

































Feldenkrais Research Journal • volume 4 (2008)

Article

Awareness Through Movement Sequence on Fibromyalgia Patients

Julie Dean
Student, Mount St Mary's College of Physical Therapy, Los Angeles

Suzanne Yuen
Student, Mount St Mary's College of Physical Therapy, Los Angeles

Stacy Barrows
PT, CFP, Century City Physical Therapy, Los Angeles

Abstract
The purpose of this study was to describe the effects of a Feldenkrais Awareness Through Movement
(ATM) sequence on fibromyalgia patients. Subjects met twice a week for a one hour group ATM lesson,
and were instructed to follow through daily with practice tapes: after two months, subjects were placed on
a one month home program. Pre-test and post-test data, which included a modified Fibromyalgia Impact
Assessment (FIA) questionnaire, a pain scale, photographical postural analysis, and observational video
analysis of walking, were collected and analyzed on five fibromyalgia patients. A paired t-Test on the
modified FIA and other descriptive analyses showed moderate improvement in the subjects. It was
concluded that the Feldenkrais Method has potential value as a possible adjunct to the physical therapy
treatment of selected fibromyalgia patients.

Keywords
Feldenkrais Method, Awareness Through Movement, case study, fibromyalgia, assessment, research,
clinical study

Copyright ©: The copyright for this paper remains with the author(s).

Please cite: (First published in the) Feldenkrais Research Journal, volume 4; 2008.

Service marks: The terms Feldenkrais®, Feldenkrais Method®, Awareness Through Movement®, ATM®,
Functional Integration®, and FI® are service marked terms of the International Feldenkrais® Federation
(IFF) and Feldenkrais professional guilds and associations in many countries. In keeping with academic
conventions, they will not be service marked in the entire text as may be required in nonacademic use,
but only for the first and most prominent use of the terms. In recognition that these phrases are formal
terms referring to specific practices within the Method, and to the Method as a whole, capitalization of all
the words in each term has been retained.

Published by the International Feldenkrais® Federation (IFF) https://feldenkrais-method.org
Available online at https://feldenkraisresearchjournal.org

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ISSN 1817-4000

The purpose of this study was to describe the effects of a Feldenkrais
Awareness Through Movement (ATM) sequence on fibromyalgia patients.
Subjects met twice a week for a one hour group ATM lesson, and were
instructed to follow through daily with practice tapes: After two months,
subjects were placed on a one month home program. Pre-test and post-test
data, which included a modified Fibromyalgia Impact Assessment (FIA)
questionnaire, a pain scale, photographical postural analysis, and observational
video analysis of walking, were collected and analyzed on five fibromyalgia
patients. A paired t-Test on the modified FIA and other descriptive analyses
showed moderate improvement in the subjects. It was concluded that the
Feldenkrais Method has potential value as a possible adjunct to the physical
therapy treatment of selected fibromyalgia patients.

Julie R. Dean, Suzanne A. Yuen and Stacy A. Barrows, PT,CFP

Stacy Barrows can be reached at E-mail sabccpt@aol.com
(mailto:sabccpt%40aol.com) or www.centurycitypt.com (http://www.centurycitypt.com/)

Introduction

Fibromyalgia or fibrositis is the most common cause of severe musculoskeletal
pain in persons seen by physicians, especially rheumatologists. (1) Although
persons with fibromyalgia display diffuse musculoskeletal pain, chronic fatigue,
sleep disturbance, and tender point sensitivity (1,2,3), medical tests show no
significant abnormalities. Secondary symptoms associated with this disorder
may include morning stiffness, headaches, gastrointestinal problems,
depression, soft tissue swelling, paresthesia, menstrual changes,
temporomandibular joint dysfunction, vertigo and thyroid problems. (2,4) Also,
certain etiological factors such as emotional distress, trauma, noise, repetitive
motion and climate, especially heat and lights, have been reported to
exacerbate symptoms. (2,4) Poor postural habits have also been shown to
aggravate fibromyalgia symptoms. (2,4)

Treatment programs for individuals with fibromyalgia have been diverse and
varied, and as yet no one single treatment has worked for every patient. Some
patients have reported partial symptom relief with tricyclic drugs (7), while
others have experienced success with traditional modalities such as heat and
ice. (1) Treatment through active stretching, postural education, body
mechanics, and other forms of therapy has also provided some benefits. (1,2)
Specifically, it has become apparent that persons with fibromyalgia benefit

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from aerobic conditioning and other exercise programs. (8,9,10,11,12) According
to standards for fitness developed by the American Heart Association for a
normal population, showed that 80% of patients with fibromyalgia are
physically unfit. (13) McCain and colleagues conducted two studies involving
aerobic exercise with fibromyalgia patients. (11,12) One study showed that pain
scores, pain diagrams, and total myalgic scores improved significantly after a
program of cardiovascular exercise. (12) The other showed only modest
improvement in pain and other fibromyalgia symptoms measured. (11) Bennett
hypothesized that a decreased activity level in fibromyalgia patients, and
therefore decreased level of fitness, was due to patients' chronic pain and
fatigue, making them more susceptible to muscle microtrauma: (8) Nichols and
Glenn hypothesized that a program of aerobic exercise might increase the
resistance of muscle to this microtrauma. (14) Results from this study were
inconclusive. In fact, patients actually rated the disability section of their
assessment as being higher after the program. Results vary among the few
studies looking at exercise with fibromyalgia. One problem causing these
varied results could be poor compliance to exercise programs. This decreased
compliance may be the result of pain, fatigue, and a lack of personal efficacy.
(8,10,13)

