Pugh, Judith Dianne PhD, MEd; Williams, Anne M. PhD, MSc
In the general population, the 1-year incidence of individuals experiencing an initial episode of low back pain ranges between 6.3% and 15.4% and that of any low back pain episode ranges between 1.5% and 36%, with a 38.1% average 1-year prevalence.1 Back pain is often a recurrent, chronic-episodic condition.1 Its impacts can be substantial including pain; disability; activity limitation; participation restriction such as problems caring for dependents and limits to interpersonal interaction, employment and social activities; and health care costs and personal financial burden.1,2 Chronic back pain is a common cause for patient visits to general practitioners and physiotherapists and use of prescribed analgesics.3 Conventional treatments and therapies, such as nonsteroidal anti-inflammatory drugs and opioid analgesics, physical medicine/rehabilitation, and physiotherapy, however, provide limited benefit.2–5 Benefits from commonly used complementary and alternative medicine (CAM) therapies, such as acupuncture, spinal manipulation, and massage, are also inconclusive.2,4 The Feldenkrais Method, however, shows potential for musculoskeletal complaints such as neck-shoulder pain,6 back pain,7 gait,8,9 mobility,9,10 and balance.10 The Feldenkrais Method is widely known in Germany and the United States, particularly among physical therapists. The International Feldenkrais Federation has member organizations in 17 countries and Training Accreditation Boards in Australia, Germany, and the United States.11
THE FELDENKRAIS METHOD
The Feldenkrais Method, developed by Dr Moshe Feldenkrais in the 1940s, is a form of somatic education for exploring how we sense and how we move to develop new ways of moving more efficiently, with ease and without pain.12–14 In one mode of instruction, Awareness Through Movement (ATM), the Feldenkrais practitioner verbally guides individuals or groups of people through structured explorations of movement13 in which “learning comes by the experience of the manipulation” and reveals alternatives to act or move in the environment.15(pp117–118) In the other mode of instruction, Functional Integration (FI) sessions, the Feldenkrais practitioner imparts information to an individual through manipulation and passive movements rather than verbally,16 that is, facilitated movement.15
Research relative to the effectiveness of ATMs as a physical treatment for chronic back pain is limited. Stephens17 found that orthopedic patients with low back pain using ATMs and FI had improved control of movement, balance, and trunk flexion; diminished back pain; and increased capacity for physical activity and exercise. A pilot study showed that a single 30-minute audiotaped ATM lesson focused on the awareness of breathing gave people with chronic low back pain a sense of control over their bodies, helping to reduce their emotional response to pain, although not their perception of the sensory and evaluative dimensions of pain.7
Bearman and Shafarman18 studied the 1-year efficacy and cost-effectiveness of ATM lessons to treat 7 patients with chronic musculoskeletal neck, shoulder and/or back pain, headache, or postinjury pain. These patients experienced limited response to conventional treatments; relied on analgesics or self-medicated with alcohol or illicit drugs; and experienced depression, broken relationships, and social isolation. All patients had less pain and improved functional status and quality of life after treatment. Although these benefits diminished within a year for reasons not elaborated, they were judged healthier than at the outset. Compared to the year prior to the ATM intervention, this group had fewer health care visits and consumed less medication thereby reducing their health care costs by 40% in the year following the intervention.
As coauthor of this article, I (J.P.) personally experienced ATM lessons in 2008 in an attempt to reduce my pain and disability from a back injury that occurred 2 decades ago, having received little relief from conventional and CAM therapies. As registered nurses, my colleague (coauthor A.W.) and I were interested in my personal experience of markedly reduced back pain and calf claudication and improved functional ability within a year of attending weekly ATMs. I continue weekly ATMs and practice regularly; work and exercise unimpeded by back pain; do not take medications; and have not required surgery. My experiences suggested that the Feldenkrais Method might, therefore, have positive impacts on the lives of others using it for their chronic back pain. Our aim in this qualitative study was to explore the experiences of adults who regularly attend ATMs to help manage their chronic back pain.
We took a phenomenological approach19 to capture the essentiality of participants' experiences of using the Feldenkrais Method to help them recover form and function diminished by chronic back pain. The focus of phenomenological inquiry is the structure and essence or core meanings of the phenomenon experienced, which assumes a commonality of experience including the interpretation of that experience.20 This has been described as deriving an objective essence by “aggregating subjective experiences of a number of individuals.”21(p32) To do so without being unduly influenced by preconceptions from our knowledge or experience of the Feldenkrais Method, we utilized Moustakas'19 methodology of transcendental phenomenology, which specifically requires setting aside or going beyond biases and prejudgments (the Epoche process) to see phenomena as if for the first time. A phenomenological approach has the additional benefit of providing a vicarious experience that health care providers unfamiliar with the Feldenkrais Method may find useful when deciding upon a treatment modality for clients with chronic back pain.
