O R I G I N A L A R T I C L E

Focus on Alternative andComplementary Therapies

Volume 18(3) September 2013 126–132© 2013 Royal Pharmaceutical Society

DOI 10.1111/fct.12050ISSN 1465-3753

Preliminary evidence on the Feldenkrais Method asan alternative therapy for patients with chronic obstructivepulmonary disease

Ayiesah Ramli, Joseph H Leonard, Roslan Harun

AbstractBackground The Feldenkrais Method (FM) is an alternative therapy used by patients with chronic obstructive pulmonarydisease (COPD). However, evidence of the effectiveness of the FM among persons with COPD is lacking.Objective To investigate the impact of the FM in patients with COPD.Methods An observational pilot study was conducted in 11 COPD patients attending a university teaching hospital. TheFM was administered for a period of 8 weeks. The 6-min walking test (6MWT) was used to measure functional capacity;forced expiratory volume in 1-s, predicted percent (FEV1 pred %) was used to evaluate lung function, and the Health-RelatedQuality of Life questionnaire was used to measure QoL before and after the intervention.Results Paired t-tests showed significant improvements in 6MWT from baseline to 8 weeks post-FM [P=0.01, t=-4.869,difference (Df)=10, 95% confidence interval (CI): -113.9, 42.4] with a large effect size (d=0.72). Similarly, there was asignificant improvement in the FEV1 pred % (P=0.01, t=6.278, Df=10, 95% CI: 17.9, -37.6) with a large effect size (d=-2.0).Conclusion The FM improve functional capacity and lung function among patients with COPD.

KeywordsComplementary therapy • Feldenkrais Method • mind–body therapy • respiratory disease

Introduction

Chronic obstructive pulmonary disease (COPD) is aleading cause of morbidity and mortality, and report-edly kills nearly three million people annually.1,2

Adding to this, the COPD mortality rate is expectedto rise by 50% over the next 15 years.2 The conditionof COPD also adversely affects QoL,1,2 with thedisease burden substantially adding to healthcareresource utilisation and spending.1

Chronic obstructive pulmonary disease is a chroniccondition of which physical function, social functionand general health are severely affected.3 Evidencefrom earlier studies suggests that anxiety and depres-sion are also present among patients with COPD.4

Since COPD is an incurable condition, treatment ismainly aimed at effective disease management, theprevention of disease progression and the improve-ment of symptoms and exercise tolerance. In light ofthis, alternative modalities should be considered ifthey generate comparable improvements in exercisecapacity and health-related QoL in patients withCOPD.

The use of CAM among patients is steadily growing.5

Since CAM is reported to be effective for the treatmentof a number of chronic conditions, such as coronaryartery disease, headaches, incontinence, cancer andprolonged low back pain,6 patients who initially tryallopathic medicine may develop a positive awarenessof alternative medicine and start to seek out CAM.5

bs_bs_banner

126

While the efficacy of pulmonary rehabilitation inCOPD is well established,7 the role and efficacy ofcomplementary and alternative exercise practice inCOPD is under-explored. In this study, the efficacy ofthe Feldenkrais Method (FM), a complementary exer-cise therapy, was investigated in patients with COPD.

The FM is rapidly gaining popularity among manyhealth professionals, including physiotherapists. TheFM is a movement education technique principledbehind mind–body interaction, which emphasisesmovement teaching based on sensory motor aware-ness and cognitive perception of the movement.8 Theprinciple behind the FM is to perform movementwith minimal effort and maximum efficiency.8 Theaim of the technique is to provide an individualisedfeeling and an experience of evaluating one’s move-ment patterns.9 The experiences learned by patientshelp them to break down harder movementsinto simpler lighter movements with little energyconsumption.

The movement awareness and mind–body–behaviour interaction that occurs during the move-ment therapy may help to regulate the emotional,mental, social and behavioural factors that affecthealth.9 As such, the practice of the FM is believed tohave relaxation effects, as well as improving copingskills and cognitive behaviours among COPDpatients.10 It is therefore justifiable that the FM beintegrated into pulmonary rehabilitation sessions asit may assist elderly COPD patients to move better,and thus improve their ability to carry out activitiesof daily living. The main aim of this pilot study wasto observe the therapeutic impact of the FM amongpatients with COPD. The main hypothesis of thestudy was that patients undergoing the FM will dem-onstrate improvement in lung function, exercise tol-erance and QoL.

