Review Article The Effectiveness of the Feldenkrais Method…feldenkraisinstitute.com/images/uploads/Hillier_2015.pdf · Review Article The Effectiveness of the Feldenkrais Method:

Review ArticleThe Effectiveness of the Feldenkrais Method: A SystematicReview of the Evidence

Susan Hillier1 and Anthea Worley2

1 International Centre for Allied Health Evidence, Sansom Institute of Health Research, School of Health Science,University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia2School of Health Science, University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia

Correspondence should be addressed to Susan Hillier; [email protected]

Received 16 December 2014; Revised 4 March 2015; Accepted 9 March 2015

Academic Editor: Cun-Zhi Liu

Copyright © 2015 S. Hillier and A. Worley. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The FeldenkraisMethod (FM) has broad application in populations interested in improving awareness, health, and ease of function.This review aimed to update the evidence for the benefits of FM, and for which populations. A best practice systematic reviewprotocol was devised. Included studies were appraised using the Cochrane risk of bias approach and trial findings analysedindividually and collectively where possible. Twenty RCTs were included (an additional 14 to an earlier systematic review). Thepopulation, outcome, and findings were highly heterogeneous. However, meta-analyses were able to be performed with 7 studies,finding in favour of the FM for improving balance in ageing populations (e.g., timed up and go test MD −1.14 sec, 95% CI −1.78,−0.49; and functional reach test MD 6.08 cm, 95% CI 3.41, 8.74). Single studies reported significant positive effects for reducedperceived effort and increased comfort, body image perception, and dexterity. Risk of bias was high, thus tempering some results.Considered as a body of evidence, effects seem to be generic, supporting the proposal that FMworks on a learning paradigm ratherthan disease-based mechanisms. Further research is required; however, in the meantime, clinicians and professionals may promotethe use of FM in populations interested in efficient physical performance and self-efficacy.

1. Introduction

The Feldenkrais Method (FM) was developed over a periodof decades in the last century by Dr. Moshe Feldenkrais.He claimed the basis of the approach was founded in thehuman potential for learning how to learn [1]. As such, heoperationalized an experiential process or set of processes,whereby an individual or a group could be guided througha series of movement- and sensation-based explorations.Thepurpose of these explorations was to practise the nonlinearprocess of sensing the difference between twoormore optionsto achieve the stated movement task, and making a discern-ment about which may feel easier, that is to say, performedwith less effort.These perceptual discernments are predicatedon a judgement that is positive (pleasurable, easy, and withless effort) compared with experiencing a less favourablefeedback signal such as pain, strain, or discomfort. Furtherto this, the participants are encouraged to generate manyalternative movement solutions to the guided task to increase

the opportunity for further distinctions and improvementsto be made. Thus the process of intention, action, gainingfeedback, making decisions, and reenacting with adaptationsconstitutes the learning framework in a somatic context [2].

The two modes of delivery that are offered to the publicare either individual, manually directed lessons (functionalintegration, FI) or group, verbally directed classes (aware-ness through movement, ATM). The nomenclature for bothreflects the fundamentals of the approach—that movementhas to be based on a functional or meaningful intentionfor the system to engage and that by becoming awareof what and how we act (move) we become in a betterplace to choose an alternative behaviour (movement pattern)[3]. Both modes of delivery apply the same principles ofperceptual exploration through movement that is passivelyand/or actively performed.

The method has been applied in varied domains acrosscountries, from general education or children with learningissues to enhancing performance in sports and theatre.

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2015, Article ID 752160, 12 pageshttp://dx.doi.org/10.1155/2015/752160

2 Evidence-Based Complementary and Alternative Medicine

The clinical applications have received the most interest inthe published literature because of the intuitive appeal ofbasing a health recovery process on a learning paradigm andbecause of the inherent fostering of self-efficacy that occursparticularly in a group setting.

In the climate of evidence-based practice in the healthdomain, any approach being offered to the public is beingscrutinized for evidence of effectiveness and, if effective, forwhat type of benefit and of what magnitude for any clinicalpopulation. An earlier systematic review of the evidence forthe method was published in 2005 by Ernst and Canter [4].This review included six randomised controlled trials (RCTs)of low to moderate quality in populations such as peoplewith multiple sclerosis, chronic low back pain, and neckissues. They concluded that there was promising evidencebut its credibility was tempered due to the low number ofstudies, high level of clinical heterogeneity between studies,and methodological flaws. The methods employed by Ernstand Canter [4] were robust for the time; however, their riskof bias assessment used a now discarded tool (the Jadad)and their search covered until 2003. Therefore, it is timelyto systematically update the evidence for the FeldenkraisMethod with current review procedures.

This review had the aims of

(1) systematically identifying and appraising the evi-dence for the effectiveness of the Feldenkrais Methodacross domains;

(2) determining what is the nature and order of magni-tude of any beneficial effects and for which popula-tion/s.

2. Materials and Methods

2.1. Criteria for Considering Studies for This Review. Weemployed systematic review methods based on the PRISMAguidelines [5].

