Steven Shafarman

ABSTRACT
Very young children outgrow crawling as they learn to walk, and a similar process could help people of any age heal and recover from chronic pain. Two approaches, the Feldenkrais Method and FlexAware exercises, are based on this idea. A study of the efficacy and cost effectiveness of the Feldenkrais Method in the treatment of chronic pain was conducted by the Santa Barbara Regional Health Authority (SBRHA), a Medicaid provider. The study involved seven patients with migraine headaches and/or musculoskeletal problems. Patient satisfaction, function, and perception of pain were evaluated by using the National Pain Data Bank (NPDB) protocol of the American Academy of Pain Management. Participants reported more mobility and decreased perception of pain, both immediately after the program and in a one-year follow-up questionnaire. Results compared favorably with NPDB comparison groups. SBRHA compared Medicaid patient costs for one-year periods pre- and post-intervention. Patient costs dropped; savings exceeded the cost of the intervention. Adding FlexAware exercises to any such program seems likely to make it even more effective. Further research is warranted.

INTRODUCTION
As very young children learn to walk, they outgrow crawling. A similar process could help people of any age heal or recover from back pain, migraine headaches, carpal tunnel syndrome, and other disorders.

From the time they start crawling at about eight months, very young children are moving constantly, unless they are restrained in a car seat, focused on some object, asleep, or ill. Observing one or touching gently, it is easy to perceive that every breath involves movement in the back and sides as well as in front. When reaching for something, muscles engage throughout the body, not just in the arm but also at the pelvis and hip joints.

Very young children learn to walk through self-directed sensorimotor exploration. Guided always by comfort, they gradually develop the necessary skill and strength. Motivated mostly by curiosity, they actively seek to make more sense of their experience with gravity, objects, and other features of the world. The world includes people, of course, and some of the child’s exploration involves imitation. New movements are repeated many times, becoming reliable and intentional while being incorporated into further learning. Falling is normal and useful.
Stated more simply, young children learn by playfully exploring and imitating. Throughout that process, muscles and bones grow stronger, neural connections are made and reinforced, body and mind are integrated.

Most of the time, except when they are upset or disturbed, young children breathe and move harmoniously, efficiently. Efficient movement means that as any muscle contracts, some opposite muscle lengthens, and opposing muscles have relatively equal, low tonus. The skeleton aligns so that bones, not muscles, ligaments, or cartilage, support the body’s weight, transmitting gravity and other forces. That efficiency is why children between the age of two and ten or twelve or sometimes older are much more flexible than adults and, for their size and weight, stronger than adults.

As people age, everyone acquires habits of straining some muscles while underusing others, stiffening joints and misaligning bones. Such habits typically intensify over time and in stressful situations. The experience of stress, regardless of the apparent cause or trigger, entails holding the breath, at least partially, and other inefficient movements. Inefficient movements irritate joints, nerves, muscles, and other tissues. Responses to irritation include calcification, impaired circulation, and tissue degeneration.

The way young children learn and move is the basis for the Feldenkrais Method and FlexAware exercises.

The Feldenkrais Method

The Feldenkrais Method has two forms. With individuals, it is primarily non-verbal, teaching through touch and movement. Usually done with the student sitting or lying on a low, padded table, the practitioner gently and precisely moves the student, turning the head for example, or lifting a leg or arm. Practitioners are carefully trained to ensure that movements are comfortable. Movements are generally small, although they can be quite large and playful. Students remain fully clothed.

With groups, the practitioner uses verbal directions to guide students through specific sequences that systematically mobilize the entire body. The emphasis is on awareness, on sensing differences and connections, which is why the practice is called “Awareness Through Movement”. Both forms commonly use movements remote to any area of pain or injury. For example, movements of the feet or head and neck can relieve problems involving the lower back. Most lessons take 45 to 60 minutes.

Feldenkrais lessons, with their educational emphasis, are compatible with conventional and complementary or alternative medical treatments.

Dr. Moshe Feldenkrais (1904-1984) was a mathematician, engineer, and neuroscientist who earned his doctorate at the Sorbonne. During the 1930s, he was principle assistant to Nobel chemistry laureate Frèdèric Joliot-Curie. Feldenkrais was also the first European to earn a black belt in judo and a founder of the Judo Club of Paris. Applying science to judo, he saw that judo masters while performing move efficiently like young children.

In England during World War II, he did weapons research for the British Admiralty. Working on the development of sonar required him to spend time on boats, which aggravated a knee injury he had incurred playing soccer as a young man in Palestine. Doctors recommended surgery, and several told him that after the operation there was only a 50 percent chance he would be able to walk without a crutch or cane. He rejected their prognosis and their treatment. Instead, he dedicated himself to understanding movement learning and healing from a developmental neurological perspective. Without surgery, he regained the ability to walk normally and do judo.

