Feldenkrais Research Journal • volume 7 (2023) Systematic Reviews The effectiveness of the Feldenkrais Method: A systematic review of the evidence Susan Hillier International Centre for Allied Health Evidence, Sansom Institute of Health Research, School of Health Science, University of South Australia Anthea Worley School of Health Science, University of South Australia Contact: susan.hillier@unisa.edu.au This article was originally published in Evidence-Based Complementary and Alternative Medicine; 2015. Volume 2015, Article ID 752160. The PDF version of the article follows. The HTML version can be found at Hindawi: https://doi.org/10.1155/2015/752160 Abstract 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. Keywords Feldenkrais Method, Awareness Through Movement, Functional Integration, systematic review, Cochrane approach, mechanisms of action, function, functional reach, balance training, dexterity, self-efficacy, reduced perceived effort, body image perception Copyright ©: The copyright for this paper remains with the author(s). Published by the International Feldenkrais® Federation (IFF) https://feldenkrais-method.org Available online at https://feldenkraisresearchjournal.org mailto:susan.hillier@unisa.edu.au https://doi.org/10.1155/2015/752160 https://feldenkrais-method.org/ https://feldenkraisresearchjournal.org Please cite: Feldenkrais Research Journal, volume 7; 2023. 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. Review Article The Effectiveness of the Feldenkrais Method: A Systematic Review of the Evidence Susan Hillier1 and Anthea Worley2 1International Centre for Allied Health Evidence, Sansom Institute of Health Research, School of Health Science, University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia 2School of Health Science, University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia Correspondence should be addressed to Susan Hillier; susan.hillier@unisa.edu.au Received 16 December 2014; Revised 4March 2015; Accepted 9March 2015 Academic Editor: Cun-Zhi Liu Copyright © 2015 S. Hillier and A. Worley. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The FeldenkraisMethod (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 FMworks 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. 1. Introduction 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 learning how to learn [1]. As such, he operationalized an experiential process or set of processes, whereby an individual or a group could be guided through a series of movement- and sensation-based explorations.The purpose of these explorations was to practise the nonlinear process of sensing the difference between twoormore options to achieve the stated movement task, and making a discern- ment about which may feel easier, that is to say, performed with less effort.These perceptual discernments are predicated on a judgement that is positive (pleasurable, easy, and with less effort) compared with experiencing a less favourable feedback signal such as pain, strain, or discomfort. Further to this, the participants are encouraged to generate many alternative movement solutions to the guided task to increase the opportunity for further distinctions and improvements to be made. Thus the process of intention, action, gaining feedback, making decisions, and reenacting with adaptations constitutes the learning framework in a somatic context [2]. The two modes of delivery that are offered to the public are either individual, manually directed lessons (functional integration, FI) or group, verbally directed classes (aware- ness through movement, ATM). The nomenclature for both reflects the fundamentals of the approach—that movement has to be based on a functional or meaningful intention for the system to engage and that by becoming aware of what and how we act (move) we become in a better place to choose an alternative behaviour (movement pattern) [3]. Both modes of delivery apply the same principles of perceptual exploration through movement that is passively and/or actively performed. The method has been applied in varied domains across countries, from general education or children with learning issues to enhancing performance in sports and theatre. Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2015, Article ID 752160, 12 pages http://dx.doi.org/10.1155/2015/752160 http://dx.doi.org/10.1155/2015/752160 2 Evidence-Based Complementary and Alternative Medicine 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 [4]. This review included six randomised controlled trials (RCTs) of low to moderate quality in populations such as people with multiple sclerosis, chronic low back pain, and neck issues. They concluded that there was promising evidence but its credibility was tempered due to the low number of studies, high level of clinical heterogeneity between studies, and methodological flaws. The methods employed by Ernst and Canter [4] were robust for the time; however, their risk of bias assessment used a now discarded tool (the Jadad) and their search covered until 2003. Therefore, it is timely to systematically update the evidence for the Feldenkrais Method with current review procedures. This review had the aims of (1) systematically identifying and appraising the evi- dence for the effectiveness of the Feldenkrais Method across domains; (2) determining what is the nature and order of magni- tude of any beneficial effects and for which popula- tion/s. 2. Materials and Methods 2.1. Criteria for Considering Studies for This Review. We employed systematic review methods based on the PRISMA guidelines [5]. 2.2. Types of Studies. Weconsidered all types of primary stud- ies 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. 2.3. Types of Participants and Outcomes. We included any population where there was an outcome of interest related to improvement in health and/or function. 2.4. Types of Interventions and Comparisons. Either form of Feldenkrais Method (functional integration or awareness through movement) was included as the sole approach for the intervention group.The comparison group could include placebo, inactive control, or an alternate method. 2.5. Search Methods for Identification of Studies. We searched the databases of AMED (Allied and Complementary Medicine), Embase Classic + Embase, Ovid MEDLINE(R), Cochrane, PsycINFO, PubMed, and Google Scholar from inception to July 2014. We considered all languages (the search was open to all listed journals irrespective of 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 inte- gration). An example of the terms employed in the electronic search strategy is presented in Table 1. 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 theminimum.The retained studies were examined in full to confirm inclusion. Those excluded were recorded with reasons. All retrieved studies were checked for additional refer- ences, 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 Interna- tional Feldenkrais Federation) and were asked to supply further papers by email. 2.6. Data Collection and Analysis. 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 [26] with checking and data entry by the second author. Any disagreements were resolved by consensus, with a third party if necessary. 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 het- erogeneity would be evaluated based on visual inspection of forest plots and on the "2 statistic. It was not anticipated that any other analyses would be possible (e.g., subgroup or publication bias) due to a paucity of studies. If we found that meta-analyses were not possible, then results would be synthesized and reported narratively. 3. Results 3.1. Included Studies. The systematic search yielded over 1,300 initial titles for high pass screening. See Figure 1 for the PRISMA Flow diagram. With duplicates and obviously irrelevant titles removed, 124 records were considered at the Evidence-Based Complementary and Alternative Medicine 3 Table 1: 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 Table 2: List of papers excluded with reasons. Studies Reason for exclusion Kirkby (1994) Controlled trial Bearman (1999) Pre/posttest (no control) Seegert (1999) Controlled trial Huntley (2000) Systematic review Dunn (2000) Pre/posttest (no control) Fialka-Moser (2000) Commentary Malmgren-Ohlsen (2001, 2002, 2003) Controlled trial Kerr (2002) Controlled trial Emerich (2003) Review Junker (2003) Posttest (no control) Galantino (2003) Review Gard (2005) Review Mehling (2005) Review Liptak (2005) Review Batson (2005) Pre/posttest (no control) Wennemer (2006) Pre/posttest (no 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) abstract level by both authors, with an additional two studies provided from experts in the field (newly published, one RCT, one non-RCT). Seventy-seven abstracts were excluded at this stage because they were did not report an investigation of the FM and/or did not involve a trial of effect. Forty-seven full- text articles were reviewed against the criteria and further 27 excluded with reasons noted in Table 2. Fourteen newRCTswere included alongwith the original six studies from the Ernst and Canter [4] review. See Table 3 for details of all included studies. From this total of 20 studies, there were seven studies sufficiently homogenous to allow for meta-analyses. 