The Feldenkrais method




Catherine Wycoff, PT, DPT


History of Intervention:

The Feldenkrais Method was invented by Dr Moshe Feldenkrais (1904-1984). Dr Feldenkrais was a physicistand worked as a research
assistant under Nobel laureate physicist Frederic Joliot-Curie at La Sorbonne while studying for his “Ingenieur” doctorate degree,
performing some of the first experiments in atomic research. He had practiced jiu jitsu since the early 20’s and had designed his own self
defense techniques.  He was the first European to receive a black belt in Judo ( in 1936).  In 1940, he escaped to England just as the
Germans arrived in Paris.  As a scientific officer in the British Admiralty, he conducted anti-submarine research in Scotland.  In 1942, he
published a self defense manual, Practical Unarmed Combat and Judo.  Soon after that, he suffered a crippling knee injury which was the
result of a series of sport-related injuries and of his work on submarines.  The doctors he consulted gave him a very bleak diagnosis, a 50
%chance that a surgery to repair his knees might be successful and a chance that he might not be able to walk ever again.  He refused the
surgery and started studying neurology, anatomy, biomechanics and human movement development.   Armed with his newly acquired
knowledge and his physics and martial arts background , he completely restored his ability to walk by developing a way to improve his
body that was to become the Feldenkrais method.  He stayed in London, where he published in 1949, his first book on the method:
“Body and Mature Behaviour”
Inspired by his thorough examination of the relationship between the nervous system and movement, Dr Feldenkrais designed hundreds
of movement lessons designed to access the motor learning centers.  He started to give lectures about his new ideas, began to teach
experimental classes, and work privately with some colleagues.  He also studied the work of George Gurdjieff, F.M. Alexander, William
Bates and went to Switzerland to study with Heinrich Jacoby.
In 1954, Feldenkrais moved permanently to Tel Aviv, Israel where he made his living solely by teaching his method.  
In the mid 1950’s Feldenkrais presented his work in Europe and the United States.  He taught his first teacher training program in San
Francisco over 4 summers in 1975.  He began the 235-student Amherst training in 1980, but was only able to teach the first two summers
of the program. He stopped teaching after becoming ill in the fall of 1981.  He died in 1984.
Since then his students have developed standards for professional trainings and have become trainers themselves.  The 4 years, 800 hours,
professional trainings are now held all over the world.  Graduation from an accredited training gives students the title of certified
Feldenkrais Practitioners.

Theory

The description of the Feldenkrais Guild of North America is as follows: “The Feldenkrais Method is a form of somatic education that
uses gentle movement and directed attention to improve movement and enhance human functioning.  These movements result in increased
range of motion, improved flexibility and coordination, and allow the students to rediscover their innate capacity for graceful efficient
movements.  By expanding the self-image through movement sequences, the method enables students to include more of themselves in
their movements.  They become aware of their habitual neuromuscular patterns and rigidities, and learn to move in new ways.” 1
Feldenkrais practitioners (FP) believe that more efficient actions can emerge from guided exploration of movement that promotes
improved attention and awareness and refines the ability to detect information and make perceptual discriminations. The exploration can
also be done through imagery with very little or no active movement.
The goal of the method is to get people to become self directed learners who can then apply and expand their learning in every day life.

The method can be taught individually or in groups:
In Functional Integration (FI), the Feldenkrais Practitioner (FP) guides his student’s movements through gentle non-invasive touch and
words.  It is an individual session.
For groups, Awareness Through Movement lessons, are taught by a FP who verbally guides the group through a sequence of structured
movement explorations aimed at discovering one’s own habitual movement patterns and learning new alternatives. Many lessons are
based on developmental movements and ordinary functional activities.  Some are based on more abstract explorations of joints, muscle
and postural relationships.

