20

the reaching movements into pushing power keeping the shoulder blades free, the breathing

relaxed and the head and neck resting. After this session she was mostly pain free but had

soreness with higher levels of resistance in her pushup. She returned after one week ofworking with these movements at home and reported that her shoulder function was!{)Vo

of normal. We continued working with FI in sitting and standing integrating the Lshoulder into full overhead reaching movements with lateral flexion of the trunk and inprone working with full weight bearing and rotational movements of the neck and trunk.

At the erid of the session she was able to take her full body weight in a full pushup withscapular protraction and was pain free in all movements. She was discharged after this

third treatment session. The key was to establish a mmfortable base of support forshoulder movements to build on.

CASE 4

V.J. is a massage therapist rvho spends hours each day leaning over a rvaist high

table, working on people rvith her hands. This is i,ery difficult w,ork for people rvho have

normal posture but V.J. has a mild scoliosis. She is also a mother of 2 boys, the most

recent was deliver"d by Cesarean section 9 1,ears ago. She u,as referred for treatment oflumbar and thoracic pain n,ith muscle spasms and possible SI joint involvement.

On initial evaluation she presented w,ith a25_30. R low, thoracic C_curve scoliosis.

Her L shoulder w,as loler than the R. Her L illiac crest w,as higher than the R and her ribcage tvas rotated back to the R. Both SI joints n,ere painful to palpation but alignment

appeared good. She also had pain ri,ith the compression of spinous processes and

paraspinal muscles in the mid thoracic and low, Iumbar regions bilaterally. Her strength by

MMT was normal except for hip flexors 4_l5BlL,hip extensors L 4_15,R 3+/5 and

adductors on the L +15 ivith pain. Her upper and iow,er abdominals were 3+/5.

Functronally she rvas able to do all ADL,s and w,ork but she n,as in parn all the time and not

able to sleep rvell. V.J.'s pMH was unremarkable and there w,as no history of surgery

2l

except the C-section. She rvas taliing no medications but rvas seeing a chiropractor

bileekly which she had been doing for over a year.

V.J.'s goals were to reduce her pain so that she could rvork more easily and sleep

better. The problem of pain management revoh,ed around understanding the use of her

spine and being able to use better biomechanics in the work and life. The question for V.J.

rvas: Holv could she leam to be more atvare of her spinal movement so that she could

organize her prsture better and use good biomechanics consistently?

The treatment plan rvas to begin by addressing problems of abdominal rveakness

and then move into using ATM and FI to develop her awareness of spinal function and

postural control. We began lvith traditional supine strengthening of lolver and upper

aMominals. She then moved to an ATM lesson involving control of flexion in supine by

bringing the elbow an knee together and then rolling torvard the side. Initially rolling to the

R was much easier than rolling L. This lesson n as supplemented by a supine lesson of

reaching to the foot in hooklying and then rolling to the side which was also easier to

control on the R. In each of these she rvas initially unable to roll all the rvay to her side

lvithout losing her balance. As she developed more control in these movements, she began

to report soreness in her neck as a result. At the beginning of the 4th session, she reported

feeling much stronger and more flexible and having much less back pain and sleeping

better. The neck parn rvas addressed using FI to help her to organize the movement of her

head, neck and upper spine. Tw'o nerv ATM lessons moved to more difficult use of the

spine in (1) rolling backward in supine to put her feet over her head (the plorv in Yoga).

She rvas initially to rveak in the abdominals to roll up rvithout support from her arms and

could not bring her knees to rest on her head. In this movement she also had trouble

maintaining her balance due to asymmetry of control. The other movement rvas (2) supine

bridging from the feet to the head using the arms to support and maintain balance. This

rvas easier but caused parn in her low' back so rvas abandoned. At the end of this lesson,

she reported that she felt like she had a "single body" that rvas no longer going all different

22

directions. At the beginning of the 5th session, she reported feeling much straighter in

standing, but that it took 3 days for the soreness to go arvay and her neck rvas hurting

again. Functional Integration rvork rvas done in prone to continue the process of

reorganizing movement of her neck and shoulders. Work lvith the supine backrvard roll to

the plow position continued and the movement became easier. At the begrnning of the 6th

session, she reported that friends remarked on her straighter posture. Lower back pain rvas

completely resolved at this point. She was able to lvork with no lorv back pain but mid-

thoracic and neck pain rvere still a problem. During this lesson rve w,orked w'ith FI in

sitting and prone to lengthen the spine and improve the ease of rotation tow,ard the L aad

extension. These movements rvere then picked up in ATM lessons in prone lengthening

the legs and extending and rotating the spine L and R, slorvly then quickl1,; in standing rvith

lveight shifting and lateral flexion of the trunk; and continuing to improve control of the

plow to reach fully to the feet overhead and move the legs and head simultaneously. At the

end of this session all the thoracic and neck pain rvas resolved and her breathing w,as much

deeper and slorver. We discussed the biomechanics of her w,orkrng in standing and

plantargrade positions. In the next session a series of 4 briei ATM lessons started rvith ( 1)

rolling into the plorv lvhich rvas no\\, much easier and (2) prone of elborvs alternately

flexing the legs to the side and turning to look at the knee. Thrs movement u'as initially

much more difficult on the L rvith R lumbar pain but became easier, pa:nfree and more

symmetrical. We then took a break and did an ATM lesson in hooklf ing that tvas very

much like progressive relaxation. I asked her to use her developing sense of control

around her spine and tighten muscles in the pattern ri'hich produced her scoliosis and pain.

When she did this she noticed small movements of rotation of the pelvis and L hip. The

pattern was then relaxed and lengthened and tightened again altematell'until she could do it

at easily. We returned to tn'o more brief ATM lessons in hook11,'ing: (3) actively rolling the

pelvis L, center, and R and (4) pushing w'ith her feet to discover the minimum amount of

effort needed to roll her peh,is L, center and R. She ri'as initially unable to organize a

23

pushing, rolling movement with her L foot As has discovered how to do this movement,

she felt her pelvis and sacrum lying flat in supine for the first time in her memory. When

she stood up, she reported feeling wonderful, like she was not being twisted or pulled and

her ribs were not straining against each other. She noted what a pleasure it was to bend

over and tie her shoes and feel both sides of her pelvis and back working in a fluid way

together. She was discharged at the end of this session with these 4 ATM lessons as her

home exercise progftrm. A month later she reported in a follow-up phone conversation,

that she was feeling even better and having no problems in her work.

1A

SYNOPSIS

Functional Integration@ and Awareness Through Movement@ are aspects of the

Feldenkrais Method which have been used successfully in the rehabilitation of people with

orthopedic problems. These methods are approaches to motor learning which can be used

to facilitate change and integration in postural control and general musculoskeletal control.

This article describes the background and development of the Feldenkrais Method, and its

philosophical and scientific basis. An outcome survey of the use of Feldenkrais Method

with 180 orthopedic patients is presented. Four case studies are also presented as

illustration of how this method can be integrated into a physical therapy practice.

Feldenkrais Method is an excellent approach to use in the rehabilitation of people rvith

orthopedic physical therapy problems.

25

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26

216-221, Lg91

8. Chinn J, Trujillo D, Kegerreis S, et al: Effect of a Feldenkrais intervention on symptomatic

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10. Dennenberg N and Reeves GD. Changes in health locus of control and activities ofdaily living in a physical therapy clinic using rhe Feldenkrais Merhod of sensory moror

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Learning. Nerv York, International Urur.ersities press Inc..1949

27

16. Feldenkrais M. Awareness Through Movement Health Exercises for personal Growth.

New York, Harper and Row pub.,lg7T

17. Feldenkrais M: The Elusive Obvious. Cupertino, CA., Meta publications, 1g3l

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19. Guide To Physical Therapist pracrice. physical Therapy 77(ll): tL75_l6SO. 199g

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*,ith chronic lorv back pain treated according to Feldenkrais principles. An exploratory study.

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24. Jackson-Wy,att O, Gula D, Kireta A, et al: Effects of Feldenkrais practitioner training

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28

25. James M, Kolt G, McConville J, et al: The effects of a Feldenkrais program and

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26.Kaas J: Plasticity of sensory and motor maps in adult mammals. Ann. Rev. Neurosci.,

14:137-167, 1991.

?i|.Kelso JAS: Dynamic Patterns: The Self-Organization of Brain and Behavior.

Cambridge, MA., The MIT press, 1995

28. Kisner C and Colby LA: Therapeutic Exercise Foundations and Techniques, ed 3.

Philadelphia, FA Davis, 1996.

