The Feldenkrais Method (FM) has broad application in populations interested in improving awareness, health, and ease of function. This review aimed to update the evidence for the benefits of FM, and for which populations. A best practice systematic review protocol was devised. Included studies were appraised using the Cochrane risk of bias approach and trial findings analysed individually and collectively where possible. Twenty RCTs were included (an additional 14 to an earlier systematic review). The population, outcome, and findings were highly heterogeneous. However, meta-analyses were able to be performed with 7 studies, finding in favour of the FM for improving balance in ageing populations (e.g., timed up and go test MD −1.14 sec, 95% CI −1.78, −0.49; and functional reach test MD 6.08 cm, 95% CI 3.41, 8.74). Single studies reported significant positive effects for reduced perceived effort and increased comfort, body image perception, and dexterity. Risk of bias was high, thus tempering some results. Considered as a body of evidence, effects seem to be generic, supporting the proposal that FM works on a learning paradigm rather than disease-based mechanisms. Further research is required; however, in the meantime, clinicians and professionals may promote the use of FM in populations interested in efficient physical performance and self-efficacy.
The Feldenkrais Method (FM) was developed over a period of decades in the last century by Dr. Moshe Feldenkrais. He claimed the basis of the approach was founded in the human potential for
The two modes of delivery that are offered to the public are either individual, manually directed lessons (functional integration, FI) or group, verbally directed classes (awareness through movement, ATM). The nomenclature for both reflects the fundamentals of the approach—that movement has to be based on a
The method has been applied in varied domains across countries, from general education or children with learning issues to enhancing performance in sports and theatre. The clinical applications have received the most interest in the published literature because of the intuitive appeal of basing a health recovery process on a learning paradigm and because of the inherent fostering of self-efficacy that occurs particularly in a group setting.
In the climate of evidence-based practice in the health domain, any approach being offered to the public is being scrutinized for evidence of effectiveness and, if effective, for what type of benefit and of what magnitude for any clinical population. An earlier systematic review of the evidence for the method was published in 2005 by Ernst and Canter [
This review had the aims of systematically identifying and appraising the evidence for the effectiveness of the Feldenkrais Method across domains; determining what is the nature and order of magnitude of any beneficial effects and for which population/s.
We employed systematic review methods based on the PRISMA guidelines [
We considered all types of primary studies in the first instance in order to fully explore the potential populations and outcomes covered. In the final inclusion only studies with a random allocation and a stated control group were included. Any secondary researches (systematic and semisystematic reviews) found were not included, but rather their included studies were retrieved in full and added to the potential pool in order for all primary studies to be appraised with a consistent method.
We included any population where there was an outcome of interest related to improvement in health and/or function.
Either form of Feldenkrais Method (functional integration or awareness through movement) was included as the sole approach for the intervention group. The comparison group could include placebo, inactive control, or an alternate method.
We searched the databases of AMED (Allied and Complementary Medicine), Embase Classic + Embase, Ovid MEDLINE(R), Cochrane, PsycINFO, PubMed, and Google Scholar from inception to July 2014. We considered all languages (the search was open to all listed journals irrespective of language) and publication status (we would include unpublished trials wherever found, e.g., through experts in the field or grey literature such as organizational websites).
The search terms included variations and combinations of methodology terms (such as randomised, trial, clinical, and controlled), with intervention terms such as Feldenkrais Method, (awareness through movement and functional integration). An example of the terms employed in the electronic search strategy is presented in Table
Example of search strategy.
Number | Searches | Results |
---|---|---|
1 | (Clinical trial or randomised trial or controlled trial).mp. [mp = ab, hw, ti, sh, tn, ot, dm, mf, dv, kw, nm, kf, ps, rs, an, ui] | 1900972 |
2 | (Feldenkrais or awareness through movement or functional integration).mp. [mp = ab, hw, ti, sh, tn, ot, dm, mf, dv, kw, nm, kf, ps, rs, an, ui] | 2239 |
3 | 1 and 2 | 47 |
4 | Removing duplicates from 3 | 40 |
From the generated lists from each database, duplicates were removed and the first high level sift was performed by one author based on title alone. The second level of review was performed by both authors and required retrieval of the abstract at the minimum. The retained studies were examined in full to confirm inclusion. Those excluded were recorded with reasons.
All retrieved studies were checked for additional references, and experts in the field were contacted to assist in identifying any further studies published or unpublished. Experts were provided from the membership of peak FM bodies (the Australian Feldenkrais Guild and the International Feldenkrais Federation) and were asked to supply further papers by email.