Methodology

Study designThis observational pilot study was conducted atthe outpatient physiotherapy department, UniversitiKebangsaan Malaysia Medical Centre, Kuala Lumpur,Malaysia. A total of 11 participants (three women andeight men), aged between 53 and 73 years, partici-pated in the study. The mean [M � standard devia-tion (SD)] age, weight and height of participantswere 63 � 8 years, 61.9 � 12.9kg and 156.2 � 9.1cm,respectively. All participants were recruited by con-venience sampling from a database of patients withCOPD that were scheduled to receive pulmonaryrehabilitation. All participants met the inclusioncriteria; that is, were diagnosed with severe COPD(stages III and IV) by a respiratory physician, dis-played no signs of exacerbation over the past 2months, and received any one bronchodilator medi-cation.11 Participants who received more than one

medication (e.g. steroids and antibiotics), reportedrepeated exacerbations, had extreme cognitiveimpairment (i.e. Mini Mental Examination score ofless than 24), were unable to understand both Malayand English and had prior pulmonary rehabilitationwere considered unsuitable to participate in thisstudy. Ethics approval was obtained from the medicalresearch secretariat and ethics committee of theUniversiti Kebangsaan Malaysia Medical Centre.Informed, written consent was provided by all par-ticipants prior to their participation in the study.

OutcomesOutcomes were assessed at the beginning of the studyand after the 8-week FM exercise programme byqualified physiotherapists with more than 3 years’experience in the area of cardio-respiratory physi-otherapy. Demographic information, such as age,sex, marital status, residence and drug history, werecollected from participants. The 6-min walking test(6MWT) was administered to determine the func-tional capacity of the patients, to monitor diseaseprogress and to evaluate disease prognosis amongCOPD patients.12,13 Lung function was measured byspirometry, and the severity of the spirometry valuewas evaluated by forced expiratory volume in 1-s,predicted percent (FEV1 pred %).14 The SF36 was usedto measure the health-related quality of life (HRQoL)of participants.15

Feldenkrais Method interventionThe FM prescribed for participants was based on thework of Moshe Feldenkrais.16 The FM exercises weretaught to participants in groups through ‘awarenessthrough movement’ (ATM) classes. Table 1 shows theFeldenkrais movements practised by the participantsof this study. Activities included relaxation exercises,breathing exercises, floor exercises for trunk andpelvic movements (rolling on the floor from side toside, trunk twisting and pelvis rolling forward andbackward) and upper limb movements. All exerciseswere commenced in the supine position to maximiseproprioceptive movement feedback and to minimiseenergy requirements during tasks.

During ATM classes, the therapist guided a desiredmovement through a sequence of gentle non-strenuous movements. Participants were prompted todiscover how their body moves more comfortablyand efficiently. Attentive repetition was encouragedto prompt the mind component of the participantduring the intervention by asking them to carefullyperceive different movement segments and self-evaluate the ease and difficulties of performing themovements. Initially, the participants were madeto perceive and understand heavier movements;later, participants were prompted to feel lightermovements by disassociating movements throughdifferent segments. Thus, the mind component of

Original Article 127

participants was cued to master the feeling of move-ment ease and freedom from chronic discomfort. Themovements were taught in a series of lessons over aperiod of 8 weeks with gradual progression of selectedmovements based on participant comfort. A qualifiedphysiotherapist trained in the FM administered theintervention. No complications or adverse effectswere reported during the intervention.

Statistical analysisAll data were analysed using the Statistical Packagefor Social Sciences [SPSS; (version 19.0)] software. Itwas impossible to calculate the sample size for thisstudy as no previous clinical data of the FM for COPDwere available. This prevented prediction of a powercalculation and, as such, this study was considered apilot study. All data were examined for normalitybefore analysis. Descriptive analysis was performed toevaluate the characteristics of the participants. Differ-ences in outcome measures from baseline to 8 weekspost-intervention were analysed by paired t-tests. Thelevel of significance was set at P<0.05 (5%) for allmeasures. Cohen’s d was calculated to estimate the

effect size of the intervention, with values of 0.2,0.5 and 0.8 considered small, medium or large,respectively.17

Result

A total of 17 participants were assessed for eligibility;13 participants met the inclusion criteria and partici-pated in the study. However, only 11 participantscompleted the full 8-week study period. The flow ofstudy participants throughout the trial is illustratedin Figure 1. Table 2 shows the demographic and clini-cal characteristics of the subjects. All 11 subjects whoparticipated in the study were diagnosed with stageIII COPD.