2.2. Types of Studies. Weconsidered all types of primary stud-ies in the first instance in order to fully explore the potentialpopulations and outcomes covered. In the final inclusion onlystudies with a random allocation and a stated control groupwere included. Any secondary researches (systematic andsemisystematic reviews) found were not included, but rathertheir included studies were retrieved in full and added to thepotential pool in order for all primary studies to be appraisedwith a consistent method.

2.3. Types of Participants and Outcomes. We included anypopulation where there was an outcome of interest related toimprovement in health and/or function.

2.4. Types of Interventions and Comparisons. Either formof Feldenkrais Method (functional integration or awarenessthrough movement) was included as the sole approach forthe intervention group.The comparison group could includeplacebo, inactive control, or an alternate method.

2.5. Search Methods for Identification of Studies. We searchedthe databases of AMED (Allied and ComplementaryMedicine), Embase Classic + Embase, Ovid MEDLINE(R),Cochrane, PsycINFO, PubMed, and Google Scholarfrom inception to July 2014. We considered all languages (thesearch was open to all listed journals irrespective of language)and publication status (we would include unpublished trialswherever found, e.g., through experts in the field or greyliterature such as organizational websites).

The search terms included variations and combinationsof methodology terms (such as randomised, trial, clinical,and controlled), with intervention terms such as FeldenkraisMethod, (awareness through movement and functional inte-gration). An example of the terms employed in the electronicsearch strategy is presented in Table 1.

From the generated lists from each database, duplicateswere removed and the first high level sift was performed byone author based on title alone. The second level of reviewwas performed by both authors and required retrieval of theabstract at theminimum.The retained studies were examinedin full to confirm inclusion. Those excluded were recordedwith reasons.

All retrieved studies were checked for additional refer-ences, and experts in the field were contacted to assist inidentifying any further studies published or unpublished.Experts were provided from the membership of peak FMbodies (the Australian Feldenkrais Guild and the Interna-tional Feldenkrais Federation) and were asked to supplyfurther papers by email.

2.6. Data Collection and Analysis. Relevant data wereextracted from each of the included studies using a standardtrial summary sheet by one author and checked by the second.Data included author, date, study design, population sample,intervention, comparison, outcome measures, results, andcomments. A risk of bias evaluation was also performed foreach study by one author using standard Cochrane tables[26] with checking and data entry by the second author. Anydisagreements were resolved by consensus, with a third partyif necessary.

Where possible, data were extracted for meta-analyses.We planned to extract and analyse data to calculate individualand total effect sizes through odds ratios or mean differences(fixed effect or random effect if the studies were small and/orheterogeneous) and 95% confidence intervals. Statistical het-erogeneity would be evaluated based on visual inspectionof forest plots and on the 𝐼2 statistic. It was not anticipatedthat any other analyses would be possible (e.g., subgroup orpublication bias) due to a paucity of studies.

If we found that meta-analyses were not possible, thenresults would be synthesized and reported narratively.

3. Results

3.1. Included Studies. The systematic search yielded over1,300 initial titles for high pass screening. See Figure 1 forthe PRISMA Flow diagram. With duplicates and obviouslyirrelevant titles removed, 124 records were considered at the

Evidence-Based Complementary and Alternative Medicine 3

Table 1: Example of search strategy.

Number Searches Results

1 (Clinical trial or randomised trial or controlled trial).mp. [mp = ab, hw, ti, sh, tn, ot,dm, mf, dv, kw, nm, kf, ps, rs, an, ui] 1900972

2 (Feldenkrais or awareness through movement or functional integration).mp. [mp =ab, hw, ti, sh, tn, ot, dm, mf, dv, kw, nm, kf, ps, rs, an, ui] 2239

3 1 and 2 474 Removing duplicates from 3 40

Table 2: List of papers excluded with reasons.

Studies Reason for exclusionKirkby (1994) Controlled trialBearman (1999) Pre/posttest (no control)Seegert (1999) Controlled trialHuntley (2000) Systematic reviewDunn (2000) Pre/posttest (no control)Fialka-Moser (2000) CommentaryMalmgren-Ohlsen (2001,2002, 2003) Controlled trial

Kerr (2002) Controlled trialEmerich (2003) ReviewJunker (2003) Posttest (no control)Galantino (2003) ReviewGard (2005) ReviewMehling (2005) ReviewLiptak (2005) ReviewBatson (2005) Pre/posttest (no control)Wennemer (2006) Pre/posttest (no control)Porcino (2009) DescriptiveMehling (2009) Review (assessment)Connors (2010) Content analysisConnors (2011a) Controlled trialConnors (2011b) Pre/posttest (no control)Mehling (2011) Inquiry (phenomenological)Ohman (2011) Pre/posttest (no control)Laird (2012) Review

Mehling (2013) Intervention (not exclusivelyFeldenkrais)

Gross (2013) ReviewWebb 2013 Pre/posttest (no control)

abstract level by both authors, with an additional two studiesprovided from experts in the field (newly published, one RCT,one non-RCT). Seventy-seven abstracts were excluded at thisstage because they were did not report an investigation of theFM and/or did not involve a trial of effect. Forty-seven full-text articles were reviewed against the criteria and further 27excluded with reasons noted in Table 2.