Relevant data were extracted from each of the included studies using a standard trial summary sheet by one author and checked by the second. Data included author, date, study design, population sample, intervention, comparison, outcome measures, results, and comments. A risk of bias evaluation was also performed for each study by one author using standard Cochrane tables [
Where possible, data were extracted for meta-analyses. We planned to extract and analyse data to calculate individual and total effect sizes through odds ratios or mean differences (fixed effect or random effect if the studies were small and/or heterogeneous) and 95% confidence intervals. Statistical heterogeneity would be evaluated based on visual inspection of forest plots and on the
If we found that meta-analyses were not possible, then results would be synthesized and reported narratively.
The systematic search yielded over 1,300 initial titles for high pass screening. See Figure
List of papers excluded with reasons.
Studies | Reason for exclusion |
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Kirkby (1994) | Controlled trial |
Bearman (1999) | Pre/posttest (no control) |
Seegert (1999) | Controlled trial |
Huntley (2000) | Systematic review |
Dunn (2000) | Pre/posttest (no control) |
Fialka-Moser (2000) | Commentary |
Malmgren-Ohlsen (2001, 2002, 2003) | Controlled trial |
Kerr (2002) | Controlled trial |
Emerich (2003) | Review |
Junker (2003) | Posttest (no control) |
Galantino (2003) | Review |
Gard (2005) | Review |
Mehling (2005) | Review |
Liptak (2005) | Review |
Batson (2005) | Pre/posttest (no control) |
Wennemer (2006) | Pre/posttest (no control) |
Porcino (2009) | Descriptive |
Mehling (2009) | Review (assessment) |
Connors (2010) | Content analysis |
Connors (2011a) | Controlled trial |
Connors (2011b) | Pre/posttest (no control) |
Mehling (2011) | Inquiry (phenomenological) |
Ohman (2011) | Pre/posttest (no control) |
Laird (2012) | Review |
Mehling (2013) | Intervention (not exclusively Feldenkrais) |
Gross (2013) | Review |
Webb 2013 | Pre/posttest (no control) |
PRISMA flow diagram.
Fourteen new RCTs were included along with the original six studies from the Ernst and Canter [
Randomised controlled trials of FM (Ernst and Canter, 2005 [
Author (year) | Study design | Sample | Intervention | Control | Outcome | Results | Comments |
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Ruth and Kegerreis (1992) [ |
RCT |
30 healthy volunteers | Single FM sequence | Participation in other random activities | Degree of neck flexion (goniometer); perceived effort during flexion | Greater degree of neck flexion (goniometer) ( |
Study has pilot character |
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Johnson et al. (1999) [ |
RCT |
20 people with MS | FM: |
8 weeks sham nontherapeutic body work | L and R hand dexterity (pegboard test); |
NSD |
Positive result could be due to multiple testing for significance |
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Lundblad et al. (1999) [ |
RCT |
97 females with neck and shoulder problems | FM: 4 individual sessions, 12 group sessions of 50 mins pw, for 16 weeks, home audio tapes | (C1) physiotherapy 2 |
Clinical assessments (4 measures); |
Prevalence of neck pain and disability during leisure decreased in FM versus C1 or C2 ( |
Important baseline differences, possible regression to the mean. High dropout rate and per protocol analysis. Multiple testing for significance |
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Stephens et al. (2001) [ |
RCT |
12 people with MS | FM: 8 |
Educational sessions over 10 weeks | 3 clinical tests of balance; |
Significant improvement in FM compared to C for mCTSIB and Balance Confidence Scale; other 4 outcomes NSD | Very small sample size. No baseline data or statistical analysis available |
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Smith et al. (2001) [ |
RCT |
26 patients with chronic low back pain | FM: one 30-minute session | Attention control | Pain (McGill); |
FM not C reduced affective dimension of pain pre-post ( |
Only acute effects were measured. Baseline differences between FM and C in duration of back pain may be important |
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Grübel et al. (2003) [ |
RCT |
66 patients with cancer | FM: |
C: no adjunct therapy | Body image questionnaire; Frankfurter body concept scales; |
Both groups improved in all outcome measures | Nonsignificant trend favoured FM |
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Additional RCTs | |||||||
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Brown and Kegerreis (1991) [ |
RCT |
21 (12 men and 9 women) volunteers pain-free | FM: 45 min audio tape “activating the flexors” lesson | C: listened to the same 45 min audio tape modified to include only instructions pertaining to exercise movements | EMG activity of flexors and extensors (UL) |
NSD | There was an overall decrease in mean flexor activity with no change in mean extensor activity for both groups. |
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Chinn et al. (1994) [ |
RCT |
