Basic Body Awareness Therapy for Persons With Autism
Condition: Autism
MeSH terms: Autistic Disorder
Study type: Interventional

Summary: 
      Autism is a diagnosis with certain criteria, especially social and communicative
      disabilities. Several body functions may be affected to create these disabilities, such as
      lack of ability to understand that other people think or feel differently than the person
      with autism, difficulty to experience bodily signals or deviant function of sensory
      modalities.

      Several theories describe that our physical, physiological, psychological and existential
      being can not be separated from each other. The combination of described difficulties in
      autism makes the perception of the surrounding world or the people within it difficult to
      understand or interpret, i.e., lack of a sense of coherence. The inner experience of the
      person as well as the expression of his/her movement qualities will be the effects.

      There are physiotherapeutic intervention techniques of body awareness, with the purpose to
      increase the connection to the body and to work with more functional movements. Instead of
      working with improving the well-being by cognitive top-down techniques, body awareness
      techniques work bottom-up.

      The hypothesis is that an intervention with body awareness therapy will increase the
      possibility for persons with autism to improve movement quality, and increase contact with
      bodily signals. It will give a better chance to understand and interpret the world and people
      in different context, conquering a sense of coherence.

      The study include at least 40 participants with autism randomized to two groups: 1.)
      intervention once a week for 12 weeks and 2. ) a control group (who will be invited to the
      therapy after ending study participation). They will be recruited from patient records in
      habilitation care. The criteria are: having autism, being 15-30 years, not having an
      intellectual impairment and not having a severe depression. The participants are to have been
      assessed with the standardized "Basic Body Awareness Scale Movement Quality and Experience",
      BAS MQ-E, and been found to being relevant participants for body awareness intervention in
      regard to the expressed individual health problem.

      Two assessments will be used. The primary one addresses each participants´s individual health
      problem, using a visual 11-graded scale (NRS), grading the present experience of the health
      problem. The secondary one is BAS MQ-E. The assessments will be administered as follows: i)
      prior to; NRS + BAS MQ-E, ii) after 7 occasions; NRS and iii) maximum 2 months after
      intervention; NRS + BAS MQ-E.
    

Detailed description: 
      Introduction Movement quality is a concept that describes how movements are performed in
      space, time and amount of energy. When the quality is good, the movement is perceived as
      unrestricted and gives a sense of freedom, physically and mentally. Movement quality and body
      awareness are dependent on each other. Body awareness is the ability to be consciously
      present and interpret signals from your own body. A physiotherapeutic treatment method that
      describes how movement quality and body awareness interact on a deeper level is Basic Body
      Awareness Therapy (BBAT).

      The purpose of BBAT is to raise physical and mental awareness by strengthening the interplay
      between sensory impressions and motor ability, gaining knowledge of movement patterns and
      habits that are not functional. Man's ability to perceive, take care of, control and use the
      body in a functional manner affects the quality and expression of the movements. According to
      the theory behind BBAT, movement quality and body awareness are both important abilities to
      develop bodily self-consciousness.

      In order to distinguish between oneself and others, ability to gather and make conscious
      sensory impressions through the body is demanded. In order to understand the impressions and
      the world around us, one need to be able to integrate sensory impressions to each other into
      an information with deeper meaning, the creation of perceptual coherence. The perceptual
      coherence is the basis for knowledge of one's own body and movement quality. Body awareness
      increases with more experience of movement. based on the physiotherapeutic bodyself, the
      subjective ("I as my body") and objective ("I in my body") identity we use to meet and
      understand the world. The bodyself comes to expression through the degree of movement quality
      and can as such be observed.

      When people with autism grow up, their development differs from typically developed peers.
      They may find it difficult to understand that other people have their own thoughts and
      feelings, so-called theory of mind and to understand their own feelings and inner states.
      They may lack central coherence, being able to merge details to the whole. They may also
      react differently to smells, flavors, sounds or materials carried on the body, having
      difficulty imitating others, have less flexibility to achieve motion targets, have poorer
      motor skills and/or sensorimotor function. In autism, the ability for multi-sensory
      integration is often inadequate. In this way, context and meaning can become less
      comprehensible and meaningful. This can lead to changes in the bodyself.

      As children with autism exhibit worse body awareness and movement quality than children with
      typical development, it may be likely that body and movement experiences are reduced through
      upbringing. This can affect physical and mental health, as seen in autism. A study from 1991
      examined how young adults with autism describe how movement quality from a body function
      perspective affects their ability to maintain daily activities and participation. The
      attention it required of the individual to attempt to master stereotyped movements to be
      considered "normal", resulted in increased mental energy utilization as they constantly
      watched their own behavior, also creating anxiety. In a previous study we interviewed eleven
      young adults with autism about their experiences about body and movement, as well as examined
      them with one motor and one body awareness instrument. The results showed conflicting
      feelings about their bodies and movements, but also how movement quality was related to the
      way the individual had access to functional strategies to handle everyday situations or not.
      There is little knowledge about the effects of various interventions that focus on body
      awareness and movement quality in this group.