Physical therapy has been called upon to assist the patient to a more
comfortable means to exercise and assume ease of posture and functional
activities. There have been multiple philosophies of therapeutic exercise and
neuromuscular reeducation used in the past. Recently, physical therapists have
become aware of another approach called the Feldenkrais method. By clinician
report, this approach has assisted patients with diagnoses such as cerebral
palsy, stroke, and head injury. The approach is designed to assist individuals in
reorganizing their movement patterns kinesthetically. (15,16) While there is
limited research on this, proper application of this method may lead to
reduction of pain, stress, muscular tension and soreness, and may increase
flexibility and efficiency of movement. (15,17,18,19) Brown and Kegerreis
showed that normal subjects perceived movements easier to perform after
Feldenkrais sessions, thus furttier supporting the claim that the Feldenkrais
method facilitates movement by helping the person reorganize the
biomechanics of the movement, therefore decreasing effort used and
increasing efficiency of the movement. (20)

The Feldenkrais method is divided into two modes of instruction: 1) Awareness
Through Movement (ATM), and 2) Functional Integration (FI). In ATM,
individuals perform small, gentle movement patterns, usually in a group setting,
in response to verbal or written cues. The movements are self-directed and
performed within each person's comfort range. Mental imagery of the
movements is encouraged if the movements are perceived by the patient or the
instructor to be too difficult. Mental imagery is also occasionally used as part
of the lesson for all participants. Mental imagery has been widely studied and
documented for its positive effects on learning. (21,22) The literature supports
the view that mental imagery has also been found to enhance awareness-of the
body. (22) In contrast, FI is individualized instruction. The individual is guided
hands-on by a Feldenkrais practitioner, who may be a physical therapist,
through gentle and slow movements. (15,18,23)

The Feldenkrais method functions to increase the person's sensitivity and
awareness of physical movement. (18) Its aim is to improve the individual's



ability to learn by reprogramming the sensorimotor learning ability of the
central nervous system. (23,24) This ability of the central nervous system to
learn and relearn movement patterns and its controlling influence over other
components of movement has long been recognized. (5) The Feldenkrais
method encourages "practitioners to work with patients in an instructional
manner, rather than attempting to correct them." (24) By experimenting with
movement, the central nervous system begins to distinguish which body
positions are more or less efficient and thus helps to improve the person's gross
motor ability. (23,24) This process is much like the experimental and explorative
movement that helps a baby progress through the developmental motor
milestones. (16,23,25)

The effectiveness of the Feldenkrais method has been documented in only a
few studies. Case studies demonstrated that the method has reduced pain in
patients with acute and chronic back problems. (15) A study by Ruth and
Kegerreis reported increases in neck flexion range of motion after participating
in a Feldenkrais ATM sequence. (26) Because of the lack of clinical studies on
the Feldenkrais method, more research is needed to substantiate its validity as
an appropriate treatment philosophy.

Instead of depending on short-term passive therapy to temporarily relieve their
symptoms, fibromyalgia patients should be encouraged to take the initiative to
progress towards long-term management. Long-term management involves
assisting the patient to be responsible and self-reliant in participating in an
active exercise program. (1,3) In order to enhance the ability of the patient with
fibromyalgia to exercise and to move within an dynamically efficient postural
alignment, the Feldenkrais method was evaluated for its potential use in
reducing pain and improving kinesthetic sense. Decreased pain and improved
kinesthetic sense would provide the patient with more comfortable movement
choices to increase the capacity for physical movement.

The purpose of this study was to describe the effects of a Feldenkrais
Awareness Through Movement sequence on fibromyalgia patients using a
modified Fibromyalgia Impact Assessment, pain scale, photographical postural
analysis, and observational video analysis of gait.

Methods

Subjects:

Initially, nine fibromyalgia patients, who self-reported as being diagnosed with
fibromyalgia, were recruited by rheumatologist referral and from several
Southern California Fibromyalgia support groups. No documented physician
confirmation of the diagnosis was obtained. All subjects were female, whose
ages ranged from thirty to fifty-one years-old, and dates of fibromyalgia
diagnoses ranged from 1986 to 1994 (Table 1). Exclusion criteria included any
person(s) involved in litigation, and any individual(s) with a medical condition
that would prevent consistent participation in the study. A sample of
convenience was used to provide for an experimental group only, with no
attempt at random selection. Before participation, all subjects signed informed
consent forms approved by the Mount St. Mary's College Human Subjects
Committee. After one week, one subject voluntarily discontinued her
participation in the study. During the course of the study, three subjects



experienced acute onset of medical conditions. Data from these individuals
were excluded from group analysis; however, for individual case study, data
from one of the excluded subjects (i.e. Subject 6) was retained and analyzed
descriptively . Pre-test and post-test data, therefore, were collected and
analyzed on the remaining five fibromyalgia subjects.