Fourteen newRCTswere included alongwith the originalsix studies from the Ernst and Canter [4] review. See Table 3for details of all included studies. From this total of 20 studies,

there were seven studies sufficiently homogenous to allow formeta-analyses.

3.2. Description of Studies. Publication dates ranged from1991 [12] to 2014 [25]. Populations under investigation in theincluded RCTs ranged from healthy volunteers [6, 12, 15–17, 19, 24], healthy ageing [21–23], institutional ageing [25],people withmultiple sclerosis [7–11, 13], eating disorders [14],myocardial infarct [18], and sleep bruxism [20]. Studies gen-erally had small sample sizes with a mean of 40.8 participants(SD 23.5).

The nature of the Feldenkrais interventions also variedin delivery mode, intensity, and frequency. The predominantmethods were single or multiple ATM lessons deliveredeither in a group or individually using audio recording.The comparison groups were most commonly an alternateform of therapy. Fourteen trials had active controls (suchas relaxation classes or generic movement/balance classes)and six had a passive or inactive control (usual activities/nointervention).

Outcomes were also highly heterogeneous in keepingwith the needs of the diverse populations and are listedin Table 3. The measures related to performance or activityoutcomes (e.g., balance or dexterity), symptoms (e.g., pain,effort or mood) or were related to quality of life.

3.3. Excluded Studies. Table 2 summarises the list of studies(27) that were retrieved but excluded. Reasons for exclusionwere predominantly around design: two were systematicreviews; five were controlled trials (not randomly allocated);eight had no control group; eightwere nonsystematic reviews;onewas not exclusively Feldenkrais in the intervention group;one was a content analysis of an intervention; one was aphenomenological analysis; and one was a commentary.

3.4. Risk of Bias in Included Studies. Risk of bias was high inmost studies. Less than a quarter of the studies had adequaterandom allocation processes and only a third had blindingof outcome assessments. It has to be acknowledged that fortrials requiring an intervention like Feldenkrais it may bedifficult or inappropriate to expect blinding of therapists oreven participants, though participants can be blinded to theintervention of interest if there is a plausible comparisongroup (such as a relaxation or other forms of movement-based class). Figures 2 and 3 summarize the risk of biasanalysis. It can be seen that a definitive judgement could notbe made in many cases as it could not be confirmed whether


Scre

enin

gIn

clude

dEl

igib

ility

Iden

tifica

tion Records identified through

database searching (after high leveltitle screening) (n = 176)

Additional records identifiedthrough other sources (n = 2)

Records after duplicates removed(n = 124)

Records screened (n = 124) Records excluded (n = 77)

Full-text articles assessedfor eligibility (n = 47)

Full-text articles excluded,with reasons (n = 27)

Studies included inqualitative synthesis (n = 20)

Studies included inquantitative synthesis

(meta-analysis) (n = 7)

Figure 1: PRISMA flow diagram.

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other biases

0 25 50 75 100

Low risk of biasUnclear risk of bias

High risk of bias

(%)

Figure 2: Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.


Table3:Ra

ndom

isedcontrolledtrialsof

FM(ErnstandCa

nter,2005[4],𝑛=6)w

ithup

datedRC

Ts𝑛=14.

Author

(year)

Stud

ydesig

nSample

Interventio

nCon

trol

Outcome

Results

Com

ments

Ruth

and

Kegerreis(1992)

[6]

RCT

2parallelgroup

s30

healthy

volunteers

Sing

leFM

sequ

ence

Participationin

other

rand

omactiv

ities

Degreeo

fneckflexion

(gon

iometer);perceivedeffort

durin

gflexion

Greater

degree

ofneck

flexion

(gon

iometer)(𝑃<0.01);less

perceivedeffortd

uringflexion

(𝑃<0.05)

Stud

yhasp

ilotcharacter

John

sonetal.

(1999)[7]

RCT

2-grou

pcrossover(2ph

ases)

20peop

lewith

MS

FM:8×45min

sessions

atweekly

intervals

8weeks

sham

nontherapeuticbo

dywork

LandRhand

dexterity

(pegbo

ardtest)

;8symptom

/perform

ance

scores;

5moo

dscales

NSD

Lessperceivedstr

essfollowing

FM(𝑃=0.01)

Positiver

esultcou

ldbe

due

tomultip

letesting

for

significance

Lund

blad

etal.

(1999)[8]

RCT

3parallelgroup

s

97females

with

neck

and

shou

lder

prob

lems

FM:4

individu

alsessions,12grou

psessions

of50

mins

pw,for

16weeks,

homea

udio

tapes

(C1)ph

ysiotherapy2×

50minsp

erweekfor16

weeks;hom

eexercise

s(C

2)no

interventio

n

Clinicalassessments(4

measures);

physiologicaltests(18measures)

complaint

indices(5measures);

VASpain

ratin

gs(2

measures);

disabilityandsic

kleave

measures(4measures)

Prevalence

ofneck

pain

and

disabilitydu

ringleisu

redecreased

inFM

versus

C1or

C2(𝑃<0.05)

31of

33measuresN

SD

Impo

rtantb

aseline

differences,possib

leregressio

nto

them

ean.