29. L-ake B: Acute back pain: Treatment by the application of Feldenkrais pnnciples. Australian

Family Physician 14(11): II75 - 1178, 1985

30. t ake B: Photoanalysis of standing posture in controls and low, back pain: Effects of kinesthetic

processing (Feldenkrais Method) in posrure and gait. 1n Woollocom M and Horak F (eds):

Control Mechanisms VII.. Eugene, OR, U of Oregon hess, 1992

31. Nagarajan SS, Blake DT, Wright BA, et al: practice related improvements in somatosensor).

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and modality. J Neurosci i8(4): 1559-70,1998

32. Narula M, Jackson O, Kulig K: The effects of six u'eeks Feldenkrais Method on selected

functional parameters in a subject w'ith rheumatoid arthritis. phy,sical Therapy,T2: (suppl.) 5g6,

1992

29

33. Narula M: Effect of six week Awareness Through Movement lessons - the Feldenkrais

Method- on selected functional movement parameters in individuals with rheumatoid arthritis: a

pilot study using single subject case study design. Master's Thesis, Oakland University,

Rochester, MI, 1993

34. Nervell, G. Moshe Feldenkrais: A Biographical Sketch of His Early Years. Somatics'7, 1992.

35. Newell KM: Motor skill acquisition. Ann. Rev. Psychol. 42: 213-231, L99L

36. Phipps A,Lnr ,z R, Powell R , et al: A functional outcome study on the use of movement re-

education in chronic pain management. Master's Thesis, Pacific University, School of

Physical Therapy, Forest Grove, OR, 1997

37. Reese, M. Function: Realizing Intentions. Feldenkrais Journal 7: 14-20,19%.

38. Ruth S, Kegerreis S: Facilitating cerv'ical flexion using a Feldenkrais Method: Arvareness

Through Movement. J Sports Phys. Ther. 16(1): 25-29,1992

39. Saraswati, S: Investigation of Human Postural Muscles and Respiratory Movements.

Master's Thesis, University of New South Wales, Australia, 19{39

40. Shenkman M and Butler RB: A model of multisystem evaluation, interpretation, and treatment

of individuals with neurologic dysfunction. Physical Therapy 69(7): 538-Y7, 1989

41. Shenkman M, Donovan J, Tsubota J et al: Management of individuals with Parkinsons

Disease: Rationale and case studies. Physical Therapy 69i 94+955, 1989

30

42. Stephens JL, C pendergast, BA Roller, and RS Weiskittel: Changes in coordination, economy

of movement and well being resulting from a Z_Day workshop in Awareness Through

Movement. Program abstracts from ApTA, Combined Sections Meeting, Boston, MA, 199g

43. Stephens JL, Call S, Evans K et al: Responses to l0 Feldenkrais Awareness Through' ' Movement @ lessons by 4 women with multiple sclerosis: Improved quality of life. physical

' Therapy Case Reporrs Z(2): 58-69,I9E9

44. Stephens JL, Davidson JA, DeRosa JT, et al: Effects of ArvarenessThrough Movement, a

motor learning strategy, on hamstring length in healthy subjects. program abstracts from

APTA, Annual Conference and Exposition, Indianapolis, IN, 2000

45.Talmi,A. First Encounters ri,ith Feldenkrais. Somatics 3 (1), 19g0

46. Thelen E and Smith Fts. A Dynamic Systems Approach to the Development of Cognition and

Action. MiT Press, 1994

Table 1. Practice distribution by age and gender

agel gender M F Total

72-25,) 4 6

26-45 2t 37 58

46-65 33 62 95

66 up 7 14 2l

Totals 63 LL7 180

Table2 Top 5 regions by body part of primary diagnosis

Low back

Neck

Whole body

Knee

Shoulder

66

42

4l

13

11

Table 3. ICD-9 codes of primary diagnoses by region

Region ICD-9 code of primary diagnosis

Hand

Shoulder

Tlvl,J 524.6

Cervical 088.81, 7?0.2, 722.0, 1Df, 7z?.8, 723.1, 723.3, 723.4,

723.9, 728.2, 729.t,738.4, 847.O

Thoracic

Lumbar

72?.73, 7?2.8, 724.02, 724.2, 724.3, 724.4, '724.9, 729.L,

738.4, 756.12, 846.0, U7.2,

Hip TBE, 715.95, 716.0-1T68 7t6.Bs

Knee 715.85, 715.96, "716.0, 1rc.e, 777.9, 726.6, 824.0, 836.3,

844.0,

Foot/Ankle

Whole Bodl'

8t2.12

Whole Spine 9

Table 4. Description of outcomes: 7o goals met

Score e

1 v, a sesslons

ew or no met

some met

4 most met

5 1 of goals met

Table 5. Outcomes by Area of Primary Diagnosis, not including consults

Region Outcome n

ftmge

# sessions

Mean

# sessions

Hand 5 2 4-7 5.5

Shoulder 4

5

4

5

2-18

2-33

7.5

11.8

TN4J 4

5

1

1

7

1

Cervical 2-3

4

5

5

t?

T

2-t6

r-82

1-105

7

26.1

13.1

2

1

4

3-4

t6

1 11;- L-

3.5

16

7.0

Thoraclc 2-3

4

5

2-3

A+

5

2

12

4l

3-10

2-80

1-88

6.5

18.2

11.5

Lumbar

4

5

2

6

2-r5

8-30

8.5

13.8

Hip

Knee ^a,-)

4

5

1

3

8

3- 11

1-10

6

5.7

3.6

2A

6

20

6

1

1

4

5

v 4

5

7

3

10-30

9-10

2Lt

9.3

(scoliosis)

3

4

5

1

1

5

2

16

3-4A

2

16

t5.2

Totals 157 l-105 12.5

Some Effects of the Fetdenkrais Method@On Parkinsons Symptoms and Function

Larry L. Wendell, ph.D.

lntroduction

When lstarted receiving Feidenkrais Method@ Lessons in March 1ggg, I had been diagnosedwith Parkinson's Syndrome almost !fteen years before. For the first seven V"r* i*i? patient ota general practitioner, who then retireg Fgr the past eight years I have been a patieni of aneurologist, who was very helpful in allowing me to expLriment with medication'regimens. He alsoallowed me to try various kinds of natural frealing therapies. I seemed to experience sometemporary relief from two of these therapies, but-there were no records t<epi to qrrntify ihe results.Through a friend, I met Marityn M. Johnson, M.Ed., a certified Feldenkrais Method@ practitioner,who expressed interest in participating in a somewhat formal experiment to see what benefits aperson with an advanced case of parkinson,s Disease could deiive from a series of FetdenkraisMethod@ lessons. We documented the results with an email log, some daily tables and plots ofcondition over time and medication regimen. We atso kept a vijeo rectrO of the progress. A

Primary Medication: Sinemet (lncludes dopamine precursor, Levodopa) Other medications includeEldepryl, Amantadine, and Mirapex.

Description of Gondition, as of February lggg for three dopamine tevels:

What follows are the descriptions of the symptoms that defined my physical and emotionatcondition the month prior to beginning the Fetdenkrais Method@ 6dro*. It il jJ;Gly thelowest point that I had experienied *.g becoming a parkinsonian. par-ki;;;;;:ffiff s andmedication side effects depend on whether the levil of the neurotransmitter dopamine isinsufficient, sufficient or excessive. To accommodate this for compirison of before and afterFeldenkrais Method@ lessons, conditions are described ,"brrrt"iy io,

"r.n level.

lnsufficient Dopamine (Less than required for normal neuromuscular control)

This condition occurs when I inadvertenfly miss a dose of Sinemet that is the source of thesupplemental dopamine required to offsei the dopamine deficit caused by a shortug, oidopamfne-producing cells in the substantia nigra. The deficiency can also be caused bytactors allecting the absorption of the medicat-ion as it trayerses the digestive tract and theblood stream to the brain where it is needed.

FunctionAll my muscles were tight. lt was very difficult to move any part of my body; I couldn,teven turn over in bed or get up from a sitting position without assistanc!. i'nrJ"illortcomplete lack of small motor skills and couldn,t button a shirt or peel an orange.

PostureMy upper body leaned fonrrard, from the waist up, about twenty degrees from verticaland leaned to the right side about ten degreer. irVitf, significant.ffort and pain in the

1

lower back I could correct the fonrvard leaning, but I could not correct the tean to theright.

MovementIt was as if I was trying to move in a vat of molasses. When I was trying to initiatewalking, it felt like my feet were stuck to the floor. t would tean forwird until I started tofall, then shuffle quickly with short choppy steps to catch up. This was very difficultwhen exiting a theaterin a targe slow moving crowd. This condition became a source ofgreat embarrassment.