Table 1: General Subject Characteristics

SUBJECT
#

AGE
(YEARS)

ONSET OF
FM
SYMPTOMS
(DATE)

DATE OF
DIAGNOSIS

OTHER
TREATMENT
INTERVENTIONS

OTHER
MEDICAL
PROBLEMS

1 47 1992 1994 PT OA, LBP

2 33 1989 1989 acupuncture, massage LBP, CFS, HoTN2
to CFS

3 49 1993 1994 PT, OT, BFB,
chiropractor, massage

LBP, tendonitis,
bursitis, mental
illness, ulcer or
other stomach
disease,
depression,
anxiety

4 51 1984 1987
PT(massage), trigger
point injections, pain
management program

LBP, ulcer or
other stomach
disease, anemia or
other blood
disease,
depression,
anxiety, allergy and
sinusitis

5 37 1990-1994 1994 PT, BFB, chiropractor

OA (neck),
tendonitis, carpal
tunnel syndrome?,
ulcer or other
stomach disease,
depression

6* 30 1993 1994  

LBP,
tendonitis/bursitis,
anemia or other
blood disease,
depression,
anxiety,
amenorrhea, CFS

PROCEDURE:

A pilot study was conducted, and modifications were made for the final study.
The final research study was conducted over three months. Initially, all subjects
were asked to state information regarding current health status, medications,
and previous fibromyalgia treatment on a written patient demographic profile
(Appendix A), adapted from the Fibromyalgia Impact Assessment. A modified
Fibromyalgia Impact Assessment (FIA), pain scale, photographical postural



analysis, and observational video analysis of gait served as the pre-test and post-
test measurements. The modified FIA consisted of the following five sections:
functional mobility, fibromyalgia pain, sleep and fatigue, work, and level of
tension (Appendix B). The pain scale was numerically arranged from 0 to 20,
with "0" equivalent to no pain, and "20" representing very severe pain
(Appendix C). Also included with the pain scale were anterior and posterior
body diagrams on which the subjects marked areas of pain.

Figure 1

A modified FIA and pain scale were completed by each subject; the former was
administered verbally. For postural assessment, three full body photographs
(anterior, posterior and right lateral views) of each individual standing in front
of a grid were taken (Figure 1). (15) Subjects wore a bathing suit or other
appropriate attire. A plumb line suspended from the ceiling was used to
represent a line of reference. (27) The tripod of the camera was positioned at
the same distance from the grid/subject for pre-test and post-test
measurements. For the anterior and posterior views, the fixed reference point
used to align the subject with the plumb line was the point midway between
the heels. (27) For the right lateral view, the individual was aligned with the
fixed reference point slightly anterior to the right lateral malleolus. (27) Lastly,
while being videotaped in an anterior-posterior view, each subject was
instructed to walk towards and away from the video camcorder twice. To
ensure consistent objective measurements, investigators acted independently
in gathering data; one experimenter was in charge of administering the written
assessment tools, another was responsible for postural photography, and the
third investigator videotaped each subject's gait.

For the duration of the study, subjects were instructed to continue taking their
medications as currently prescribed. For two months, subjects met twice per
week for one hour Feldenkrais ATM lessons, taught and verbally instructed by
a physical therapist, certified as a Feldenkrais practitioner. The ATM lessons
were sequenced specifically for individuals with chronic pain; the sixteen
lessons were designed to be simplified and access normal daily postural



movement strategies, such as flexion, extension, sidebending and rotation.
(23,28) Subjects were positioned in prone, supine or sidelying during the
lessons, and when unable to perform a particular movement secondary to pain,
subjects were encouraged to visualize and imagine the movement. In addition,
subjects were asked to practice that same instructed lesson on tape once daily
on "non-instructional" days. In order to record *the precise number of
Feldenkrais lessons performed, attendance was taken at each session, and each
subject was given a monthly calendar on which to indicate whether or not a
taped lesson was practiced at home.

At the conclusion of the eight weeks of classroom instruction, subjects were
placed on a four week home program in which they were asked to continue
practicing the taped Feldenkrais lessons, once daily at home. To encourage
compliance, a check-off calendar was provided for each subject, and
investigators made one follow-up phone call to each subject midway through
the home program.

Following the home program, subjects reconvened to complete the post-test
measurements. Subjects were allowed to see previous modified HA and pain
scale scores. (29) Lastly, subjects completed a written post-study questionnaire,
created to elicit feedback and any comments regarding the study (Appendix
D).

Data Analysis:

A five point scale was utilized to score the modified FIA. Depending on how
each question was phrased (either positively or negatively biased), the value of
the answer was accommodated such that the scale of the scores was reversed
for some questions. For example, if a question (i.e. Appendix B - Sect. 1,
Question #4) tended to be negatively biased, "All Days" would be scored as 1
point and "No Days" scored as 5 points. Overall, a subject with a higher
positive modified FIA score corresponded with a "better" overall health status.

The body diagrams, which accompanied the pain scale, were logically divided
into specified regions of the body (Appendix E). From these diagrams, total
number of painful regions and location of pain could be identified.

The postural photographs were analyzed randomly by a physical therapist to
determine the presence and severity (minimal, moderate and severe) of
common postural deviations, given a form with a broad list of descriptors
(Appendix F).

Lastly, the observational gait analysis for each subject was performed randomly
by another physical therapist, who noted any changes in head alignment,
shoulder symmetry, arm swing and pelvic symmetry.

Due to the small sample size, data was analyzed descriptively (mean, standard
deviation, percentage change), with the exception of a paired t-Test, p<0.05
performed on the modified FIA and pain scale.

Results

Five subjects completed the study and were included in the final data analysis.
Total compliance for these five subjects, which included attending the group



lessons and practicing the tapes daily, ranged from 51.1% to 76.1% Attendance
to the group lessons ranged from 68.7% to 87.5%. Compliance with practicing
the taped lessons ranged from 45.8% to 73.6% (Table 2).