We recruited a convenience sample of English-speaking adults (18 years or older) in metropolitan Perth, Western Australia, with a history of chronic back pain (lasting 6 months or longer) who had completed at least 1 series of ATM lessons conducted by an Australian Feldenkrais Guild–accredited Feldenkrais practitioner. Our key industry advisor informed Feldenkrais practitioners of impending contact, encouraging them to assist recruitment. An approach letter was sent to Feldenkrais practitioners asking them to distribute information flyers inviting clients meeting the study criteria to participate. Two men and 10 women were recruited; each gave their written informed consent. The university's Human Research Ethics Committee approved the study. We omitted one woman's interview from the analysis as she had not attended ATM lessons for more than 12 months and was not an information-rich case.20
The 11 participants ranged in age from 37 to 76 years (M = 58.3, SD = 12.1) and their average age at first episode of back pain was 31 years (SD = 16.2). Most were educated to Advanced Diploma/Diploma level (n = 7), others to certificate level (n = 2) or year 12 or equivalent (n = 2). Five participants were retired, 3 were employed, 2 were unemployed, and 1 was a carer and student. Two had never married; the others were married (n = 6), widowed (n = 2), or divorced (n = 1).
Average duration of back pain was 27 years (SD = 15.6); 6 participants had had back pain for more than 50% of their lives and 3 for 40% to 50% of their lives. Most had specific back pain for which they had a medical diagnosis: lumbar and/or sacral disc problems (n = 4), fractured vertebrae (n = 2), fibromyalgia (n = 2), or ankylosing spondylitis (n = 1). Three had nonspecific back pain without a medical diagnosis. Participants had practiced the Feldenkrais Method for their back pain between 1.5 and 35 years (M = 14, SD = 9.2).
I conducted semistructured interviews lasting approximately 60 minutes between February and May 2011, mainly in participants' homes except for 3 conducted by telephone for their convenience. Part 1 of the interview comprised demographic and health status questions including educational attainment, long-term conditions restricting everyday activities, and medication use. Part 2 comprised open-ended questions about participants' experiences of back pain before and since practicing the Feldenkrais Method; changes they associated with back pain; how they felt during ATMs; and what the Feldenkrais Method meant to them.
I set aside my presuppositions about the effectiveness of the Feldenkrais Method for chronic back pain (bracketing) and attended to participants' accounts with curiosity and openness.19,22,23 Although I tried not to compare participants' stories to my own, some of their thoughts and feelings were immediately familiar whereas others shed new light on my own experiences. Thus the research process had heuristic qualities; as I learnt more about practicing the Feldenkrais Method for chronic back pain my self-awareness and self-knowledge grew.19 We both considered this aspect of the research process with the same detached interest or curiosity that we did the participants' experiences.23
A research assistant transcribed the digitally recorded interviews and transcripts were checked for accuracy. Data were analyzed to identify salient features24 of participants' experiences of ATMs to manage their chronic back pain. Statements were initially listed without attributing more significance to one or another (horizontalization).19 Reduction and elimination followed to derive meanings or “horizons that [stood] out as invariant qualities of the experience”19(p180) or its essence, which could be understood, abstracted, and labeled.19 Eleven participant interviews were sufficient to reach theoretical saturation; the horizons of experience were grouped into core themes. Then coauthor (A.W.) read coded transcripts and confirmed the consistency and credibility of data reduction and emergent themes.24 This triangulation helped us guard against presuppositions arising from previous readings, my experiences of back pain and the Feldenkrais Method, and participants' claims.22
Individual textural descriptions were written of the “what” of participants' experiences of back pain before practicing the Feldenkrais Method; then structural descriptions of how ATMs helped each of them manage their back pain.24 Considering the universal structures of time, space, bodily concerns, and relation to self and to others shifted the analysis from a textural to a structural description.19 Nine participants checked their textual and structural descriptions. Apart from a few minor changes regarding chronology, they reported that their experiences were accurately recorded and rendered (a fair account) and that our interpretation captured the essential aspects (interpretive validity) of their experience.
Composite textural and structural descriptions of the regularities were derived from the individual textural and structural descriptions to depict what was common to this group of adults with chronic back pain who attended ATMs without sacrificing unique or contrasting experiences.25 In the final reduction, these were integrated into a synthesis of the meanings and essences19 of the management of chronic back pain by Awareness Through Movement in the Feldenkrais Method. To protect participant identity and confidentiality, identifiers are not included.
Two main themes emerged from this study: (a) chronic back pain and the route to the Feldenkrais Method and (b) feeling empowered by the Feldenkrais Method. As shown in the Figure, before practicing the Feldenkrais Method, participants' back pain was an overwhelming, limiting, and uncontrollable phenomenon. On commencing ATM lessons, their back pain diminished rapidly; progressively their self-awareness, comfort, movement repertoire, confidence, functioning, and participation increased so that they felt in control of the pain and their lives.
FIGURE. Impact of Aw...Image Tools
Chronic back pain and the route to the Feldenkrais Method
Participants described the back pain they lived with for many years as restricting their functional abilities. Hence, they were preoccupied with finding an underlying reason for it that was amenable to treatment. Until then, they were cautious about provoking or exacerbating their back pain, self-imposing restrictions, and physical limitations.
