Post on 26-Aug-2018
Review ArticleThe Effectiveness of the Feldenkrais Method: A SystematicReview of the Evidence
Susan Hillier1 and Anthea Worley2
1 International Centre for Allied Health Evidence, Sansom Institute of Health Research, School of Health Science,University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia2School of Health Science, University of South Australia, P.O. Box 2471, Adelaide, SA 5001, Australia
Correspondence should be addressed to Susan Hillier; susan.hillier@unisa.edu.au
Received 16 December 2014; Revised 4 March 2015; Accepted 9 March 2015
Academic Editor: Cun-Zhi Liu
Copyright © 2015 S. Hillier and A. Worley. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.
The FeldenkraisMethod (FM) has broad application in populations interested in improving awareness, health, and ease of function.This review aimed to update the evidence for the benefits of FM, and for which populations. A best practice systematic reviewprotocol was devised. Included studies were appraised using the Cochrane risk of bias approach and trial findings analysedindividually and collectively where possible. Twenty RCTs were included (an additional 14 to an earlier systematic review). Thepopulation, outcome, and findings were highly heterogeneous. However, meta-analyses were able to be performed with 7 studies,finding in favour of the FM for improving balance in ageing populations (e.g., timed up and go test MD −1.14 sec, 95% CI −1.78,−0.49; and functional reach test MD 6.08 cm, 95% CI 3.41, 8.74). Single studies reported significant positive effects for reducedperceived effort and increased comfort, body image perception, and dexterity. Risk of bias was high, thus tempering some results.Considered as a body of evidence, effects seem to be generic, supporting the proposal that FMworks on a learning paradigm ratherthan disease-based mechanisms. Further research is required; however, in the meantime, clinicians and professionals may promotethe use of FM in populations interested in efficient physical performance and self-efficacy.
1. Introduction
The Feldenkrais Method (FM) was developed over a periodof decades in the last century by Dr. Moshe Feldenkrais.He claimed the basis of the approach was founded in thehuman potential for learning how to learn [1]. As such, heoperationalized an experiential process or set of processes,whereby an individual or a group could be guided througha series of movement- and sensation-based explorations.Thepurpose of these explorations was to practise the nonlinearprocess of sensing the difference between twoormore optionsto achieve the stated movement task, and making a discern-ment about which may feel easier, that is to say, performedwith less effort.These perceptual discernments are predicatedon a judgement that is positive (pleasurable, easy, and withless effort) compared with experiencing a less favourablefeedback signal such as pain, strain, or discomfort. Furtherto this, the participants are encouraged to generate manyalternative movement solutions to the guided task to increase
the opportunity for further distinctions and improvementsto be made. Thus the process of intention, action, gainingfeedback, making decisions, and reenacting with adaptationsconstitutes the learning framework in a somatic context [2].
The two modes of delivery that are offered to the publicare either individual, manually directed lessons (functionalintegration, FI) or group, verbally directed classes (aware-ness through movement, ATM). The nomenclature for bothreflects the fundamentals of the approach—that movementhas to be based on a functional or meaningful intentionfor the system to engage and that by becoming awareof what and how we act (move) we become in a betterplace to choose an alternative behaviour (movement pattern)[3]. Both modes of delivery apply the same principles ofperceptual exploration through movement that is passivelyand/or actively performed.
The method has been applied in varied domains acrosscountries, from general education or children with learningissues to enhancing performance in sports and theatre.
Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2015, Article ID 752160, 12 pageshttp://dx.doi.org/10.1155/2015/752160
2 Evidence-Based Complementary and Alternative Medicine
The clinical applications have received the most interest inthe published literature because of the intuitive appeal ofbasing a health recovery process on a learning paradigm andbecause of the inherent fostering of self-efficacy that occursparticularly in a group setting.
In the climate of evidence-based practice in the healthdomain, any approach being offered to the public is beingscrutinized for evidence of effectiveness and, if effective, forwhat type of benefit and of what magnitude for any clinicalpopulation. An earlier systematic review of the evidence forthe method was published in 2005 by Ernst and Canter [4].This review included six randomised controlled trials (RCTs)of low to moderate quality in populations such as peoplewith multiple sclerosis, chronic low back pain, and neckissues. They concluded that there was promising evidencebut its credibility was tempered due to the low number ofstudies, high level of clinical heterogeneity between studies,and methodological flaws. The methods employed by Ernstand Canter [4] were robust for the time; however, their riskof bias assessment used a now discarded tool (the Jadad)and their search covered until 2003. Therefore, it is timelyto systematically update the evidence for the FeldenkraisMethod with current review procedures.