High

drop

outratea

ndper

protocolanalysis.

Multip

letestingforsignificance

Stephens

etal.

(2001)[9]

RCT

2parallelgroup

s12

peop

lewith

MS

FM:8×2–4ho

urs

sessions

over

10weeks

Educationalsessio

nsover

10weeks

3clinicaltestsof

balance;

3symptom

scales

Sign

ificant

improvem

entinFM

comparedto

Cform

CTSIBand

BalanceC

onfid

ence

Scale;other4

outcom

esNSD

Very

smallsam

ples

ize.No

baselin

edatao

rstatistic

alanalysisavailable

Smith

etal.

(2001)[10]

RCT

2parallelgroup

s

26patie

ntsw

ithchroniclow

back

pain

FM:one

30-m

inute

session

Attentioncontrol

Pain

(McG

ill);

anxiety(STA

I)

FMno

tCredu

cedaffectiv

edimensio

nof

pain

pre-po

st(𝑃=0.04)C

notF

Mim

proved

sensorydimensio

nof

pain

pre/po

sttest(𝑃=0.03)

NSD

fore

valuatived

imensio

nof

pain

oranxiety

Onlyacutee

ffectsw

ere

measured.Ba

selin

edifferences

betweenFM

and

Cin

duratio

nof

back

pain

may

beim

portant

Grubeletal.

(2003)

[11]

RCT

2parallelgroup

s66

patie

ntsw

ithcancer

FM:5×50minutes

sessions

offunctio

nal

integrationin

additio

nto

conventio

nal

therapies

C:no

adjuncttherapy

Body

imageq

uestion

naire

;Frankfurterb

odyc

oncept

scales;

quality

oflife;

senseo

fmovem

ent;andbo

dyaw

areness

Both

grou

psim

proved

inall

outcom

emeasures

Non

significanttrend

favoured

FM

Additio

nalR

CTs

Brow

nand

Kegerreis(1991)

[12]

RCT

2parallelgroup

s

21(12men

and9

wom

en)

volunteers

pain-fr

ee

FM:45m

inaudio

tape

“activatingthe

flexors”lesson

C:listenedto

thes

ame

45min

audiotape

mod

ified

toinclu

deon

lyinstructions

pertaining

toexercise

movem

ents

EMGactiv

ityof

flexorsand

extensors(UL)

Perceptio

nof

effortd

uring

flexion

movem

ent

NSD

Therew

asan

overalldecrease

inmeanflexora

ctivity

with

nochange

inmeanextensor

activ

ityforb

othgrou

ps.

Chinnetal.

(1994)[13]

RCT

2parallelgroup

s

23subjectswith

upperb

ack,neck,

orshou

lder

discom

fort

FM:singleA

TMlesson

;22m

inaudio

tape

C:sin

gles

ham

treatment;30

mins

gentleneck

and

shou

lder

exercises

Functio

nalreach

task;

perceivedeffortd

uringthetask

NSD

Redu

cedperceivedeffortinFM

grou

p(𝑃<0.05)

Smallsam

ples

ize


Table3:Con

tinued.

Author

(year)

Stud

ydesig

nSample

Interventio

nCon

trol

Outcome

Results

Com

ments

Laum

eretal.

(1997)[14]

RCT

2parallelgroup

s30

patie

ntsw

itheatin

gdisorder

FM:9-hou

rcou

rse

C:didno

tpartic

ipatein

FM

Body

CathexisS

cale;

Body

PartsS

atisfactio

nScale;

Body

perceptio

n;em

otion

inventory;Ano

rexia-

Nervosa-Inventory

for

Self-Ra

ting;

eatin

gdisorder

inventory-2

FMparticipantsshow

edincreasin

gcontentm

entw

ithregard

toprob

lematiczoneso

ftheirb

odyandtheiro

wnhealth

andacceptance

andfamiliarity

with

theirb

ody

Fullarticlein

German

James

etal.

(1998)[15]

RCT

3parallelgroup

s

48healthy

undergradu

ate

students

FM:4×45-m

inute

sessions

over

2weeks

of4different

ATM

lesson

srecordedon

audiocassette

Relaxatio

n:4×45min

sessions

over

2weeks

listenedto

relaxatio

ntraining

audiocassette

C:no

supervise

dles

sons

Ham

stringleng

th(m

odified

AKE

test)

NSD

Insufficientexp

osure,low

statisticalpo

wer

Hop

pere

tal.

(1999)[16]

Stud

y1:RC

T2parallelgroup

sStud

y2:subsam

pleo

fStudy

1

Stud

y1:75

undergradph

ysio

students

Stud

y2:39

participantsfro

mStud

y1

Stud

y1:FM

:single

ATM,45m

inaudio

cassetteles

son(no

priorF

Mexperie

nce)

Stud

y2:4different

ATM

lesson

sover2

weeks

Stud

y1:C:

listenedto

softno

nverbalm

usic

Stud

y2:sameA

TMles

sons

over

4sessions

in2weeks

when

subjectshadpriorF

Mexperie

nce

Mod

ified

AKE

test(ham

string

leng

th);

Sitand

Reachtest;

Borg’s6–

20ratin

gof

perceivedexertio

n(duringsit

andreachtest)

Stud

y1:NSD

Stud

y2:forp

erceived

exertio

nsig

nificantm

aineffect

𝑃=0.0003.