According to Dr. Feldenkrais2, the following elements are essential in order for learning to take place:
- the student should be allowed to perform a movement at their own rhythm,
- the movement should be repeated a number of times, so that the students can refine it each time based on their individual feedback, , but
only as long as they pay attention to them, as soon as they become mechanical in nature, the repetitions should be stopped and new
variation of the movement explored.
-the student’s intent should be to make the movement better, and not right.  What could be seen as mistakes in a right or wrong situation
becomes learning in a situation where betterment is the goal.
-the lesson should include many variations of all the components of the final movement, including performing the same movement in
different orientations.
-the movements should be pleasant and easy in order to increase the chance that they will become habitually spontaneous.  It is argued
that faced with a choice, the nervous system will favor a pleasant movement over a painful one.
-the lesson includes learning about one’s own habitual patterns of movement first, before exploring alternatives with the idea that it is
only when you know what you do that you can do what you want.
-The intention of the teacher is not to correct a wrong motor pattern but to make the student aware of their habits and then to show them
other possible ways to move, in an empowering, nonjudgmental way.  
The method does not claim to be a therapy; the beneficial effects are considered to merely be a consequence of a better use of oneself.  
The local tissue level is therefore never addressed directly, and when improvement at the local tissue level occurs, it is thought to be the
result of a better organization of the neuromuscular system 13.
When reading the method’s approach to learning described above, one cannot help but be reminded of the adaptive codes of motor
learning described in Lederman’s book : “The science and practice of manual Therapy” .
Cognition, described as “being aware of/attentive to the process and taking an active conscious part in it” 2, is considered to be an
essential element of the first phase of motor learning.
The need for numerous repetitions, allowing for feedback and therefore refinement of the motor program when necessary and  the
importance of the student’s active participation either through active movements or through taking an active part in a passive movement
through attention are also described  as important elements of motor learning.  
Two other important concepts of the method are the concept of body and mind being one, and the concept of reversibility.  Feldenkrais
believed that body and mind could not be separated, and that a motor pattern is linked to each emotional state and even to every thought.  
He believed that a thought that is not linked to an action is not useful. 21
From his experience in martial arts and combat, he had found the ideal movement should be reversible at each moment, and could be
enacted without prior rearrangement.  In combat, the time needed to shift weight or rearrange one’s posture could mean the difference
between life and death. 21   All these elements are included in the movement lessons he designed.  
One last but extremely important key to the method is the need for the teacher to be him/herself aware of his habitual patterns and of as
many variations of movements as possible. The first two years of the training focus on developing the future teachers’ awareness of their
own selves, so that they can better distinguish their clients’ limitations from their own.

The evidence in the research literature for the Feldenkrais Method is encouraging, but further studies on bigger samples, and more directed
toward the principles behind the results are still needed.  Below are a few of the peer reviewed studies that shed some light on the
possible applications of the method or of its principles:
A recent study in Physical Therapy 3 found ATM lessons to be the first method to increase hamstring length without stretching and
found its results to be comparable to classical stretching. Further research is needed to understand through which mechanism the
lengthening happened.
Even though it not the primary goal of the method, significant decrease in chronic pain complaints have been described in 4 studies 4,5,6,7
following Awareness through movement sessions. In one study 7 , the Feldenkrais Method(FM) was found to be a little better at
improving  both psycho physiological symptoms and pain than traditional physical therapy (performed in the study’s occupational
therapy center).  The authors suggest that the pedagogic method used in the FM (and described in the theory above) was responsible for
the improved result.
In a study on sensory motor learning’s effect on chronic low back pain (CLBP) patients’ movement capacity 8, CLBP patients were
found to have improved their performance so much that they did no longer differ from the healthy control group.  They had retained a
more efficient behavior 12 month after the intervention.
A group of 59 elderly women were found to have improve after 10 weeks of ATM lessons on ADL scores, Timed Up and Go and Berg
balance assessment. 9 ATM was also found to improve balance and balance confidence in a group of people with MS. 10  
The FM also uses imagery of a movement as a way to improve movement efficiency and to decrease effort.  A study by Dunn, PA and
Rogers, DK 15 found that, after an ATM of imaging one half of the body being brushed by a soft bristle, there was a significant increase
in forward flexion range on that side. This correlates with a number studies on visualization described in Lederman’s book, page 134, in
which visualizing a movement facilitates motor learning.
Stephens, in his article on the Feldenkrais method 17 found that the Method is an excellent approach to use in rehabilitation of people
with orthopedic physical problems.
On the psycho physiological level, several studies 11, 12, 14, 16  have found that the FM results in decreased stress, increased self
confidence, a more positive self image and an improved level of acceptance of the body.  In her study of 78 patients with non specific
musculoskeletal disorders, Eva Malgrem-Olson and colleagues found self image to be a good predictor of outcome, and to be closely
linked to the number of symptoms a person is experiencing.(Ohman and Armelius, 1990).  They also found the Feldenkrais method to be
slightly superior to the conventional focus on just the physiological aspects of musculoskeletal disorders.
Dr Feldenkrais said: “What I am after is to restore each person to their human dignity”.  I my opinion, this approach to students-teacher
interactions is a big part of the success of the method.  Feldenkrais Practitioners, in their non judgmental approach, create an environment
( which they believe to be conducive to learning) in which the person is accepted as he/she is, and is presented with options that expand
their capacities, in opposition with the medical view that something is wrong and must be made right.  
It would be interesting to further study how awareness influences self image, well being and self confidence, and how it helps decrease
pain in chronic non specific musculoskeletal pathologies
Finally, body awareness therapy was found to have positive effects in a study of patients with fibromyalgia and chronic pain 18.
As with many body mind methods, research on the Feldenkrais Methods is at its beginning and many of the studies could not be included
in this paper because of their methodological problems, low quality, and small sample size.  A lot of the articles rely on case studies and
cannot therefore be extrapolated to the general population.  One thing all studies agree on is the safety of the method.  The movements are
so small and performed so slowly that they are less strenuous than what the person usually does on a daily basis.  The emphasis put on
no pain or strain of any kind also helps make this method extremely safe.