Table 3 shows the baseline values and changes afterthe 8-week FM intervention for the 6MWT, FEV1 pred% and HRQoL. The paired t-test showed significantimprovements in the 6MWT from baseline to 8 weeks[P=0.01, t=-4.869, difference (Df)=10, 95% confi-dence interval (CI): -113.9, 42.4]. Similarly, after 8weeks of the FM, there was a significant improve-ment in the FEV1 pred % (P=0.01, t=6.278, Df=0, 95%CI: 17.9, -37.6). The effect sizes (Cohen’s d) of FM for

Table 1 Feldenkrais intervention for the patients with chronic obstructive pulmonary disease

No. Feldenkrais exercises Weeks Duration

1. Introductory session to Feldenkrais exercises• Sharing the principles of the Feldenkrais Method• Orientation of the body in floor• Cognitive awareness of the body and environmental contact

Weeks 1 and 2 30 min

2. Warm-up exercises• Movement awareness and orientation of upper limb• Movement awareness and orientation of lower limb• Orientation of the body in floor• Cognitive awareness of movements and the environmental contact

Weeks 2–8 20 min at secondweek, 5 min(other weeks)

3. Feldenkrais breathing exercises• Movement awareness of inspiration• Movement awareness of expiration• Cognitive awareness of breath in and breath out and associated movements• Perceiving the easiness in the breath

Weeks 3–8 15 min

4. Feldenkrais exercises to pelvis• Rolling clockwise• Rolling pelvis anticlockwise• Pelvic side tilting• Cognitive awareness and cueing for proprioception during the movements• Structural and regional differentiation of movements together with breathing

awareness

Weeks 4–8 15 min

5. Feldenkrais exercises for trunk• Rolling to one side• Rolling to another side• Structural and regional differentiation of movements during side movement

with breathing awareness• Side to side movement with cognitive awareness and synchronized breathing

Weeks 5–8 15 min

6. Cool down movements• Breathing exercises• Orientation of the body in floor• Cognitive awareness of the body contact with the environment/floor

Weeks 3–8 5 min

Focus on Alternative and Complementary Therapies September 2013 18(3)128

both the 6MWT and FEV1 pred % were d=0.72 andd=-2.0, respectively, which are large. The HRQoL, onthe other hand, did not change significantly betweenthe baseline and post-intervention period (P>0.05).

Discussion

To the best of our knowledge, this is the first reportedstudy to examine the effectiveness of the FM forCOPD. Significant improvements in 6MWT and FEV1pred % were found after 8 weeks of the therapy. Thecurrent study therefore provides basic evidence tosupport the practice of the FM as a complementarytreatment for COPD. With no adverse effects reportedthroughout the entire intervention period, the FMmight be a safe alternative practice for COPD patientswho have reduced functional capacity and exercisetolerance.

The popularity of CAM is steadily increasing,with the use of CAM among persons with COPD

being widely reported.18 A number of studies haveexamined the use of CAM practices, such aswarm-needling therapy,19 Chinese herbal medicine,20

nutritional supplementation21 and transcutaneousnerve stimulation,22 for patients with COPD. As wellas routine pulmonary rehabilitation based exerciseprogrammes, alternative therapies that involve somesort of movement regime also yield reasonable out-comes among patients with COPD, including taichi,23 whole-body vibration24 and qigong.25 Like thesetherapies, the FM also involves movements per-formed with cognitive awareness. Hence, the princi-ples behind the therapeutic effects obtained using theFM in the current study are in accordance with thefindings of previous studies that involve other formsof alternative movement therapy.