NSD

others

Inbo

thstu

dies

therew

asa

significantd

ifference

inexertio

nlevelsbetween

males

andfemales

with

males

exertin

gmore

irrespectiveo

fgroup

Koltand

McC

onville

(200

0)[17]

RCT

2parallelgroup

s

54un

dergrad

physiotherapy

studentsw

ithno

priorF

Mexperie

nce

FM:4×45min

ATM

lesson

svia

audiocassette

over

a2-weekperio

d

Relaxatio

n:4×45min

relaxatio

nsessions

via

audiocassette

over

a2-weekperio

dC:

nospecifictasks

over

2-weekperio

d

Bipo

larform

ofthep

rofileo

fmoo

dstates

(POMS-BI)

NSD

Com

posed-anxiou

sscoreso

fthe

POMS-BI

didvary

significantly

over

time(𝑃=0.001)for

all

participants.

Females

inFM

and

relaxatio

ngrou

psrepo

rted

significantly

lower

anxietyscores

atcompletioncomparedwith

control

Nodifferences

betweenFM

andrelaxatio

ngrou

ps

Lowee

tal.

(2002)

[18]

Pseudo

rand

omized,

consecutivea

llocatio

n

60patie

nts

transfe

rred

tono

rmalward

after

acute

treatmentfor

MI

FM:2×30min

individu

alsessions

Relaxatio

n:2×30min

individu

alPM

RC:

nobo

dy-orie

nted

interventio

ns

Body

imageq

uestion

naire

(FKB

-20,German

version);

HospitalA

nxietyand

DepressionScale-German

version(H

ADS-D);

Mun

ichQualityof

Life

Dim

ensio

nsList(M

LDL);

German

versionGeneralized

Self-Effi

cacy

Scale(GSE

S)

NSD

Overallim

provem

entswere

seen

inMLD

L,GSE

S,and

FKB-20

Stephens

etal.

(200

6)[19

]RC

T2parallelgroup

s38

graduate

students

FM:5×15min

ATM

sessions/w

k,audiotapeo

ver

3-weekperio

d

C:regu

lard

aily

activ

ities

AKE

(ham

stringmuscle

leng

th)

Sign

ificant

increase

inhamstr

ing

muscle

leng

th(𝑃=0.005)in

ATM

grou

pcomparedwith

control

Participantsvarie

dgreatly

inthed

urationandnu

mbero

fho

mes

essio

nscompleted

Quinteroetal.

(200

9)[20]

RCT

2grou

p(crossover

desig

nfor

control)

3-to

6-year-old

child

renwith

sleep

brux

ism

FM:3

hrsessions×

10du

ring10-w

eek

perio

dbasedon

ATM

C:no

details

Vario

usmeasureso

fjoint

functio

n;no

cturnalbruxism

Statisticallysig

nificantincreaseo

fCV

Aangle(𝑃=0.0)for

FMc.f.C

.Afte

rintervention77%parentsin

FMrepo

rted

nono

cturnal

brux

ismc.f.15.38%forC

Atbaselin

etwogrou

pswere

comparable


Table3:Con

tinued.

Author

(year)

Stud

ydesig

nSample

Interventio

nCon

trol

Outcome

Results

Com

ments

Vrantsidise

tal.

(200

9)[21]

RCT

2grou

ps(crossover

desig

nfor

control)

55participants

aged≥55

years

FM:gettin

ggrou

nded

gracefully

program

(based

onAT

M)2×40–6

0min

sessions/w

kover

8weeks

C:continue

with

usual

activ

ity

Frenchay

Activ

ityIndex;

Hum

anAc

tivity

Profi

le;

Assessm

ento

fQualityof

Life;

Mod

ified

Falls

Efficacy

Scale;

AbbreviatedMentalTestS

core;

four-squ

ares

teptest;

timed

upandgo

test;

theS

tepTest;

Timed

Sit-T

o-StandTest;

ClinicalStrid

eAnalyzer;

force-platform

measureso

fgait,

mob

ility,and

functio

n;satisfactionsurvey

Sign

ificant

effectsforg

aitspeed

(𝑃=0.028)a

ndMod

ified

Falls

Efficacy

Scale(𝑃=0.003)for

FMgrou

p;near

significanteffectfor

timed

upandgo

test(𝑃=0.056)

Positivefeedb

ackfro

msurvey

Nosig

nificantb

aseline

differences

betweengrou

ps.

Highclassa

ttend

ance

Ullm

annetal.

(2010)

[22]

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47relativ

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unctionalScale

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ffectfora

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retal.

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FM1:AT

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roup

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neffectw

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comparedto

controlgroup

for

dexterity

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bietal.