Case presentation:

Patient is a 63 year old male office worker referred to physical therapy for constant pain in the lumbar region in standing and walking,
going down both legs.
Mild lumbar pain started one year ago, when the patient moved from the US to Austria, to an office with a bad chair.  Last December, he
unloaded and reloaded a truck with heavy boxes to help a friend, and felt pain in his back and down both legs that made him limp in pain.
Pt underwent quintuple bypass surgery in 1999, and must walk everyday to keep his heart in good shape.  He is consulting today
because his back pain has prevented him from walking from his home to work and back (15 minutes walk) despite the use of daily pain
medicine.  Pt reports that he used to enjoy walking as exercise. Patient is married with one grown daughter, works in an office in the
administrative section of a big embassy.  He sits in front of the computer or in meeting 90 % of the time; his job does not entail any lifting
or driving.  His apartment has no stairs and his building has an elevator. He has received 2 months ago a new ergonomic chair that fits him
well.  Pt wears small frame glasses which contain 3 different prescriptions.
He currently takes the following medications:  Altese for his heart, Lipitor to regulate cholesterol, vitamins, Percaset for pain everyday.

Evaluation:

-Cardiovascular/pulmonary: Resting heart rate: 62, blood pressure: 122/80
-Integumentary: Pt presents with a vertical scar over his sternum, and on his right thigh. Both scars are flexible in all directions and pink.
-Neuromuscular: normal reflexes throughout.
-Communication system: Pt is alert and well oriented.
-Musculoskeletal:
Standing:
Frontal plane:
ASIS and PSIS symmetrical, right scapula slightly higher than left, no significant spinal deviation. Both legs rotated inward, feet inverted
with increased pressure on first metatarso-phalangeal joint bilaterally.
Sagittal plane:
Mild increase lumbar lordosis, thoracic kyphosis, forward head posture.  Both shoulders rounded.  
Gait assessment:
Good balance.  
Trunk: bent forward, decreased rotation and lateral bending.
Pelvis: excess forward rotation, lacks backwards rotation
Hip: inadequate extension, internally rotated and adducted.
Knee:  bilateral valgus
Ankle: inversion, medial fore foot contact
ROM:
T spine AROM and PROM decreased in rotation bilaterally and lateral bending right more than left
Decreased AROM  and PROM L scapula in elevation.
Full lumbar PROM in all directions, decreased AROM in extension, and in R and L rotation with pain EOR.
SLR negative bilaterally.
Muscle strength:
Spinal extensors: 4/5, spinal flexors: 5/5, R lateral flexors 4/5, L lateral flexors 5/5, rotators: 5/5.  
Hip extensors: 4/5, hip flexors 5/5
Pain:
To the touch L3-L4 and L4-L5 bilaterally,
After 3 minutes of walking,
EOR in lumbar rotation and extension.

Diagnosis:
Patient presents with impaired joint mobility, Motor function, Muscle performance and range of Motion associated with localized
inflammation (4E according to the guide to physical therapy practice) of the spine.  The ICD 9 CM code associated with his pathology is
724.2 (low back pain).

