Frank Wildman, Ph.D.
James Stephens, Ph.D., P.T.
The first research study involving Feldenkrais Method® (FM) was published in 1977 with several more appearing in the next decade. Since 1988 there has been an increasing amount of research done and recently this has been increasing each year. Because FM has such a wide range of effects, a wide range of outcomes has been looked at and reported. Most of the clinical studies to date have involved a very small number of subjects (6 or fewer). Some are larger, using control group designs. The areas of outcome break down into the following four general themes:
- PAIN MANAGEMENT: Case studies describing the resolution of chronic back pain following the failure of other methods to ameliorate the problems have been published by Lake (1) and Panarello-Black (2). A retrospective study of 34 patients using FM as an adjunct to treatment in a chronic pain management clinic showed that FM helped to reduce the pain and improve function and still was used independently by patients two years postdischarge (3). Dennenberg (4) showed decreased pain and increased functional mobility using FM as a component of treatment for 15 pain patients. The primary result of this study was to show that there were changes in the pattern of health locus of control in patients participating in FM. A study using a group ATM intervention with five fibromyalgia patients showed significant decrease in pain and improved posture, gait, sleep, and body awareness (5). Lake (6) showed changes in posture in patients with chronic back pain following FM. Chinn et al (7) showed improvements in functional reach in symptomatic subjects. Idebergs (8) showed significant changes in pelvic rotation and pelvic obliquity during rapid walking in 10 patients with back pain compared to normal controls, following a series of Functional Integration lessons. Narula showed decreased pain and improved function, including improved biomechanic efficiency, measured by motion analysis, in a sit-to-stand transfer from a chair, in several people with rheumatoid arthritis following six weeks of ATM lessons (9).
- FUNCTIONAL PERFORMANCE AND MOTOR CONTROL: Function is a result of movement. Changes in the process of control of movement therefore influence function. As noted above in relation to pain patients, there were changes in movement pattern leading to reduction of pain. These were patterns involved in the activities of walking (8), transfers (9) (10) posture, reaching, and general activities of daily living (11) (12).
As well as with orthopedic pain patients, functional improvements have been described in people with neurologic diagnoses. Although there was no formal quantitative assessment of balance, four women with multiple sclerosis reported improvements in balance in daily activities and improved walking and transfers, as assessed by video motion analysis. (13)
Shenkman described improvements in posture in individuals with Parkinson’S disease using FM as part of the intervention strategy (14). Shelhav-Siiberbush has reported case studies of two children with cerebral palsy who made major functional gains during several years of FM work (15). Ginsburg has anecdotally described functional and motor control improvements in young people with spinal cord injuries who were involved in the “Shake a Leg” program (16). Gilman has reported improved control of stuttering in two patients (43).
As well as improving function in people with impairments, FM also is used to improve athletic function. At this time the evidence for this is mostly anecdotal for skiing (17) and kayaking. Jackson-Wyatt’s has reported a case study of improved jumping following a Feldenkrais intervention.
There is also interest in athletic injury prevention using ATM to improve flexibility and control. An initial study published in this area showed no increase in hamstring length following a single ATM lesson (19). However, this study has several important design problems and further work is underway as follow-up.
- PSYCHOLOGIC EFFECTS: Feldenkrais’ initial intentions in the application of his work were to improve a person’s awareness of the body in action (Awareness Through Movement), improving the integration of functions (Functional Integration) and thereby effect a process of change leading to greater emotional maturity (20). This has been studied very little. Dennenberg (4) has noted changes in health locus of control. Self-efficacy has been shown to be a significant correlate of successful rehabilitation, but there have been no studies published on this to date. Several studies are under way with patients with diagnoses of multiple sclerosis and fibromyalgia.
In an interesting study using analysis of clay figures, Deig described expansion in the detail and form of body image after a series of ATM lessons (22). Shelhav-Silberbush has shown improvements in mobility skills, social function and IQ scores in a class of learning impaired children (23). Recently, in a matched control group study of 30 children with eating disorders, Laumer concluded that a course of ATM facilitated an acceptance of the body and self, decreased feelings of helplessness and dependence, increased self-confidence and a general process of maturation of the whole personality (24).
- QUALITY OF LIFE: Quality of life and its associated measures of perceived health status is becoming an increasingly important and widely used construct in assessing the overall outcome of a process of rehabilitation. In a problematic study that showed no significant functional or physiologic changes, Gutman (25) showed a trend toward improvement in overall perception of health status in a healthy older adult population. This finding has been corroborated in a similar population by improvements in vitality and mental health as measured by the SF-36 (26) and in a group of women with multiple sclerosis using the Index of Well-Being (13) (27).
Theory underlying the Feldenkrais Method® assumes a process of learning that is based in hard changes in the nervous system. Through this process an image of the body is constructed that corresponds to movement. In movement, a person then interacts with the environment in a loop of perception and action that further refines movement and the sensory-perceptual processes. Dynamic systems theory as described by Thelen (28) and Kelso (29) best fits the observed processes of the Feldenkrais Method. This theory accounts for the process of skill acquisition, functional development, and organization change resulting from changes in posture and coordination (30) and relies on an understanding of the body as having a modifiable internal representation of body scheme (31) that includes the shape of the body surface, limb length, sequence of linkage, and position in space (32). The process of skill acquisition, coordination change, or functional or motor development is driven by a process of active exploration involving awareness (27) (33).