Back pain was often experienced as a constant, diffuse stiffness and discomfort yet had a focus, particularly, between the shoulder blades or lower back. For many, their muscles felt “rock hard.” Pain could be so intense it was nauseating and participants might be sensitive to the lightest touch. Back pain fluctuated between different levels of pain or discomfort at different times of the day. The “nagging, heavy sensation” that many had on waking might recede but was “always there in the background.” Some had lived with fluctuating back pain for so long that they could not discriminate between pain and discomfort. All, however, had vivid memories of being in extreme pain and distress. Although ATMs kept their back pain in abeyance, most knew that severe back pain could recur: “it can still put me on the floor. It can still knock me out.”
Back pain was a background phenomenon that had restricted participants' movement and ability to perform activities. Before discovering and practicing the Feldenkrais Method for their back pain, participants tried multiple treatments and therapies to alleviate it.
Restricted movement, restricted activities
Specific activities, inactivity, or both activity and inactivity could trigger participants' back pain as could tiredness, “overdoing it” and emotional stress. Although prolonged immobility commonly provoked or worsened back pain, the pain itself made it difficult for participants to keep still for extended periods whether standing, sitting, or lying. Regardless of the trigger, chronic back pain and the memory of it literally immobilized them and restricted their ability to perform daily activities, to exercise or play sports, and to work at capacity or at all.
The unpredictable nature of back pain and the memory of it could disrupt participants' day-to-day functioning through fear of provoking pain. Whenever one participant considered her future, for example, she anticipated all that could go wrong and doubted her ability to move without hurting herself and causing pain:
I thought if I moved the wrong way my back is going to spasm; I am going to be in trouble; I'm going to spend weeks at the physio; I am not going to be able to do things; I am not going to be able to get into the car properly or do anything.
One participant's back pain was so debilitating before commencing the Feldenkrais Method that she experienced long absences from work. She found herself “crawling around on the floor for days and days and eventually gave up altogether ... had to put the mattress on the floor.” Another woman also spent hours lying on the floor because of her back pain. She worried about how she could care for her young son when reduced to lying on the floor twisted, in pain and constantly tired after managing only a few hours at work.
Often participants relinquished exercise and sports due to their back pain. One described an insidious cycle of back pain and weight gain, which restricted her ability to exercise and contributed to weight gain and worsening pain. Another participant's back pain progressively restricted her mobility, resulting in her stopping nonessential activities, including recreation. This woman regarded herself as “always a spectator” and felt that she missed out on the “extra pleasure” in life.
Those without a strong social support structure felt socially and culturally isolated by chronic back pain. In one man's case, it disrupted his relationships with family and friends and caused depression:
Every time I brought it up it was pushed aside .... Family members including my older brother still and my parents still don't want to hear anything about back injuries, you know? ... We don't talk about the underbelly of it. ... you know? “Get over it, get on with it.”
Chronic back pain and its associated physical limitations made this man feel weak and vulnerable, unable to participate in the sports culture that had previously been a large part of his life. He was unable to work to the same extent as before like many of the other participants; he grew to doubt his masculine identity, worried about his prospects, and experienced anxiety and depression. He portrayed himself as “damaged goods”:
Definitely getting a partner, as a male, in Australia with a damaged back is not an easy thing. ... growing up in Perth being so sports focused here and such a physical sort of world. ... when I couldn't participate in surfing or partying hard. ... the invites stopped, lost a lot of friends. ... lost my ability and money and with that loss of ability to earn or to take care of myself the anxiety became pretty unbearable because how am I going to meet the next rent? I became very helpless. I didn't have the coping skills to deal with a body that didn't work and then I fell into very deep depression. ... It really just took out my whole existence.
Although some treatments or therapies helped participants cope with their chronic back pain in the short-term, they all sought long-term solutions. Whether they had lived with chronic back pain for 6 years or 54 years, they wanted to self-manage their back pain, strengthen their bodies, and perform daily activities of living with minimal restriction.
Treatment and therapies before the Feldenkrais Method
Participants underwent numerous physical examinations by health practitioners for their back pain, often including diagnostic tests. Most had back pain for years before obtaining a medical diagnosis if at all.
With the exception of one person, who suffered a traumatic spinal injury, those without a diagnosed back disorder or obvious injury nonetheless traced their back pain to a specific event, accident, or medical complaint since their teenage or early adult years. Obtaining a definitive diagnosis and reason for their ongoing back pain was grueling. It impacted their sense of self-esteem and self-worth and required determination to find a health practitioner who could “look at the big picture. ... join the dots up.” Only 2 participants had operations to repair herniated discs or to sever nerve roots and 2 had manipulation under anesthetic or prolotherapy. Others refused surgical interventions such as discectomy and spinal fusion no matter the severity of their back pain.
