The Effectiveness of the Feldenkrais Method a Systematic Review of the Evidence
The Feldenkrais Method (FM) has broad application in populations interested in improving awareness, wellness, and ease of function. This review aimed to update the evidence for the benefits of FM, and for which populations. A best practice systematic review protocol was devised. Included studies were appraised using the Cochrane risk of bias approach and trial findings analysed individually and collectively where possible. Twenty RCTs were included (an additional 14 to an before systematic review). The population, outcome, and findings were highly heterogeneous. All the same, 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 get test Medico −1.14 sec, 95% CI −one.78, −0.49; and functional reach test MD 6.08 cm, 95% CI 3.41, viii.74). Single studies reported significant positive furnishings for reduced perceived try and increased condolement, body image perception, and dexterity. Risk of bias was loftier, thus tempering some results. Considered as a body of evidence, effects seem to be generic, supporting the proposal that FM works on a learning paradigm rather than disease-based mechanisms. Further enquiry is required; however, in the meantime, clinicians and professionals may promote the use of FM in populations interested in efficient physical performance and self-efficacy.
ane. Introduction
The Feldenkrais Method (FM) was developed over a period of decades in the final century by Dr. Moshe Feldenkrais. He claimed the ground of the approach was founded in the human potential for learning how to acquire [1]. As such, he operationalized an experiential procedure or prepare of processes, whereby an private or a group could be guided through a series of movement- and sensation-based explorations. The purpose of these explorations was to practise the nonlinear process of sensing the difference between 2 or more options to achieve the stated move job, and making a discernment about which may feel easier, that is to say, performed with less effort. These perceptual discernments are predicated on a sentence that is positive (pleasurable, piece of cake, and with less attempt) compared with experiencing a less favourable feedback signal such as hurting, strain, or discomfort. Farther to this, the participants are encouraged to generate many alternative movement solutions to the guided task to increase the opportunity for further distinctions and improvements to be made. Thus the process of intention, action, gaining feedback, making decisions, and reenacting with adaptations constitutes the learning framework in a somatic context [2].
The two modes of delivery that are offered to the public are either individual, manually directed lessons (functional integration, FI) or group, verbally directed classes (awareness through movement, ATM). The classification for both reflects the fundamentals of the approach—that movement has to be based on a functional or meaningful intention for the system to appoint and that by condign aware of what and how nosotros act (motility) we become in a ameliorate place to choose an culling behaviour (motion pattern) [3]. Both modes of delivery utilize the same principles of perceptual exploration through movement that is passively and/or actively performed.
The method has been applied in varied domains across countries, from general education or children with learning issues to enhancing operation in sports and theatre. The clinical applications have received the nearly interest in the published literature because of the intuitive entreatment of basing a wellness recovery process on a learning paradigm and considering of the inherent fostering of cocky-efficacy that occurs particularly in a group setting.
In the climate of testify-based do in the health domain, any approach being offered to the public is being scrutinized for evidence of effectiveness and, if effective, for what blazon of benefit and of what magnitude for any clinical population. An earlier systematic review of the bear witness for the 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 equally people with multiple sclerosis, chronic low dorsum pain, and neck issues. They ended that in that location was promising prove merely its credibility was tempered due to the low number of studies, high level of clinical heterogeneity between studies, and methodological flaws. The methods employed by Ernst and Amble [4] were robust for the time; withal, their risk of bias assessment used a now discarded tool (the Jadad) and their search covered until 2003. Therefore, it is timely to systematically update the evidence for the Feldenkrais Method with current review procedures.
This review had the aims of (ane) systematically identifying and appraising the evidence for the effectiveness of the Feldenkrais Method beyond domains; (2) determining what is the nature and order of magnitude of any benign effects and for which population/s.
2. Materials and Methods
2.1. Criteria for Because Studies for This Review
We employed systematic review methods based on the PRISMA guidelines [5].
2.2. Types of Studies
We considered all types of primary studies in the first instance in order to fully explore the potential populations and outcomes covered. In the final inclusion but studies with a random allotment and a stated control grouping were included. Any secondary researches (systematic and semisystematic reviews) constitute were not included, simply rather their included studies were retrieved in full and added to the potential puddle in guild for all chief studies to be appraised with a consistent method.
ii.iii. Types of Participants and Outcomes
We included any population where there was an consequence of involvement related to improvement in health and/or function.
ii.4. Types of Interventions and Comparisons
Either form of Feldenkrais Method (functional integration or awareness through movement) was included as the sole approach for the intervention grouping. The comparison group could include placebo, inactive control, or an alternate method.
2.five. Search Methods for Identification of Studies
We searched the databases of AMED (Allied and Complementary Medicine), Embase Classic + Embase, Ovid MEDLINE(R), Cochrane, PsycINFO, PubMed, and Google Scholar from inception to July 2014. We considered all languages (the search was open to all listed journals irrespective of linguistic communication) and publication status (we would include unpublished trials wherever found, e.thousand., through experts in the field or grey literature such equally organizational websites).