(2014)

[25]

RCT

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amic

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uality

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nly

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:Feldenk

raisMetho

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ified

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nificantd

ifference;STA

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perlim

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neee

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Rand

om se

quen

ce g

ener

atio

n (s

elect

ion

bias

)

Bitter et al. 2011

Brown and Kegerreis 1991

Chinn et al. 1994

Hillier et al. 2010

Hopper et al. 1999

James et al. 1998

Johnson et al. 1999

Kolt et al. 2000

Laumer et al. 1997

Lundblad et al. 1999

Nambi et al. 2014

Quintero et al. 2009

Ruth and Kegerreis 1992

Smith et al. 2001

Stephens et al. 2001

Stephens et al. 2006

Ullman et al. 2010

Vrantsidis et al. 2009

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Figure 3: Risk of bias summary: review authors’ judgements abouteach risk of bias item for each included study.

therewas a clear risk of bias (given a red status) orwhether theauthors had simply not stated the process in sufficient detailfor a judgement to be made; hence the risk of bias indicatorwas left blank.

3.5. Effects of Interventions. Sufficiently homogenous data(same population, intervention, comparator, and outcomemeasure) were able to be extracted to performmeta-analysesin the areas of balance training in ageing populations.

Four studies [21–23, 25] reported on the timed up andgo assessment for balance and mobility, just failing to find infavour of Feldenkrais classes (Figure 4(a)); pooling postinter-vention measures gave a mean difference of −0.78 s (95% CI−1.69, 0.13), 𝑃 = 0.09. However, heterogeneity was high (𝐼2 =49%). Therefore, a sensitivity analysis was performed as onestudy by Hillier et al. [23] compared Feldenkrais to anotherbalance class whereas the other three studies compared theFM class to wait list control or no class. Removal of Hillieret al. [23] (Figure 4(b)) revealed a larger effect size with amean difference of −1.13 (95% CI −1.7, −0.56), 𝑃 = 0.0001,and heterogeneity reduced to a negligible level (𝐼2 = 5%). Itwas also noted that Nambi et al. [25] had narrow outcomevariability which led to a heavier weighting in the meta-analysis.

Two studies [21, 22] evaluated balance confidence usingthe Falls Efficacy Scale after FM classes (Figure 5). Pooledresults trended in favour of the FM, however, failed to reachsignificance (MD 0.59, 95% CI −0.08, 1.26; 𝑃 = 0.08).

Two studies [23, 25] evaluated balance using the func-tional reach test after FM classes (Figure 6)—pooled resultsfound in favour of the FM classes (compared to nothingor another generic balance class) with a mean difference of6.08 cm (95% CI 3.41,8.74), 𝑃 < 0.00001.

Meta-analysis was also able to be performed using threestudies measuring the influence of FM classes on hamstringlength in healthy populations [15, 16, 19]. The authors allreported the measure as an active knee extension test; how-ever, on visual inspection, the results appeared heterogeneousin terms of magnitude and range; therefore, a standardizedmean difference (rather than MD) was calculated. No sig-nificant effect was found after the intervention comparedto control (SMD 0.15, 95% CI −0.49, 0.79; 𝑃 = 0.65) andstatistical heterogeneity was unacceptably high (𝐼2 = 73%)(Figure 7).

Single randomised controlled studies reported statisti-cally significant, positive benefits compared to control inter-ventions and included the following:

(i) greater neck flexion and less perceived effort aftera single FM lesson for neck comfort [6]; reducedprevalence of neck pain and disability in symptomaticwomen after FM (individual and group sessionscompared to conventional care or home exercises) [8];reduced perceived effort in FM group for people withupper torso/limb discomfort [13];

(ii) improved balance in people with MS after eight FMsessions [9];

(iii) improved body image parameters in people witheating disorders after a nine-hour FM course [14];

(iv) reduction in nocturnal bruxism in young childrenafter 10-week course of FM lessons [20];

(v) improved dexterity in healthy young adults after asingle session of FM class [24].

Seven of the 20 studies failed to show any superior posi-tive effects of FM compared to other comparison modalities.See Table 3 for details. No studies reported adverse events.


Study or subgroup

Total (95% CI)

Mean

7.0615

11.5312.15

SD

1.721

4.062.9

Total

11202526

82

Mean

6.9216.1

11.5114.34

SD

0.881

4.134.3

Total

11202229

82

Weight

29.2%43.1%11.8%15.9%

100.0%

IV, random, 95% CIFeldenkrais Control Mean difference Mean difference

IV, random, 95% CI

0 5 10Favours Feldenkrais Favours control

−10 −5Heterogeneity: 𝜏2 = 0.40; 𝜒2 = 5.90, df = 3 (P = 0.12); I2 = 49%Test for overall effect: Z = 1.67 (P = 0.09)

0.14 [−1.00, 1.28]−1.10 [−1.72, −0.48]0.02 [−2.33, 2.37]

−2.19 [−4.11, −0.27]

−0.78 [−1.69, 0.13]

Hillier et al. 2010Nambi et al. 2014Ullman et al. 2010Vrantsidis et al. 2009

(a)

Study or subgroup

Total (95% CI)