The significant improvements in 6MWT and FEV1pred % obtained after the FM can be explained byunderstanding the disease process of COPD and themechanism of the FM. In COPD, reduced respiratory

Feldenkrais exercise intervention

Allocation

Assessed for eligibility (n=17)

Excluded (n=4) Not meeting inclusion criteria (n=2)

Allocated to conventional intervention (n=13) Received allocated intervention (n=13)

Analysed (n=11) Excluded from final analysis (n=1)

Reasons:

Did not include in analysis as patient did notcome back for post interventional datacollection (n=1)

Reason:Discontinued intervention in the middledue to transport difficulty (n=1)

Declined to participate (n=1) Other reasons (n=1)

Final analysis

Drop outs

Figure 1 Study flow chart.

Original Article 129

capacity and reduced muscle strength are associatedwith decreased exercise and functional capacity.26 Insevere cases of COPD, the respiratory muscles areexposed to increased breathing work, which resultsin extreme breathlessness and peripheral musclefatigue.27,28 As a consequence, patients are not able toperform high-intensity exercises and might reportfatigue during such exercises.28 On many occasions,the COPD patient becomes breathless on minimalexertion, which causes a decline in physical activity.29

Such a deterioration in health during routine livingactivities is usually accompanied by significantlimitations of function, and increased anxiety anddepression.29 Therefore, we opine that performinghigh-intensity and strenuous exercises might bestressful for patients with COPD.

In contrast, subjects involved in the FM wereskilled at generating an efficient movement by

learning to move the body with minimal resist-ance.30,31 Hence, the body needed to work lessmetabolically to produce the desired functionalmovements.32 The subjects learnt to be more awareof themselves and their bodies to work better withthe reduced stress level. Thus, the energy was pre-served and resulted in efficient movement pat-terns.33 In the FM group, the participants wouldfocus their mind and body on movement perform-ance, but not view mind and body separately.9 Thisapproach of single body–mind–soul unity duringmovement patterns helps to identify inefficientmovement patterns from their everyday activitiesand enables them to be converted into effectivefunctional patterns.8 Therefore, the therapeutic ben-efits obtained in the current study might be due tocognitive awareness of skilful movement patternsperformed by the participants.

Several limitations of the study need to beaddressed. The small sample size is one of the mainlimitations. As previous published data on the FM forCOPD were not available, it was impossible to calcu-late the sample size and power for this study. Thus,the results of this pilot study need to be interpretedwith caution. Nevertheless, the preliminary thera-peutic evidence generated by the current pilot studymight be still of clinical importance for alternativetherapists who practice the FM for COPD patients.Absence of a control or placebo group is anotherlimitation. Since this is a pilot study, and the purposewas to document the benefits of the FM, futurestudies should be carried out using a suitable controlgroup and random selection of a larger sample ofCOPD patients.

Conclusion

This pilot study found completion of an 8-week FMprogramme led to significant improvements in the6MWT and FEV1 pred % among participants with

Table 2 Demographic and clinical characteristics of the participants

Characteristic Value

Gender, n (%)Men 3 (41.2)Women 8 (58.8)

Age (years), mean � SD 63.53 � 9.87Smoking historySmokers, n (%) 2 (52.9)Classification of disease severity in COPD

(FEV1 pred %)<30% ( severe airflow) 031–50 (moderate airflow) 1151–80 (mild airflow) 0

FEV1 % predicted, mean � SD 40.50 � 9.72Presence of comorbidities

No additional disease 6One to two additional diseases 2More than two additional diseases 3

COPD, chronic obstructive pulmonary disease; FEV1 pred %,forced expiratory volume in 1s, predicted percent; SD, standarddeviation.

Table 3 Differences between scores at baseline and 8 weeks after Feldenkrais exercises

Outcome measure BaselineM � SD

8 weeks of FEM � SD

P-value

Six-min walk test (m) 272.72 (� 92.63) 350.90 (� 122.10) 0.01FEV1 pred % 42.18 (� 12.8) 69.97 (� 14.8) 0.01Health-related QoL

Physical function 64.0 (� 22.34) 54.0 (� 19.5) 0.107Role physical 45.0 (� 28.6) 47.7 (� 25.1) 0.617Bodily pain 58.9 (� 21.9) 65.3 (� 28.8) 0.360General health 52.2 (� 15.7) 46.1 (� 17.7) 0.185Vitality 58.1 (� 16.3) 58.6 (� 14.5) 0.896Social function 61.5 (� 24.5) 66.0 (� 26.2) 0.515Role emotional 55.4 (� 26.8) 60.4 (� 21.4) 0.483Mental health 64.3 (� 13.6) 64.0 (� 20.1) 0.586

FE, Feldenkrais exercises; FEV1 pred %, forced expiratory volume in 1s, predicted percent; M, mean; SD, standard deviation.