The search terms included variations and combinations of methodology terms (such as randomised, trial, clinical, and controlled), with intervention terms such as Feldenkrais Method, (awareness through movement and functional integration). An case of the terms employed in the electronic search strategy is presented in Table 1.
| | ||
| 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 move or functional integration).mp. [mp = ab, hw, ti, sh, tn, ot, dm, mf, dv, kw, nm, kf, ps, rs, an, ui] | 2239 |
| iii | 1 and 2 | 47 |
| 4 | Removing duplicates from iii | xl |
| | ||
From the generated lists from each database, duplicates were removed and the start high level sift was performed by ane author based on title alone. The second level of review was performed by both authors and required retrieval of the abstract at the minimum. The retained studies were examined in full to confirm inclusion. Those excluded were recorded with reasons.
All retrieved studies were checked for additional references, and experts in the field were contacted to assist in identifying any further studies published or unpublished. Experts were provided from the membership of peak FM bodies (the Australian Feldenkrais Guild and the International Feldenkrais Federation) and were asked to supply further papers by electronic mail.
ii.6. Data Collection and Analysis
Relevant data were extracted from each of the included studies using a standard trial summary canvas by 1 author and checked by the 2d. Data included author, date, study pattern, population sample, intervention, comparison, event measures, results, and comments. A risk of bias evaluation was also performed for each study past one author using standard Cochrane tables [26] with checking and data entry past the second author. Any disagreements were resolved by consensus, with a third political party if necessary.
Where possible, information were extracted for meta-analyses. We planned to extract and analyse data to calculate individual and total effect sizes through odds ratios or mean differences (stock-still effect or random effect if the studies were minor and/or heterogeneous) and 95% confidence intervals. Statistical heterogeneity would be evaluated based on visual inspection of forest plots and on the statistic. It was not anticipated that any other analyses would be possible (e.g., subgroup or publication bias) due to a paucity of studies.
If we establish that meta-analyses were not possible, and then results would be synthesized and reported narratively.
three. Results
iii.1. Included Studies
The systematic search yielded over one,300 initial titles for high pass screening. See Figure 1 for the PRISMA Flow diagram. With duplicates and evidently irrelevant titles removed, 124 records were considered at the abstruse level by both authors, with an additional two studies provided from experts in the field (newly published, i RCT, i non-RCT). Seventy-seven abstracts were excluded at this phase because they were did not report an investigation of the FM and/or did not involve a trial of event. Forty-seven full-text articles were reviewed against the criteria and further 27 excluded with reasons noted in Table 2.
| | |
| Studies | Reason for exclusion |
| | |
| Kirkby (1994) | Controlled trial |
| Bearman (1999) | Pre/posttest (no control) |
| Seegert (1999) | Controlled trial |
| Huntley (2000) | Systematic review |
| Dunn (2000) | Pre/posttest (no control) |
| Fialka-Moser (2000) | Commentary |
| Malmgren-Ohlsen (2001, 2002, 2003) | Controlled trial |
| Kerr (2002) | Controlled trial |
| Emerich (2003) | Review |
| Junker (2003) | Posttest (no control) |
| Galantino (2003) | Review |
| Gard (2005) | Review |
| Mehling (2005) | Review |
| Liptak (2005) | Review |
| Batson (2005) | Pre/posttest (no control) |
| Wennemer (2006) | Pre/posttest (no command) |
| Porcino (2009) | Descriptive |
| Mehling (2009) | Review (assessment) |
| Connors (2010) | Content analysis |
| Connors (2011a) | Controlled trial |
| Connors (2011b) | Pre/posttest (no control) |
| Mehling (2011) | Enquiry (phenomenological) |
| Ohman (2011) | Pre/posttest (no control) |
| Laird (2012) | Review |
| Mehling (2013) | Intervention (not exclusively Feldenkrais) |
| Gross (2013) | Review |
| Webb 2013 | Pre/posttest (no command) |
| | |
Fourteen new RCTs were included along with the original six studies from the Ernst and Canter [four] review. See Table three for details of all included studies. From this total of xx studies, there were seven studies sufficiently homogenous to let for meta-analyses.