Mean

7.0615

11.5312.15

SD

1.721

4.062.9

Total

11202526

71

Mean

6.9216.1

11.5114.34

SD

0.881

4.134.3

Total

11202229

71

Weight

81.7%7.4%

10.9%

100.0%

IV, random, 95% CI

Not estimable

Feldenkrais Control Mean difference Mean differenceIV, random, 95% CI

Favours Feldenkrais Favours control0 5 10−10 −5

−1.10 [−1.72, −0.48]0.02 [−2.33, 2.37]

−2.19 [−4.11, −0.27]

−1.14 [−1.78, −0.49]

Heterogeneity: 𝜏2 = 0.03; 𝜒2 = 2.10, df = 2 (P = 0.35); I2 = 5%Test for overall effect: Z = 3.45 (P = 0.0006)

Hillier et al. 2010Nambi et al. 2014Ullman et al. 2010Vrantsidis et al. 2009

(b)

Figure 4: (a) Effect sizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance and mobility). (b) Effectsizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance andmobility) withHillier 2010 removed (controlgroup was alternate balance class).

Study or subgroup

Total (95% CI)

Mean9.6

8.63

SD1.71.6

Total2526

51

Mean9.357.73

SD1.71.9

Total2229

51

Weight

47.4%52.6%

100.0%

IV, random, 95% CIFeldenkrais Control Mean difference Mean difference

IV, random, 95% CI

Favours control Favours Feldenkrais

0.25 [−0.72, 1.22]0.90 [−0.03, 1.83]

0.59 [−0.08, 1.26]

0 5 10−10 −5Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 0.90, df = 1 (P = 0.34); I2 = 0%Test for overall effect: Z = 1.73 (P = 0.08)

Ullman et al. 2010Vrantsidis et al. 2009

Figure 5: Effect sizes of Feldenkrais versus control for the Falls Efficacy Scale (balance confidence).

Study or subgroup

Total (95% CI)

Mean31.8936.7

SD3.982.7

Total1120

31

Mean27.6229.6

SD4.974.7

Total1120

31

Weight

36.2%63.8%

100.0%

IV, random, 95% CI4.27 [0.51, 8.03]7.10 [4.72, 9.48]

6.08 [3.41, 8.74]

Feldenkrais Control Mean difference Mean differenceIV, random, 95% CI

Favours control Favours Feldenkrais0 5 10−10 −5

Heterogeneity: 𝜏2 = 1.43; 𝜒2 = 1.55, df = 1 (P = 0.21); I2 = 36%Test for overall effect: Z = 4.47 (P < 0.00001)

Hillier et al. 2010Nambi et al. 2014

Figure 6: Effect sizes of Feldenkrais versus control for the functional reach test (measured in cm; balance).


Study or subgroup

Total (95% CI)

Mean

20.933.5149

SD

11.12.417.4

Total

751418

107

Mean

21.534.4

141.8

SD

13.72.567.6

Total

751715

107

Weight

41.6%29.4%29.0%

100.0%

IV, random, 95% CIFeldenkrais Control Std. mean difference Std. mean difference

IV, random, 95% CI

0 1 2Favours control Favours Feldenkrais

−0.05 [−0.37, 0.27]−0.35 [−1.07, 0.36]0.94 [0.21, 1.66]

0.15 [−0.49, 0.79]

−2 −1Heterogeneity: 𝜏2 = 0.23; 𝜒2 = 7.31, df = 2 (P = 0.03); I2 = 73%Test for overall effect: Z = 0.46 (P = 0.65)

James et al. 1998Stephens et al. 2006

Hopper et al. 1999

Figure 7: Effect sizes of the Feldenkrais Method on the active knee extension test.

4. Discussion

4.1. Summary of Main Results. The majority of the 20included studies reported significant positive effects of FM ina variety of populations and outcomes of interest. A high riskof bias/poor methods reporting does temper the interpreta-tion of these findings.The low amount of confirmed/reportedadherence to best practice conduct of RCTs may be partiallyattributable to the age of the studies when knowledge in thearea of trial conduct was less.

Neverthelessmeta-analyses in the area of balance trainingin ageing populations were found in favour of the FM classesfor clinical measures such as the timed up and go andfunctional reach tests. Both of these measures are predictiveof falls risk. Whilst the TUG effect size was probably notclinically significant (1- to 2-second change), the functionalreach test effect size would arguably indicate a clinicallymeaningful change (able to reach further 6 cm).

Given the positive effects in particular outcome domainsit is interesting to speculate on themechanism of action of theFM; however, it is to be noted that this was not the purpose ofthe review. The favourable evidence for reduced perceptionsof effort, improved dexterity, improved comfort and reducedbruxism all support the proposed mechanism of action viapromotion of awareness, relaxation andmore efficient action.Inconsistent results were found for improving hamstringslength indicating that a “relaxation” effect may be variable.

The populations varied in age and diagnosis indicatingthat a beneficial effect is possible across different domains;again this is consistent with the use of the FM in diversepopulations and also consistent with the notion that it is nota healing or disease-specific mechanism of action but ratherone based on more generic learning and self-improvement.