3.2. Description of Studies. Publication dates ranged from 1991 [12] to 2014 [25]. Populations under investigation in the included RCTs ranged from healthy volunteers [6, 12, 15– 17, 19, 24], healthy ageing [21–23], institutional ageing [25], people withmultiple sclerosis [7–11, 13], eating disorders [14], myocardial infarct [18], and sleep bruxism [20]. Studies gen- erally had small sample sizes with a mean of 40.8 participants (SD 23.5). The nature of the Feldenkrais interventions also varied in delivery mode, intensity, and frequency.The predominant methods were single or multiple ATM lessons delivered either in a 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 3. The measures related to performance or activity outcomes (e.g., balance or dexterity), symptoms (e.g., pain, effort or mood) or were related to quality of life. 3.3. Excluded Studies. Table 2 summarises the list of studies (27) that were retrieved but excluded. Reasons for exclusion were predominantly around design: two were systematic reviews; five were controlled trials (not randomly allocated); eight had no control group; eightwere nonsystematic reviews; onewas not exclusively Feldenkrais in the intervention group; one was a content analysis of an intervention; one was a phenomenological analysis; and one was a commentary. 3.4. Risk of Bias in Included Studies. 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 2 and 3 summarize the risk of bias analysis. It can be seen that a definitive judgement could not be made in many cases as it could not be confirmed whether 4 Evidence-Based Complementary and Alternative Medicine Sc re en in g In clu de d El ig ib ili ty Id en tifi ca tio n Records identified through database searching (after high level title screening) (n = 176) Additional records identified through other sources (n = 2) Records after duplicates removed (n = 124) Records screened (n = 124) Records excluded (n = 77) Full-text articles assessed for eligibility (n = 47) Full-text articles excluded, with reasons (n = 27) Studies included in qualitative synthesis (n = 20) Studies included in quantitative synthesis (meta-analysis) (n = 7) Figure 1: PRISMA flow diagram. Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other biases 0 25 50 75 100 Low risk of bias Unclear risk of bias High risk of bias (%) Figure 2: Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies. Evidence-Based Complementary and Alternative Medicine 5 Ta bl e 3: Ra nd om ise d co nt ro lle d tri als of FM (E rn st an d Ca nt er ,2 00 5[ 4] ,#=6) wi th up da te d RC Ts #=14. Au th or (y ea r) St ud yd es ig n Sa m pl e In te rv en tio n Co nt ro l O ut co m e Re su lts Co m m en ts Ru th an d Ke ge rr eis (19 92 ) [6 ] RC T 2p ar all el gr ou ps 30 he alt hy vo lu nt ee rs Si ng le FM se qu en ce Pa rti cip at io n in ot he r ra nd om ac tiv iti es D eg re eo fn ec k fle xi on (g on io m et er ); pe rc eiv ed eff or t du rin gfl ex io n G re at er de gr ee of ne ck fle xi on (g on io m et er )( !<0.01 ); les s pe rc eiv ed eff or td ur in gfl ex io n (!<0.0 5) St ud yh as pi lo tc ha ra ct er Jo hn so n et al. (19 99 )[ 7] RC T 2- gr ou p cr os so ve r( 2p ha se s) 20 pe op le wi th M S FM :8×45 m in se ss io ns at we ek ly in te rv als 8w ee ks sh am no nt he ra pe ut ic bo dy wo rk L an d R ha nd de xt er ity (p eg bo ar d te st) ; 8s ym pt om /p er fo rm an ce sc or es ; 5m oo d sc ale s N SD Le ss pe rc eiv ed str es sf ol lo wi ng FM (!=0.0 1) Po sit iv er es ul tc ou ld be du e to m ul tip le te sti ng fo r sig ni fic an ce Lu nd bl ad et al. (19 99 )[ 8] RC T 3p ar all el gr ou ps 97 fe m ale sw ith ne ck an d sh ou ld er pr ob lem s FM :4 in di vi du al se ss io ns ,1 2g ro up se ss io ns of 50 m in s pw ,f or 16 we ek s, ho m ea ud io ta pe s (C 1) ph ys io th er ap y2 × 50 m in sp er we ek fo r1 6 we ek s; ho m ee xe rc ise s (C 2) no in te rv en tio n Cl in ica la ss es sm en ts (4 m ea su re s) ; ph ys io lo gi ca lt es ts (18 m ea su re s) co m pl ain ti nd ice s( 5m ea su re s) ; VA Sp ain ra tin gs (2 m ea su re s) ; di sa bi lit ya nd sic k lea ve m ea su re s( 4 m ea su re s) Pr ev ale nc eo fn ec k pa in an d di sa bi lit yd ur in gl eis ur ed ec re as ed in FM ve rs us C1 or C2 (!