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| RCT: randomised controlled trial; FM: Feldenkrais Method; MS: multiple sclerosis; Fifty: left; R: right; C: control; prisoner of war: per week; VAS: visual analogue scale; mCTSIB: Modified Clinical Test of Sensory Integration and Residual; NSD: no significant difference; STAI: State/Trait Anxiety Alphabetize; EMG: electromyography; UL: upper limb; ATM: awareness through movement (lesson); min: minutes; AKE: agile knee extension exam; MI: myocardial infarct; PMR: progressive muscle relaxation; c.f.: compared with; SF-36: brusque class 36; PI: Pilates. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3.2. Description of Studies
Publication dates ranged from 1991 [12] to 2014 [25]. Populations under investigation in the included RCTs ranged from good for you volunteers [6, 12, xv–17, 19, 24], healthy ageing [21–23], institutional ageing [25], people with multiple sclerosis [7–11, 13], eating disorders [fourteen], myocardial infarct [18], and sleep bruxism [xx]. Studies mostly had pocket-sized sample sizes with a mean of twoscore.8 participants (SD 23.5).
The nature of the Feldenkrais interventions also varied in delivery mode, intensity, and frequency. The predominant methods were single or multiple ATM lessons delivered either in a grouping or individually using audio recording. The comparison groups were virtually commonly an alternating form of therapy. Xiv trials had agile controls (such equally relaxation classes or generic motility/residual classes) and half dozen had a passive or inactive control (usual activities/no intervention).
Outcomes were also highly heterogeneous in keeping with the needs of the diverse populations and are listed in Table 3. The measures related to functioning or activity outcomes (e.g., remainder or dexterity), symptoms (e.m., 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 exclusion were predominantly around design: two were systematic reviews; v were controlled trials (non randomly allocated); eight had no control group; 8 were nonsystematic reviews; one was not exclusively Feldenkrais in the intervention grouping; one was a content analysis of an intervention; one was a phenomenological analysis; and i was a commentary.
3.iv. Risk of Bias in Included Studies
Hazard of bias was high in most studies. Less than a quarter of the studies had acceptable random allocation processes and only a third had blinding of result assessments. It has to exist acknowledged that for trials requiring an intervention like Feldenkrais it may be difficult or inappropriate to expect blinding of therapists or even participants, though participants tin can be blinded to the intervention of interest if there is a plausible comparing group (such every bit a relaxation or other forms of movement-based class). Figures two and 3 summarize the risk of bias analysis. It can be seen that a definitive judgement could not be made in many cases as information technology could non be confirmed whether there was a clear risk of bias (given a red status) or whether the authors had but not stated the procedure in sufficient detail for a judgement to be made; hence the take a chance of bias indicator was left blank.
iii.five. Furnishings of Interventions
Sufficiently homogenous information (aforementioned population, intervention, comparator, and outcome mensurate) were able to be extracted to perform meta-analyses in the areas of residual training in ageing populations.
4 studies [21–23, 25] reported on the timed upwards and go cess for balance and mobility, just failing to find in favour of Feldenkrais classes (Figure 4(a)); pooling postintervention measures gave a hateful difference of −0.78 s (95% CI −ane.69, 0.13), . However, heterogeneity was high (). Therefore, a sensitivity analysis was performed as 1 written report by Hillier et al. [23] compared Feldenkrais to another residual form whereas the other three studies compared the FM class to look listing control or no class. Removal of Hillier et al. [23] (Figure 4(b)) revealed a larger effect size with a mean difference of −one.13 (95% CI −i.7, −0.56), , and heterogeneity reduced to a negligible level (). It was also noted that Nambi et al. [25] had narrow event variability which led to a heavier weighting in the meta-analysis.
(a)
(b)
Two studies [21, 22] evaluated residuum confidence using the Falls Efficacy Calibration after FM classes (Figure 5). Pooled results trended in favour of the FM, withal, failed to attain significance (MD 0.59, 95% CI −0.08, one.26; ).
Two studies [23, 25] evaluated rest using the functional reach test later FM classes (Effigy 6)—pooled results institute in favour of the FM classes (compared to nothing or another generic balance form) with a mean divergence of 6.08 cm (95% CI 3.41,viii.74), .
Meta-analysis was also able to be performed using three studies measuring the influence of FM classes on hamstring length in salubrious populations [xv, 16, 19]. The authors all reported the measure as an agile knee extension test; however, on visual inspection, the results appeared heterogeneous in terms of magnitude and range; therefore, a standardized hateful divergence (rather than Doctor) was calculated. No pregnant upshot was found later on the intervention compared to command (SMD 0.15, 95% CI −0.49, 0.79; ) and statistical heterogeneity was unacceptably high () (Effigy 7).
Unmarried randomised controlled studies reported statistically pregnant, positive benefits compared to control interventions and included the post-obit: (i) greater neck flexion and less perceived effort afterwards a single FM lesson for neck comfort [half dozen]; reduced prevalence of neck pain and disability in symptomatic women after FM (individual and group sessions compared to conventional intendance or home exercises) [viii]; reduced perceived effort in FM group for people with upper trunk/limb discomfort [13]; (two) improved balance in people with MS later on eight FM sessions [ix]; (iii) improved body paradigm parameters in people with eating disorders afterwards a nine-60 minutes FM course [14]; (iv) reduction in nocturnal bruxism in immature children afterward 10-week course of FM lessons [20]; (v) improved dexterity in salubrious young adults after a single session of FM class [24].