 

Table 2: Lessons and Practice Compliance

SUBJECT
#

LESSONS
ATTENDED

(16)

DAYS
PRACTICED

(72)

TOTAL
COMPLIANCE

(88)

1 14 53 67

2 11 38 49

3 11 34 45

4 14 33 47

5 14 49 63

( ) = maximum # lessons &/or days

 

Improvements were recorded in the total modified FIA scores (p<0.05) as well
as in each section of the modified FIA. Significant improvement, however, was
reached only for the pain and sleep/fatigue sections as well as for the total score
of the modified FIA (p<0.05). (Fig. 2) A nonsignificant trend of improvement
was also noted in the level of tension section (Table 3). Four out of five subjects
improved their total modified FIA scores, with the greatest percentage change
being 35.7% (Table 4). Three out of five subjects improved their scores in the
functional mobility section, with the greatest percentage change at 25.0%. All
five subjects improved their scores in the pain section, with percentage
changes ranging from 30.8% to 53.8%. The sleep/fatigue section also showed
improvement in all five subjects, with improvements ranging from 6.3% to
60.0% change. Three of five subjects improved in the work section, with the
greatest percentage change being 25.0%. In the level of tension section, three
of five subjects improved their scores, with the greatest improvement being
77.8%.

 

Table 3: Modified FIA mean scores (standard deviation) and p-values



SECTION # PRE-TEST MEAN
(SD)

PRE-TEST MEAN
(SD)

P-
VALUE

#1 – functional
mobility

43.2

(9.149)

45.6

(5.505)
0.381

#2 – fibromyalgia
pain

12.2

(3.633)

17.0

(4.950)
0.003*

#3 – sleep/fatigue
13.4

(4.775)

17.6

(5.505)
0.022*

#4 – work
12.4

(4.278)

13.2

(3.421)
0.242

#5 – level of tension
13.2

(2.588)

17.0

(3.3536)
0.106

Total Scores
94.4

(20.403)

110.4

(18.515)
0.046*

* significant at p < 0.05



Figure 2

Table 4: Individual modified FIA scores with percentage change

SECT # SUBJECT #1 SUBJECT #2 SUBJECT #3

  PRE POST % PRE POST % PRE POST %

#1 (60) 53 52 -1.9 44 48 9.1 32 37 15.6

#2 (30) 17 23 35.3 7 10 42.9 11 15 36.4

#3 (35) 20 25 25.0 8 10 25.0 10 16 60.0

#4 (20) 17 18 5.9 16 15 -6.3 8 10 25.0

#5 (30) 14 22 57.1 13 13 0 9 16 77.8

Total (175) 121 140 15.7 88 96 9.1 70 94 34.3

SECT # SUBJECT #4 SUBJECT #5

  PRE POST % PRE POST %

#1 (60) 36 45 25.0 51 46 -9.8



#2 (30) 13 20 53.8 13 17 30.8

#3 (35) 13 20 53.8 16 17 6.3

#4 (20) 8 10 25.0 13 13 0

#5 (30) 14 19 35.7 16 15 -6.3

Total (175) 84 114 35.7 109 108 -0.9

( ) = maximum score possible, % = percentage change pre. vs post.

Mod FIA sections: #1 = functional mobility; #2 = fibromyalgia pain;

#3 = sleep/fatigue; #4 = work; #5 = level of tension

Figure 3



SUBJECT # PAIN SCALE (0-20) # PAIN REGIONS

  PRE POST PRE POST

1 7 2 10 7

2 14 11 33 44

3 13 15 20 18

4 14 14 20 12

5 9 10 13 8

 

The paired t-Test performed on the pain scale did not prove to be significant at
the 95% confidence interval (p<0.05), with a p-value of 0.486. (Fig. 3) Two
subjects reported decreased pain scores, while two subjects reported slightly
increased pain scores. One subject reported the same pain score. Four subjects
reported a decrease in the number of areas of pain on the body diagram, while
one subject reported an increase in the number of pain spots (Table 5, Fig. 4).

Table 5: Pain scores

 

Minimal improvements in posture were noted, with the majority of these being
in the alignment of the head and feet. Four of the five subjects demonstrated
more neutrally aligned feet while three of the five subjects demonstrated the
head to be more neutrally aligned on the neck. There were areas of the body
observed to be less neutrally aligned for all five subjects.

Minimal improvements were also noted in gait. Three of the five subjects had
improved arm swing. One subject was observed to have a more symmetrical
pelvis during gait. Some negative changes were noted in the head alignment of
two subjects and in the shoulder symmetry and arm swing of another subject.

In the post-study feedback questionnaire, four subjects reported that the
Feldenkrais method helped them become more aware of their body, its
movement patterns and limitations. Two subjects stated that the Feldenkrais
method did not seem to help their pain, two subjects did not address pain on
the feedback questionnaire, and only one subject reported that the Feldenkrais
method helped to decrease her pain.



Although Subject 6 was excluded from the group data analysis secondary to an
acute onset of a medical condition, it is interesting to report her individual
results, since she did complete the study. Her total compliance was 33%, with a
lesson attendance of 81% and daily tape practice of 22%. She improved her
total modified FIA score from 75/175 pre-test to 90/175 post-test, with
improvements in each individual section except for section 1 (functional
mobility), in which her score decreased slightly. Her pain scale score decreased
from 10 to 7 on the 20 point scale and the number of spots, in which she
reported pain on the body diagrams, decreased from 13 to 5. In reference to the
postural analysis, the subject's knees, shoulders and clavicles were noted be
more neutrally aligned. The subject's head, lumbar spine and feet were found to
be slightly less neutrally aligned. No significant changes were noted in gait
analysis, except subject's head was slightly aligned to the right. On the post-
study feedback questionnaire, she noted that the Feldenkrais method brought
awareness to areas of her body that were painful, and helped her learn to
change body movement patterns to help decrease the pain.