GaitWhen I got underuay, my gait would evolve into a short stepped shuffle with armshanging stiffly at my sides with no swing at all. t could not geiaround in a public llr..in this condition, because of the danger of failing or running into someone. When in thiscondition, my walker was no help. I simply had to resort to i wheel chair.

Emotional OutlookI was sinking into the depths of despair. Every time I went into this frozen state I beganto fear that I would never come out of it. I had tried many unconventional approaches inan attempt to find some relief from this monster whose power over me was-growingever stronger. I prayed for help, but was beginning to think I must not be wortny oiit.

Sufficient Dopamine (Adequate for normal neuromuscular control)

I was in this condition a very small percentage of the time. During a gpical day I wouldexperience three to five cycles between the conditions associated wiih insufficient Aojamineand excessive dopamine. Since the transitions between extreme conditions took only'ten totwenty minutes each, I was experiencing relatively normal muscular control tor seveiai.nortperiods, scattered throughout the day, totaling no more than one to two hours a day. inerest of the waking hours of the day was spent in dealing with the parkinson's ,y*p[orsdescribed in the previous section: "lnsufflrcient Dopamine," and those described in thefollowing section: "Excessive Dopamine."

Excessive Dopamine (more than required for normal neuromuscular control)

The first few years on Sinemet were very successful. I could function normally most of thetime because there was litile concern about over-dosing with the Levodopr. fh"re appearedto be no serious side effects from having an over suppli of Dopamine in the brain. However,after about four years on the Sinemet, taking this miiacie drug to alleviate parkinson,ssymptoms got extremely complicated. Something had changeO in the way the medicationworked. The rigidity had become more severe when the medication was iow. However; if forsome reason, I had taken too much medication, I began to experience dyskinesia, thedreaded combination of random and cyclical involuniary movements I had seen in a NOVAvideo program about the parkinsonian drug addicts thai initially responded so well toSinemet.

FunctionAll muscles generally loose, except for erratic spasms that cause diskinetic movements.lnstead of not being able to turn over in bed I trrashed around so violenfly that I would

2

have to get up for my wife's peace and safeg. I was abte to jump up out of a chairinstead of someone having to lift me up. With all the rocking back and forth from onefoot to the other, I would have the appearance of being in a-frign ,t"t" of anxiety. 6'n'."a receptionist in a dentist's office asked me if I needed to use in" bathroor. As';;"-'condition cycled between the frozen state and the diskinetic state there was usuallyabout a fifteen-minute window in which my fine motor skills would return to normal. tcould easily button a shirt, peel an orange or thread a needle, untit Oiskin".i. *orijstart and intensify to a level determined by the amount of excess Oof amine present.

Postureln spite of the perceived looseness and erratic movements, my upper body still leanedforward, from the waist up, about t*9-nty degrees from vertical, and teaned to the rightside about ten degrees. With litfle effori, belause the diskinetic condition seemed todiminish the pain in the lower back,. t could easily correct the forward leaning *n.n"r"rI remembered to try. I could not find a way to coirect the lean to the right.

MovementAb.9u! half the people with parkinson,s Disease are not "frozen" but exhibit a conditioncalled "resting tremor." I have been in the half which do not

"rp"ri"n.e this condition.

lronically, it seems as though those of us without resting tremolrr" ff"gred with thedopamine-induced side effect of diskinesia. Many people have told m" Ihat theythought my diskinetic movements were associated with the pafry-fif" tremor. Theseconditions may be related, but are actually quite different. Wne,i I am in a diskineticstate, the motion caused by the excess oidopamine is not a singie"ycle tremor. lt israndom muscle spasms that cause me to writhe and gyrate uncontroilably. Unless ilgets extremely severe, I can at least move around without the horrible cliustrophobicfeeling of the rigid condition. Even though it is a source of embarrassment, especially inpublic, it is preferable to feeling frozen.l naO learned that mild to moderate di;kin;;i;could be stopped quickly and completely by focusing my complete attention on retaxingand letting nothing distract me. The instlnimy atteniion was divert"J, tne diskinesiacame back as if it had never been interrupted.

Gaitln the diskinetic state walking was much easier. To me, the movements felt much morefluid, but when I observed them in a video clip, they had a quality to tnem that remindedme of someone who was inebriated The short_stepped shufile with arms hanging stifflyat my sides was gone. My arms seemed to swing aiound erratically. I could glt r-rornjsatisfactorily in a public place in this condition. l-seemed to have a suppty of resflessenergy that lasted until the excess dopamine was used up. When this occurred lwouldfeel the rigid state coming on and have to exit to the car before having to be taken outof such places in a wheelchair. - "--"'r

Emotional OutlookMy most positive outlook seemed to occur as I began to enter the diskinetic state. Idon't know whether the short-lived euphoria came-from the excess dopamine or the factthat I was released once again from the frozen state. The frustrating aspect of thisphenomenon was that I knew it would not last long, and wouldn,t make much of a dentin the overall state of depression.

3

-Description of Condition, as of February 2000 for three dopamine levets:

. What follows are the descriptions of the symptoms that defined my physicat and emotionalcondition after one year of Feldenkrais Method@ lessons. To faciiitate comparison the format isthe same as for the Description of 'Conditions as of February 1ggg, before the lessons began.

tnsufficient Dopamine (Less than required for normal neuromuscular control)

This condition still occurs when I inadvertenfly miss a scheduled dose of Sinemet or if it isblocked in some way on its journey through the digestive tract and the vascular system onthe way to the brain. The only time that t voluntarily skip medication to allow the fiozencondition envelope me is just before a dental appointment. When a dentist has a driil in mymouth, it is much safer to lie frozen like a rock than to be wildly thrashing around in adiskinetic fit.

FunctionFor this level of dopamine, the descriptors in the previous section are all stiil essentiallythe same.

PostureMy posture has improved dramatically. Even with a dopamine deficiency, the forwardtilt of my body, from the waist up, is practically gone. The tilt to the right side is atsosignificantly decreased. The Feldenkrais Method@ lessons I experie-nced havecontributed to correction of this condition.

MovementI still get the oven,rhelming feeling of claustrophobia with a severe dopaminedeficiency. This occurs occasionally during the night if I have missed iaking ascheduled medication. I very seldom get into this iondition during the day because Ihave improved the management of my medication regimen. lf it dies happen, theFeldenkrais Method@ lessons have helped me learn to focus on where i am going toput my feet and I can at least walk reasonably well for a short distance to getlo alar o,a place to sit down. I have almost eliminated the "falling forward,, and .running to catchup'mode which had become almost routine before the Feldenkrais Method@ tessons.This routine resulted in frequentfails, several of which resulted in broken bones.

GaitThis is the area that the lessons have really been successful. The specific learning inthis area gave me a whole new pattern of walking. This pattern included moving m-yshoulders and hips in opposition to each other. This resulted in a naturat swinglngttmy arms that looked quite normal. When the dopamine is low, this does requirLs6meeffort mentally.

Emotional Outlook

lven in the dopamine deficiency state, my attitude and ouflook improved tremendously.The depression that was so difficult to deal with went away. I am very optimistic aboutthe future.

4

Sufficient Dopamine (Adequate for normat neuromuscular control)

The time I spent in this condition increased dramatically. During a typical day I stillwoutdexperience several cycles between insufficient and excessive Oip#ine, bu[ they *i" off!9h lower amplitude. Since the transitions were between much milder conditions, the timein the "normal" mode was much greater. Sometime.s fhLs

,normal,,mocle even occupiesmosf

of the day.

Excessive Dopamine (More than required for normal neuromuscular control)

Since I have had the Feldenkrais Method@ tessons, it is easier for me to regutate mymedication level, and I don't have as many "excessive dopamine" periods. The lessons seemto have widened the window substantially between being'frozenand diskinetic.

FunctionAll my muscles and ligaments are very loose and pliable. The intensity of the diskinesiais significanfly reduced. I have to be carefulwith nighttime medication'regim"r,, ili i ,,able to sleep better even with mild diskinesia. The lessons have improve-d my phyiicatcondition so that I am now able to exercise for both aerobic and strength buildingpurposes. The excessive dopamine is worked otf during exercise withiut ;;;;i;;diskinesia. I have been able to perform woodworking taiks that have beendiscouragingly difficult in the past few years.

PostureEven with the excessive dopamine in my system, my posture is almost normal.

Movementlf the excessive dopamine is severe, I still have the same movement problemsdescribed above. The main benefit in this area of the Feldenkrais Method@ tessonshas been in the diminishing of the amplitude of the cycles between being frozen anObeing diskinetic. They have also helped me to gain a litile more control over stoppingthe diskinetic movements.