This review had the aims of
(1) systematically identifying and appraising the evi-dence for the effectiveness of the Feldenkrais Methodacross domains;
(2) determining what is the nature and order of magni-tude of any beneficial effects and for which popula-tion/s.
2. Materials and Methods
2.1. Criteria for Considering Studies for This Review. Weemployed systematic review methods based on the PRISMAguidelines [5].
2.2. Types of Studies. Weconsidered all types of primary stud-ies in the first instance in order to fully explore the potentialpopulations and outcomes covered. In the final inclusion onlystudies with a random allocation and a stated control groupwere included. Any secondary researches (systematic andsemisystematic reviews) found were not included, but rathertheir included studies were retrieved in full and added to thepotential pool in order for all primary studies to be appraisedwith a consistent method.
2.3. Types of Participants and Outcomes. We included anypopulation where there was an outcome of interest related toimprovement in health and/or function.
2.4. Types of Interventions and Comparisons. Either formof Feldenkrais Method (functional integration or awarenessthrough movement) was included as the sole approach forthe intervention group.The comparison group could includeplacebo, inactive control, or an alternate method.
2.5. Search Methods for Identification of Studies. We searchedthe databases of AMED (Allied and ComplementaryMedicine), Embase Classic + Embase, Ovid MEDLINE(R),Cochrane, PsycINFO, PubMed, and Google Scholarfrom inception to July 2014. We considered all languages (thesearch was open to all listed journals irrespective of language)and publication status (we would include unpublished trialswherever found, e.g., through experts in the field or greyliterature such as organizational websites).
The search terms included variations and combinationsof methodology terms (such as randomised, trial, clinical,and controlled), with intervention terms such as FeldenkraisMethod, (awareness through movement and functional inte-gration). An example of the terms employed in the electronicsearch strategy is presented in Table 1.
From the generated lists from each database, duplicateswere removed and the first high level sift was performed byone author based on title alone. The second level of reviewwas performed by both authors and required retrieval of theabstract at theminimum.The retained studies were examinedin full to confirm inclusion. Those excluded were recordedwith reasons.
All retrieved studies were checked for additional refer-ences, and experts in the field were contacted to assist inidentifying any further studies published or unpublished.Experts were provided from the membership of peak FMbodies (the Australian Feldenkrais Guild and the Interna-tional Feldenkrais Federation) and were asked to supplyfurther papers by email.
2.6. Data Collection and Analysis. Relevant data wereextracted from each of the included studies using a standardtrial summary sheet by one author and checked by the second.Data included author, date, study design, population sample,intervention, comparison, outcome measures, results, andcomments. A risk of bias evaluation was also performed foreach study by one author using standard Cochrane tables[26] with checking and data entry by the second author. Anydisagreements were resolved by consensus, with a third partyif necessary.
Where possible, data were extracted for meta-analyses.We planned to extract and analyse data to calculate individualand total effect sizes through odds ratios or mean differences(fixed effect or random effect if the studies were small and/orheterogeneous) and 95% confidence intervals. Statistical het-erogeneity would be evaluated based on visual inspectionof forest plots and on the 𝐼2 statistic. It was not anticipatedthat any other analyses would be possible (e.g., subgroup orpublication bias) due to a paucity of studies.
If we found that meta-analyses were not possible, thenresults would be synthesized and reported narratively.
3. Results
3.1. Included Studies. The systematic search yielded over1,300 initial titles for high pass screening. See Figure 1 forthe PRISMA Flow diagram. With duplicates and obviouslyirrelevant titles removed, 124 records were considered at the
Evidence-Based Complementary and Alternative Medicine 3
Table 1: Example of search strategy.
Number Searches Results
1 (Clinical trial or randomised trial or controlled trial).mp. [mp = ab, hw, ti, sh, tn, ot,dm, mf, dv, kw, nm, kf, ps, rs, an, ui] 1900972
2 (Feldenkrais or awareness through movement or functional integration).mp. [mp =ab, hw, ti, sh, tn, ot, dm, mf, dv, kw, nm, kf, ps, rs, an, ui] 2239
3 1 and 2 474 Removing duplicates from 3 40
Table 2: List of papers excluded with reasons.