In the 1950s, he lived in Israel and was renowned for helping prime minister David Ben-Gurion recover from decades of back pain and breathing difficulties; Ben-Gurion even learned to stand on his head. In the late 1960s in Israel and in the ’70s and ’80s in the United States, Feldenkrais taught nearly three hundred people to be practitioners. There are now thousands of practitioners using his methods around the world. Professional programs are offered in many countries. Research is being done.

Research with Chronic Pain Patients

A study of patients with long-term chronic pain was published in 1999 in the American Journal of Pain Management. The authors were Dr. David Bearman and Steven Shafarman. The study was sponsored by the Santa Barbara Regional Health Authority (SBRHA), which is a Medi-Cal (California Medicaid) provider.

Patients with chronic pain are often unhappy with their health care and demanding of their primary care providers. The medical staff of SBRHA had identified a number of patients who had exhausted conventional medical options and were difficult to manage, and costly. When the study was conducted in 1995, annual health care costs for chronic pain Medicaid patients in the Santa Barbara area were $1,000 to $7,000. SBRHA sought a treatment intervention that would help the patient, assist the primary care provider with patient management, and be cost-effective.

Dr. David Bearman, Medical Director of SBRHA, learned of the Feldenkrais Method from an independent case manager for workers’ compensation who described the good results she had been seeing with her patients who had not responded to conventional treatments. The SBRHA administrative and medical staff was concerned about the lack of research substantiating the benefits of the Feldenkrais Method. So Dr. Bearman invited Steven Shafarman, a practitioner who learned directly from Dr. Feldenkrais, to teach a demonstration Awareness Through Movement lesson to staff members. Their positive experiences reassured SBRHA management, which recommended a pilot program to the Board of Directors. The Board approved it as a one-time special benefit and requested a formal evaluation.

SBRHA medical staff offered the program to patients with chronic musculoskeletal pain of the neck, shoulder, arm, and/or back; tension and migraine headaches; and pain following injury. Excluded were patients whose pain had significant structural causes, and those with cancer, over age 70, or whose total annual health care costs were less than $1,000. The patients’ primary care physicians were contacted to see if they concurred with the intervention.

Seven patients participated in the program. Most had chronic musculoskeletal pain in several areas. Most had coexisting depression and anxiety. Three had been in serious automobile accidents. Two had migraine headaches.

The goals of the treatment were to reduce complaints of pain, improve mobility and skill functioning, reduce use of licit and illicit analgesics, and reduce demand for health care services during the one-year follow-up period.

METHODOLOGY

The program began with a 2-week intensive phase, 4 to 5 hours each day, 4 days each week. That was based on the immersion characteristic of standard pain management programs. A secondary phase involved 6 more weeks with one meeting each week, 4 hours for the first two meetings, 2 hours for two meetings, and then just one hour for each of the final meetings.

The program consisted primarily of Awareness Through Movement lessons. Lessons were chosen and designed to emphasize ways to sit and walk comfortably and to breathe easily and efficiently. Some individualized Feldenkrais was done with most of the participants, but only for about 5 minutes at a time within the group setting. At each meeting, participants were encouraged to describe any benefits they were experiencing and to reflect on how they were integrating new ideas and movement possibilities into their everyday activities. Group discussions were intentionally oriented toward positive issues and away from reports of pains or problems.

EVA LUATION

The American Academy of Pain Management’s National Pain Data Bank (NPDB) test instrument was administered before the program, immediately post-treatment, and (by telephone) at one-year post-treatment. It involves participant self-assessment of quality of life, functional status, satisfaction, and perception of pain. The NPDB classifies and analyzes the benchmarks and quality of pain treatment programs throughout the United States. The NPDB compared the Feldenkrais program with 12 other programs with 365 chronic pain patients in the category of “Small Multidisciplinary, Outpatient.”

All 7 participants completed the program. Six of them were located and participated in the follow-up telephone survey.
Cost effectiveness was evaluated based on total health care costs and pharmacy costs. Using SBRHA data, Medicaid costs were compared for the year preceding the Feldenkrais intervention and for one year following the end of the intervention.

RESULTS
Demographics. With regard to age, sex, race, marital status, and level of education, there were no significant differences between participants in the Feldenkrais program and those in the 12 comparison programs. Ages were widely distributed; there were slightly more females than males; more than half were divorced.

More SBRHA patients were unemployed. More lived alone. They had lower incomes, predominantly derived from disability payments. A significantly higher percentage reported sexual or physical abuse as children or adults. (Of the 7 SBRHA patients, 57 percent reported some type of abuse, compared with only 9.5 percent of the 365 patients in the other groups.) Fewer of the SBRHA patients were injured at work. Fewer of the SBRHA patients were current smokers but more were alcohol drinkers.