GaitThis is the area in which the Feldenkrais Method@ lessons produced the most visibleresults. ln contrast to the insufficient dopamine condition, in ihis state I can apply theprinciples I have learned to walk normaily with litile or no effort. When t have thisfeeling, rf's as if I never had pa*inson,s Drsease. The excess dopamine is simply usedup as it is in the exercise routines. ln this condition I have been able to do many thingsthat I thought I had to give up forever, such as jogging, dancing, /arO work,woodworking, and going to plays and other cutiuiat events.

Emotional OutlookWith the enhanced good feeling caused by the excess dopamine my ouflook becameeuphoric. A very encouraging aspect of this transformation is to have people, whohaven't seen me in one to five years, express their amazement in ine improvement ofmy overall condition. A lady, who lives across the street, said she could not believe thechanges she was observing in my ability to get around.

5

Observations and Conclusions

At the beginning of this experiment it became clear that one of the immediate benefits ofFeldenkrais Method@ lessons was the loosening of the rigidity of my parkinsonian body. Thisincluded the rigidity caused during a low dopamine period and a residual rigidity that wisindicated by an ever-present tilt fonvard and to the right from the waist up. Even though it wasvery pleasant, the effect on the low dopamine rigidity usually lasted only a few hours. However,the loosening effect on the residual rigidity proved to be cumulative. Before the FeldenkraisMethod@ lessons the tilt of my torso was always there, even during normal and high dopamineperiods. The fact that, after six months of lessons, the fonvard tilt was gone and the tilt to the rightwas down to about two degrees at all three dopamine levels is strong evidence that this effect iscumulative.

This noticeable improvement in posture has been accompanied by a significant increase in therange of motion in my neck, arms legs and upper back. This welcome change has also hetd firm,even though the lesson frequency, during the last six months of the experiment, dropped fromtwice a week to once or twice a month. A surprising side effect of this new flexibility was that, sixyears after sadly giving them up forever, moderately intensive aerobic and strength developingexercises were, not only possible, but also exhilarating.

The most exhilarating and visibly dramatic result of this experiment was the change in my ability tomove on my feet. The lessons in this area were covered intensely during the first six months of theexperiment and the very dramatic improvements in my ability to walk have not declinedsignificantly since then. During periods of extreme rigidity (which occur much less frequenfly now)walking requires great concentration and physical effort, but is no longer impossible. Duringperiods of adequate or excessive dopamine, walking with a comfortable stride, an erect poiture,and a natural arm swing is not only efforiless, it feels like floating. lt is even possible to jog anddance again after giving them up several years ago (l have proof of this on videotape).

-

ln reporting the very positive results that I experienced from this experiment, t want to be sure tomake some important clarifications to prevent misunderstanding. The results of this experimentapply to only one Parkinsonian, me. Because of the variability in the nature of the parkinsonsSyndrome, the results cannot be reliably extrapolated. lt is also important to point out here thatthis experiment did not show any evidence of improvement in the parkinsons condition. The samelevel of medication is required. The frozen condition is just as severe when the medication teveldrops below the critical threshold, but now I can walk out of it. The Feldenkrais Method@ lessonsdid not cure or improve my Parkinson's condition; they improved my ability to cope with it.

It is as if I have been given a new life. At age 63 I realize that this life is going to be much shorterthan the one just completed, so I have no time to waste. I feel that I must share this experiencewith all those who are facing the grim prospects of dealing with the progressively degenerativecondition called Parkinson's Disease.

June 15, 2000

b

ABSTRACT

This study examined the effectiveness of a structured, group motor learning process,

Awareness Through Movement (ATM), on balance, balance confidence and self-efficacy.

Twelve people with multiple sclerosis were randomly assigned to ATM or control grcups.

The ATM group participated in 8 classes,2 to 4 hours each while the control group

participated in educational sessions, over l0 weeks. Five outcome measures were used: the

modified Clinical Test of Sensory Interaction in Balance (mCTSIB) and Limits of Stability

tests; the Activities-specific Balance Confidence Scale; prospective falls; Equiscale; and the

Multiple Sclerosis Self-Efficacy Scale. Participants significanfly improved mCTSIB scores 15

to 6Vo and balance confidence lTVo comparel to controls. There was a trend toward

improvement ia all other measures includiog self-efficacy compared to controls. These

results suggest that this type of motor learning intervention can be effective in improving a

variety of physical and psychological parametem related to balance and postural coatrol.

Improvements in Balance and Balance Confidence Resulting from use of

Awareness Through Movement, a Structured, Group Motor Learning

Process: a Randomized, Controlled Study in People with Multiple

Sclerosis.

James Stephens, PT, Ph.D. \ilidener University, Institute for Physical

Therapy Education, Chester, PA 19013

Dominique DuShuttle, MS, PT

Carla Hatcher, MS, PT

Jenifer Shmunes, MS, PT

Christine Slaninka, MS, PT

Widener University, Institute for Physical

Therapy Education, Chester, PA 19013

k .4d C.- g^l kc-A -- 9 Nt'-40s, R"au-t' e-.b Zae 1

children with

i0,988-991,

atology of the

rt presented at

a7 -608, 1976.

,\nat Rec

\OA7?:474-

eer-Verlag

;ystem, Alt

Feldenkrais Method@

FRANK WILDMAN

JAMES STEPHENS

LE1A AUMCr-vl.^*-k'

1f4tfu,ra"!,

-n/\1S,5 -

or.. )- A.ir*1

C(.; .c,u-u ^ pltIo R+{c."-."r- r\,*d S\f"7n"Jt;g

Zoe.o

(.

Origins and Histor r-

ll our socicrr. qle do. br the pr,-rril-t.: a7 geat rerL,,ord or rna:nse punrs/rmenl. so dtsrolt tlte eten

de,reloptr,er,L o,Ithe slsien... ti'Lcitt,Lir,'\ c;i, becrrn; e:tcL'ndei or:'esrricied. Theresuh rs rhc; we har,c

tL Provide special condtaorts f ti j.,t-rilvg11-,g cdnlt rrctturatt,Ln ol r,arry crrested l'unctiotts. The major -

i4 of people need u, re-forr, parrern-t oi niotioris ont) attttudes that shrt,,Lltd r,euer hate bee-n excludelrtr negLeued.

The rnettrod i-. nan'ied after the israeh screnrist Moshe Feldenkrais, DSc (1904-1954).

Feldenkrais worked as a nuclear phvsicrst u'ith the Nc,be1 Laurearc joliot-Cr-rne. After ir,-

luring hrs knee rr.r a soccer garne, I)r. Feldenkrais learned that a surgerv had onlr' a 50"ru

chance of improving his condrtion, b,-rt ri rhe surgen' were unsuccessful ir would coninehim tcr a wheelchair for tiie rest oil-iis life . Unsatrsfied s'ith t}-rese pmspects, he proceedecl

to learn anarom), kinesiology, and phvsrologi. and cornbined these u,irh his kr-ro*,ledge oirnechar-rics, phvsrcs, electricaL engineering, and martial arts (he rvrote severalbookr.rn JuJoand was the iirst non-Japanese to earn a l-.lack belt in thrs discipline). Tl-us endeavor notonh,restored most of the frincrion to his injured knee but also marked the begrnning oihisrnvestlgatiolr into hum:in function, develt-,prnent, and learning that was to occupv him {or

the rest oi hrs liie and eventuallr. lead to the developitrent of the Feldenkrais Ntethod. Frorn

the 1970s on he taught the rnethod throughout the world. He rLrecteil the Feldenkrais h-r-

stitute rn Tel Aviv ur-rtil hi-s dearh in i 9E4.

Mechanisms of Action According to its Ow'n Theor,v''t\an!

oi c:u faiiings. phrsical ar.imentol,rLeedndbe constderedos diseases nbe utred, bt*rather as

on ocqtLtred renth of a Leanted fau|"t,: r'ode of doing. Actx;ns repeoted tnnurnerabLe time: f or !ea?5 oil

er.Ld. such as aL! our h_abLtL1aj acti6rts . mctuA et,en the b1,ne.s , lei oktne *te mrLsculz; enereLope. The phls-

tcaiJa,"LLtsthatappeartnottrboatirrnEaiterLU.u)ei.bornare marni. iheresuiiojactir"rr-'- v-e'hn-.ein-

393

394 S E C T I o \ T r' O FieldsofPractice

posed on it. Fauky modes of sanl)ng anlwalkingpodwe faulry feet. ar'lir is tfu modz of snnding and

woJktng that must be coneued rLnd not the feet,

Moshe Feldenkrais

Unlike other animals, which are preprogrammed to survive, human chiidren musr learn

to mLrve. Although a cat is born with the knowledge of how to mo\ie gracefulll', it takesyears ftrr humans to learn mo\terrent well enough to function independentll, in the u,orld.The necessity and ability to learn individual patterns of movement leads to a variety in hu-man movement and posture unknown in other species and can be considered the most dis-tinguishing fearure o{ mankind.