Studies Reason for exclusionKirkby (1994) Controlled trialBearman (1999) Pre/posttest (no control)Seegert (1999) Controlled trialHuntley (2000) Systematic reviewDunn (2000) Pre/posttest (no control)Fialka-Moser (2000) CommentaryMalmgren-Ohlsen (2001,2002, 2003) Controlled trial
Kerr (2002) Controlled trialEmerich (2003) ReviewJunker (2003) Posttest (no control)Galantino (2003) ReviewGard (2005) ReviewMehling (2005) ReviewLiptak (2005) ReviewBatson (2005) Pre/posttest (no control)Wennemer (2006) Pre/posttest (no control)Porcino (2009) DescriptiveMehling (2009) Review (assessment)Connors (2010) Content analysisConnors (2011a) Controlled trialConnors (2011b) Pre/posttest (no control)Mehling (2011) Inquiry (phenomenological)Ohman (2011) Pre/posttest (no control)Laird (2012) Review
Mehling (2013) Intervention (not exclusivelyFeldenkrais)
Gross (2013) ReviewWebb 2013 Pre/posttest (no control)
abstract level by both authors, with an additional two studiesprovided from experts in the field (newly published, one RCT,one non-RCT). Seventy-seven abstracts were excluded at thisstage because they were did not report an investigation of theFM and/or did not involve a trial of effect. Forty-seven full-text articles were reviewed against the criteria and further 27excluded with reasons noted in Table 2.
Fourteen newRCTswere included alongwith the originalsix studies from the Ernst and Canter [4] review. See Table 3for details of all included studies. From this total of 20 studies,
there were seven studies sufficiently homogenous to allow formeta-analyses.
3.2. Description of Studies. Publication dates ranged from1991 [12] to 2014 [25]. Populations under investigation in theincluded RCTs ranged from healthy volunteers [6, 12, 15–17, 19, 24], healthy ageing [21–23], institutional ageing [25],people withmultiple sclerosis [7–11, 13], eating disorders [14],myocardial infarct [18], and sleep bruxism [20]. Studies gen-erally had small sample sizes with a mean of 40.8 participants(SD 23.5).
The nature of the Feldenkrais interventions also variedin delivery mode, intensity, and frequency. The predominantmethods were single or multiple ATM lessons deliveredeither in a group or individually using audio recording.The comparison groups were most commonly an alternateform of therapy. Fourteen trials had active controls (suchas relaxation classes or generic movement/balance classes)and six had a passive or inactive control (usual activities/nointervention).
Outcomes were also highly heterogeneous in keepingwith the needs of the diverse populations and are listedin Table 3. The measures related to performance or activityoutcomes (e.g., balance or dexterity), symptoms (e.g., pain,effort or mood) or were related to quality of life.
3.3. Excluded Studies. Table 2 summarises the list of studies(27) that were retrieved but excluded. Reasons for exclusionwere predominantly around design: two were systematicreviews; five were controlled trials (not randomly allocated);eight had no control group; eightwere nonsystematic reviews;onewas not exclusively Feldenkrais in the intervention group;one was a content analysis of an intervention; one was aphenomenological analysis; and one was a commentary.
3.4. Risk of Bias in Included Studies. Risk of bias was high inmost studies. Less than a quarter of the studies had adequaterandom allocation processes and only a third had blindingof outcome assessments. It has to be acknowledged that fortrials requiring an intervention like Feldenkrais it may bedifficult or inappropriate to expect blinding of therapists oreven participants, though participants can be blinded to theintervention of interest if there is a plausible comparisongroup (such as a relaxation or other forms of movement-based class). Figures 2 and 3 summarize the risk of biasanalysis. It can be seen that a definitive judgement could notbe made in many cases as it could not be confirmed whether
4 Evidence-Based Complementary and Alternative Medicine
Scre
enin
gIn
clude
dEl
igib
ility
Iden
tifica
tion Records identified through
database searching (after high leveltitle screening) (n = 176)
Additional records identifiedthrough other sources (n = 2)
Records after duplicates removed(n = 124)
Records screened (n = 124) Records excluded (n = 77)
Full-text articles assessedfor eligibility (n = 47)
Full-text articles excluded,with reasons (n = 27)
Studies included inqualitative synthesis (n = 20)
Studies included inquantitative synthesis
(meta-analysis) (n = 7)
Figure 1: PRISMA flow diagram.
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other biases
0 25 50 75 100
Low risk of biasUnclear risk of bias
High risk of bias
(%)
Figure 2: Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.
Evidence-Based Complementary and Alternative Medicine 5
Table3:Ra
ndom
isedcontrolledtrialsof
FM(ErnstandCa
nter,2005[4],𝑛=6)w
ithup
datedRC
Ts𝑛=14.
Author
(year)
Stud
ydesig
nSample
Interventio
nCon
trol
Outcome
Results
Com
ments
Ruth
and
Kegerreis(1992)
[6]
RCT
2parallelgroup
s30
healthy
volunteers
Sing
leFM
sequ
ence
Participationin
other
rand
omactiv
ities
Degreeo
fneckflexion
(gon
iometer);perceivedeffort
durin
gflexion
Greater
degree
ofneck
flexion
(gon
iometer)(𝑃<0.01);less
perceivedeffortd
uringflexion
(𝑃<0.05)
Stud
yhasp
ilotcharacter
John
sonetal.