Ten of the 11 participants had taken over-the-counter medications at some point with varied results—mostly paracetamol or panadeine, glucosamine, fish oil or Omega 3 fatty acids, or vitamin or mineral supplements. Six had taken prescription-only or pharmacist-only analgesic medications and/or nonsteroidal anti-inflammatory drugs for lengthy periods. One person had tried self-medicating, combining alcohol and prescription analgesics to “drink the pain away.” However, 2 participants avoided prescription medications believing that they “masked the problem.” Masking the pain could exacerbate the habits responsible for pain, interfere with useful feedback, and leave the person in “a much worse state.”
Irrespective of whether or not they had a medically diagnosed back problem, conventional medicine had not alleviated participants' back pain or helped them to cope. Before practicing the Feldenkrais Method, all had searched years for an effective nonsurgical therapy. Physiotherapy and medical exercise therapy were the most tried of all therapies. Of the CAMs, the manipulative therapies of chiropractic medicine and remedial massage and the alternative system of Traditional Chinese Medicine, particularly, acupuncture, featured. However, the relief from CAMs was variable and usually short lasting and the therapy was often expensive. Some found osteopathic and chiropractic treatments, in particular, too aggressive or aggravating.
Even when CAM gave short-term symptomatic relief, participants sought a therapy that was affordable, long lasting and enabled them to perform everyday activities. After exhaustively trying other therapies, most tried the Feldenkrais Method on the recommendation of a friend or a health practitioner, whereas others inadvertently “came across” it. It was common to start with FI sessions, which some continued while attending weekly ATM lessons whereas others only attended ATMs.
Feeling empowered by the Feldenkrais Method
Before practicing the Feldenkrais Method, participants were at a loss about why they continued to experience back pain despite the lack of any or additional medical evidence for their back pain. ATM lessons restored their sense of control of their bodies, back pain, and lives. ATM lessons helped them become aware of their body and the interconnections between its parts; their habitual holding patterns and unhelpful patterns of movement; and so they started to develop a greater repertoire of movement within their own limitations. Most did not regularly practice between weekly ATM lessons but they routinely employed techniques of the Feldenkrais Method.
Asked to sum up what the Feldenkrais Method meant, one person replied, “Self-empowerment. Yep and choice. You really are holding the reins to your own physical movement or your own ability.... It's in no one else's hands besides yours.” ATMs gave each of them a system of movement and techniques for dealing with back pain confidently, preemptively, and safely:
There's been a couple of times where I have gone, “Oh dear, my back's going on me” [and] I have been able to lie on the floor and do some of the things I've been taught. I have been able to help myself to, you know, get the whole thing moving again.... It feels like you can almost start to control your body and your mind. ... rather than feeling like it's controlling you. You actually have this ability—even imagining doing things—that you can get your body to do what you kind of want it to.... it's been just that slow progression into doing that proper learning, what affects you, how you can move, how you can do things, how you can relieve it [back pain] and do all that yourself.
ATMs helped participants reinstate their sense of their body and engaged them in managing their body and back pain whereas they thought that conventional treatments did not encourage active participation in healing. Therefore, participants characterized the Feldenkrais Method as a constructive practice that made a qualitative difference to their body's emotional state:
Our relationships with our bodies are non-existent until we hurt our bodies. ... I think Feldenkrais encourages you to have a relationship with your body that is positive. ... it is also one where you're in control of yourself rather than being totally a victim and totally up to the physio saying, ‘Can you fix me?’ ... and you haven't emotionally or mentally been involved in that process at all, even if you ask questions. ... So you get an understanding with Feldenkrais about what a movement is and how it impacts you.... It improves your relationship with your own body, which is emotionally very useful.
Participants considered ATM lessons integral to their self-maintenance, to becoming and remaining pain free and allowing them to participate more fully in life. ATM lessons were also appealing as they found them a cost-effective, timesaving, and sustainable way to relax and prevent the recurrence of back pain. Some utilized techniques from lessons between sessions when their back felt “bad” but otherwise found that weekly ATM lessons were sufficient. Others, however, incorporated a series of movements into their daily routine:
So I get up and I go through what you do in an ATM class.... Half an hour, 4 to 5 times a week [since] 2000.... Look for me it's become a way of life. So it's something I incorporate into everyday as part of the exercise program and that's simply that the more consistently I do my ATMs, the less pain I'm in, the more things I can do.... We're only using a very low percentage of our physical capacity and [with] ATMs you get access to greater economical movements.... And I'm doing all these things that I just never thought were possible and I mean it started with thinking I'd never be out of pain.... But if I was to stop ATMs tomorrow it would only be a few weeks—and I've done it several times—it would only be a few weeks before I start to go backwards.
Whether practicing intermittently when symptomatic or regularly between ATM lessons, participants were able to abridge the ATM routines to fit the available time. Moreover, they did not need to replicate an entire ATM lesson at home to benefit.
Participants each felt empowered in terms of their back pain and their lives through the development of gentle self-awareness of the interconnections in their bodies and of their habits and holding patterns from ATMs. They learned to build a repertoire of movements while staying within their own limits. At the same, they reconciled the dissonance between the Feldenkrais Method and the culture of competition.