23 subjects with upper back, neck, or shoulder discomfort | FM: single ATM lesson; 22 min audio tape | C: single sham treatment; 30 mins gentle neck and shoulder exercises | Functional reach task; |
NSD |
Small sample size |
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Laumer et al. (1997) [ |
RCT |
30 patients with eating disorder | FM: 9-hour course | C: did not participate in FM | Body Cathexis Scale; |
FM participants showed increasing contentment with regard to problematic zones of their body and their own health and acceptance and familiarity with their body | Full article in German |
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James et al. (1998) [ |
RCT |
48 healthy undergraduate students | FM: |
Relaxation: |
Hamstring length (modified AKE test) | NSD | Insufficient exposure, low statistical power |
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Hopper et al. (1999) [ |
Study 1: RCT |
Study 1: 75 undergrad physio students |
Study 1: FM: single ATM, 45 min audio cassette lesson (no prior FM experience) |
Study 1: C: listened to soft nonverbal music |
Modified AKE test (hamstring length); |
Study 1: NSD |
In both studies there was a significant difference in exertion levels between males and females with males exerting more irrespective of group |
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Kolt and McConville (2000) [ |
RCT |
54 undergrad physiotherapy students with no prior FM experience | FM: |
Relaxation: |
Bipolar form of the profile of mood states (POMS-BI) | NSD |
No differences between FM and relaxation groups |
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Löwe et al. (2002) [ |
Pseudorandomized, consecutive allocation | 60 patients transferred to normal ward after acute treatment for MI | FM: |
Relaxation: |
Body image questionnaire (FKB-20, German version); Hospital Anxiety and Depression Scale-German version (HADS-D); |
NSD | Overall improvements were seen in MLDL, GSES, and FKB-20 |
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Stephens et al. (2006) [ |
RCT |
38 graduate students | FM: |
C: regular daily activities | AKE (hamstring muscle length) | Significant increase in hamstring muscle length ( |
Participants varied greatly in the duration and number of home sessions completed |
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Quintero et al. (2009) [ |
RCT |
3- to 6-year-old children with sleep bruxism | FM: 3 hr sessions |
C: no details | Various measures of joint function; |
Statistically significant increase of CVA angle ( |
At baseline two groups were comparable |
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Vrantsidis et al. (2009) [ |
RCT |
55 participants aged ≥55 years | FM: getting grounded gracefully program (based on ATM) |
C: continue with usual activity | Frenchay Activity Index; |
Significant effects for gait speed ( |
No significant baseline differences between groups. |
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Ullmann et al. (2010) [ |
RCT |
47 relatively healthy independently living ≥65-year-olds | FM: 1 hour ATM sessions 3x/week for 5 weeks (provided by instructor) | C: waitlist | Falls Efficacy Scale; |
Balance ( |
At baseline groups comparable except for higher BMI in intervention group |
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Hillier et al. (2010) [ |
Pseudorandomized control trial |
22 healthy people postretirement | FM: ATM class, 1 hr/week for 8 weeks | C: generic balance class 1 hr/week for 8 weeks | SF-36; |
Significant time effect for all measures except for WOFEC |
Post hoc individual analysis comparisons made |
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Bitter et al. (2011) [ |
RCT |
29 healthy university students | FM1: ATM lesson |
C: relaxation lesson |
Purdue Pegboard Test; Grip-lift test; subjective changes | FM1 significant group by time intervention effect when compared to control group for dexterity | |
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Nambi et al. (2014) [ |
RCT |
60 institutionalized ageing people | FM: ATM classes |
PI: Pilates classes |
Functional reach test; |
Both FM and PI improved all measures ( |
RCT: randomised controlled trial; FM: Feldenkrais Method; MS: multiple sclerosis; L: left; R: right; C: control; pw: per week; VAS: visual analogue scale; mCTSIB: Modified Clinical Test of Sensory Integration and Balance; NSD: no significant difference; STAI: State/Trait Anxiety Index; EMG: electromyography; UL: upper limb; ATM: awareness through movement (lesson); min: minutes; AKE: active knee extension test; MI: myocardial infarct; PMR: progressive muscle relaxation; c.f.: compared with; SF-36: short form 36; PI: Pilates.
Publication dates ranged from 1991 [
The nature of the Feldenkrais interventions also varied in delivery mode, intensity, and frequency. The predominant methods were single or multiple ATM lessons delivered either in a group or individually using audio recording. The comparison groups were most commonly an alternate form of therapy. Fourteen trials had active controls (such as relaxation classes or generic movement/balance classes) and six had a passive or inactive control (usual activities/no intervention).