Focus on Alternative and Complementary Therapies September 2013 18(3)130

COPD. However, these results cannot be generalisedwithout further investigation in larger populations ofpatients with COPD. Nevertheless, this study did gen-erate some preliminary evidence to support the use ofthe FM as a complementary therapy for patients withCOPD.

Conflict of interest None declared.

References1 Simoni-Wastila L, Blanchette CM, Qian J et al. Burden

of chronic obstructive pulmonary disease in Medicarebeneficiaries residing in long-term care facilities. Am JGeriatr Pharmacother 2009; 7: 262–70.

2 Gürgün A, Gürgün C. Chronic obstructive pulmonarydisease and cardiovascular system. Tuberk Toraks 2008;56: 464–71.

3 Stavem K, Lossius MI, Kvien TK, Guldvog B. Thehealth-related quality of life of patients with epilepsycompared with angina pectoris, rheumatoid arthritis,asthma and chronic obstructive pulmonary disease.Qual Life Res 2000; 9: 865–71.

4 Janssen DJ, Spruit MA, Leue C et al. Symptoms ofanxiety and depression in COPD patients enteringpulmonary rehabilitation. Chron Respir Dis 2010; 7:147–57.

5 Giordano J, Boatwright D, Stapleton S, Huff L. Blend-ing the boundaries: steps toward an integration ofcomplementary and alternative medicine into main-stream practice. J Altern Complement Med 2002; 8:897–906.

6 Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications forpractice. J Am Board Fam Pract 2003; 16: 131–47.

7 Langer D, Hendriks E, Burtin C et al. A clinical practiceguideline for physiotherapists treating patients withchronic obstructive pulmonary disease based on a sys-tematic review of available evidence. Clin Rehabil 2009;23: 445–62.

8 Jain S, Janssen K, DeCelle S. Alexander technique andFeldenkrais method: a critical overview. Phys MedRehabil Clin N Am 2004; 15: 811–25.

9 Hillier S, Porter L, Jackson K, Petkov J. The effects ofFeldenkrais Classes on the health and function of anageing Australian sample: a pilot study. Open Rehabil J2010; 3: 62–6.

10 Maizes V, Rakel D, Niemiec C. Integrative medicineand patient-centered care. Explore (NY) 2009; 5: 277–89.

11 Rabe KF, Hurd S, Anzueto A et al. Global strategy forthe diagnosis, management, and prevention of chronicobstructive pulmonary disease: GOLD executivesummary. Am J Respir Crit Care Med 2007; 176: 532–55.

12 Rasekaba T, Lee AL, Naughton MT et al. The six-minutewalk test: a useful metric for the cardiopulmonarypatient. Intern Med J 2009; 39: 495–501.

13 Morales-Blanhir JE, Palafox Vidal CD, Rosas Romero MJet al. Six-minute walk test: a valuable tool for assessingpulmonary impairment. J Bras Pneumol 2011; 37:110–7.

14 Pellegrino R, Viegi G, Brusasco V et al. Interpretativestrategies for lung function tests. Eur Respir J 2005; 26:948–68.

15 Obidoa CA, Reisine SL, Cherniack M. How does theSF-36 perform in healthy populations? A structuredreview of longitudinal studies. J Soc Behav Health Sci2010; 4: 30–48.

16 Bearman D, Shafarman S. The Feldenkrais Method inthe treatment of chronic pain: a study of efficacy andcost effectiveness. Am J Pain Manag 1999; 9: 22–7.

17 Kraemer HC, Kupfer DJ. Size of treatment effects andtheir importance to clinical research and practice. BiolPsychiatry 2006; 59: 990–6.