Discussion

Pain, sleep/fatigue sections and overall total of the modified FIA were found to
be statistically significant in our sample of subjects as a whole. This suggests
that the Feldenkrais method has potential value in reducing pain and
decreasing fatigue in fibromyalgia patients, as measured by the modified FIA.
However, it is interesting to note that the pain scale scores, as a group, did not
show significant improvement. Three subjects reported the same or worse pain
on the pain scale but reported improved scores on the pain section of the
modified FIA. One possible reason for this would be that the modified FIA
pain section asks the subject to report to whaf degree pain interferes with their
daily activities and sleep, in addition to asking the subject how often they
experienced pain and its severity. The 20 point pain scale simply asks the
subject to report the intensity of the pain at that specific point in time.
Perhaps the subjects had severe pain less often over the four week period or
perhaps other changes (i.e. decreased level of tension and fatigue, or increased
body awareness) made it possible to perform their daily activities, therefore
improving their modified FIA pain score. This hypothesis is supported by the
statistical significance of the sleep/fatigue section of the modified FIA, and the
fact that four of five subjects reported that the Feldenkrais method improved
their body awareness on the post study feedback questionnaire. As a whole, our
results support this hypothesis. Fibromyalgia patients are prone to
unpredictable flare-ups during the course of their condition, which may have
caused their pain scale scores to increase or decrease at a specific point in time.
(30) The statistical significance of the total modified FIA scores suggests a
possible improvement in the overall health status of the subjects in our study,
although subject S reported no significant change. The functional mobility,
work and level of tension sections of the modified FIA did not prove to be
statistically significant. Our small sample size could possibly explain this for
the level of tension section (p=0.11). A longer duration with the lessons and/or
practice tapes may be required to see changes in these sections. Nelson states
in regards to the Feldenkrais method, "A reasonable amount of time must be
allotted to absorb what is learned...Students are encouraged to learn at their
own pace." (23) It is also possible that the patients did not fully understand the
concepts behind the Feldenkrais method. The subjects may not have had a



kinesthetic sense that was sensitive enough to apply the verbally instructed
movement concepts of the method. Understanding the concepts of the
Feldenkrais method and its premises is important for each subject, as they
need to be able to relearn comfortable movement patterns, reorganizing them
at the central nervous system level. (23,24) Perhaps inclusion of FI, the hands-
on, individualized form of the Feldenkrais method, would have been beneficial
to enhance each subject's kinesthetic sense and awareness, enabling them to
more fully understand the premises and concepts of the method. The ATM
group lessons were analyzed specifically to see if this would provide a more cost
effective form of the method in light of today's changing health care. However,
further analysis of FI is warranted.

It is interesting to note that three of the five subjects reported fairly significant
positive percentage changes on the level of tension section of the modified
FIA. It is also important to remember that other variables, such as personality,
background, learning style, or stressful events occurring during the course of
the study may have affected the results in all sections of the modified FIA.

As mentioned earlier, when looking at the post-study feedback questionnaire,
we found that four out of five subjects stated that they felt the Feldenkrais
method made them more aware of their body and its movements. According to
the literature, one of the primary claims of the Feldenkrais method is that it
functions to increase awareness of physical movement by improving
kinesthetic sense. (18) Subject feedback from this study supports this claim.
This enhanced body awareness may be a reason for the significant
improvement in the pain section for all five subjects and improvement in the
level of tension section for three of the five subjects. The subjects may have felt
more confident in their ability to make movement choices, thereby decreasing
anxiety and stress in daily activities. If it is possible to decrease pain through
use of the Feldenkrais method, as measured by the 20 point pain scale,-it may
be necessary for a person to first improve their kinesthetic sense, increasing
their movement choices, and then learn to make the most comfortable choices.

The Feldenkrais method also incorporates mental imagery as a means to
enhance body awareness, primarily in situations when a person has difficulty
performing the movements. Fairweather and Sidaway found that ideokinetic
imagery training produced positive postural alignment changes in high school
and college students with and without low back pain, especially when
combined with kinesthetic awareness activities. (22) Warner and McNeill
conducted a review of literature regarding the effects of mental imagery and
practice on physical skills and found that mental imagery and practice have
been consistently shown to produce physical results and enhance motor
learning in the areas of sports and health care services when training is
conducted over time. (21) One's ability or willingness to imagine movement,
the sensitivity of one's kinesthetic sense and the amount of time allotted for
training are factors that may have come into play or interacted in our study to
impact the effectiveness of the Feldenkrais method on each individual subject.

A final factor which may have influenced the results of our study were the
compliance rates, since the Feldenkrais method claims to be more effective
when used consistently over time as would any motor learning method. Some
possible reasons for missed lessons and practice days would include the daily
drive to the site of the study. Several subjects informally expressed a concern



that this may have contributed to their level of stress and fatigue. The
fluctuating nature of fibromyalgia symptoms may have also made it difficult for
subjects to be consistent. There were also occasional scheduling conflicts for
each of the subjects that could not be helped. Overall, however, compliance
rates in our study were fairly high, ranging from 51.1% to 76.1%, including
attending group sessions and practicing lessons daily at home. Compliance to
attending group lessons was higher than compliance with practicing daily
lessons.

Subject 6, who was excluded from data analysis but completed the study, was
an interesting case to analyze. Although her compliance was fairly low, probably
due to her acute medical conditions, she showed improvement in her total
modified FIA scores, as well as in each separate section with the exception of
the functional mobility section. She also reported a decreased pain scale score.
Subject 6 has a background in dance and has been involved in other therapy
that emphasizes development of kinesthetic awareness. This would suggest
that a person with a particular background, perhaps one that involves other
kinesthetic awareness training, may respond more positively and/or more
quickly to the Feldenkrais method. Subject 6 also reported on her post-study
feedback questionnaire that she felt an enhanced body awareness, and stated
several specific areas of her body where she observed improvement.