Living with chronic back pain for lengthy periods meant that participants lost a sense of their bodies and felt disconnected and uncoordinated. ATMs alerted them to such disconnectedness with and between parts of their bodies.
Body scans performed at the start and end of each ATM lesson involved careful, close observation of the body to perceive its characteristics internally and its relationship to the external environment in terms of posture, position, and physical contact or absence of contact with the environment. Participants found that this awareness brought the possibility of change and improvement:
You lie on your back and just notice where you're pressing heavily on the floor and where your body is lifted away and go over your whole body like that. I was absolutely horrified because I recognized my body was in a twisted, mangled place. And it was a torturous place and, of course, once you recognize that automatically the brain says, “You don't have to be like that” and it started changing.
Scanning at the end of an ATM lesson helped them detect changes in posture and movement over the course of the lesson. Scanning was a purposeful activity that they could perform on an ad hoc basis to improve their posture when standing, sitting, or lying.
The series of directed movements in ATM lessons helped participants become aware of their bodies and the interconnections between parts of the body by thinking before performing movements, imagining movements and feeling. Lessons proceed as a structured process for learning to move and become aware of how movement occurs:
You follow verbal instructions to make movements with your body and those movements are slow and thoughtful, not aerobic and fast. And they keep saying to you, “Less is more.” So if you move less you're going to learn more.... You're thinking while you are making the movements. You're thinking about how you're making the movement, where it's actually coming from, what are the bits involved in it. You become much more aware that one bit is joined to another bit.
Throughout an ATM lesson, participants create “sensory maps” of their newly discovered or rediscovered bodies:
I'm listening internally to my body. I'm thinking about the mapping of the body, the particular points.... And if you can't seem to feel a particular side of your body as well as the other side, it's because your awareness isn't mapped out.... You suddenly become aware that you've got a whole body and you've got all these points joined together and if you move one point it's going to impact on the whole.
Participants acquired a greater understanding of human anatomy during ATMs than they previously had: “I got to be 65 and thought my pelvis was my pubic bone! And to just understand your skeleton for a layperson has made a huge difference to me.” Identifying the parts of their bodies helped them isolate, relax, and move individual parts. Their knowledge of biomechanics also increased. As they recognized how they moved one part of their body, they became more aware of how other parts were or were not involved in that movement, and how they could improve on that movement to move with great efficiency and minimal stress. In particular, they learned to engage multiple, relevant parts of their body in a movement rather than putting the entire load on a single part:
I think it's the mechanics that really teach you that economical movement, you know, because you're not fighting against how it was designed to work.... So things become very light when you are not forcing your will and just allowing the natural [movement].... By learning to become aware of different parts of my body I'm then able to employ them and integrate them into what I call “sharing the load”.... With the Awareness Through Movement I'm able to, the word I'm looking for here is “involve.” So more muscles involved in the job; more bones moving to get involved in lifting; softening the throat ... slowly awakening parts of your body that don't often move that actually help the overall process of movement.
It was not necessary to memorize the numerous steps that the Feldenkrais practitioner guided participants through in an ATM lesson. Instead, they learnt to feel and consciously recognize what was happening in their bodies so that they could recognize that same feeling again. They learnt to feel a position, feel a movement, and recognize the feeling when their bodies moved in a manner that was “good” and comfortable for them:
It's the feeling, coming back to the feeling.... It's very much a gentle awareness but it's also very deep concentration.... And then I'll find when I'm walking around doing something [that] something feels a little different and I'll become more aware. It's more of an awareness than a doing and then I come back to the feeling.
Feldenkrais practitioners' verbal instructions guided participants to explore their bodies and learn new ways of being and moving that were unique to each:
They don't tell you how to do the exercise; you're all talked through the exercise. There is no right way for standing ... so there is a tendency in Feldy (sic) not to show you.... There is just the right way for you and eventually you will find the right way and correct it. You have to make a connection and until you make the connection with your internal body map, you won't be able to put your body in the right position.
Participants developed awareness of what they were doing during ATM lessons from “tuning in” or “listening” to their bodies rather than forcing movement as they relearned everyday movements like walking, sitting down and getting up, rolling over in lying, and reaching. ATMs involved sensing and feeling and deliberate thought, which one person termed “being mindful” in any situation:
How am I standing? What am I feeling now.... Being mindful of where weight is on your feet. Is it balancing? Are you on your toes or your heels or are you midway? Where is your head in space and how are you feeling? Do you feel weightless or do you feel heavy somewhere?
Participants often monitored their posture and movement throughout the day to make them feel more comfortable. The more they practiced the Feldenkrais Method and actively thought about what they were doing, the more discriminating they became when moving and while at rest.