Pain history. SBRHA patients reported having pain in more areas than patients in the comparison programs, suggesting that the pain experienced was also more severe. SBRHA patients had been experiencing pain for longer periods of time; 100 percent reported pain for more than 24 months, compared with only 47.2 percent of patients in the comparison groups.

Prior to the program, SBRHA patients had received more treatment for their pain, including a greater number of surgeries and hospitalizations. Other treatments SBRHA patients had done included acupuncture, heat, manipulation, counseling, exercises, and medication.

Functional status. Patients treated in both the Feldenkrais program and comparison groups reported an increase in their ability to walk, bathe, dress, use the bathroom, drive a car, and engage in sex without the interference of pain. A noteworthy example is driving a car: Pretreatment, 71 percent of participants in the Feldenkrais program experienced pain all the time while driving; post-treatment was zero.

Patient satisfaction. At the conclusion of the Feldenkrais program, 100 percent of the patients reported some level of improvement. That compares quite favorably with data from the NPDB, which gives 55.5 percent as the general expectation of improvement. In both the SBRHA and NPDB groups, high percentages reported feeling less depressed, suffering less anxiety, and also being able to relax more. A higher percentage of SBRHA patients reported that they were able to return to some of the activities they had participated in prior to their pain.

Perception of pain. Prior to the Feldenkrais program, 28 percent of the SBRHA patients reported excruciating pain. At the conclusion of the treatment phase, none reported excruciating pain.

Cost effectiveness. A factor of obvious importance is the number of health care visits. In the year prior to the Feldenkrais program, 71 percent had more than 20 appointments with a health care professional and the rest had 8-10 appointments. In the year following the program, all had between 11-15 visits.

Pretreatment, 14 percent of SBRHA patients were using 5 or more medications; post-treatment, that was zero. For NPDB comparison groups, pretreatment, 3.2 percent were using 5 or more medications; post-treatment, that increased to 6 percent.

SBRHA documented combined pharmaceutical and outpatient medical costs of $141 per member per month (pmpm) during the 13 months prior to the intervention. For the 14 months following the program, costs were just $82 pmpm. That represents a 40 percent decrease. The $54 pmpm savings means that SBRHA more than recovered its direct cost of $700 per member. (Standard intensive pain treatment programs cost from $7,000 to $30,000 per patient.)

Summary and conclusions. Initially, SBRHA patients were in worse condition than patients in NPDB comparison groups. They had more problems and had been in pain longer. They also had greater barriers associated with psychosocial factors including less income, problematic employment status, and histories of abuse.

Following the program, SBRHA patients showed significant improvement in their perception of pain, functional status, and quality of life, and they had decreased the numbers of medications they were using. Results were similar to or better than NPDB comparison groups.

At the one year follow-up, SBRHA patients had lost some of the benefits they reported immediately after the program, but there was still significant progress overall.
The cost of the SBRHA program was a small fraction of standard pain treatment programs.

The study concluded that the Feldenkrais Method shows promise in the treatment of patients with chronic pain secondary to headaches and/or musculoskeletal problems.

DISCUSSION
As the Feldenkrais practitioner who designed and conducted the program, I was initially concerned about the program’s diversity. As noted above, 2 participants had migraine headaches, 3 had been in serious automobile accidents, most had musculoskeletal pain in several areas, and most had coexisting depression and anxiety. Those differences proved useful, however, making it easier for us to focus on common experiences instead of diagnoses.

Through the combination of Feldenkrais lessons and discussion, participants quickly saw that, for each of them in slightly different ways, pain involved stiffening and holding the breath. On learning that this is universal, a reflex, all were reassured. More important, that knowledge helped them understand how they could help themselves by breathing and moving more comfortably. Using comfortable movements to recover from pain and stress was the main theme of the intensive phase of the program.

The lessons gave participants concrete experiences of doing unfamiliar or previously painful movements while actively reducing effort and seeking comfort. Through the discussions, participants were encouraged to apply the insights gained from the lessons to activities they had once enjoyed but been unable to do because of pain. For example, one participant had been an avid surfer before a serious automobile accident. In the second week of the program, early one morning he went out on his surfboard for the first time in more than two years. When he reported that to the group later the same day, he talked about how he was careful to do only what was really comfortable and safe. And he described the immense pleasure and significance he experienced.

It seemed that all of the participants understood the logic of learning to move more efficiently as a way to facilitate healing. All seemed to appreciate that this idea suggests autonomy and greater personal responsibility for healing. All seemed to be genuinely inspired by the example of very young children.