Over the last 15 years, research in the area of neuroplasticity has built a solid foundation for the concept that interaction with the environment and changes in the structure of the body are represented by measurable changes in the process of representation in the cortex (34) (35). These changes may underlie and be related to basic processes of learning (36) (37). This plasticity of the central nervous system may be both the source of chronic functional problems and the means to recovery from them (38) (39).
Although none of the research on Feldenkrais Method® addresses this basic level of physiologic function, physiologic changes do occur that fit within this theoretic framework. Some functional changes have been mentioned in the previous section. Others include changes in function of trunk and cervical muscles reflected by changes in EMG activity (41) (41), changes in muscle function and posture related to improvements in abdominal breathing (42), and changes in body image or scheme (21) (23). Narula (43) also has reported increases in EMG activity in cases of low back pain where it appears that painful muscles had become inactive. It may be that reintegration of these muscles into normal movement patterns stimulates blood flow and thus a normal healing process.
Risk and Safety
There is very little risk involved in the use of this method. It is both conservative and safe. People are instructed to stay generally within the bounds of pain-free ranges of motion and use as little effort as possible to perform a movement. Comfort and ease and the explicit guides are understood to be part of the optimal conditions for learning. It is still possible for a person who has fibromyalgia or adhesive capsulitis to do too much and have pain as a result. However, if this should occur, limits are learned that then can be applied to future sessions. This kind of outcome happens infrequently and most often in home sessions not supervised by a practitioner, in which the student reverts back to a “more is better” philosophy so common in our culture. Often as a result of a slow and comfortable approach, people learn that they can do much more with much greater safety and comfort than they had imagined possible.
Generally, no statistics are known or published on the efficacy of this method. All conclusions about this are based on hearsay and general impressions. One of the authors (JS) takes the liberty here to report on the efficacy of using Feldenkrais Method® as part of a rehabilitation process with 166 patients over the last five years in his private practice. Outcome has been judged on percentage of the original goals established at the initial visit that were achieved by the time of discharge. Four levels of outcome were used: 1) 100% achieved; 2) 75% to 90% achieved; 3) 50% to 75% achieved; and 4) less than 50% achieved.
Orthopedic cases made up 84% and neurologic cases made up 16% of the population. Age range was from 8 to 84 years, with most people being between 30 and 60 years. In thirty-five cases of back pain, 77% reached level 1 outcome and 91% reached a level 1 or 2. Of twenty cases of osteoarthritis, 80% reached level 1 and 95% reached level 1 or 2. 76% of seventeen people with a primary diagnosis of neck pain reached level 1 and 88% reached at least level 2. In thirteen shoulder diagnoses, 69% achieved level 1 and 92% reached at least level 2. Of six people with fibromyalgia, 83% reached level 1 and all reached at least level 2. Of fourteen people with tendonitis or bursitis or other hip and knee problems, 85% reached level 1, an additional 7% reached level 2, and another 7% reached level 3. Of eight people with back and leg pain from spinal stenosis of spondylolisthesis, 63% achieved level 1, an additional 12% reached level 2, and 25% achieved level 3 or 4. Of three TMJ cases, 2 reached level 1 and the other reached level 2. And of five people with scoliosis, 80% reached level 1 and 20% reached el 3. Reaching level 1 does not mean that the scoliosis was reversed. It means that pain was significantly reduced and function improved with long-term success.
Of the twenty-seven neurologic cases, 60% were people with multiple sclerosis or stroke. Of the people with stroke, 50% achieved level 1 and 50% achieved level 2. Of the multiple sclerosis cases, 50% reached level 1 and only 17% were discharged below level 2.
Overall, out of one hundred sixty-six patients, 70% reached level 1, 22% reached level 2, 6.6% reached level 3, and 1.2% were at level 4 at discharge.
Ongoing and Future Research
As we stated at the beginning of this section, research on the Feldenkrais Method has just started in the last ten years. Several studies are now in progress related to balance and self-efficacy in people with multiple sclerosis; function and length of the hamstrings; pain, function, and self-efficacy in people with fibromyalgia; the efficacy of ATM as an adjunct to cardiac rehabilitation; and, back pain related to postural and motor control variables. The Feldenkrais Guild also is in the process of establishing a procedure for systematic collection of outcome data by all practitioners across the U.S. who want to participate in a multisite outcome study.
Other areas for future research include: injury prevention and performance enhancement in athletes, dancers, and musicians; controlled outcome studies with people who have had strokes, head injuries, and cerebral palsy; introduction of ATM into elementary schools to enhance self image, attention capacity, and learning; study of other psychologic dimensions, such as body scheme, self-esteem, self-efficacy, anxiety, and learning; and inquiry into physiologic mechanisms of action, including balance and postural control, proprioception, and timing and sequencing on muscle activity in movements.