Although participants might “hone in on” one part of their body in an ATM lesson, they often perceived benefits in other parts of their body. They actively thought about specific parts of their body and a series of movements; yet they also found that other cognitive activity occurred in the background:
You might be lying down on the floor and then just concentrating on lifting the right part of your pelvis just slowly off the floor by putting pressure on another part ... but what you're actually doing, when you think it through, you can feel all your vertebrae opening if you really concentrate, if you allow yourself to really, I suppose it's meditate that through, but it's through the power of thought to do it initially. Our instructor spends 50 minutes doing one side of your body and then you only really need about 10 minutes to do the other side, which absolutely amazes me; but you can get evened up by doing that because your mind has already learned how to do that.
Most participants found that ATM lessons had a therapeutic, meditative quality that engaged both their body and mind to induce profound relaxation and a sense of stillness: “I find it incredibly relaxing because it's like a moving meditation ... a positive internal relationship ... it drives you within.” They found it the antithesis of many other forms of exercise. Having lived with back pain for so long, though, feeling relaxed was a new sensation for participants such that they also had to learn to “... find that feeling of relaxation.”
Habits and holding patterns
Invariably chronic back pain was a repercussion of habitual ways of moving or not moving arising from a fear of provoking pain. To contain their back pain, participants had developed “holding” patterns and patterns of inappropriate movement that only worsened their situation:
I was really aware of trying not to move the wrong way or do the wrong thing to actually make it worse and not being confident to do just a lot of everyday things.... I felt like I was just continually trying not to do things and going to the physio because I was moving the wrong way trying so hard not to hurt my back more. But I was actually creating bigger problems.... I have been holding myself in the same way that I have been holding myself for years trying to not make things worse but I would make it worse.
ATM lessons helped all participants become aware of the maladaptive habitual postures and patterns of movement that they persevered with even if their injury was healed or their back pain had subsided. They learnt ways to release such damaging holding patterns, rigidity, and tension and relinquish their habitual ways of moving to counter the long-term physical impacts that created chronic back pain.
Learning to recognize and overcome habitual postures and patterns of moving was considered an ongoing process because “...a lifetime of habit doesn't just go away.” Even though participants became more aware of how to move more comfortably and with less strain on individual body parts, it was challenging not to fall back into habitual holding patterns or ways of moving. Sometimes events and stresses threatened progress in establishing new habits or patterns of movement: “When things affect me deeply I find it difficult to maintain the newer patterns and it's easy to slip into the old patterns, which is associated with tension and anxiety.” However, ongoing practice in ATMs made them mindful of their unhelpful habits and increased their sense of security in the newer, helpful habits that they had developed or were developing.
Building a repertoire of movements
When participants became aware of their bodies, it opened up new possibilities for more coordinated and efficient movement that required less effort of them. ATM lessons helped participants increase their repertoire of movement patterns, one small movement and insight at a time.
Rather than falling back on their habitual holding patterns and ways of moving, participants found that they had more options to automatically or deliberately choose from:
This sounds like it didn't happen, but it did. I was sitting in the middle seat [of the airplane].... My daughter and my husband had gone to sleep on either side of me and I needed to go to the loo.... And I thought it through on how I was going to lift onto my left. I was going to lift myself up, then lift my foot up, then I was going to take it right over. I can't believe I did it, but I did—over my daughter onto the other side. Lifted my other foot up, stood there straight as a die.
For those whose bodies had been “hard wired” since childhood by years of physical labor or sports, the Feldenkrais Method was a process that “... created more options ... unwiring the system and just creating choice where it wasn't before.” Moreover, in ATM lessons, participants were coaxed to move their bodies in a way that they might previously have been fearful of in case it precipitated back pain. They learnt to adjust their bodies toward a desired end by relaxing and building on small and often different movements.
Staying within their limits
ATM lessons often took participants outside their comfort zone by disrupting their habitual ways of moving and introducing sequences of movement that were unfamiliar to them and sometimes disconcerting to perform. At the same time, however, the lessons enhanced participants' awareness of their limitations.
Staying within their limits—what they were capable of—helped participants build on the repertoire of movements newly available to them thereby improving their functioning:
It's got a much more overall approach and it accepts that the body is a dynamic organism that is changing and it's not trying to work on some model of “I'm trying to get you to be a perfect, functioning body.” It's working on the idea of “we'll do the best we can for your body, with the amount of wear and tear your body has got and the amount of muscle capacity your muscles have got.” So it's a far more sympathetic approach.
They each realized that only little movements were required and they should remain comfortable throughout ATM lessons. This meant overcoming their tendency to compare themselves to others:
Even at 66 you think that you have to be able to do what everybody else can do. So sometimes you may (sic) push yourself a little bit more.... I have to learn to do it smaller and that's my issue; it's not Feldenkrais' issue. We're told enough times to take it easy, do it slow.
Participants developed their capacity for and repertoire of movement gradually without forcing movements:
So it's an idea in your mind as much as anything and by learning the comfortable range and then coming back to it again. And the next time, you'll find your comfortable range has increased and it'll increase dramatically because you haven't pushed yourself.