      The objective of this study is to investigate effects of a BBAT intervention for young adults
      with autism. Research question: Can an intervention with BBAT help young adults with autism
      to improve their movement qualities in everyday activities and achieve individually expressed
      need to improve?

      Participants The participants will be young adults with autism, living in the region of
      Skaraborg in Västra Götaland or in the region of Kronoberg. See 10. Eligibility criteria.

      All patients with autism, within the criteria, that has been examined with BAS MQ-E may be
      eligible for participation in this study. Individual needs for improvement are discussed with
      each individual. If relevant needs are expressed, which may be encountered with BBAT, and the
      patient is motivated for intervention, he/she will be included in the study following
      informed consent. The expressed individual need will be defined in a statement, such as "I
      experience muscle tensions" or "I can calm myself before bedtime". The intervention will
      start within one month after performing BAS MQ-E and administered individually. A control
      group is used within the patient group. With a significance level of 0.05, a power of 0.8 and
      a moderate effect, at least 20 participants are calculated for in the intervention and
      control groups respectively.

      Ethics The study is approved by The Regional ethical review board in Gothenburg (Dnr 651-17).

      Instruments Numeric rating scale Individually expressed health problem is estimated on an
      individualized 11-degree numeric rating scale (NRS). See 9. Outcome measures.

      BAS MQ-E Movement quality will be examined with Body Awareness Scale Movement Quality and
      Experience (BAS MQ-E). See 9. Outcome measures.

      Methods A pragmatic randomized controlled study, pRCT, will be conducted. Participants are
      jointly managed for Skaraborg and Kronoberg and randomized to intervention group and control
      group. The distribution is managed by an independent person. Randomization takes place by
      using a random generator function at http://gallerit.se/slumptal/, with numbers 1 and 2. All
      1 means that the participant is randomized to the intervention group, all 2 to the control
      group.

      Intervention group: The layout is individualized based on the results of BAS MQ-E, all three
      parts. The individually expressed health problem is estimated on the NRS scale. After
      assessment, 12 occasions are given with BBAT approximately once a week (3-4 months).

      Control group: Treatment as usual for 3-4 months. Individualized NRS estimation and
      assessment with BAS MQ-E are performed according to flowchart. The participant will then have
      access to BBAT if they wish.

      Data collection BAS MQ-E (1) used in the study has been collected either from a previous
      validation study or from everyday clinic. BAS MQ-E (2), parts Movement test and
      Questionnaire, will be performed maximum 1 month after the end of the intervention by an
      independent examiner. Own rating of the individualized health problem using the VAS will be
      performed prior to the intervention (1), after 7 occasions of intervention (2) and maximum 2
      months after last occasion of intervention at 12 weeks, approximately 20 weeks total (3).

      Data analysis The primary outcome measure are the results from the NRS ratings. Further, the
      scores from BAS MQ-E, parts Movement test and Questionnaire, as secondary outcome measure.
      ANOVA will be used for statistical analysis of differences for repeated measures prior to,
      during and after the intervention. The intervention- and control groups will be analyzed to
      each other for any statistical significant difference using Mann Whitney U test (significance
      level p<0,05).

      Clinical significance of the study Body and movements are often described as problems in
      persons with autism. But it omits that there are also resources in the body to find
      strategies for everyday life. By strengthening body functions and enhancing movement quality
      and body awareness through a body therapy intervention, the person with autism can better
      understand themselves. Strengthened body functions then provide the basis for the
      individual's opportunities for development and increased participation in society. Expected
      results thus follow the UN Convention on the Rights of Persons with Disabilities, i.e. to
      eliminate obstacles for people with disabilities to enjoy their human rights and
      participation, in full and equal to others.
    

Intervention name(s): Body awareness therapy
Intervention type(s): Behavioral
Intervention description(s): The physiotherapist uses body awareness techniques, i.e. guiding the participant in movement qualities such as stability, breathing, flow and grounding. Conscious awareness focused on bodily experiences is a key component to be able to reflect on what your body signals.
As a baseline a standardized observation of the movement quality of the individual is performed. The physiotherapist needs special education in the body awareness technique used, to rightly perform and analyse the observation and administer the intervention.
The aim of the body awareness therapy is to raise physical and mental awareness by strengthening the interplay between sensory impressions and motor ability and to gain knowledge of own movement patterns that are not functional and to form alternatives to these.
Other intervention name(s): Basic body awareness therapy
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Autism; Movement; Body-mind therapy; Physiotherapy