Prognosis:
According to the Guide to Physical Therapy Practice, the patient should, over the course of 2 to 4 months, demonstrate optimal joint
mobility, motor function, muscle performance and ROM and the highest level of functioning in home, work, community and leisure
environments.  The expected number of visits needed is between 6 and 24.  Given the overall good health and high motivation of this pt,
he is expected to achieve his goals after 6 to 8 visits.
Intervention:
The first lesson will be described in details to show the strategies used.  It is to be assumed that the following lessons use the same
principles of making the patient aware of his habitual patterns first, and then presenting him, through gentle manual guidance with
alternative options. And finally, allowing the patient to experience the same configuration in different orientations.
In the first session, the patient was asked to lie supine on the treatment table and to pay attention to the contact of his body with the
table. He was quickly able to feel the distance between his low back and the table, therefore visualizing his lordosis. He also noticed that
the back of his thighs did not touch the table, which with the therapist guidance made him aware of the shortness of his hip flexors. His
attention was then brought to the direction his big toes were pointing, which made him aware of the IR of his legs.
Note: the supine position allows the patient to pay attention to himself without having to worry about gravity and balance.
The therapist then pushed through the foot, in the direction of the hip and asked the patient to localize his hip joints with the therapist’s
help. (Where do you feel your thigh bone meets your pelvis?).  Patient repeatedly pointed to his iliac crests.  After looking at a skeleton
and differentiating the iliac crest from the hip joint, patient was then asked to feel the hip joint that he had now seen on the skeleton in
himself with many repetitions and the help of the feedback from the therapist.  Once the patient had localized the hip, he noticed a
decrease in lumbar lordosis, and hip flexors activity as his self image started to match his actual anatomy better, and he started to let go of
unnecessary contraction of the superficial hip flexors, concentrating on the deeper hip flexors for stabilization.
Patient was then brought back to sitting to feel his hips in sitting and then to standing, and finally to walking.  These are important as
each orientation feels different to the body and requires its own learning.
The patient came for a total of 3 sessions, during which he was taught in the same manner to find all the movements of his pelvis thanks
to a lesson called the pelvic clock that guides the patient through an exploration of all possible movements in the pelvis.  He was taught
the effect that wearing the small frame glasses has on his posture and his freedom of movement.  He was also taught how to relax his eyes
regularly, learning by contrast, first to overwork the eyes and then to relax them.
A large amount of time was spent on exploring the ribs one by one to find again the movements that had been lost after the heart surgery.
Lederman described this in his book as “re-owning” the parts of your body that, at some point, have been ostracized by the nervous
system because of pain, and have never been claimed back.
With the help of the therapist, the patient explored scapular glides, comparing his right side with his left, in supine, side lying, prone,
sitting, standing and walking.
Finally, all this was brought together in a lesson on walking, given in side lying, where all the movements necessary for smooth walking
were put together, with involvement of the head, shoulders, ribs, arms, spine, pelvis, leg and feet, with and without glasses and with eyes
open and closed.  The movements were passive, guided by the therapist while the patient paid attention at first. They were repeated
many times, and then gradually actively performed by the patient with an emphasis on making the movement easier and using a little less
effort each time.

Outcome:
The patient came once a week for three weeks.  At his last session, he reported that he had been walking from home to work and back
without pain and was weaning himself off of the pain medicine.  He had regained full active and passive ROM of his spine without pain.
His muscle strength was 5/5 throughout. His gait still showed some internal rotation of the hip that he could control when he paid
attention.  It now included arm sway and upright posture. The foot contact was still a bit inverted.  He was using what he had learned in
the lessons to keep his back moving when sitting for long periods of time.

Complementary Manual Therapy Interventions:
The Feldenkrais Method is only a motor learning method; several other methods will need to be used to address the local tissue level
when necessary.  
-Because pain is counterproductive in Feldenkrais when the therapist is trying to give the patient a pleasant experience in order to re-own
a part of themselves, iontophoresis, ice, and other anti-inflammatory treatment should be used to allow the treatment to be done without
pain in cases where patient’s motor problems have resulted in inflammation,
-If the decreased ROM is due to thickening or shortening of the connective tissue or scars, myofascial release would be helpful in freeing
the restricted joint.  It would then be interesting to make the patient aware of his restrictions first, and then do the myofascial release
followed by a Feldenkrais lesson.
-a home exercise program, with an emphasis on paying attention to the part of the body that has been explored in the Feldenkrais lesson,
would also be appropriate when strengthening is needed.
-Therapeutic exercises are also commonly used when strengthening is the goal.

Alternative Manual Therapy Intervention:
The Alexander Method and Body Awareness Therapy are methods based on the same principles.  Any method that uses awareness,
multiple repetitions, small and slow movements, and emphasis on as little effort as possible and also the idea than rather than fixing the
body, the intervention is aimed at expanding its capacities and ranges of choice 19 might yield the same outcomes.