Future studies in the area of fibromyalgia and the Feldenkrais method may
include ones that measure the reliability and/or validity of the modified FIA,
since it is different in organization, scoring and content than the original FIA.
It might also be helpful to quantify gait changes by analyzing velocity, stride
length, step length, cadence, and other parameters (i.e. functional activities). A
study with a longer time frame of lessons and/or practice days would be helpful
to look at the long term effects of the Feldenkrais method on fibromyalgia
patients. It would also be interesting to look at a study beginning with
individualized, hands-on Functional Integration, then moving subjects into a
program of group ATM lessons. This might increase understanding of the
concepts of the Feldenkrais method, as well as satisfy the move towards more
cost-effective health care. After data collection was completed, FI was
performed on one individual who reported increased understanding of the
concepts of the method. Also, a larger sample size with a control group
receiving traditional physical therapy would perhaps shed more light on the
effects of the Feldenkrais method and its potential use as an adjunct to the
physical therapy treatment of selected fibromyalgia patients. Lastly, due to the
discrepancy between pain scale scores and FIA pain section results, the
perception of pain continues to warrant further investigation.

Summary

In conclusion, the Feldenkrais method has potential value as a possible adjunct
to the physical therapy treatment of selected fibromyalgia patients, as
evidenced by the statistical significance of the pain and sleep/fatigue sections
and the total modified FIA scores. The key points are:

1. Those who improve their kinesthetic sense and mental imagery may have
more success with the method.

2. Increased body awareness, reported by four out of five subjects, may be a
bridge to more comfortable, efficient movement, which may decrease pain



and fatigue over time.
3. If able to move more comfortably, fibromyalgia patients might increase

participation in aerobic exercise and other treatments.
4. ATM lessons are a cost-effective way to increase body awareness.

Acknowledgements

Mark Reese, PhD, CFP
The Reese Movement Institute, Inc., Cardiff by the Sea, CA

Lawrence W. Goldfarb, PhD, CFP
Champagne, Illinois

MSMC Physical Therapy Department
Los Angeles, CA

Monique Peterson, PT, OCS
Robyn Smith Physical Therapy, Manhattan Beach, CA

Craig Newsam, MPT
Ranchos Los Amigos Medical Center, Downey, CA

Marilyn Pink, MS, PT
Centinela Biomechanics Lab, Los Angeles, CA

South Bay Hospital - Physical Therapy Department
Torrance, CA

The Center for Physical Health
Los Angeles, CA

Dorothy Johnson, RN
Southern California Arthritis Foundation

Southern California Fibromyalgia Support Groups

Ken Nies, MD & Richard Goldin, MD
Torrance, CA

Peng Fan, MD & Associates
Van Nuys, CA

Gideon Darvish, MD
Inglewood, CA

Cinder Marshall, MD & Associates
Inglewood, CA

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18. Peterson R. Feldenkrais integrates body and brain through movement.
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20. Brown E, Kegerreis S. Electromyographic activity of trunk musculature
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21. Warner L, McNeill ME. Mental imagery and its potential for physical
therapy. Physical Therapy, 1988 April, 68(4): 516-21.

22. Fairweather MM, Sidaway B. Ideokinetic imagery as a postural
development technique. • • h •uart-rl for Exercise and Sport. 1993
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23. Nelson SH. Playing with entire self: the Feldenkrais method and
musicians. Seminars in Neurology. 1989 June, 9(2): 97-104.

24. Wildman F. Learning - the missing link in physical therapy. Physical
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pp. 51-70.

26. Ruth S, Kegerreis S. Facilitating cervical flexion using a Feldenkrais
method: awareness through movement. JOSPT. 1992 July, 16(1): 25-9.

27. Kendall, FP. Muscles: Testing and Function - Fourth Edition with Posture
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30. Fan PT, Blanton ME. Clinical features and diagnosis of fibromyalgia. The
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31. Ruth S, Kegerreis S. Facilitating cervical flexion using a Feldenkrais
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32. Kendall, FP. Muscles: Testing and Function - Fourth Edition with Posture
and Pain. 1993, Williams & Wilkins, Baltimore, Maryland. pg. 71 - 72, 100.

33. Mark Reese, PhD, CFP. The Reese Movement Institute, Inc., Cardiff by
the Sea, California.

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Subjects See Their Previous Responses? I Chron Dis. 1985, 38 (12): 1003-
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?), J. D. S. Y. R.(+ A. & (/volume/author/78) , Yuen S. A. (/volume/author/74) , &
Stacy A. Barrows, PT C. F. P. (/volume/author/79) (2008).  Awareness
Through Movement Sequence on Fibromyalgia Patients
(/volume/4/dean) . Feldenkrais Research Journal. 4,

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APPENDIX A 

PATIENT PROFILE 
 
Please provide us with the following information about yourself:  
 
1.  What is your age at this time? 

 
2.  What is your sex (male or female)? 

 
3.  What is your racial background? (check one)  

 
White 

Black 
_ H i s p a n i c  

_ A s i a n  or Pacific Islander 
_ A m e r i c a n  Indian or Alaskan Native 
_ O t h e r  (specify): 

 
4.  What is your current marital status? (check one)  

 
Married 
Separated 
Divorced 
Widowed 
Never married 

 
5.  What is the highest level of education you have received? 

(check one) 
 

Less than high school diploma 
High school diploma or GED One 
to four years of college 

_ _ C o l l e g e  graduate 
__Professional or graduate school  

 
6.  How long have you had fibromyalgia (months,years)?  

7.  Have you had sleep problems? 

 Yes   No 

 
7a. If yes, did they predate your 

fibromyalgia pain? 
 