Since practicing Feldenkrais, most participants allowed themselves “down time” and avoided fatigue in order for change to occur; they recognized that becoming fatigued was counterproductive. By taking it slow and taking time out to rest, they felt more able to “work around” their limitations and so were less likely to experience pain and more likely to avoid injury:
[The pain] is actually minimal compared to what it used to be.... It's minimal because of 2 things; one, I know my limitations a lot more so I don't do the things I used to do and that's mainly because of the Feldenkrais awareness stuff. I know what my body can do and how it does it and I know my weak area ... then I work my day around it.... I've got to allow enough time and take enough pressure off myself.... The best thing that the ATM has taught me is learn at my own pace.
To learn to avoid discomfort, some first had to recognize the state of being comfortable. Hence, it was the absence of back pain or discomfort that alerted them to the extent of their back pain or discomfort:
[It] is permission and an understanding of being comfortable. The understanding that I don't do anything that is uncomfortable; if it becomes uncomfortable I stop, become aware of where, what it is and then something can be done about it.... I didn't know how uncomfortable I was feeling until I stopped feeling it.
The awareness of being comfortable and their limitations enabled participants to stop movements or activities before their back pain fully evolved. They learnt when they were on the “edge of pain” and stopped. If movement felt wrong, did not feel comfortable, or “did not sit well,” they stopped. Often staying within their own limits and not pushing themselves changed participants' relationship with their back pain from one of fear to an exploratory process. ATM lessons provided a safe place to “... explore with a curiosity a positive feeling rather than fear ... immobilizing, overtaking pain.”
Dissonance between the Feldenkrais Method and the culture of competition
Changing their attitude to achievement was an integral element in participants becoming empowered through practicing the Feldenkrais Method. Not pushing into pain or discomfort was a defining characteristic of ATM lessons for them. Staying within personal limits was essential to developing self-awareness; it enabled participants to tune into the negative aspects of their posture and movement. Practicing the Feldenkrais Method required reorientation of both their thoughts and behaviors. Being asked to stay within their own limits and not eliciting pain or discomfort was often at odds with their past life experiences and self-expectations as well as the expectations of others and the perceived prevailing emphasis on “measured results.”
Participants had to ignore mantras from their past such as “Work as hard as you can and do your best.” As one explained, “We've got this ridiculous idea in the modern world that you [should] soldier on. Soldiering on isn't really the master plan.” Instead, participants had to work within their own capacity, within their comfort zone while often tolerating feeling confused as their old patterns of movement gradually changed. They had to separate their concept of the Feldenkrais Method from exercise. During ATM lessons, Feldenkrais practitioners routinely asked participants to “do less” rather than push themselves to perceive and achieve changes in their respective patterns of movement:
You don't have to do it hard; do it slowly, move the minimal and that is what is important to learn.... It's the mind working with the movement is what others don't understand. They need aerobics or they need all these things that are more movement. It is all trying to move the body without using the mind.
They each came to appreciate the dissonance between prevailing cultural attitudes and the Feldenkrais Method:
The culture that I feel I am in, and have always been in, is a striving culture; it's a trying; it's a showing that you are trying; it's reaching goals; it's being successful. And I found that Feldenkrais was the absolute opposite and was balm for my soul. And the pain side, I wasn't asked to do anything; I didn't have to overcome the pain ... and for me that enabled me to release the tension, the holding because I wasn't going to have to do something that might hurt.
Thus ATM lessons created a safe place in which participants could quietly connect or reconnect with their bodies. Lessons boosted their confidence in their ability to sense and achieve changes in their posture and movement without having to perform. Instead of being “compelled” to move, participants could listen to instructions from their Feldenkrais practitioner and decide whether and how much to move: “I think that's the gentle challenging rather than the big phallic, ‘I've got to achieve today!’”
In essence, chronic back pain inexorably wore participants down and reduced them to spectators in life. The Feldenkrais Method is a movement therapy and continual learning process that reconnected them with their bodies, expanded their options and capacity for movement, and empowered them to manage their bodies and deal proactively with their back pain. Their repertoire of movements and functional abilities grew even though they stayed within their own limits such that they gradually reconciled themselves to the dissonance between the Feldenkrais Method and the prevailing culture of competition.