Once they have reached a ievel of proficiency sufficient foi walking, jumping, or play-ing sporrs, most people srop learning neui movements and irnproving their body awareness.'lThatever style of movelrient has been learned at this point, mostiy rhrough trial and er-

ror and imitation of models in the sociai environment, then begins to form a personal set

of movement habiis. These movement habits tend to overuse certain muscles and loinrswhile neglecring or ignoring the r-rse of others, thus ieading to a limited range of movemenrand gross inef6ciency.

Manl'people find rhey are simply unable to improve at activities that interest them, be

they sports, dance, or music. Thev avoid engaging in actir.ities where they could be con-fronted with a iack of coordinaticn and awareness and ne.,er learn to ski or dance because

the,, feel uncomfortable doing so.

Feldenkrais observed, "Through the 6rst .vears of 1ife, n'e organize our elltire system in a

direction which will forever after guide us in *rat direction. We end up being restricted,we don't do music, we don't do other things. 1ff/hat is more important, we find ourselves ca-pable of only doing those things tl-rat we alreadv knolr,."

In thllong run these limitations in au,areness and coordination lead to physical difficul-ties. such as recurring pain, repetitive stress injuries. or problems recovering from injuries.

"This great abilitl to fmm indiudual rwuous patlu and muscuktr pottems m"dtes it possibLe t'a' fauLt,.t

functioning n be lrunled. Th.e ectrlier thr fauk occurs, tht more engrainrl it appears, anl is . Faulc^y be-

hauiu wiLL appeor in tfu executiy,e motar m.e.chanisms uhich will seem later, whcn the neruous slstem has

g-oum fiued. n thr unltsirable motiliry , n be irkerent in thz person anl utwkerabb. . It wiLL remain largely

so urtless the tlewous pattLs Noduring the w,lzsiroblc pattern of moalitl are undone and reshuffbd intoabettn configuration."

Moshe Feldenkrais, Body and Mature Behaqior

No other ai'iimal has ti-rt abilrtv tc, changt anul reorgani:e rhe vvav it perfonns familiaractivities the ruar hurnan berr-rgs can. Peopie har-e the capaclt) to make each rvalk thei, takea different r,,'alk, cornple!elr r-Lell u-r sr1 1er to m.rke eacl-i rnovernent a nerv erprricnce.

\et thrs amau ing capacitr-to learn Ls rareh'useJ; most pe..ple tLnd one u,ay oidoing sorne-

thing and srick to rt until inailv a knee or a hack breaks dorvi-r. Then thel'assume that theirdistress rvas causecl bl the actir.'rtv they pertorne.i rather than their particular wa_v of per-forming the activitl.

The Felilenkrais Method sees protrlems as a conseqLrence of arrested or incompLete lean-r-

ing that leaves its rrark on ali biologic functr.rns, from digestion, breathing, and rr.rscularcontroi tr--. the -.exual irct and soci:rl adjustmer-rt.

Feldenkrars MeC-rc,de

Bv recapitulatlng the explorator.t st\le of learning naturaL to iniants, patrenls oi the

Feldenkrars Method dtscover ne1\- ways tr-r sense and triove that expand a\i:areness and c1e-

velop more efhctent and cotnfortable n-ioten'reni.

Biologic lvlechanism of Action

395

tnding anl

rrLlst lSarn

,', rt takes

he wor1d.

:rv in hu-mosr dis-

,, or pia1,-

\i areness.

al and er-

i -..,nai set

rr-rd lointsli)\relrent

them, be

.1 1--e con-.t becausc

tstem in a

restricted,rselves ca-

rl drficul-rL irjuries.

Personal experience reduces the initralil' unlrn'iited nutrrber of possible combinations oi

nervous inierconnections to a tew preferred and active patlerns o{ moving and acting Once

an adequate and sociallv acceptable level ot tnotor iunctionrng ls achieved, the process oi

exploratorv learning and der.'elopment oi tire bodv rrnage is suspended The acq'-rrred mr've -

menl patterns gro\\' so fan-rilLar through repeated use that lhe\ creatc a secn'ringl-r ''inalier-abie bodl rn-rage (for example, a person's walk or manner of speaking rs as fixed as a signa-

ture ) The bodv irnage, bound bi' tnotor habits and perceptions. l--ecomes the basis ibr an

rndivrduai's sense of self. lnfantil-rave a theoreticallr'uniitritetl abilitr to change and reor-

ganize the rvar lhel perform faniiliar activiries. Growtng into adults, thel-progressiveLt re-

strict therr repertoire of movernents' using an ever-siraller part oi ptoter-rtLal hun-ran

functionrng.lnefhcLer-rt movelrent hat,irs ol'crrl,llrk certain tnltscles and loints rvhile neglectrnu or

rgnoring the use oi others, rhu"t leading to a iurrrtecl ran,qc oi lrlo\iement 'rtld gr"t- Illcttl-

ciencr. ir-r the iong run these ltrritations in awareness ancl coorCtnation clln ieaJ to sei'ert

phvsrcal dihrculties. Parts oi articulatlons can hLi 11'11i1 fi'[rous tlssues. especLalir bctr'rten

vertebrae u'here there rs Lrrtlt movelrent tn generai. Ltgainen'is shorten 6'1 l-'g6911g il1'trlei-

elastic; solTre nuscle tibers becorne too strong. Others in the same muscle group *'ill atro-

phr. ln rhe l.nc run Jefcrrn rtrJn -(i' in

Forms of Therapyt"t ior iauLtl

FauL4 he-

.s slstem has

ruin hrgell;htLffled into

ns familiari the,v takelence.rlng some-

: that therrr. av of per-

,1ete iearn-I m,-rscr-rlar

The Feldenkrais Method uses two approaches in working with patients: Awareness Through

Movement (ATM) iessons and Funcrional lnregration (Fl).

Awareness Through n\ {ouemer"'

ATlv{s are verballr'directe.'l movelnent selluence: presented ir, a gror-rp settit-tg Lets'''ns gen-

eralll last from Z0 to 60 mir-rutes. Ti-rere arc hundre.ls oi AT\Is to choose irom rn tire

Feldenkrars lvlethod. The mecl-r.inLstt-ts ot breathir-rc, speaking arri aii aspects oi E'i'stural

controi are explored and improved r.r'hiLe perceptual capacttLes arc increa,eJ. Ti-re aim oi

these lessons is not relaxation but heaithl, porverful. eas1, and pLeasurable action'

Participants engage in preciselr- structure.i lr\o\relrent exploratLons thar rnvtlive think-

ing, sensing, movlng, and imagining. The lessons are c,{ien based or.r developmental move-

ments, like rolling, crawling, or moving frorn Iving to sirting or explcrrations c-ri loint, mus-

cle, an.1 postural relationshrps. N4ir-rute, barelr'perceprible moven-rents are used extci-tsivelr'

to reduce latent tonus (degrec of rn."oluntarl contractiot-rs) rn the muscies The graiual re-

duction of useLess eftort increases the kine-rihetic scllsttlvit\'

396 s E c T I o N T w o FieldsofPracrice

The lessons begin rvirh ct-,rnf.rrtab1e, eas\ llluvellleilis tilat gradualil er-oivt inlo tl"love-

ments of greater range and complexirl', recaprtulatrng the childhoo''l experience oi orrgi-

naiiv learning to organi:e and contrc'l nlovements' Functions that reqiitrc repetLlrun to

learn are t^ulht tl-rror.-,gh numerous variations that naintain the t-ioveltr- oI t1-re sttuittion'

Cnce noveit,v rvears off, awareness is dulled and no learning takes place.