<0.0 5) 31 of 33 m ea su re sN SD Im po rta nt ba se lin e di ffe re nc es ,p os sib le re gr es sio n to th em ea n. H ig h dr op ou tr at ea nd pe r pr ot oc ol an aly sis .M ul tip le te sti ng fo rs ig ni fic an ce St ep he ns et al. (2 00 1) [9 ] RC T 2p ar all el gr ou ps 12 pe op le wi th M S FM :8 ×2–4h ou rs se ss io ns ov er 10 we ek s Ed uc at io na ls es sio ns ov er 10 we ek s 3c lin ica lt es ts of ba lan ce ; 3s ym pt om sc ale s Si gn ifi ca nt im pr ov em en ti n FM co m pa re d to C fo rm CT SI B an d Ba lan ce Co nfi de nc eS ca le; ot he r4 ou tc om es N SD Ve ry sm all sa m pl es ize .N o ba se lin ed at ao rs ta tis tic al an aly sis av ail ab le Sm ith et al. (2 00 1) [10 ] RC T 2p ar all el gr ou ps 26 pa tie nt sw ith ch ro ni cl ow ba ck pa in FM :o ne 30 -m in ut e se ss io n At te nt io n co nt ro l Pa in (M cG ill ); an xi et y( ST AI ) FM no tC re du ce d aff ec tiv e di m en sio n of pa in pr e- po st (!=0.0 4)Cnot FM im pr ov ed se ns or yd im en sio n of pa in pr e/ po stt es t( !=0.03 ) N SD fo re va lu at iv ed im en sio n of pa in or an xi et y O nl ya cu te eff ec ts we re m ea su re d. Ba se lin e di ffe re nc es be tw ee n FM an d C in du ra tio n of ba ck pa in m ay be im po rta nt G rü be le ta l. (2 00 3) [11 ] RC T 2p ar all el gr ou ps 66 pa tie nt sw ith ca nc er FM :5×50 m in ut es se ss io ns of fu nc tio na l in te gr at io n in ad di tio n to co nv en tio na l th er ap ies C: no ad ju nc tt he ra py Bo dy im ag eq ue sti on na ire ; Fr an kf ur te rb od yc on ce pt sc ale s; qu ali ty of lif e; se ns eo fm ov em en t; an d bo dy aw ar en es s Bo th gr ou ps im pr ov ed in all ou tc om em ea su re s N on sig ni fic an tt re nd fa vo ur ed FM Ad di tio na lR CT s Br ow n an d Ke ge rr eis (19 91 ) [12 ] RC T 2p ar all el gr ou ps 21 (12 m en an d 9 wo m en ) vo lu nt ee rs pa in -fr ee FM :4 5m in au di o ta pe “a ct iv at in gt he fle xo rs” les so n C: lis te ne d to th es am e 45 m in au di o ta pe m od ifi ed to in clu de on ly in str uc tio ns pe rta in in g to ex er cis em ov em en ts EM G ac tiv ity of fle xo rs an d ex te ns or s( U L) Pe rc ep tio n of eff or td ur in g fle xi on m ov em en t N SD Th er ew as an ov er all de cr ea se in m ea n fle xo ra ct iv ity wi th no ch an ge in m ea n ex te ns or ac tiv ity fo rb ot h gr ou ps . Ch in n et al. (19 94 )[ 13 ] RC T 2p ar all el gr ou ps 23 su bj ec ts wi th up pe rb ac k, ne ck , or sh ou ld er di sc om fo rt FM :s in gl eA TM les so n; 22 m in au di o ta pe C: sin gl es ha m tre at m en t; 30 m in s ge nt le ne ck an d sh ou ld er ex er cis es Fu nc tio na lr ea ch ta sk ; pe rc eiv ed eff or td ur in gt he ta sk N SD Re du ce d pe rc eiv ed eff or ti n FM gr ou p (!<0.0 5) Sm all sa m pl es ize 6 Evidence-Based Complementary and Alternative Medicine Ta bl e 3: Co nt in ue d. Au th or (y ea r) St ud yd es ig n Sa m pl e In te rv en tio n Co nt ro l O ut co m e Re su lts Co m m en ts La um er et al. (19 97 )[ 14 ] RC T 2p ar all el gr ou ps 30 pa tie nt sw ith ea tin gd iso rd er FM :9 -h ou rc ou rs e C: di d no tp ar tic ip at ei n FM Bo dy Ca th ex is Sc ale ; Bo dy Pa rts Sa tis fa ct io n Sc ale ; Bo dy pe rc ep tio n; em ot io n in ve nt or y; An or ex ia - N er vo sa -In ve nt or yf or Se lf- Ra tin g; ea tin gd iso rd er in ve nt or y- 2 FM pa rti cip an ts sh ow ed in cr ea sin gc on te nt m en tw ith re ga rd to pr ob lem at ic zo ne so f th eir bo dy an d th eir ow n he alt h an d ac ce pt an ce an d fa m ili ar ity wi th th eir bo dy Fu ll ar tic le in G er m an Ja m es et al. (19 98 )[ 15 ] RC T 3p ar all el gr ou ps 48 he alt hy un de rg ra du at e stu de nt s FM :4×45- m in ut e se ss io ns ov er 2w ee ks of 4 di ffe re nt AT M les so ns re co rd ed on au di oc as se tte Re lax at io n: 4×45m in se ss io ns ov er 2w ee ks lis te ne d to re lax at io n tra in in ga ud io ca ss et te C: no su pe rv ise d les so ns H am str in gl en gt h (m od ifi ed AK E te st) N SD In su ffi cie nt ex po su re ,l ow sta tis tic al po we r H op pe re ta l. (19 99 )[ 16 ] St ud y1 :R CT 2p ar all el gr ou ps St ud y2 :s