Outcomes were also highly heterogeneous in keeping with the needs of the diverse populations and are listed in Table
Table
Risk of bias was high in most studies. Less than a quarter of the studies had adequate random allocation processes and only a third had blinding of outcome assessments. It has to be acknowledged that for trials requiring an intervention like Feldenkrais it may be difficult or inappropriate to expect blinding of therapists or even participants, though participants can be blinded to the intervention of interest if there is a plausible comparison group (such as a relaxation or other forms of movement-based class). Figures
Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.
Sufficiently homogenous data (same population, intervention, comparator, and outcome measure) were able to be extracted to perform meta-analyses in the areas of balance training in ageing populations.
Four studies [
(a) Effect sizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance and mobility). (b) Effect sizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance and mobility) with Hillier 2010 removed (control group was alternate balance class).
Two studies [
Effect sizes of Feldenkrais versus control for the Falls Efficacy Scale (balance confidence).
Two studies [
Effect sizes of Feldenkrais versus control for the functional reach test (measured in cm; balance).
Meta-analysis was also able to be performed using three studies measuring the influence of FM classes on hamstring length in healthy populations [
Effect sizes of the Feldenkrais Method on the active knee extension test.
Single randomised controlled studies reported statistically significant, positive benefits compared to control interventions and included the following: greater neck flexion and less perceived effort after a single FM lesson for neck comfort [ improved balance in people with MS after eight FM sessions [ improved body image parameters in people with eating disorders after a nine-hour FM course [ reduction in nocturnal bruxism in young children after 10-week course of FM lessons [ improved dexterity in healthy young adults after a single session of FM class [
Seven of the 20 studies failed to show any superior positive effects of FM compared to other comparison modalities. See Table
The majority of the 20 included studies reported significant positive effects of FM in a variety of populations and outcomes of interest. A high risk of bias/poor methods reporting does temper the interpretation of these findings. The low amount of confirmed/reported adherence to best practice conduct of RCTs may be partially attributable to the age of the studies when knowledge in the area of trial conduct was less.
Nevertheless meta-analyses in the area of balance training in ageing populations were found in favour of the FM classes for clinical measures such as the timed up and go and functional reach tests. Both of these measures are predictive of falls risk. Whilst the TUG effect size was probably not clinically significant (1- to 2-second change), the functional reach test effect size would arguably indicate a clinically meaningful change (able to reach further 6 cm).
Given the positive effects in particular outcome domains it is interesting to speculate on the mechanism of action of the FM; however, it is to be noted that this was not the purpose of the review. The favourable evidence for reduced perceptions of effort, improved dexterity, improved comfort and reduced bruxism all support the proposed mechanism of action via promotion of awareness, relaxation and more efficient action. Inconsistent results were found for improving hamstrings length indicating that a “relaxation” effect may be variable.
The populations varied in age and diagnosis indicating that a beneficial effect is possible across different domains; again this is consistent with the use of the FM in diverse populations and also consistent with the notion that it is not a healing or disease-specific mechanism of action but rather one based on more generic learning and self-improvement.
The findings of this updated review have strengthened since the 2005 review by Ernst and Canter [
This review is not without its own limitations. This review includes all trials aimed at improving health and/or function so we have trials of healthy individuals as well as people with a clinical presentation. We have not included an analysis of publication bias, though we are confident that by using experts in the field and checking grey literature (organizational websites) we have made every effort to capture unpublished (negative) trials. We attempted to account for statistical heterogeneity and can conclude that the analysis for the timed up and go is more robust with the removal of Hillier et al. [
There is promising evidence that FM may be considered for balance classes in ageing populations, both as a preventative approach and for people at risk of falls. There is also some evidence for the use of FM where reduced effort, efficiency of movement, and awareness can play a part in reducing pain or discomfort.
Further high quality research is required comparing FM to other modalities. Investigations should focus on the impact on self-efficacy, functional independence, and ease and efficiency of functioning, both as strategies for promotion of wellness and wellbeing and also for people with impairment who wish to improve their sense of ease. Mechanisms of effect also need to be investigated. Particular attention needs to be paid to the reporting of best practice trial design and to controlling for a potential placebo effect.
There is further promising evidence that the FM may be effective for a varied population interested in improving functions such as balance. Careful monitoring of individual impact is required given the varied evidence at a group level and the relatively poor quality of studies to date.
Funding was from professional bodies involved in promoting FM but the bodies were not involved in the conduct of the review other than to identify experts within their membership to identify any missed/unpublished trials.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Anthea Worley conducted the search and preliminary inclusions. Both authors contributed to the review of all papers and constructed the final report. One of the authors (Susan Hillier) was also author for two included studies; these were independently scrutinized.
The authors wish to acknowledge the financial assistance of the Australian Feldenkrais Guild and the International Feldenkrais Federation in supporting the costs of the search and appraisal.