The lessons are so arranged that thev require.oncenl:rattJn tLl sense kinaestl'retic dif'

ferences. \flitl-iout real attention it is impossible to tbllou' to the next stage ir-r the lesson'

Mechanrcal repetition without attenlion is drscouraged and cften impossible'

An tmportant goal of ,{TM lessons is to learn hou' the most basic 1ro\ erlent tunction)

ur. orgarrir.d an'J to teach awareness oi the skeletori anLl its orientaiion' The participants

1-rave the Llpportunlt)' to learn tt-r eiiminate unnecessarv energv expenditure and efiicientlt'

mobili:e their intentions it-tto actions. Since leirrning is a highlv individLral matter' studenls

are encouraged to learn at thelr own !-race in a nunconlpEtLtLtt niannur' This is rvi-ri' the

same lesson often mat'beneiit people oidiverse ages, backgrourids, and abilities'

F unc ti onal Int e gr ati on

For patients ilesiring more individual attet-rtLon, Feldenkrais cre:rted a f-iands-or-i techr-ii'1ue

called Functional Integration (FI). Each Fi lesson is taik'recl for the needs of t1-re particu-

Lar sir-rdent: it is usuallv per{ormed u'itl'r tl-re patient in a hori:ontal positron to reilLrce as

much as possrble the influence of gravitv or-r the l-'od.v and thus free the nervous s-vstem' Tl-re

reaction of the nervous.qysterr to the grai'rlationai {ielci l-ras becorne a habit, and although

this renains sLr, it is diflicuit ro bring t}-re muscles to respond ciiiferentlv to tl-re san-ie stim-

ulus. Obi'iouslv rhen it i-s drflicult to hring about anv reai chanse in rhe nervous '\vsteln

rvrthout reducing or eliminating the grar tt\ cl-tcct.

The practirioner conlntunicates through gentie and nonlnv:lsite touch tl-re experience

of comfort, pleasure irncl ease of 11o"'s1Tlent, s'hiie rhe plrtrent learns htls' to reorganize rhe

bodv and L-.eha.,ror in ner.,n'and nore efiectitt u'av.. The practitior,er's tc,uch is instructive

and informative, not corrective. Patient-s are encouraged to explore ne\\', more erpanded

fur-ictionai motor patterns that theY can then translate into neu' abilities

The Feldenkrars Method offers patier-rts ne\\ mcl'erren! chotces t'i ailorving them to ex-

perience dilterences betu'een efibrduL anJ efl.rrtless, eihcient anC ir-reiticient, nerrtral ar'd

pleasurable movements. Unless Lr-riln'idua1.t can sense these distir-rcrions, they har''e no

choice over the quality of dreir rlotements anl are red,-rce.1 to acting like a machine' Cnce

thel learn to differentiirte movements and their q'.ralities, thei acquire altemative lvar's of

perlorming the san-re task ar-rC regain a broader range oi tl-reir possibilities'

Demographics

Feldenkrars practitioners can be folrnd worldrvide' ln the United Srates thei' are ct-'ncentt lted

along the easr and \\'est Coast-( and the greater Chicago area. Countries that use ihe method

n-ro".t heavilv are Australia, Gennanv, Stveden, Switzerland, The Netherlan.ls, and France.

The r.vork i: used rvLth infant, adolescent, adu1t, and geriatnc ptrtients.

r6leloenKrar! ivlethod - 39i

InCications and Reasons for Referralnto move-e of origi-retition tosituation.

thetic dif-:l-re Iesson.

tunction-s

l ticipantseflicientll,r, stui'lents

r: *'hr, the

The Feldenkrais Method is applied ro resrore funcrrc,n lost through accidenr or degener-arive diseases a-. u'eil as to improve function rn people whc. need rcr uroro\-e high-lcve1skills.

1t rs r-rsed r.vith a1l types of clrnrcai disorders, fron-r heir-riplegia anC cerebrai palsr.ro acurror chronic back and other parn problems. It rs used bt. proiessional athletes. ciancers andmusicians who have recurring inlurres,rr srress svlltptoms and br' coaches and phvsical ed-

ucation reachers in movement anal1--.is and teaching tecl'rniqr-ie. Other major areas of ap-plication include older aduis *'irh moloi limiiations, people with breathinc disr,.rders. :rn.ithose suifering frorn chronic anxieil ani psvchosomatic disorders.

Office Applications

iechniquere particlt-reduce as

stem. TI-ie

1 althoughitille stlln-lLi.c svsttm

rPerlence

canize thenstructi\.eexpanc{ed

lern to ex-

:utra1 and'have noine. Cncet,6 11'21y5 of

A simple ranking of conditions responsive ro rhis form of therapy is as foliows. As wirh allalternative therapies, use of the Feldenkrais Merhod does not preciude the use of main-stream medical therapies in addition.

Top level: A therapy ideally suitedfor these condinons

Autism; back pain; balance problems; cerebral palsy; chronic anxiety; chronicfatigue syndrome; chronic pain; closed head injuries; CVA (siroke); dystonia;fibromyalgia; head and neck pain; irritable bowel syndrome; moror limitations;multiple sclerosis; muscular dystrophy; neurologic disorders; open head injuries;orthopedic injuries; poslpartum care; posrsurgical tissue rrauma; psychosomaticdisorders; repetitive stress injuries; stress; rcmporomandibular joint pain; andwhiplash

Second level: One of thebetter therapies for these conditiors

Hypertension; insomnia; lazy eye; osreoarthritis; osreoporosis; periodic leg moverrentsyndrome; sleep disorders; and rinnitus

Third level: A +,aluable adjwtctive therapl for these conditions

Arthritis; cancer; constipation; emphysema; mensrrual cramps; and vision

R.esearch Base

',centrated

re methodi France.

Eqsidence Based

The 6rst research studl.involi,ing Fellenkrais N,lethod (FM) was pubhsherl in 1977 rvrrl'rseveral more appearing in the next decade. Srnce 1938 there has been an incrc.rsinu amuLlnrof research done and recentil this h:rs Lreen rncreasins each vear. Because FN4 has such a

wide range of effects, a $,ide ranec of olrtcomes has been looked at and reported. Most oi

398 S E C T I ON T wO FieldsofPractice

the clinical studies to Cate har,e ir-n'olveJ a \.er1. smil11 nurnber oi sublecrs ( 6 or ferver) . Someare larger, using control gror-rp designs. The areas of outcone break dor,vn ir-ito the folLor,l.-ing four general rhemes:

1. Pain management: Case studies describing rf ie resolution oichronic l--ack pain fol-lorving the failure of c,rher nlerhods ro ameliorate the problems have been publrshedL,1'Lake1 and Panareli,,-BIack.: A rcrr()specrrve stud).of 34 parients using FM a-. anadjunct ro rrearlnenr in a chronic pain management clinic shor.ved rhar Flv{ helpecl roreduce rhe pain anil improve function anci stil1 was used independenrlr bv parients 2

years postdLSCha.se.l L)ennenberga shorved decreased pain and ir-rcreased functionalmobiLin-usrng FN'I as a cornDonent of treatn-iei-rt for 15 pain patients. The prim:irr,result ol this srudr ri,as to shorv that there were cl-ianges ln the patrern of healtl-r iocusol contrr',l in parrents parricipaiing ir-r FM. A srudr. uslns a group ATN,I inren,entionrvith hve 6brt,.ir-rralqia patients showed signihcant decrease in pain anJ improvedI'u)f Llrc. g-rrt. ilrrl-. rrrJ i. -i, n\\argllgs5. Lnk.' .h.,*.J chang.. lfi 1, .1,11. ln farlent.ri,ith chronic back pain toilou'ing FM. Chrnn et .rL; s['r..* e.i rnrFrD\.e men.s in func-tional reach in svmptonaric su'njects. Idebergs shou,ed signihcanr changes rn peivicrotatioll and pelr.ic obLiq,-irti during rapid waiking in 1C patients r.vLrh back pain coir-pared to normaL controis, itriior.,.'ing a series of Fur-rctirrnal lntegration lessons. Narr-Llasl'rorved decreaseJ pain ani rrnpr,'lr-eJ iunctron, inclutling rmprovc.l biou-rech;.rr-ric ei6-ciencr', rneasureJ bl motrc,n analr'sis, rn a sit-tcr-stitnd trtrnsfer trorn a chair, in severaLpeopLe r,,,itl-r rheurnatorr'l arthriris io1ir,,r,rr-rg 6 n,eeks of -AT\4 less,rns.e

2. Functional performance and motor control: Frrnc!ior-r rs a resul! trf rni)r'ernent.Char-rges in the process oicontrol .rin.,r'emenr rhereiore influence fur-rcrion. Asrroteci above in reLation to pain !atients. theri \\crr .i,.iLt._!r{ rrL 1ll,,\-cment patternleading to reductittn oi pair,. These ricre F.au.rns Lnvo1,,,cj in the acrir,itie-. ofri,alkings, [.ar-rsfers''1" posrLrre , re,rchlng. :LnJ generai :rttLllties oiiiaih,ii..i*g.".']