ub sa m pl eo fS tu dy 1 St ud y1 :7 5 un de rg ra d ph ys io stu de nt s St ud y2 :3 9 pa rti cip an ts fro m St ud y1 St ud y1 :F M :s in gl e AT M ,4 5m in au di o ca ss et te les so n (n o pr io rF M ex pe rie nc e) St ud y2 :4 di ffe re nt AT M les so ns ov er 2 we ek s St ud y1 :C :l ist en ed to so ft no nv er ba lm us ic St ud y2 :s am eA TM les so ns ov er 4 se ss io ns in 2w ee ks wh en su bj ec ts ha d pr io rF M ex pe rie nc e M od ifi ed AK E te st (h am str in g len gt h) ; Si ta nd Re ac h te st; Bo rg ’s 6– 20 ra tin go fp er ce iv ed ex er tio n (d ur in gs it an d re ac h te st) St ud y1 :N SD St ud y2 :f or pe rc eiv ed ex er tio n sig ni fic an tm ain eff ec t !=0.00 03. N SD ot he rs In bo th stu di es th er ew as a sig ni fic an td iff er en ce in ex er tio n lev els be tw ee n m ale sa nd fe m ale sw ith m ale se xe rti ng m or e irr es pe ct iv eo fg ro up Ko lt an d M cC on vi lle (2 00 0) [17 ] RC T 2p ar all el gr ou ps 54 un de rg ra d ph ys io th er ap y stu de nt sw ith no pr io rF M ex pe rie nc e FM :4×45 m in AT M les so ns vi a au di oc as se tte ov er a 2- we ek pe rio d Re lax at io n: 4×45m in re lax at io n se ss io ns vi a au di oc as se tte ov er a 2- we ek pe rio d C: no sp ec ifi ct as ks ov er 2- we ek pe rio d Bi po lar fo rm of th ep ro fil eo f m oo d sta te s( PO M S- BI ) N SD Co m po se d- an xi ou ss co re so ft he PO M S- BI di d va ry sig ni fic an tly ov er tim e( !=0.00 1)foral l pa rti cip an ts. Fe m ale si n FM an d re lax at io n gr ou ps re po rte d sig ni fic an tly lo we ra nx iet ys co re s at co m pl et io n co m pa re d wi th co nt ro l N o di ffe re nc es be tw ee n FM an d re lax at io n gr ou ps Lö we et al. (2 00 2) [18 ] Ps eu do ra nd om ize d, co ns ec ut iv ea llo ca tio n 60 pa tie nt s tra ns fe rr ed to no rm al wa rd aft er ac ut e tre at m en tf or M I FM :2×30 m in in di vi du al se ss io ns Re lax at io n: 2×30m in in di vi du al PM R C: no bo dy -o rie nt ed in te rv en tio ns Bo dy im ag eq ue sti on na ire (F KB -2 0, G er m an ve rs io n) ; H os pi ta lA nx iet ya nd D ep re ss io n Sc ale -G er m an ve rs io n (H AD S- D ); M un ich Q ua lit yo fL ife D im en sio ns Li st (M LD L) ; G er m an ve rs io n G en er ali ze d Se lf- Effi ca cy Sc ale (G SE S) N SD O ve ra ll im pr ov em en ts we re se en in M LD L, G SE S, an d FK B- 20 St ep he ns et al. (2 00 6) [19 ] RC T 2p ar all el gr ou ps 38 gr ad ua te stu de nt s FM :5×15 m in AT M se ss io ns /w k, au di ot ap eo ve r 3- we ek pe rio d C: re gu lar da ily ac tiv iti es AK E (h am str in gm us cle len gt h) Si gn ifi ca nt in cr ea se in ha m str in g m us cle len gt h (!=0.0 05)in AT M gr ou p co m pa re d wi th co nt ro l Pa rti cip an ts va rie d gr ea tly in th ed ur at io n an d nu m be ro f ho m es es sio ns co m pl et ed Q ui nt er o et al. (2 00 9) [2 0] RC T 2g ro up (c ro ss ov er de sig n fo r co nt ro l) 3- to 6- ye ar -o ld ch ild re n wi th sle ep br ux ism FM :3 hr se ss io ns × 10 du rin g1 0- we ek pe rio d ba se d on AT M C: no de ta ils Va rio us m ea su re so fj oi nt fu nc tio n; no ct ur na lb ru xi sm St at ist ica lly sig ni fic an ti nc re as eo f CV A an gl e( !=0.0) fo rF M c.f .C . Aft er in te rv en tio n 77 % pa re nt si n FM re po rte d no no ct ur na l br ux ism c.f .1 5.3 8% fo rC At ba se lin et wo gr ou ps we re co m pa ra bl e Evidence-Based Complementary and Alternative Medicine 7 Ta bl e 3: Co nt in ue d. Au th or (y ea r) St ud yd es ig n Sa m pl e In te rv en tio n Co nt ro l O ut co m e Re su lts Co m m en ts Vr an tsi di se ta l. (2 00 9) [2 1] RC T 2g ro up s( cr os so ve rd es ig n fo r co nt ro l) 55 pa rti cip an ts ag ed ≥55year s FM :g et tin g gr ou nd ed gr ac ef ul ly pr og ra m (b as ed on AT M )2×40– 60 m in se ss io ns /w k ov er 8 we ek s C: co nt in ue wi th us ua l ac tiv ity Fr en ch ay Ac tiv ity In de x; H um an Ac tiv ity Pr ofi le; As se ss m en to fQ ua lit yo fL ife ; M od ifi ed Fa lls Effi ca cy Sc ale ; Ab br ev iat ed M en ta lT es tS co re ; fo ur -s qu ar es te p te st; tim ed up an d go te st; th eS te p Te st; Ti m ed Si t-T o- St an d Te st; Cl in ica lS tri de An aly ze r; fo rc e- pl at fo rm m ea su re so fg ait , m ob ili ty, an d fu nc tio n; sa tis fa ct io n su rv ey Si gn ifi ca nt eff ec ts fo rg ait sp ee d (!=0.0 28)and M od ifi ed Fa lls Effi ca cy Sc ale (!=0.0 03)forF M gr ou p; ne ar sig ni fic an te ffe ct fo r tim ed up an d go te st (!