The findings of this updated review have strengthenedsince the 2005 review by Ernst and Canter [4]. We were alsoable to locate studies prior to 2005 that were not found by theoriginal SR authors, presumably due to improved databaseaccess. As the previous authors reported, the studies arestill highly varied and of often questionable quality. Thereis an ongoing issue of poor reporting, resulting in risksbeing judged “unclear”; it is unknown whether this hidesundeclared risk or is simply an omission of reporting.

This review is not without its own limitations.This reviewincludes all trials aimed at improving health and/or function

so we have trials of healthy individuals as well as peoplewith a clinical presentation.We have not included an analysisof publication bias, though we are confident that by usingexperts in the field and checking grey literature (organi-zational websites) we have made every effort to captureunpublished (negative) trials. We attempted to account forstatistical heterogeneity and can conclude that the analysis forthe timed up and go ismore robust with the removal ofHillieret al. [23] (Figure 4(b)) because the comparator group differsfrom the other studies (alternate balance class versus nointervention) and secondly this studywas pseudorandomized(allocation based on enrolment day).The question of inactivecontrols is vexed and permissible when proof of conceptor pilot/phase 1 trials are being conducted. We encouragereaders to take the stage of research and the design intoaccount in their interpretation.

4.2. Implications for Practice. There is promising evidencethat FM may be considered for balance classes in ageingpopulations, both as a preventative approach and for peopleat risk of falls. There is also some evidence for the use of FMwhere reduced effort, efficiency of movement, and awarenesscan play a part in reducing pain or discomfort.

4.3. Implications for Research. Further high quality researchis required comparing FM to other modalities. Investigationsshould focus on the impact on self-efficacy, functional inde-pendence, and ease and efficiency of functioning, both asstrategies for promotion of wellness and wellbeing and alsofor people with impairment who wish to improve their senseof ease. Mechanisms of effect also need to be investigated.Particular attention needs to be paid to the reporting of bestpractice trial design and to controlling for a potential placeboeffect.

5. Conclusions

There is further promising evidence that the FM may beeffective for a varied population interested in improvingfunctions such as balance. Careful monitoring of individualimpact is required given the varied evidence at a group leveland the relatively poor quality of studies to date.


Disclosure

Funding was from professional bodies involved in promotingFM but the bodies were not involved in the conduct of thereview other than to identify experts within their member-ship to identify any missed/unpublished trials.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Authors’ Contribution

Anthea Worley conducted the search and preliminary inclu-sions. Both authors contributed to the review of all papersand constructed the final report. One of the authors (SusanHillier) was also author for two included studies; these wereindependently scrutinized.

Acknowledgments

The authors wish to acknowledge the financial assistanceof the Australian Feldenkrais Guild and the InternationalFeldenkrais Federation in supporting the costs of the searchand appraisal.

References

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[2] K. A. Connors, M. P. Galea, C. M. Said, and L. J. Remedios,“Feldenkrais Method balance classes are based on principlesof motor learning and postural control retraining: a qualitativeresearch study,” Physiotherapy, vol. 96, no. 4, pp. 324–336, 2010.

[3] P. A. Buchanan and B. D. Ulrich, “The Feldenkrais Method:a dynamic approach to changing motor behaviour,” ResearchQuarterly for Exercise and Sport, vol. 72, no. 4, pp. 315–323, 2001.

[4] E. Ernst and P. H. Canter, “The feldenkrais method—a system-atic review of randomised clinical trials,” Physikalische MedizinRehabilitationsmedizin Kurortmedizin, vol. 15, no. 3, pp. 151–156,2005 (German).

[5] D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and ThePRISMA Group, “Preferred reporting items for systematicreviews and meta-analyses: the PRISMA statement,” PLoSMedicine, vol. 6, no. 7, Article ID e1000097, 2009.

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[9] J. Stephens, D. DuShuttle, C. Hatcher, J. Shmunes, and C.Slaninka, “Use of awareness through movement improves bal-ance and balance confidence in people withmultiple sclerosis: arandomized controlled study,” Neurology Report, vol. 25, no. 2,pp. 39–49, 2001.

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[15] M. James, G. Kolt, J. McConville, and P. Bate, “The effects of aFeldenkrais program and relaxation procedures on hamstringlength,” Australian Journal of Physiotherapy, vol. 44, no. 1, pp.49–54, 1998.

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[23] S. Hillier, L. Porter, K. Jackson, and J. Petkov, “The effects ofFeldenkrais classes on the health and function of an ageingAustralian sample: pilot study,”TheOpen Rehabilitation Journal,vol. 3, no. 1, pp. 62–66, 2010.

[24] F. Bitter, S. Hillier, and L. Civetta, “Change in dexterity withsensory awareness training: a randomised controlled trial,”Perceptual and Motor Skills, vol. 112, no. 3, pp. 783–798, 2011.

[25] G.Nambi, P. S. Trivedi, S.M.Momin, S. Patel, andD. P. Pancholi,“Comparative effect of Pilates and Feldenkrais intervention onfunctional balance and quality of life in ambulatory geriatricpopulation: a randomized controlled study,” International Jour-nal of Health Sciences and Research, vol. 4, no. 3, pp. 71–77, 2014.

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