The 9 women and 2 men interviewed were aged from 37 to 76 years. Most had lived with chronic back pain and altered biomechanics for at least 40% or more of their lives. Their chronic back pain reflected central nervous system sensitization (touch, light pressure) as well as physical, psychological, and social factors.26 Before practicing the Feldenkrais Method, they tried numerous conventional and complementary treatments and therapies without lasting relief. This is not surprising as it is recognized that chronic pain is “under-recognized and under-treated” as a disease rather than a symptom.26(p8)
Chronic back pain and their memory of it impaired participants' movement and ability to perform daily activities and reduced their participation in life situations. Mobility problems are known to create restrictions in life areas including work, education, and social activities, particularly in older adults.27 Practicing the Feldenkrais Method, though, helped participants reverse mobility restrictions and related limitations. Before this, participants tried to avoid pain by not moving or not performing certain movements. Hence, they had developed habitual actions including habitual inactivity as a byproduct28 of the back pain they experienced, which worsened their back pain as is often the case.26 ATM lessons revealed to them their unhelpful, unconscious, and automatic habits thereby aiding recovery,29 helping them to enhance their movement repertoire and self-awareness.30 As Moshe Feldenkrais intended, practitioners encouraged them to proceed slowly in ATMs, to let go of self-expectations and those of others.15 Developing their capacity to learn how to move was a novel and integral feature of ATMs, in which they attended to “the means of achieving instead of the urge to succeed.”15(p93) Feldenkrais termed this “learning to learn.”15(p91)
Participants commenced ATM lessons with limited understanding of human anatomy and biomechanics. They initially did not appreciate patterns of total body connectivity,31 and the sequencing of movement between and through parts of the body. ATMs taught them about how the human body is organized, how movement can be generated and spreads, and the body's relationship to its environment to produce more efficient, effective, comfortable movement and resting postures. Considered as somatic education, the Feldenkrais Method “does not focus on pathology and symptoms, etiology and healing, but rather on the sensory-motor learning process, the development of kinesthetic potential, and the discovery of better strategic options in movement.”32(para 9) In her workshop, Neuroscience and the Feldenkrais Method, held March 2013 in Perth, Western Australia, Associate Professor S. Hillier outlined rationale from current neuroscience research and clinical practice for the action of the Feldenkrais Method. She proposes that the Feldenkrais Method is congruent with emerging ideas about neuroplasticity; motor control and learning; motor learning schedules; the role of sensation in action; sense of effort; mental imagery to improve action; the neuromatrix theory in pain; and the perception-cognition-action link.
Along with experiencing improved motor function, participants who had been practicing the Feldenkrais Method for some years, experienced long-term improvements in the affective, sensory discrimination and cognitive-evaluative dimensions of pain. This supports the proposition that perceived improvements in the sensory and evaluative dimensions of pain might be achieved with multiple ATM sessions.7 Just as cognitive behavioral therapy can reduce catastrophizing in people with musculoskeletal pain,33 so ATM lessons helped participants challenge their negative thoughts in response to back pain as well as their unhelpful behavioral responses. This is important as ongoing pain-related psychological features such as passive coping (eg, withdrawing from social activities) and pain catastrophizing can contribute to ongoing disability and diminished workforce participation.34 Moreover, people with chronic pain are “at risk of comorbid mental illness, social isolation, family breakdown and loss of income.”26(p9)
As is common for those pursuing complementary therapies, participants did not find the answers to managing their chronic back pain in conventional Western biomedicine.35 The Feldenkrais Method involves willpower but whereas self-discipline in sports, for example, might lead into pain, the Feldenkrais Method “stresses the harmonious coordination between structure, function, and achievement.”36(p51) In studies of routine behavior in life situations such as performing routine or nonroutine tasks, Avni-Babad29 found that a person's sense of safety precedes their feelings of confidence, comfort, and well-being. Feeling confident enhances a sense of comfort and well-being.29 In nursing, therapeutic emotional care is essential to facilitate a patient's emotional comfort to achieve physical outcomes.37 Emotional comfort, that is, positive feelings and feeling relaxed, is largely determined by a sense of personal control of situations or environments.37 For participants in our study, feeling safe during ATM lessons enhanced their confidence in their ability to move during everyday life and so their sense of comfort or movement without pain grew. Practicing the Feldenkrais Method renewed their confidence and self-efficacy38 by developing knowledge and skills for managing their back pain, which is an integral aspect of care for people with chronic pain.26 ATM lessons opened up possibilities and, hence, they found themselves empowered.35 Our results support conclusions of other researchers that people benefiting from ATMs are often critical of threats to self-empowerment encountered during other treatments/therapies.39
Although the sample of adults interviewed was predominantly female and educated for paraprofessional or highly skilled work, our study gives readers insight into the usefulness of ATM lessons for managing chronic back pain. Back pain is commonly a chronic-episodic condition that reduces a person's functional abilities as it restricts movement and reduces their movement repertoire; referral to a Feldenkrais practitioner early in the course of the disease might have positive benefits not often obtained by conventional and CAM treatments and therapies. The exploration of movement linked to function in ATMs appeals to people who value and prefer self-help therapies. If people perceive that they have control of back pain by awareness through movement—enhancing their knowledge of their bodies and environment, instilling a sense of confidence in their ability to move and function, and aligning with their values and beliefs—then they are likely to feel empowered. ATM lessons have the potential to reverse otherwise persistent participation restriction in people with chronic back pain and possibly avert its onset. Therefore, the Feldenkrais Method might be a useful adjunct therapy that health care providers can use to safely support people with back pain. Research examining the neuroscience underpinning the efficacy of the Feldenkrais Method in first-ever and recurrent back pain is needed. Further exploration of our proposition of the relationship between empowerment and the Feldenkrais Method is recommended.