=0.0 56) Po sit iv ef ee db ac k fro m su rv ey N o sig ni fic an tb as eli ne di ffe re nc es be tw ee n gr ou ps . H ig h cla ss at te nd an ce U llm an n et al. (2 01 0) [2 2] RC T 2g ro up s 47 re lat iv ely he alt hy in de pe nd en tly liv in g ≥65-yea r-o ld s FM :1 ho ur AT M se ss io ns 3x /w ee k fo r 5w ee ks (p ro vi de d by in str uc to r) C: wa itl ist Fa lls Effi ca cy Sc ale ; Ac tiv iti es Sp ec ifi cB ala nc e Co nfi de nc eS ca le; tim ed up an d go an d TU G wi th ad de d co gn iti ve ta sk ;G AI TR ite W alk wa yS ys te m ; ta nd em sta nc e Ba lan ce (!=0.0 30)and m ob ili ty (!=0.0 42)incr ea se d fo rF M , wh ils tf ea ro ff all in gd ec re as ed (!=0.0 42). At ba se lin eg ro up s co m pa ra bl ee xc ep tf or hi gh er BM Ii n in te rv en tio n gr ou p H ill ier et al. (2 01 0) [2 3] Ps eu do ra nd om ize d co nt ro l tri al 2g ro up s 22 he alt hy pe op le po str et ire m en t FM :A TM cla ss , 1h r/w ee k fo r8 we ek s C: ge ne ric ba lan ce cla ss 1h r/w ee k fo r8 we ek s SF -3 6; Pa tie nt Sp ec ifi cF un ct io na lS ca le (P SF S) ;t im ed up an d go te st; fu nc tio na lr ea ch te st (F RT ); Si ng le Le gS ta nc eT im e( SL S) ; W alk on Fl oo rE ye sc lo se d (W O FE C) Si gn ifi ca nt tim ee ffe ct fo ra ll m ea su re se xc ep tf or W O FE C Si gn ifi ca nt im pr ov em en ts fo rb ot h gr ou ps fo rS F- 36 ,P SF S, an d FR T. SL Si m pr ov ed FM (!=0.0 16) Po st ho ci nd iv id ua la na lys is co m pa ris on sm ad e Bi tte re ta l. (2 01 1) [2 4] RC T 3a rm s 29 he alt hy un iv er sit y stu de nt s FM 1: AT M les so n 1×40m in , do m in an th an d; FM 2: sa m eb ut no nd om in an th an d C: re lax at io n les so n 1×40m in Pu rd ue Pe gb oa rd Te st; G rip -li ft te st; su bj ec tiv ec ha ng es FM 1s ig ni fic an tg ro up by tim e in te rv en tio n eff ec tw he n co m pa re d to co nt ro lg ro up fo r de xt er ity N am bi et al. (2 01 4) [2 5] RC T 3a rm s 60 in sti tu tio na liz ed ag ein gp eo pl e FM :A TM cla ss es 3×6we ek s PI :P ila te sc las se s3×6 we ek s C: sh am wa lk in g3×6 we ek s. Fu nc tio na lr ea ch te st; tim ed up an d go te st; D yn am ic ga it in de x; RA N D -3 6 fo rq ua lit y of lif e Bo th FM an d PI im pr ov ed all m ea su re s( !<0.00 0);C im pr ov ed TU G an d D G Io nl y RC T: ra nd om ise d co nt ro lle d tri al; FM :F eld en kr ais M et ho d; M S: m ul tip le sc ler os is; L: left ;R :r ig ht ;C :c on tro l;p w :p er we ek ;V AS :v isu al an alo gu es ca le; m CT SI B: M od ifi ed Cl in ica lT es to fS en so ry In te gr at io n an d Ba lan ce ;N SD :n o sig ni fic an td iff er en ce ;S TA I: St at e/ Tr ait An xi et yI nd ex ;E M G :e lec tro m yo gr ap hy ;U L: up pe rl im b; AT M :a wa re ne ss th ro ug h m ov em en t( les so n) ;m in :m in ut es ;A KE :a ct iv ek ne ee xt en sio n te st; M I: m yo ca rd ia li nf ar ct ;P M R: pr og re ss iv em us cle re lax at io n; c.f .:c om pa re d wi th ;S F- 36 :s ho rt fo rm 36 ;P I: Pi lat es . 8 Evidence-Based Complementary and Alternative Medicine Ra nd om se qu en ce ge ne ra tio n (s ele ct io n bi as ) Bitter et al. 2011 Brown and Kegerreis 1991 Chinn et al. 1994 Hillier et al. 2010 Hopper et al. 1999 James et al. 1998 Johnson et al. 1999 Kolt et al. 2000 Laumer et al. 1997 Lundblad et al. 1999 Nambi et al. 2014 Quintero et al. 2009 Ruth and Kegerreis 1992 Smith et al. 2001 Stephens et al. 2001 Stephens et al. 2006 Ullman et al. 2010 Vrantsidis et al. 2009 Al lo ca tio n co nc ea lm en t ( se lec tio n bi as ) Bl in di ng o f p ar tic ip an ts an d pe rs on ne l ( pe rfo rm an ce b ia s) Bl in di ng o f o ut co m e a ss es sm en t ( de te ct io n bi as ) In co m pl et e o ut co m e d at a ( at tri tio n bi as ) Se lec tiv e r ep or tin g ( re po rti ng b ia s) O th er b ia se s + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + − − − − Löwe et al. 2002 Grübel et al. 2003 Figure 3: Risk of bias summary: review authors’ judgements about each risk of bias item for each included study. therewas a clear risk of bias (given a red status) orwhether the authors had simply not stated the process in sufficient detail for a judgement to be made; hence the risk of bias indicator was left blank. 