References:

1. Frequently asked questions, Feldenkrais Guild of North America, available at www.feldenkrais.com accessed 2/27/07
2. Lederman E.  The science and Practice of Manual Therapy.2nd edition, Elsevier Churchill Livingstone 2005
3. Stephens J, Davidson J, De Rosa J, Kriz M, Saltzman N Lengthening the Hamstring Muscles Without Stretching Using “Awareness
Through Movement”, Physical therapy.2006 Dec; 86(12) :1641-1650
4. Lundblad I. Elert J. Gerdle B. Randomized controlled trial of physiotherapy and Feldenkrais interventions in female workers with neck-
shoulder complaints. [Journal Article: Clinical Trial] Journal of Occupational Rehabilitation. 1999 Sep; 9(3): 179-94. (46 ref)
5. Bearman D, Shafarman S. Feldenkrais Method in the Treatment of Chronic Pain: A Study of Efficacy and Cost Effectiveness. Am. J.
Pain Management. 9 (1): 22-27, 1999.
6. Phipps A, Lopez R, Powell R (advisor), Lundy-Ekman L (advisor), Maebori D (CFP). A Functional Outcome Study on the Use of
Movement Re-Education in Chronic Pain Management. Masters Thesis at Pacific University, School of Physical Therapy, Forest Grove,
Oregon, May 1997.
7. Malmgren-Olsson E. Armelius B. Armelius K. A comparative outcome study of body awareness therapy, Feldenkrais , and
conventional physiotherapy for patients with nonspecific musculoskeletal disorders: changes in psychological symptoms, pain, and self-
image. [Journal Article: Research, Tables/Charts] Physiotherapy Theory and Practice. 2001 Jun; 17(2): 77-95. (55 ref)
8. Schon-Ohlsson C., Willen J., & Johnels B. (2005). Sensory motor learning in patients with chronic low back pain - A prospective pilot
study using optoelectronic movement analysis. SPINE, 30(17), E509-E516.
9. Hall SE, Criddle A, Ring A, Bladen C, Tapper J, Yin R, Cosgrove A, Hu Yu-Li. Study of the effects of various forms of exercise on
balance in older women. Unpublished Manuscript Healthway Starter Grant, File #7672, Dept of Rehabilitation, Sir Charles Gardner
Hospital, Nedlands, Western Australia, 1999.
10. Stephens J. DuShuttle D. Hatcher C. Shmunes J. Slaninka C. Use of awareness through movement improves balance and balance
confidence in people with multiple sclerosis: a randomized controlled study. [Journal Article, Clinical Trial, Research, Tables/Charts]
Neurology Report. 2001 Jun; 25(2): 39-49. (33 ref).
11. Johnson SK, Frederick J, Kaufman M, Mountjoy B. A controlled investigation of bodywork in multiple sclerosis. The Journal of
Alternative and Complementary Medicine 5(3): 237-43, 1999.
12. Laumer U, Bauer M, Fichter M, Milz H. Therapeutic Effects of Feldenkrais Method Awareness Through Movement in Patients with
Eating Disorders. Psychother Psychosom Med Psychol 47(5): 170-180, 1997
13. SantoroF, Maiorana C,Faccin C. Neuromuscular relaxation and CCMDP. The Zilgrei and Feldenkrais Methods 2, Dent Camos, 1989
Oct 31;57(16):84-7
14. Lowe, B., Breining, K., Wilke, S., Wellmann, R., Zipfel, S., & Eich, W. (2002). Quantitative and qualitative effects of Feldenkrais,
progressive muscle relaxation, and standard medical treatment in patients after acute myocardial infarction. PSYCHOTHERAPY
RESEARCH, 12(2), 179-191.
15. Dunn PA and Rogers DK. Feldenkrais Sensory Imagery and Forward Reach. Perceptual and Motor Skills. 91:755-57, 2000.
16. Netz, Y., & Lidor, R. (2003). Mood alterations in mindful versus aerobic exercise modes. Journal of Psychology, 137(5), 405-419.
17. Stephens J. Feldenkrais method: background, research, and orthopaedic case studies. Orthopaedic Physical Therapy Clinics of North
America. 2000 Sep; 9(3): 375-94. (46 ref).
18. Gard, G. (2005). Body awareness therapy for patients with fibromyalgia and chronic pain. DISABILITY AND
REHABILITATION, 27(12), 725-728.
19. Leri, D Learning how to learn, Gnosis Magazine, Fall 1993, 49-53
20. Ernst E., & Canter P. (2005). The Feldenkrais Method - A systematic review of randomised clinical trials. PHYSIKALISCHE
MEDIZIN REHABILITATIONSMEDIZIN KURORTMEDIZIN, 15 (3), 151-156.
21. Feldenkrais M. Body and mature Behavior, 1981, Harpers
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