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By Alan D. Forker, MD, FACC
In the report of the national institutes of health (NIH) entitled, "Alternative Medicine; Expanding Medical Horizons," three movement and physical touch therapies were discussed under the topic of Postural Re-Education Therapies: Feldenkrais, Alexander, and Trager. Now they more commonly are described under the overall title of "bodywork."1 This review will focus on the Feldenkrais method (of bodywork); the Alexander technique and Trager approach will be described briefly. All three are best utilized in the prevention and treatment of musculoskeletal disorders; but they also have been used in headaches, chronic lung disease, Ménière’s disease, and mental depression.2
The fundamental concept of each therapy is to become more self-aware and learn by experiencing and doing. From the perspective of this inexperienced observer, there appears to be much overlap between the three. When Moshe Feldenkrais, DSc, was asked to compare his technique with physical therapy, chiropractic, yoga, Shiatsu acupressure, Rolfing, Alexander technique, spiritual practices, and psychotherapies, he replied, "My work is more fundamental."3
The goal of the Feldenkrais method is to rebalance muscles with minimal muscle tone to maintain the erect posture.
Feldenkrais described the skeleton and muscles of the human body as three upside-down pyramids balanced on each other.4 Specifically, the top pyramid would be the head on top of the cervical vertebrae; the sec- ond pyramid would be shoulders above the lumbar vertebrae; and the third or bottom pyramid would be the pelvis on top of the legs. The center of gravity is high and frequently creates an unstable balance of extensors (or antigravity muscles) and flexors. To achieve and maintain erect posture, the sixth or the kinesthetic sense must be "re-educated and reset."
Feldenkrais used two forms of teaching.3-7 Awareness through movement (ATM) is taught in a group setting with verbal instruction. A student lies flat on the floor or sits in a chair, and slowly and cautiously learns to sense minor degrees of movement and what feels best (to see Figure, click here.) Exercises involving breathing, bending, and twisting—first in one direction and then in the opposite direction—are employed. Which feels more natural? Is there movement in the entire spine? Using ATM, a student learns to sense, feel, and see small differences in movement. Hundreds of exercises are utilized.
Functional integration (FI) is taught individually using gentle touch to guide the learner through different movements, usually on a table. The FI teacher develops a lesson tailored to the unique configuration of the student, and guides the student with his/her hands by tactile, kinesthetic communication, not massage or chiropractic manipulation.
Very few high-quality, published clinical research data were found searching the Feldenkrais Guild, the Internet, PubMed, and the Cochrane Collaborative Database. No data were found comparing the Feldenkrais, Alexander, and Trager bodywork techniques.
Minimal well-done clinical trial data can be presented. Most Feldenkrais data are anecdotal and consist largely of case reports. Julius Erving, Whoopi Goldberg, and YoYo Ma have tried it. A typical report, like the one by Lake, presents pre- and post-postural instruction photos of six cases and minimal objective data on physical examination, with no attempt to quantify disability.8
Johnson et al conducted a randomized controlled trial on Feldenkrais and multiple sclerosis.9 Twenty patients (15 female, 80% white) with a moderate disability score received 45 minutes of instruction weekly and were followed for 16 weeks. The sham or control groups received light touch with soft music (i.e., primarily relaxation therapy). No significant differences in any of the performance measures and symptoms occurred, but positive psychological benefits were noted.
Guttman et al published a trial of Feldenkrais vs. conventional exercise therapy in elderly residents of two retirement homes in British Columbia.10 One retirement home utilized Feldenkrais (19 treated, 19 control) and the second retirement center utilized conventional exercise (13 exercise, 16 control) for a total of 67 enrollees. Individuals who completed at least half of the sessions at six weeks were retested for rotation flexibility and balance. No significant differences in any major measurement were found. Perceived positive benefits included improved overall health, better sleep, and more energy. Limitations include the small sample size, the very short study period, and measurements that may not have been sensitive enough to show any change. Finally, what was most important: Feldenkrais, exercise, or the favorable effect of interest and attention shown to the participants?
James et al described a trial of Feldenkrais vs. relaxation therapy on hamstring length in 48 normal undergraduate physiotherapy students in Australia.11 Felden-krais lessons (four total) involved listening to one of four different audio cassette tapes; no description of the method or instruction was provided. No significant difference was shown at two weeks.
Laumer et al described the use of Feldenkrais in eating disorders.12 Fifteen patients were randomized to a nine-hour course utilizing Feldenkrais vs. 15 controls. The outcome measure was six psychological scales; with short-term follow-up, no significant differences were found. The Feldenkrais group did have increased self-confidence and contentment, and were more spontaneous and experienced fewer feelings of hopelessness.
In the 1992 NIH workshop, three studies on Feldenkrais were mentioned: One was an abstract describing one patient;13 another was an unpublished master’s thesis describing four patients with rheumatoid arthritis;14 and one utilized a small number of normal college students.15 None of the outcomes were long-term. Two recent textbooks both conclude that only anecdotal information is available.16,17
The best overall review of complementary and alternative therapies for multiple sclerosis included only one article on Feldenkrais.18 The author noted a key difference between massage and Feldenkrais: Feldenkrais methods encourage a life-long discovery process through which patients learn why they have pain and distress while they learn how to become more aware and promote self-healing.