3.5. Effects of Interventions. Sufficiently homogenous data (same population, intervention, comparator, and outcome measure) were able to be extracted to performmeta-analyses in the areas of balance training in ageing populations. Four studies [21–23, 25] reported on the timed up and go assessment for balance and mobility, just failing to find in favour of Feldenkrais classes (Figure 4(a)); pooling postinter- vention measures gave a mean difference of −0.78 s (95% CI−1.69, 0.13), $ = 0.09. However, heterogeneity was high ("2 =49%). Therefore, a sensitivity analysis was performed as one study by Hillier et al. [23] compared Feldenkrais to another balance class whereas the other three studies compared the FM class to wait list control or no class. Removal of Hillier et al. [23] (Figure 4(b)) revealed a larger effect size with a mean difference of −1.13 (95% CI −1.7, −0.56), $ = 0.0001, and heterogeneity reduced to a negligible level ("2 = 5%). It was also noted that Nambi et al. [25] had narrow outcome variability which led to a heavier weighting in the meta- analysis. Two studies [21, 22] evaluated balance confidence using the Falls Efficacy Scale after FM classes (Figure 5). Pooled results trended in favour of the FM, however, failed to reach significance (MD 0.59, 95% CI −0.08, 1.26; $ = 0.08). Two studies [23, 25] evaluated balance using the func- tional reach test after FM classes (Figure 6)—pooled results found in favour of the FM classes (compared to nothing or another generic balance class) with a mean difference of 6.08 cm (95% CI 3.41,8.74), $ < 0.00001. Meta-analysis was also able to be performed using three studies measuring the influence of FM classes on hamstring length in healthy populations [15, 16, 19]. The authors all reported the measure as an active knee extension test; how- ever, on visual inspection, the results appeared heterogeneous in terms of magnitude and range; therefore, a standardized mean difference (rather than MD) was calculated. No sig- nificant effect was found after the intervention compared to control (SMD 0.15, 95% CI −0.49, 0.79; $ = 0.65) and statistical heterogeneity was unacceptably high ("2 = 73%) (Figure 7). Single randomised controlled studies reported statisti- cally significant, positive benefits compared to control inter- ventions and included the following: (i) greater neck flexion and less perceived effort after a single FM lesson for neck comfort [6]; reduced prevalence of neck pain and disability in symptomatic women after FM (individual and group sessions compared to conventional care or home exercises) [8]; reduced perceived effort in FM group for people with upper torso/limb discomfort [13]; (ii) improved balance in people with MS after eight FM sessions [9]; (iii) improved body image parameters in people with eating disorders after a nine-hour FM course [14]; (iv) reduction in nocturnal bruxism in young children after 10-week course of FM lessons [20]; (v) improved dexterity in healthy young adults after a single session of FM class [24]. Seven of the 20 studies failed to show any superior posi- tive effects of FM compared to other comparison modalities. See Table 3 for details. No studies reported adverse events. Evidence-Based Complementary and Alternative Medicine 9 Study or subgroup Total (95% CI) Mean 7.06 15 11.53 12.15 SD 1.72 1 4.06 2.9 Total 11 20 25 26 82 Mean 6.92 16.1 11.51 14.34 SD 0.88 1 4.13 4.3 Total 11 20 22 29 82 Weight 29.2% 43.1% 11.8% 15.9% 100.0% IV, random, 95% CI Feldenkrais Control Mean difference Mean difference IV, random, 95% CI 0 5 10 Favours Feldenkrais Favours control −10 −5 Heterogeneity: "2 = 0.40; #2 = 5.90, df = 3 (P = 0.12); I2 = 49% Test for overall effect: Z = 1.67 (P = 0.09) 0.14 [−1.00, 1.28] −1.10 [−1.72, −0.48] 0.02 [−2.33, 2.37] −2.19 [−4.11, −0.27] −0.78 [−1.69, 0.13] Hillier et al. 2010 Nambi et al. 2014 Ullman et al. 2010 Vrantsidis et al. 2009 (a) Study or subgroup Total (95% CI) Mean 7.06 15 11.53 12.15 SD 1.72 1 4.06 2.9 Total 11 20 25 26 71 Mean 6.92 16.1 11.51 14.34 SD 0.88 1 4.13 4.3 Total 11 20 22 29 71 Weight 81.7% 7.4% 10.9% 100.0% IV, random, 95% CI Not estimable Feldenkrais Control Mean difference Mean difference IV, random, 95% CI Favours Feldenkrais Favours control 0 5 10−10 −5 −1.10 [−1.72, −0.48] 0.02 [−2.33, 2.37] −2.19 [−4.11, −0.27] −1.14 [−1.78, −0.49] Heterogeneity: "2 = 0.03; #2 = 2.10, df = 2 (P = 0.35); I2 = 5% Test for overall effect: Z = 3.45 (P = 0.0006) Hillier et al. 2010 Nambi et al. 2014 Ullman et al. 2010 Vrantsidis et al. 2009 (b) Figure 4: (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 andmobility) withHillier 