A-. welL as \\'rth orthopedLC p--ain patie nts. rur-,ctr.-.naL inprovemen[s have been de-scribed in peopie wlth nellrologrc Jiagrio:rs. .A,lthuucl-, rhere rr'a,i r-ro ibrmal quanririi-tive asscssnlent of baLar-rce, four u,r.me n * rth multLple scierosLs r.frortedimprovements in balance in i'lar11, acrir-itLes anJ LLIitr_-,ro,,-eJ $.aikii'rs ancl transiers. as

assessed br- vrdeo lnotion anal., si-.. il

Shenkn'ran describeJ rmpro\rements ir-r prr-.ture ln lndividuals u ith Parkin-.c-n'silisease using FN'I as part oi the ir-iterr.enrion srraregv.i4 S1-relhar.-Silherbr-rsh has re -

ported case stuliies oi tu,o ci-rildren wrrh cerebral palsr. lr,1-r,r maile lnajor innctionalgains Curing several years oiFl"l work.r; Ginsburg has ai-recdotallr,clcscribed func-tional and motor control impror-emenrs in voung people t,ith spinal cord injr.rrie,slr,'ho were involved rn rhe "shake a Leg" progr:r,r,. 16 Cii,,-,ar-, has reported irnprove.lcontroi of stuttering in tu-o patients.4J

As well as improving fr-rnction in people rvith in-rpairtnents, FM aLso is useC rcr

in-rprove atl'rLetic function. At this rrme the evidence f,lr rhis is n-rostlv anecdoral forskiiinglt an.l ka1'aking. Tackson-Wyarrls has rept,rrrd a case studi ,,f i,,rprore,Jjumpir-rg following a Feldenkrais in[erven.ion.

There also rs inreresr in athletic injr-rrr prevention usir-rg,{TM to inrprove flexibil-it,v and c()nrrLrl. An inrtial studv pr-rblished in this aiea shor.ved no increase in ham-

Feldenkrais lr'leihoCB

string length {oilorving a single ATM iesson.le Hor.'"r..r, thrs stuCr"has ser,erai iinpor-tant design problerns and firrther rvork is underwal as follou'-up.

3. Psychologic e{{ects: Feldenkrais'inrrial inrentlons rn rhe appLicarion oi hrs ivorkwere to iir-iprorre a persorL)s a\\'areness of the boJl in actron (Au,areness throughMor,ernent), Lmproving rhe inregrarron oI iunctron. (Funcrional lnregrarion) andti-rerebv effect a process of change leading ro grearer emotional ,naturirr'.lC'li ThLs ha-.

L--een studred verr, lrttle. DenncnL'erg* ha: nt,ted changes in heaith h.cr-rs oiconrrol.Self-ef6cacv has been shown rc. be a sigr-Lrlicanr correlate of successiui rehatilirarion.but there have been no srudies plrhlrshed on this ro date. Several srudles are underwav wirh patients witl'r diagnose. t>f multiple sclerosis and fibroni algia.

ln an rnteresting studv usrng anirivsis oiclal hgures. L)eig descritred expansron ir-r

the detail and forrn of bodi image after a series oiATM ie.sonr.ll Shelhav-silber'b,ushhas shorvn inprrovemenrs in mobilitv skiiis, social Iunction and lQ scores in a class oliearnrng Lmparred chriJren.:'j.ccrnrL\. rn a marcheri control group stuci_r r.vrth it-chrldrer-r r.r'ith eating drsorders, Lai:mer concludecl rhat a course oIATM facilrraredan acceptance oi the bodl anci selI, ilecreased leeiings of helplessness and depen-dence. rncreased self-confidence, and a general process of maturatron of the rvl'rolepersc,nal Ltr'.

l'

4. Qualitv of li{e: Qualiry of Liie an.l irs associated measures oiperceir.'ed heairh slatu-. is

becomrr-rE an increasrnglv rrlportant arid rurdell u-.ed construct rn assesslng theoverall L)utcolrur of :i pt.,cess ol rehabilrration. ln a pioblenatic srudv that shorle.i r-ru

signihcanr functron:rl or pl-rvsLologic char-rges. Gutrnanl'shou,ed a trentl toli.ar.l irr,-provernent rn ol,era1l lrerceprron oi heakh -rtarus in a he althi' older aduk populatron.Thrs hndLng has been corroboratecl in a similar popularion bl improven-rent-. in vital-rtv and mental heaitir a, measure.l br the SF-l6to.,n.1 ir-r a grrrtip triw.rmen r.vrti-r mu1-tiple sclerosrs using the lndex of Well-Being L r;

Basic Science

Theorr- ur-iderlvrng the FeldcnkraLs trlcrhod assuules a process of learnrng that is t,aserl u'r

hard change-. in rhe nervous svsrem. Through thrs process an irnage oi the toCv rs con-structed that corresponds to movement. 1n mo\,effrent a persL)n then interacts u.'rth tl-re en-vironment in a ioop of perceptron anl :rcrion thar turther rel-rnes rnc,vement anrl rhe,"n56p1:-perceptual processes. Dvnamic svsrrms [lLertrl as described bv Thel"n:' an j ].el.,.,-"best fits the observed processes ol the Fel.lenkrars N{erhod. This theon accounrs for tl-re

process of skillacqursitron, funcrionaL der.elopment, and organi:atron change resulting fron-r

changes in posture and coordination ji

and relres on an understandu-rg ot the bodv as har'-rng a modrhable internal representatlon oi bodr sci-rem.l' that inclucies rhe sl-rape of rhebodv surface, lirnb length, sequence oi linkage, and posrrion in space.

j- The pro.ess ot skill

acquisrtion. coordination change, c,r functionai or moror development is drrr.'en b,v a process

of active exploration involving ,*,r."r-r"r..tl llOver the last 15 vears, research in rhe area of neuroplasticitv has built a soLd founda-

tion for the concept that inreraction *'irir ihe eni'rronment and changes ln the strLlcrureol the bodv are representeil bv rneasurablr changcs in tirr process oi rcpresenrarion in thr

399

rj. Some

: iollow-

r fol-,lished

as an:lped toLents 2

ionalrary

h locus

r-rtion

ed

-ratientstnc-e lvicn com-llarularic effi-,cv eral

trn\S

12

:n de-

.ntlta-

i, as

}S

re-

nal)c-CS

,ved

0

.l for

xibilLIN

400 S E C T I o \ T \t O Fieldsofpractice

cortex.l4'li These changes ma\- underlie and be related ro basic processes of learning.16'l?This plasticit,r- of the central nervous systern ma,v be borh rhe source of chronic functionalproblems and the means ro recoverl from.rhero.36'19

Although none o{ the research on Felder-rkrais Merhod addresses this basic level of ph.ys-iologic function, physiologic changes do occur rhar fit wirhin this rheoreric framervork.Some functional changes have been mentioned in the previous secrion. Others includechanges in function of rrunk and cervical muscles reflected b1 changes in EMG acrivity,4o.4lchanges in muscle fi-rnction and posture relared to improvements in abdominal breathing,a2and changes in bodr image or r.heme.21'?l Narulaal also hns reported increases in EMGactivit)' in cases of iow back pain where it appears rhar painful muscles had become inac-tive. It ma1 be that reintegration of these muscles into normal movemenr parterns srimu-lates blood flow and thus a normal healing process.

Risk and" Safoty

There is very lirde risk involved in dre use of this method. It is borh conservarive and safe.People are instrucred ro sray generally within the bounds of pain-free ranges of morion anduse as litrle effort as possible to perform a movemenr. Comfort and ease and the explicitguides are understood to be part of rhe optimal conditions for learning. It is srill possiblefor a person who has fibrornyalgia or adhesive capsuliris ro do roo much and have pain as

a result. However, if this shor"rld occur, limits are learned that rhen can be applied to futuresessions. This kind of outcome happens infrequentiv ancl mosr often in hor-ne sessions norsupervised b.v a practitioner, in which the student reverts back to a "rnore is better" phi-losophl so colrnlon in our culture. Often as a result of a s1ou. and comfortable approach,people learn that thev can do much rrore with much greater safet,v and comfort than theyhad imagined possible.

Efficacy

Generally, no staristics are known or published on rhe efficacy of rhis method. All cor-rclu-sions about this are based on hearsay and general impressions. One of rhe arirhors (JS) takesthe libertv here to report on the eI{icac1. of using Feldenkrais Method as part of a rehabil-itation process with 166 patients over the last 5 years in his private practice. Outcoine hasbeen judged on percentage of the original goals esrablished at rhe inirial r.isit rhar wereachieved by the time of discharge. Four levels of ourcome w,ere usetl: 1) 100% achier.ecl;Z) 7 5V, to 90% achieved; 3) 50Yo to 7 5o/o achieved; and 4) less than 50% achieved.