Yes No 
 
8.- Have you had problems with fatigue? 

Yes   No 

 
8a. If yes, did they predate your 

fibromyalgia pain? 
 

Yes No 



9.  Who diagnosed your fibromyalgia? (Check all that apply) 
Specify date of diagnosis (month & year)  

 
Rheumatologist 
Internist 

_General practitioner/family doctor 
__Psychiatrist 
_ O r t h o p e d i s t  
_ O t h e r  (please specify): 

 
10.  Who follows your fibromyalgia? (Check all that apply) 

__ 

General practitioner/family doctor 
_ P s y c h i a t r i s t  

__Orthopedist 
'Other (please specify): 

11.  Are you currently seeing a psychiatrist, psychologist or 
counselor for any related problems? 

Yes No 

11a. If you answered yes to the above question, how often 
do you see this professional? 

12.  Please list your current medications. 

Name of red Dose Frequency 
(5 mg, 10 mg, etc) (1x/day, 2x/day,etc) 

13.  Please list any treatment or therapy (including any prior 
Feldenkrais experience) you have received,. other than 
medications, for your fibromyalgia. Please include dates. 

 ___ Rheumatologist  
Internist 



Rheumatoid arthritis 
__Rheumatoid 

 
 ___ Systemic lupus erythematosus 
_ S c l e r o d e r m a  

Psoriatic Arthritis 
Reiter's syndrome 
+Gout 

_ _ L o w  back pain 
Tendonitis/Bursitis 

+ _Osteoporosis 
,Other (please specify): 

 
15. Is your health currently affected by any of the following 

medical problems? 
YES NO 

 
High blood pressure 
Heart disease 
Mental illness 
Diabetes 
Cancer 
Alcohol or drug abuse 
Lung disease 
Kidney disease 
Liver disease 
Ulcer or other stomach disease 
Anemia or other blood disease 
Depression 

Anxiety 
Other (please list): 

 

14. Check any other types of arthritis that you have. (Check 
all that apply) 



APPENDIX B 
 
 

MODIFIED FIBROMYALGIA ASSESSMENT 

Investigator Copy 
 
Read the following instructions: i will be asking you questions 
regarding your health over the past four weeks. Place your 
answers on this answer sheet, remembering to the best of your 
ability. You need only to mark one appropriate category for 
each question - "All Days", "Most Days", "Some Days", "Few Days", or 
"No Days", as depicted on your answer sheet. 
 
SECTION 1: _ Functional Mobility "During the past four weeks..." 
 
1. How often were you physically able to drive a car or 

use public transportation? 
 
2. How often were you out of the house for at least part 

of the day? 
 

3. How often were you able to run errands in the neighborhood? 
 
4. How often did someone have to assist you to get 

around outside you home? 
 

5. How often were you in a bed or chair for most of the day?. 
 
6. How often were you able to do regular exercise that 

is a normal part of your schedule? 
 
7. Were you able to walk several blocks or climb a few flights 

of stairs? 
 

8. Did you have trouble bending, lifting or stooping? 
 
9. Did you have trouble either walking one block or climbing 

one flight of stairs? 
 
10. Were you unable to walk unless assisted by another person 

or by a cane, crutches or walker? 
 
11. Did you have difficulty sitting for longer than half an 

hour? 
 
12. Did you have difficulty standing for longer than half an 

hour? 



SECTION 2: _ Fibromyalgia Pain "During the past four weeks..." 

1. How often did you have any pain at all? 

2. How often did you have severe pain? 

3. How often did you have pain in two or more particular spots 
at the same time? 

4. How often did your morning stiffness resolve within one 
hour from the time you woke up? 

5. How often does your pain interfere with what you want to 
do? 

6. How often did your pain make it difficult for you to sleep? 

SECTION 3 :  __ Sleet 8 Fatigue "During the past four weeks..." 

1. How often did you have difficulty falling asleep at night? 

2. How often did you sleep through the night? 

3. How often did you wake up earlier than you planned? 

4. How often did you feel well rested in the morning? 

5. How often did you feel tired during the day? 

6. How often did you feel that you tired easily? 

7. How often did you feel too tired to do what you wanted 
to do? 



SECTION 4: _ Work "During the past four weeks..." 
 
**Note: Complete this section only if you are currently involved in 
paid work, housework, schoolwork or volunteer work. "All Days" 
would coincide with the number of days usually worked or normal 
workload. 

1. How often were you able to do any paid work, housework, 
schoolwork, or volunteer work? 

2. On the days that you did work, how often did you have to 
work a shorter day or less time than usual? 

 
3. On the days that you did work, how often were you able to 

do your work as carefully and accurately as you would 
like? 

4. On the days that you did work, how often did you have to 
change the way your paid work, housework, schoolwork, or 
yolunteer work is usually done? 

SECTION 5: _ Level of Tension "During the past four weeks..." 
 
