her hips, she learnt how to find her centre of gravity and, she says, her walking improved.⁴

The focus of conductive education is not purely on motor skills. Conductors also seek to foster cognitive, emotional, and social development. And for some children, NICE is their full time schooling, so conductors focus on intellectual development. Researchers have described conductors in this setting as combining the skills of a teacher, physiotherapist, occupational therapist, and speech and language therapist.⁵ But the aim is for children to eventually transfer to their local schools.

Training as a conductor

Initially, conductors practising at NICE were trained at the Petõ Institute. Since 1997, however, NICE has been training conductors in conjunction with the University of Wolverhampton, UK. The University of Keele, UK, also trains conductors in association with Scope (a charity working with people with cerebral palsy). "Each year, more and more conductors are entering the profession," Melanie Brown says. These newly trained conductors are helping increase provision of conductive education throughout the UK, and across the world--graduates from NICE are employed in Canada, Germany, and Peru.⁶

Ignorance about conductive education

NICE operates a system of open referral. Health professionals can refer people, but most service users are self referring. John's father read about NICE in a newspaper. When he and John asked their general practitioner (GP) for advice about conductive education, they were met with silence. "The GP didn't know anything about conductive education," he says. This is a common experience. Parents whose children attend NICE recently reported lack of awareness of conductive education among professionals involved in the care of their child, including GPs, neurologists, physiotherapists, and health visitors.⁷

Parents said such professionals need educating about conductive education. Accordingly, NICE offers training courses and workshops for a range of professionals.⁷

Lack of funding

Once someone has been referred to NICE, an initial meeting is arranged to discuss their needs and aims, and whether conductive education is appropriate for them. If it is decided that conductive education would be appropriate, the individual then faces the problem of funding. Conductive education is a fee paying service. Children may receive funding from their local education authority (LEA), although this requires conductive education to be written into the child's statement of special education needs. But families often have to fight for this in tribunals.

These difficulties were highlighted recently in the case of Alice Randall, who has cerebral palsy. Alice's family wanted her to attend a school (run by Scope) that offers conductive education. But the LEA insisted Alice should attend a local mainstream primary school instead. Alice's father was so desperate to raise money for the Scope school fees that he decided to auction one of his kidneys over the internet.⁸ NICE currently offers free placements for children aged three years or under and their parents, thanks to charity donations,⁶ but families still have to self fund their travel and accommodation costs.

Adults have similar problems. Some receive charity funding. Others try to obtain NHS or social services funding, but most are self funding. This means people who cannot afford the fees may be excluded from conductive education. People with motor disorders in other countries, such as Germany, experience similar problems. German conductors suggest difficulties obtaining public funding may be due to the lack of evidence of the effectiveness of conductive education.

Research

There is a lack of research into the effectiveness of conductive education. Some studies have evaluated it in children with cerebral palsy, but many of these studies used subjective impressions of parents or professionals as measures of effectiveness. And more recent studies have concluded that conductive education may be effective in some individuals, but that current evidence does not prove it to be more effective than other interventions, such as physiotherapy, or "conventional" special schooling.⁹

Melanie Brown says, "We are starting to gather evidence to evaluate the impact of conductive education on the health related quality of life for people with Parkinson's disease, multiple sclerosis, and stroke."

In the meantime, John plans to continue his conductive education. "I want to work on my writing and speech, and hope to go back to university one day," he says. But for now, John says, "I'm taking things step by step."

For more information visit www.conductive-education.org.uk.

Keri-Michèle Lodge, second year medical student, Leicester Warwick Medical Schools
Email: K-M.Lodge@warwick.ac.uk


studentBMJ 2004;12:437-480 December ISSN 0966-6494

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