Orthopedic cases made up E4ozo and neurologic cases made up L6Vo o{ rhe population.Age range was from 8 to 84 years, with most people being berween 30 and 60 years. In 35cases of back pain, 777o reached 1evel 1 ourcome and 917o reached a level I or Z. O{ Z0cases ofosteoarthritis, 80% reached ievel 1 and 95% reached level 1 or 2.760/o of 17 peo-ple with a primary diagnosis of neck pain reached level 1 and 88% reached ar leasr level Z.In 13 shoulder diagnoses, 69% achieved level 1 and 92% reached ar leasr ievel 2. Of6 peo-ple with fibromyalgia, 837o reached level 1 and all reached ar leasr level Z. Of 14 peoplewith tendonitis or bursiris or orher hip and knee probiems, 857o reached ievel 1, an addi-

1

Felcler-rkrais M.tL,.rJ a

tior-rirl 7i)o reacheJ lei.'el 2. and another 7ozi, reached level i. Cf 6 people lr'irh back and leg

pain {rom spinai stenosis ol spondvlolisthesis, 6J9'o achieved leve1 1. an additronal 12?"

reached level 2, and 25oii, achieved level 3 or 4. Cf 3 TMJ cases' 2 reached level 1 antl the

other reached ievel Z. And of 5 1,et4rle r.vith scoltosis, 8C9o reached level 1 anil 20% reached

levei l. Reaching level 1 does nol mean that rhe scoliosis \\'as reversed. lt tr-reans thatpain

*-as signihcantlv reduced and iunction impror-ed !vlth long-term success.

Cf the 27 ner-rrologic cases, 60o,t' *.ere p'eoplg u'ith multiple sclerosis or stroke Oi the

people u'rth srroke,50% achiever1 ler.'ei i anci 5C9'r achieved level J. Cirhe mlririple scle -

rosIS cases,5Cuiu reached leve1 1 and i.rnir j7),, riere drschargtd belor'r'lcr'ei l"

Ci'crall. c-,ut of 16[r pattents,7Ct),, reacheJ lerel i. ]l'li, rtacl-red level 2.6.6o2i' reacheil

ievci J, and 1.1% u,'ere at ier.'e1 4 at drschatge.

F uture or Ongoing Resear ch

As we stated at the beginning of this section, research on the Feldenkrais Method has jr-rst

started in the lasr 10 years. Several studies now are in progress related to balance and self-

ef6cacy in people with muitiple sclerosis; function and length of the hamstrings; pain' func-

tion, and self-eficao' in people with fibrorryal-sia; the efficac,v of ATM as an adiunct to car-

diac rehabilitation; and back pain related to postural and motor control variables. The

Feidenkrais Guild alstl is in the process of establishing a procedure for svsteiaatic collec-

tion of outcome data bv all practitioners across the U.S. who want to partlclpate tn a mul-

tisite outcome studl'.

Other areas for future research include: injurr prevention and performance enhance-

ment in athleres, dancers, and musicians; controlied outcome srudies with people who have

had suokes, head injuries, and cerebral palsy; introduction of ATM into elemenlary schools

to enhance self-image, attentiot.t capacity, and learning; stud.v of other ps-vchologic di-

mensions, such as body scheme, self-esteem, self'efficaci, anxiety, and learning; and inquiry

into physiologic mechanisms of action, including balance and postural control, proprio-

ception, and timing and sequencing on muscle activitl in rnovements.

401

,rr-rg.'u''7

nctional

of phys-r,er.vork.

include'" i,)',ot o'

I rh Lng,

in E\,{C,.,- ;,-..-

is stirnu-

rnd saie.

tror-r ande xplicitpossible

: pain as

lrr futurelOnS not:er" phi-rproach,ran thev

Visiting a Professional

c,rnciu-S) takes

rehabil-olne has

lilt were

-1-rieved;rJ.

,ulatron.

rs. In 35

r. of z01 7 peo-ler.'el 2.

)i 6 peo-

i people,rn addi-

The Feltlenkrars Nlctho.i ts a learnLug expertellce, and pecrpie learn best rvf ietr cotnfortal-'i.'

Alvareness Tl'rrough N'lovernei-rt ciasses are t:rught on a floor with a carpet or mats, on chairs,

or in star-rJrng posltr()n. Stlr.ienrs !-ia\ attcltlion to thetr o\\'n sensations antl rnovement5 As

the teacher gurde. therr, to erpiore a basrc 5ul-'1ect, such as hori ttl impror c lllrnlng )u stu-

dents can see ialther arounii thcrl. selve-. r',ith less effort and more tntegrated movement'

For Functiot-ral lntegratior-r, thc Feldenkrai-. hands-on lvork, the practilroner lakes a func-

tionaL moverrent i'rtston anil tnqutres as t"r .luration ancl possihle causes oi the complaint'

The p-.r3g1t11.ner explains that FelJe nkrais rvork is not a medic:r1 procedure or sr-rbstirure

for n-redrcal atteiltrorl. During the inrtial inten'ieu the practirioner obscne-c the lrosturalhabits of tht stuclcnt. Then ri-rt clothed stuCenr lies, sits. or stands in one oi about 30 drf-

ferenr posititrns. The practilroner sLrpporls tht sru.lent's postural habits with pillor.vs so that

402 S E C T I oN T w o FieldsofPractice

the student rs most comfortable and able to brearhe. This means a person rl'ho is signi{i-cantlv bent forrvard rn sranding .,vi1l require ample pillows behind the head u'hen reclined,so the habitual curvature is supported. The student is asked to pay attention and neitherheLp nor hinder. The practitioner works genti). Each hands-on lesson and class deveLops

several basic lunctiorLal subjects, such as balance, brtathing, turning, or linding the rela.tionship betrveen the head and the peir.,is.

Credentialing

Initial certilication is granred bv the eCucarional direcror of training prosrams atrer stu-dents have passed a supen'ised clinLc. Cerrification must be maintained through continu-ing education requirements on a brannual basis.

The Cuild oi Certiiied Feldenkrais Praciirioners sets star-idards for Tialning Programsand certificaiion,

Training

The trarning required to be a cerri6ed Feldenkrars pracririoner requires 160 dals of traii-r-rng spreaC over a period of over 3 1,ears. The rrarnrngs are usua1l_v raught in segmenrs meer-ing tr-vo or three trmes per year. The trainings prepere stuclenrs to reach Alvareness Througl'rMoveme nt lessons to grolrps and develop a private pracrice in Functional integration. Com-petence ancl achievement are addressed on a conrinual basis throughout the duration oithe program on an individual basis. Students enrer trainings rn this rr,etl-rod from a rvidevaner] oi backgrounds.

\t/hat to Look for in a Provider

As ivith an\ ari i-.r crait, the longer practitionershar.e worked. the more sure are theLrhandsand rhe greater levels of expertise ancl master): they have developed. The directorl.of p13s-titioners from the Feldenkrais Guild ir-rdrcates rhe ),ear in wl-rich each pracrrrioner cuni-pleted professional trainrng.

Ti-re patient shoulC feel trusr Ior and rapport r.i,ith the pracririoner, particularly for Func-tional integration, rn lr,hrch the parienr rvill be ph,vsically touched.

Barriers and Kev issues

As phvsicians are recogni:ing rhe brain-bodv relatronship and the importance of leaming,interest in this scienrificallv-based sysrem continues ro gro\f.

],tI

l.:i,l:r:iii:

n-

t

4a4 S E C T I o N T w o FielcisofPractice

References

1. Lake B: Acute L,ack paii-r: trearment b1 the application of Feldenkrais principles. AusrraFamPhr-sician 14( 1 1 ):1 1 7i- 1 1 i8, 1985.

2. Panarello-Biack D: PT's o,,vn back pain leads her to start Feldenkrais training, PT Bull, April8, 1992:9.

3. Phipps A et aL, A functional outcome stud.v on the use of movement re-educarion in chrcnicpain management, master's thesis, Forest Grove, Ore, May 1997, Pacifrc Universitl', School ofPhvsical Therap1,.

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a:i

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405

ric,1 of

1

,e

n

r1

ic

o{

er's

:tict)

446 S E C T I o N T 1I o FreidsofPracrice

38. Jenkins V'M et al: Funcrronal reorgalli:atlon of primarv somatosensorl cortex in adult or'vl

monke.vs after behar,ioralll controlled tactile stimuiation. J Neurophls 6l'82-i04, 1990.

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