Moshe Feldenkrais was born in the Ukraine in 1904 and immigrated to Palestine at age 13. While playing soccer as a young man, he had a severe injury to his left knee, tearing ligaments and cartilage. In 1928, he moved to Paris to study physics, mathematics, and mechanical and electrical engineering; he obtained a doctorate of science at the Sorbonne. He was invited to work with Frederic Joliet-Curie, who was awarded the 1935 Nobel Prize in chemistry; Moshe was his principal assistant at this time.3
A bus accident aggravated his old knee injury. Moshe consulted English surgeons who told him that surgery had a 50% chance of success. He began searching for a better answer, studying anatomy, physiology, neurophysiology, exercise and movement therapy, psychotherapy, spiritual practices, Yoga, hypnosis, and acupuncture. He applied what he learned to his own knee and never had knee surgery.
In 1949, he returned to Israel as the First Director of the electronics department, Israel Defense Force. He was introduced to Prime Minister David Ben-Gurion, who had chronic back pain and breathing difficulties. Working with Feldenkrais, Ben-Gurion improved dramatically; in fact, at age 76 (1962), a photo, which was published in Parade Magazine, was taken while he stood on his head on a beach in Tel Aviv. Feldenkrais and his technique became well known in Israel.
To locate a practitioner and or join a training program, contact the Feldenkrais Guild of North America: (800) 775-2118 or http://feldenkrais.com.
The Alexander Technique is named after a Shakespearian actor, Frederick Matthias Alexander (1869-1955), who concluded that poor posture was responsible for his recurrent episodes of voice loss. The technique aims for proper alignment of the head, neck, and spine so the body can move more efficiently. The technique still is widely used by actors, musicians, and athletes to improve performance. The Alexander Technique often is taught one-on-one; a typical session lasts 30-60 minutes and costs $40-$90. The American Society of the Alexander Technique can be reached at (800) 473-0620 or http://www.alexandertech.org.2
A Hawaiian physician (and former boxer, dancer, trainer, and gymnast) named Milton Trager, MD (1909-1997) developed the Trager Approach. The technique includes compressions, elongations, light bounces, and rocking motions. A typical session lasts 60-90 minutes and costs $50-$120. The Trager Institute can be reached at (216) 897-9383 or http://www.trager.com.2
Feldenkrais appears to produce relaxation, a sense of well-being, and attention to better posture. Reputable clinics, such as Scripps in La Jolla, CA, already offer it with physical therapy; many physical therapists use it in their practices.19 With a lack of evidence-based research, it is difficult to make definite conclusions regarding the scientific merit or cost effectiveness of Feldenkrais.
For willing, interested patients with low back pain or other forms of muscular soreness and pain; movement disorders associated with cerebral palsy, Parkinsonism, or multiple sclerosis; or post-stroke disability, consider the Feldenkrais method and massage. Similarly, for entertainers and competitive athletes, the Feldenkrais method is an approach that may relieve stress and improve performance. What I most strongly recommend is long-term clinical trials that include a greater number of patients, utilize better outcome measures, and minimize dependent variables.
Dr. Forker is Professor of Medicine, University of Missouri-Kansas City School of Medicine and Clinician-Educator at Mid America Heart Institute of St. Luke’s Hospital in Kansas City.
1. Alternative Medicine: Expanding Medical Horizons. A report to NIH. Washington, DC: U.S. Government Printing Office; 1992.
2. Weil A. Self Healing. Waltertown, MA: Thorne Communications; April 2001.
3. Shafarman S. Awareness Heals: The Feldenkrais Method for Dynamic Health. Reading, MA: Perseus Books; 1997.
4. Moshe Feldenkrais. Body and Mature Behavior. Madison, CT: International Universities Press; 1949.
5. Moshe Feldenkrais. Awareness Through Movement. New York: Harper Collins; 1972.
6. Moshe Feldenkrais. Body Awareness as Healing Therapy: The Case of Nora. Berkeley, CA: Somatic Resource; 1977.
7. Moshe Feldenkrais. Master Moves. Capitola, CA: Meta Publications; 1984.
8. Lake B. Acute back pain: Treatment by Feldenkrais Principles. Aust Fam Physician 1985;14:1175-1178.
9. Johnson SK, et al. A controlled investigation of bodywork in multiple sclerosis. J Altern Complement Med 1999;5:237-243.
10. Gutman GM, et al. Feldenkrais versus conventional exercises for the elderly. J Gerontol 1977;32:562-572.
11. James M, et al. The effects of Feldenkrais program and relaxation procedures on hamstring length. Aust J Physiother 1998;44:49-54.
12. Laumer U, et al. Therapeutic effects of Feldenkrais method "awareness through movement" in patients with eating disorders [in German]. Psychother Psychosom Med Psychol 1997;47:170-180.
13. Jackson-Wyatt O, et al. Effects of Feldenkrais practitioner training program on motor ability: A video analysis. Phys Therapy 1992;72(suppl):S86.
14. Narula M. Effects of six week Feldenkrais Method on selected functional movement parameters with rheumatoid arthritis. Unpublished Master’s Thesis. Rochester, MI: Oakland University; 1993.
15. Ruth S, Keggerries S. Facilitating cervical flexion using Feldenkrais method. J Sports Phys Ther 1992;16:25-29.
16. Spencer JW, Jacobs JJ. Complementary Alternative Medicine: An Evidence Based Approach. St. Louis, MO: Mosby; 1999.
17. Jonas WB, Levin JS. Essentials of Complementary and Alternative Medicine. Philadelphia, PA: Lippincott, Williams and Wilkins; 1999.
18. Huntley A, Ernst E. Complementary and alternative therapies for multiple sclerosis: A systematic review. Complement Ther Med 2000;8:97-105.
19. Deross CP, Porterfield JA. A physical therapy model for treatment of low back pain. Phys Therapy 1992; 72:261-272.