BACKGROUND TO THE THE HARE APPROACH

The Hare Approach was named after Noreen Hare, a paediatric physiotherapist. She challenged conventional thinking in the 1970’s and 80’s, regarding the treatment and management of neurologically impaired children and was later influential in the area of adult neurological impairment.

Noreen Hare recognised that:

• Ability is as important as disability, that is, what the child can do is as important, perhaps more so, than what the child cannot do.

• True acknowledgement of environmental aspects (gravity and supporting surface) and acknowledgement of the central role of the trunk, were critical in the analysis of posture and movement.

• Ability in lying is fundamental to the development of the upright (erect) posture.

• Reliable outcome measures were not provided by established approaches practised at the time.

• The positive signs such as tonal abnormality and reflex persistence, are unreliable as a basis for physiotherapy assessment and treatment.

It is not clear when Noreen began to appreciate the importance of the trunk as the centre for gross body movement but it formed the foundation of her treatment and was well documented by 1970/71. While for many years other approaches still focussed on limb function, Noreen recognised that all movement of the trunk and appendages (limbs and head) was interdependent.

The future development of these ideas and increasing interest led to the establishment of the Hare Association For Physical Ability (HAFPA) in 1990. The objectives of the Association were to disseminate The Approach: to define, explore, record and to encourage research. The Hare Approach continues to influence thinking in both the treatment and management of neurological disability, although the origin is often unrecognised.

 History

Noreen Hare trained at Guys Hospital in London where she gained her physiotherapy diploma, with distinction, in 1956. Following a time in general physiotherapy she was introduced to working with children while at the Westminster Hospital, London. She remained in paediatrics until her retirement in 1992.

Early in her career she studied under Mrs Bertha Bobath and subsequently became a Bobath tutor. She spent six years in Canada where she was exposed to children who had suffered the appalling consequence of severe neurological disability. This prompted her to question the role of physiotherapy in the management of these conditions, and she became aware of the total lack of measurement of outcome. The beginnings of her questioning current physiotherapy practice was followed by many years of major conflict in her own mind, and eventually drove her to challenge the established practice.

In 1969 she returned to England and became superintendent at the Cheyne Centre in London until 1983. At the time The Cheyne Centre was an international centre of excellence for the treatment and management of children with cerebral palsy which also provided an education programme for doctors and therapists.

It was an ideal environment for evaluating different approaches (Bobath, Peto, Vojta, Halliwick Swiming Method); the group being homogeneous in that all the children had the same diagnosis, i.e. cerebral palsy and they were supported by a truly multi-disciplinary team. In addition Cheyne benefited from not following a particular philosophy which enabled professionals to pursue many ideas.

Amidst this highly stimulating atmosphere Noreen was formulating her ideas and constantly questioning her working practice. During regular clinical meetings these ideas were discussed, explored and questioned, her staff being encouraged to problem solve and develop their own thinking. She was never prescriptive, but always asked for justification for any actions undertaken. By doing this she not only encouraged therapists to develop their own strategies for using her ideas but also gained feedback from them which led to further development of her philosophy. In many ways this was a much more complex and difficult task that that of teaching a more firmly defined treatment.

During this time Noreen investigated normal development in depth and the relevance of this to the understanding of the problems related to the disabled child was an important step in the evolution of her thinking and ideas. This culminated in developing a means to classify ability (as opposed to disability) in all positions (The Physical Ability Scale)

Noreen was invited to present her work at courses and conferences, which required her to formulate her thinking. Her first publication stems from this time and was published by The Friends of The Cheyne Centre in 1984. (Ideas Developed at The Cheyne Centre 1969-1983).

In 1983 Noreen was appointed Superintendent Physiotherapist at University Hospital in Nottingham. Her responsibilities included bringing together the paediatric service across the whole of Nottinghamshire. This included acute and community services in hospitals, special and mainstream schools and colleges. She continued to critically appraise her own clinical work and encouraged her colleagues to do likewise.

Her staff carried out a research project that investigated the physical ability and quality of life in children with a neuromuscular condition before and after corrective surgery for scoliosis. The Physical Ability Scale, which Noreen had formulated at Cheyne, was used successfully to monitor change in this group of children. This work was published (Hallett at al 1987; Hallett 1992; Askin et al 1997).

In 1986, Noreen presented her ideas at the Physiotherapy Congress, which provoked further discussion, particularly in relation to what Noreen had termed the Human Sandwich Factor i.e. the effect of gravity in the development of posture and movement ( “Children Keep You Thinking”, Dorothy Henham, March 1988, Therapy Weekly, “Hypothesis on Movement”, Jennie Willis, August 1989, Therapy Weekly).

Following her retirement from the superintendent post in Nottingham in 1992, Noreen continued to expound her ideas through numerous courses, workshops and in consultancy work.

In 1990 the Hare Association was founded with the express purpose of disseminating the Approach; to clarify and document the ideas and to promote research..

The Association published presentations given by professionals from a variety of health related disciplines at Study Days and Workshops throughout the 1990’s ( Booklets 1-8 HAFPA ). These contributions confirmed the infiltration and wider application of the Hare Approach not only with respect to paediatrics but also into various aspects of adult neurology.

Noreen Hare was awarded a Fellowship of the CSP in 2000.

Sadly, Noreen Hare died in October 2006.

Copyright © 2007 Hare Association for Physical Ability