The year after this study was completed, SBRHA management changed. There was no subsequent program, despite Dr. Bearman’s efforts to get one approved. I was especially disappointed because my experience with the participants suggested a number of modifications that could make future programs more successful:

The intensive phase of the program had 4 to 5 hour sessions each day. That was too long; some participants were overstimulated and had to rest instead of doing the lessons. It would be better to meet for 3 hours at most. And it would be good to prolong the less intensive phase.
· A larger group would allow for more dynamic interactions and more variable responses, making it easier for participants to learn from one another. A good size would be about 15 people.
· The opening section of this article, which considered very young children and how they learn to walk and outgrow crawling, and which presented specific ideas about efficient movement, is more clear and succinct than I knew how to be at the time of the program. Those ideas could be used more effectively from the beginning.
· All of the participants requested written material about the Feldenkrais Method but nothing suitable was available at that time. My book, Awareness Heals, was published a year and a half after the program ended. It presents six basic lessons that were taught in the program. Participants in future programs could use it as a text.
· During the second week, as the participants were discovering greater ease of movement, several asked about exercising more vigorously. A few tried to do so at home, but hurt themselves. My suggestions about how to exercise were not completely satisfying to them or me. Now there are FlexAware exercises, which would be a significant addition to any such program.

Many design variations are possible regarding program size, schedule, and participant characteristics. In addition, I believe any experienced Feldenkrais practitioner could learn to teach a successful program, including the FlexAware exercises. That means programs could be easily replicated.

FlexAware exercises
FlexAware exercises, like the Feldenkrais Method, are based on the way young children learn and move. The exercises encourage awareness of the whole body while employing and teaching efficient biomechanics.

Differences between FlexAware and conventional exercises can be understood by considering one of the most common exercises, push-ups. Most people view push-ups as a good exercise to strengthen the arms and shoulders. Generally ignored, however, is the fact that doing a push-up entails stiffening and contracting muscles throughout the trunk. That rigidity impairs breathing. Stiffening and holding the breath are antithetical to the principles of efficient movement, as described in the opening of this article. There are FlexAware exercises that strengthen the arms and shoulders as effectively as push-ups, while breathing harmoniously and using trunk muscles efficiently.

All of the FlexAware exercises are coordinated with the breathing. All use breathing to increase mobility throughout the trunk, an area of movement that many other exercises ignore or actively inhibit. All are designed to increase the dynamic range of motion by contracting some muscles while lengthening opposing muscles. All facilitate a more complete experience of the body, in contrast with the conventional focus on specific parts and individual muscles. All direct attention away from the muscles and more toward sensing the skeleton in relation to gravity.

Many of the people doing FlexAware exercises have reported significant benefits with regard to the relief of musculoskeletal pain and stress-related disorders. Particularly worth noting are reports of benefits regarding repetitive strain disorders including carpal tunnel syndrome. That may be explained by the way FlexAware exercises increase mobility of the shoulderblades, collarbones, and upper back while increasing strength in those areas and generally. This merits research.

Moreover, FlexAware exercises, again like the Feldenkrais Method, emphasize awareness and skill in everyday activities, especially breathing, sitting, and walking.

CONCLUSIONS

The example of very young children suggests a new way to think about chronic pain. As very young children learn to walk, they fall many times; falling is important for learning to sense gravity, the skeleton, and how to find and maintain balance. Back pain, migraine headaches, and other stress-related and musculoskeletal disorders are often chronic and painful, but can also be like falling, steps toward learning to move more comfortably and efficiently.

For the emerging field of whole person healing, these ideas about learning and movement may be extremely useful and significant. They dissolve the notion of a split between body and mind. They recognize the role and importance of individual differences and movement habits. They view the whole person as actively creating meaning while engaging with other people and the physical environment. And they provide a way to understand healing as an aspect of everyday life, a natural activity of whole persons.

References:
Bearman D, Shafarman S (1999) American Journal of Pain Management, Vol. 9 No. 1, page 22.
Shafarman S (1997) Awareness Heals: The Feldenkrais method for dynamic health. Perseus, Reading MA.

Steven Shafarman is President of Somatic Awareness Research and Education Corporation; creator of the FlexAware™ approach to exercise, fitness, and healing; and author of Awareness Heals: The Feldenkrais Method for Dynamic Health. He lives in Washington, D.C.

Steven Shafarman
Somatic Awareness Research and Education Corporation
1400 16th Street NW
Suite 330
Washington, DC, 20036.
202-638-4200.
steven@somaticawareness.net.

Feldenkrais Method® and Awareness Through Movement® are registered service marks of the Feldenkrais Guild® of North America.
FlexAware™ is a trademark of Somatic Awareness Research and Education Corporation.

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