2010 removed (control group was alternate balance class). Study or subgroup Total (95% CI) Mean 9.6 8.63 SD 1.7 1.6 Total 25 26 51 Mean 9.35 7.73 SD 1.7 1.9 Total 22 29 51 Weight 47.4% 52.6% 100.0% IV, random, 95% CI Feldenkrais Control Mean difference Mean difference IV, random, 95% CI Favours control Favours Feldenkrais 0.25 [−0.72, 1.22] 0.90 [−0.03, 1.83] 0.59 [−0.08, 1.26] 0 5 10−10 −5 Heterogeneity: "2 = 0.00; #2 = 0.90, df = 1 (P = 0.34); I2 = 0% Test for overall effect: Z = 1.73 (P = 0.08) Ullman et al. 2010 Vrantsidis et al. 2009 Figure 5: Effect sizes of Feldenkrais versus control for the Falls Efficacy Scale (balance confidence). Study or subgroup Total (95% CI) Mean 31.89 36.7 SD 3.98 2.7 Total 11 20 31 Mean 27.62 29.6 SD 4.97 4.7 Total 11 20 31 Weight 36.2% 63.8% 100.0% IV, random, 95% CI 4.27 [0.51, 8.03] 7.10 [4.72, 9.48] 6.08 [3.41, 8.74] Feldenkrais Control Mean difference Mean difference IV, random, 95% CI Favours control Favours Feldenkrais 0 5 10−10 −5 Heterogeneity: "2 = 1.43; #2 = 1.55, df = 1 (P = 0.21); I2 = 36% Test for overall effect: Z = 4.47 (P < 0.00001) Hillier et al. 2010 Nambi et al. 2014 Figure 6: Effect sizes of Feldenkrais versus control for the functional reach test (measured in cm; balance). 10 Evidence-Based Complementary and Alternative Medicine Study or subgroup Total (95% CI) Mean 20.9 33.5 149 SD 11.1 2.41 7.4 Total 75 14 18 107 Mean 21.5 34.4 141.8 SD 13.7 2.56 7.6 Total 75 17 15 107 Weight 41.6% 29.4% 29.0% 100.0% IV, random, 95% CI Feldenkrais Control Std. mean difference Std. mean difference IV, random, 95% CI 0 1 2 Favours control Favours Feldenkrais −0.05 [−0.37, 0.27] −0.35 [−1.07, 0.36] 0.94 [0.21, 1.66] 0.15 [−0.49, 0.79] −2 −1 Heterogeneity: "2 = 0.23; #2 = 7.31, df = 2 (P = 0.03); I2 = 73% Test for overall effect: Z = 0.46 (P = 0.65) James et al. 1998 Stephens et al. 2006 Hopper et al. 1999 Figure 7: Effect sizes of the Feldenkrais Method on the active knee extension test. 4. Discussion 4.1. Summary of Main Results. 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 interpreta- tion 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. Neverthelessmeta-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 themechanism 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 andmore 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 [4]. We were also able to locate studies prior to 2005 that were not found by the original SR authors, presumably due to improved database access. As the previous authors reported, the studies are still highly varied and of often questionable quality. There is an ongoing issue of poor reporting, resulting in risks being judged “unclear”; it is unknown whether this hides undeclared risk or is simply an omission of reporting. 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 (organi- zational 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 ismore robust with the removal ofHillier et al. [23] (Figure 4(b)) because the comparator group differs from the other studies (alternate balance class versus no intervention) and secondly this studywas pseudorandomized (allocation based on enrolment day).The question of inactive controls is vexed and permissible when proof of concept or pilot/phase 1 trials are being conducted. We encourage readers to take the stage of research and the design into account in their interpretation. 4.2. Implications for Practice. 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. 4.3. Implications for Research. Further high quality research is required comparing FM to other modalities. Investigations should focus on the impact on self-efficacy, functional inde- pendence, 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. 5. Conclusions 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. Evidence-Based Complementary and Alternative Medicine 11 Disclosure Funding was from professional bodies involved in promoting FM but the bodies were not involved in the conduct of the review other than to identify experts within their member- ship to identify any missed/unpublished trials. Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper. Authors’ Contribution Anthea Worley conducted the search and preliminary inclu- sions. 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. Acknowledgments 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. References [1] M. 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