18 Abadoglu O, Cakmak E, Kuzucu Demir S. The view ofpatients with asthma or chronic obstructive pulmo-nary disease (COPD) on complementary and alterna-tive medicine. Allergol Immunopathol (Madr) 2008; 36:21–5.

19 Gao J, Ouyang BS, Sun G et al. Comparative researchon effect of warm needling therapy on pulmonaryfunction and life quality of patients with COPD in thestable phase. [In Chinese] Zhongguo Zhen Jiu 2011; 31:893–7.

20 Li W, Mao B, Wang G et al. A study of the mechanismof qingre huatan therapy in treatment of acute exacer-bation of chronic obstructive pulmonary disease byimproving airway inflammation and mucus hyperse-cretion. [In Chinese] Zhong Xi Yi Jie He Xue Bao 2008; 6:799–805.

21 Fuld JP, Kilduff LP, Neder JA et al. Creatine supplemen-tation during pulmonary rehabilitation in chronicobstructive pulmonary disease. Thorax 2005; 60: 531–7.

22 Bourjeily-Habr G, Rochester CL, Palermo F et al. Ran-domised controlled trial of transcutaneous electricalmuscle stimulation of the lower extremities in patientswith chronic obstructive pulmonary disease. Thorax2002; 57: 1045–9.

23 Yeh GY, Roberts DH, Wayne PM et al. Tai chi exercisefor patients with chronic obstructive pulmonarydisease: a pilot study. Respir Care 2010; 55: 1475–82.

24 Gloeckl R, Heinzelmann I, Baeuerle S et al. Effects ofwhole body vibration in patients with chronic obstruc-tive pulmonary disease – a randomized controlled trial.Respir Med 2012; 106: 75–83.

25 Chan AW, Lee A, Suen LK, Tam WW. Tai chi qigongimproves lung functions and activity tolerance inCOPD clients: a single blind, randomized controlledtrial. Complement Ther Med 2011; 19: 3–11.

Original Article 131

26 Singer J, Yelin EH, Katz PP et al. Respiratory and skeletalmuscle strength in chronic obstructive pulmonarydisease: impact on exercise capacity and lower extrem-ity function. J Cardiopulm Rehabil Prev 2011; 31:111–19.

27 Ambrosino N, Strambi S. New strategies to improveexercise tolerance in chronic obstructive pulmonarydisease. Eur Respir J 2004; 24: 313–22.

28 Weg JG. Therapeutic exercise in patients with chronicobstructive pulmonary disease. Cardiovasc Clin 1985;15: 261–75.

29 ZuWallack R. How are you doing? What are you doing?Differing perspectives in the assessment of individualswith COPD. COPD 2007; 4: 293–7.

30 Hopper C, Kolt GS, McConville JC. The effects ofFeldenkrais Awareness Through Movement on ham-string length, flexibility, and perceived exertion. JBodyw Mov Ther 2000; 4: 216–20.

31 Kolt GS, McConville JC. The effects of FeldenkraisAwareness Through Movement program on stateanxiety. J Bodyw Mov Ther 2000; 4: 216–20.

32 Hannon JC. The physics of Feldenkrais. part 3: stabil-ity. J Bodyw Mov Ther 2000; 4: 261–72.

33 Hannon JC. The physics of Feldenkrais. J Bodyw MovTher 2000; 4: 27–30.

Ayiesah Ramli, PhD, Associate Professor in Physi-otherapy, Physiotherapy Program, School of RehabilitationSciences, Faculty of Health Sciences, Universiti KebangsaanMalaysia, Kuala Lumpur, 50300, Malaysia.E-mail: kamalia086@gmail.comJoseph H Leonard, MS.PT, Senior Lecturer in Physi-otherapy, Physiotherapy Program, School of RehabilitationSciences, Faculty of Health Sciences, Universiti KebangsaanMalaysia, Kuala Lumpur, 50300, Malaysia.E-mail: leonardjoseph85@gmail.comRoslan Harun, MD, Professor in Respiratory Medicine,Department of Medicine, Faculty of Medicine, UniversitiKebangsaan Malaysia Medical Centre, Cheras, KualaLumpur, Malaysia.E-mail: leo_eshly@yahoo.com

Focus on Alternative and Complementary Therapies September 2013 18(3)132