Vii of the 20 studies failed to bear witness whatever superior positive effects of FM compared to other comparison modalities. See Table three for details. No studies reported adverse events.
4. Discussion
iv.1. Summary of Chief Results
The majority of the 20 included studies reported pregnant positive effects of FM in a variety of populations and outcomes of interest. A high hazard of bias/poor methods reporting does temper the interpretation of these findings. The low amount of confirmed/reported adherence to best practice conduct of RCTs may be partially attributable to the historic period of the studies when knowledge in the area of trial conduct was less.
Withal meta-analyses in the area of residual preparation in ageing populations were plant in favour of the FM classes for clinical measures such as the timed upwardly and go and functional reach tests. Both of these measures are predictive of falls risk. Whilst the TUG effect size was probably non clinically significant (i- to 2-second alter), the functional reach exam event size would arguably indicate a clinically meaningful alter (able to reach further half-dozen cm).
Given the positive furnishings in particular issue domains it is interesting to speculate on the mechanism of action of the FM; however, it is to be noted that this was not the purpose of the review. The favourable prove for reduced perceptions of effort, improved dexterity, improved comfort and reduced bruxism all support the proposed mechanism of action via promotion of awareness, relaxation and more efficient activeness. Inconsistent results were establish for improving hamstrings length indicating that a "relaxation" upshot may exist variable.
The populations varied in age and diagnosis indicating that a beneficial effect is possible across different domains; again this is consequent with the apply of the FM in various populations and also consequent with the notion that it is non a healing or disease-specific machinery of action merely rather one based on more generic learning and self-improvement.
The findings of this updated review have strengthened since the 2005 review past Ernst and Canter [4]. We were likewise able to locate studies prior to 2005 that were not establish by the original SR authors, presumably due to improved database access. Equally the previous authors reported, the studies are still highly varied and of often questionable quality. At that place is an ongoing issue of poor reporting, resulting in risks being judged "unclear"; it is unknown whether this hides undeclared run a risk or is simply an omission of reporting.
This review is not without its own limitations. This review includes all trials aimed at improving wellness and/or function and then we have trials of healthy individuals as well as people with a clinical presentation. We take non included an analysis of publication bias, though nosotros are confident that by using experts in the field and checking grey literature (organizational websites) we accept made every attempt to capture unpublished (negative) trials. We attempted to account for statistical heterogeneity and can conclude that the analysis for the timed up and get is more robust with the removal of Hillier et al. [23] (Effigy 4(b)) considering the comparator grouping differs from the other studies (alternate balance class versus no intervention) and secondly this study was pseudorandomized (resource allotment based on enrolment day). The question of inactive controls is vexed and permissible when proof of concept or pilot/stage one trials are beingness conducted. We encourage readers to take the phase of research and the blueprint into business relationship in their estimation.
4.2. Implications for Do
There is promising evidence that FM may be considered for remainder classes in ageing populations, both as a preventative approach and for people at risk of falls. There is also some testify for the use of FM where reduced endeavor, efficiency of move, and awareness can play a part in reducing pain or discomfort.
4.3. Implications for Research
Further loftier quality inquiry is required comparison FM to other modalities. Investigations should focus on the bear upon on self-efficacy, functional independence, and ease and efficiency of functioning, both equally strategies for promotion of wellness and wellbeing and besides for people with impairment who wish to ameliorate their sense of ease. Mechanisms of issue as well need to exist investigated. Item attention needs to be paid to the reporting of best practice trial design and to controlling for a potential placebo event.
v. Conclusions
In that location is further promising testify that the FM may be constructive for a varied population interested in improving functions such as remainder. Careful monitoring of individual touch on is required given the varied evidence at a group level and the relatively poor quality of studies to date.
Disclosure
Funding was from professional bodies involved in promoting FM but the bodies were not involved in the conduct of the review other than to identify experts within their membership to identify any missed/unpublished trials.
Conflict of Interests
The authors declare that there is no disharmonize of interests regarding the publication of this newspaper.
Anthea Worley conducted the search and preliminary inclusions. Both authors contributed to the review of all papers and constructed the final report. One of the authors (Susan Hillier) was as well author for ii included studies; these were independently scrutinized.
Acknowledgments
The authors wish to acknowledge the financial assist of the Australian Feldenkrais Guild and the International Feldenkrais Federation in supporting the costs of the search and appraisal.
Copyright
Copyright © 2015 Susan Hillier and Anthea Worley. This is an open up access article distributed under the Artistic Commons Attribution License, which permits unrestricted apply, distribution, and reproduction in any medium, provided the original work is properly cited.
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Source: https://www.hindawi.com/journals/ecam/2015/752160/
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