1. How often have you felt tense or highstrung? 
 
2. How often were you able to relax without difficulty? 
 

3. How often have you felt calm and peaceful? 

4. How often have you felt relaxed and free of any tension? 
 
5. Do you feel you are getting better? 
 
6. Do you feel you are getting worse? 
 
7. Do you feel you are staying the same? 



MODIFIED FIBROMYALGIA ASSESSMENT 

Subject Answer Sheet 

Subject # 

SECTION 1: __ Functional Mobility 
All Most Some Few No 
Days Days Days Days Days 

1. TRANSPORTATION 
2. OUT OF HOUSE 

 

3. ERRANDS 

4. ASSISTANCE 
5. BED/CHAIR 

 
6. EXERCISE 

 
7. STAIRS/BLOCKS 

 
8. BEND/LIFT/STOOP 

 

9. ONE STAIR/ONE BLOCK 

10. CANE/CRUTCHES/WALKER 1,1. SITTING 
 

12. STANDING 
SECTION 2: __ Fibromyalgia Pain 
 
1. PAIN 

 

2. ' SEVERE PAIN 
3. PAIN-TWO SPOTS 

 

4. MORNING STIFFNESS 
5. PAIN-INTERFERE 

 
6. SLEEP 

 



SECTION 3: _ Sleep & Fatigue 
 

All Most Some Few No 
Days Days Days Days Days 

1. FALL ASLEEP 

2. SLEEP THROUGH NIGHT 
 
3. WAKE EARLY 

 
4. RESTED 

 
5. TIRED 

 

6. EASILY TIRED 

7. TOO TIRED 

SECTION 4: _ Work 
 
1. WORK 

 
2. SHORTER SCHEDULE 

 
3. CAREFUL WORK 

 

4. CHANGE WORK SECTION 5:

 Level of Tension 

1. TENSE 
 
2. RELAXATION 

 
3. CALM/PEACEFUL 

 
4. TENSION-FREE 

 
5. BETTER 

 
6. WORSE 

 
7. SAME 



PAIN QUESTIONNAIRE 

1. How much pain do you feel RIGHT NOW? 
Circle the number on the scale below at the appropriate 
point. 

0 1 _ 2 _3 _ 4 _5 _ 6 7 8 _ 9 _ 10 _ 11 12 _ 13 14 15 _ 16 _ 17 18 19 _ 20 

Very 

severe pain 

2.  Please place an X on each area in the diagram below where you 
are presently feeling pain: 

 

No 
pain 





APPENDIX D 

Post-study feedback gyestions 

1. Would you recommend this treatment method to another with fibromyalgia? 

2. Which lessons did you feel you got the most results from? 

3. Did you achieve any changes that you feel will help you? 

4. Did the Feldenkrais Method help you? 

5. Other comments: 





APPENDIX F 

SUBJECT # ______  

Postural Assessment 
 

For each possible deviation listed below, please check or "X" the appropriate box: 
Y(yes), N (no), or UA (unable to assess). In addition, if you check Y(yes), also check 
MIN (minimal), MOD (moderate), or SEV (severe). Space is provided below for 
comments. Please complete four checklists for each subject: lateral, anterior, and 
posterior views, and frontal plane. (Note: frontal plane deviations may be noted in the 
anterior and/or posterior views) 

LATERAL VIEW Y N I UA NUN MOD SEY 
1) Forward head?       
2 Head alined in neutral on neck?       

If Y, skip #3-4       
3 Head tilted osteriorl on neck?       
       
       
       
       
       
       
       
9 Excessive thoracic k .hosis?       
10) Flattened thotacic spine?       
11) Protruding abdomen?       
12 Lumbar lordosis WNL?       

If Y, ski. # 13-14  —
_  

    
       
       
       
       
16 Anterior .elvic tilt?       
17 Posterior .elvic tilt?       
18 Knee flexed?       
19 Knee h .erextended?       
20 Ankle dorsiflexed?  ~

~  
    

21 Ankle .lantarfiexed?       
       
       
       

COMMENTS: 



SUBJECT # 

Postural Assessment 

FRONTAL PLANE (ANT/POST) Y N UA MIN MOD SEV 
1) Head in neutral alignment on       

neck? If Y, skip #2-5       
2) Head rotated to R?       
3) Head rotated to L?       
4) Head sidebent to R?       
5) Head sidebent to L?       
6) Level of shoulders equal?       

If Y, skip #7-8       
7) R.shoulder higher?       
8) L shoulder higher?       
9) Internal shoulder rotation?       
10) External shoulder rotation?       
11) Level of iliac crest equal?       

If Y, skip #12-13       
12) R iliac crest higher?       
13) L iliac crest higher?       
14) genuvarum?       
15) genuvalgum?       
       
       
       

COMMENTS: 

2 



SUBJECT # 

Postural Assessment 

POSTERIOR VIEW Y N UA _ MIN MOD SEV 
1) Trapezius muscle bulk equal       

bilaterally? If Y, skip #2-3       
2) R trapezius greater bulk?       
3) L trapezius greater bulk?       
4) Gastroc muscle bulk equal       

bilaterally? If Y, skip #5-6       
5) R gastroc greater bulk?       
6) L gastroc greater bulk?       
7) Bilateral Achilles tendons       

vertically aligned? If Y, skip       
# 8-11       

8) R foot varus?       
9) R foot valgus?       
10) L foot varus?       
11) L foot valgus?       
       
       
       

COMMENTS: 

4 



SUBJECT # 

Postural Assessment 

ANTERIOR VIEW Y N UA MIN MOD SEV 
1) Level of clavicles equal?       

If Y, skip #2-3       
2) R clavicle higher? _      
3) L clavicle higher?       
4) Out toeing WNL? (8-10 each foot)       

If Y, skip #5-6       
5) Excessive out toeing?   —    
6) In toeing?      - 
7) Feet in neutral alignment?   

- 
   

If Y, skip #8-11       
8) R foot supinated?       
9) R foot pronated?       
10) L foot supinated?       
11) L foot pronated?       
       
       
     i  

COMMENTS

3 