(1999)[7]
RCT
2-grou
pcrossover(2ph
ases)
20peop
lewith
MS
FM:8×45min
sessions
atweekly
intervals
8weeks
sham
nontherapeuticbo
dywork
LandRhand
dexterity
(pegbo
ardtest)
;8symptom
/perform
ance
scores;
5moo
dscales
NSD
Lessperceivedstr
essfollowing
FM(𝑃=0.01)
Positiver
esultcou
ldbe
due
tomultip
letesting
for
significance
Lund
blad
etal.
(1999)[8]
RCT
3parallelgroup
s
97females
with
neck
and
shou
lder
prob
lems
FM:4
individu
alsessions,12grou
psessions
of50
mins
pw,for
16weeks,
homea
udio
tapes
(C1)ph
ysiotherapy2×
50minsp
erweekfor16
weeks;hom
eexercise
s(C
2)no
interventio
n
Clinicalassessments(4
measures);
physiologicaltests(18measures)
complaint
indices(5measures);
VASpain
ratin
gs(2
measures);
disabilityandsic
kleave
measures(4measures)
Prevalence
ofneck
pain
and
disabilitydu
ringleisu
redecreased
inFM
versus
C1or
C2(𝑃<0.05)
31of
33measuresN
SD
Impo
rtantb
aseline
differences,possib
leregressio
nto
them
ean.
High
drop
outratea
ndper
protocolanalysis.
Multip
letestingforsignificance
Stephens
etal.
(2001)[9]
RCT
2parallelgroup
s12
peop
lewith
MS
FM:8×2–4ho
urs
sessions
over
10weeks
Educationalsessio
nsover
10weeks
3clinicaltestsof
balance;
3symptom
scales
Sign
ificant
improvem
entinFM
comparedto
Cform
CTSIBand
BalanceC
onfid
ence
Scale;other4
outcom
esNSD
Very
smallsam
ples
ize.No
baselin
edatao
rstatistic
alanalysisavailable
Smith
etal.
(2001)[10]
RCT
2parallelgroup
s
26patie
ntsw
ithchroniclow
back
pain
FM:one
30-m
inute
session
Attentioncontrol
Pain
(McG
ill);
anxiety(STA
I)
FMno
tCredu
cedaffectiv
edimensio
nof
pain
pre-po
st(𝑃=0.04)C
notF
Mim
proved
sensorydimensio
nof
pain
pre/po
sttest(𝑃=0.03)
NSD
fore
valuatived
imensio
nof
pain
oranxiety
Onlyacutee
ffectsw
ere
measured.Ba
selin
edifferences
betweenFM
and
Cin
duratio
nof
back
pain
may
beim
portant
Grubeletal.
(2003)
[11]
RCT
2parallelgroup
s66
patie
ntsw
ithcancer
FM:5×50minutes
sessions
offunctio
nal
integrationin
additio
nto
conventio
nal
therapies
C:no
adjuncttherapy
Body
imageq
uestion
naire
;Frankfurterb
odyc
oncept
scales;
quality
oflife;
senseo
fmovem
ent;andbo
dyaw
areness
Both
grou
psim
proved
inall
outcom
emeasures
Non
significanttrend
favoured
FM
Additio
nalR
CTs
Brow
nand
Kegerreis(1991)
[12]
RCT
2parallelgroup
s
21(12men
and9
wom
en)
volunteers
pain-fr
ee
FM:45m
inaudio
tape
“activatingthe
flexors”lesson
C:listenedto
thes
ame
45min
audiotape
mod
ified
toinclu
deon
lyinstructions
pertaining
toexercise
movem
ents
EMGactiv
ityof
flexorsand
extensors(UL)
Perceptio
nof
effortd
uring
flexion
movem
ent
NSD
Therew
asan
overalldecrease
inmeanflexora
ctivity
with
nochange
inmeanextensor
activ
ityforb
othgrou
ps.
Chinnetal.
(1994)[13]
RCT
2parallelgroup
s
23subjectswith
upperb
ack,neck,
orshou
lder
discom
fort
FM:singleA
TMlesson
;22m
inaudio
tape
C:sin
gles
ham
treatment;30
mins
gentleneck
and
shou
lder
exercises
Functio
nalreach
task;
perceivedeffortd
uringthetask
NSD
Redu
cedperceivedeffortinFM
grou
p(𝑃<0.05)
Smallsam
ples
ize
6 Evidence-Based Complementary and Alternative Medicine
Table3:Con
tinued.
Author
(year)
Stud
ydesig
nSample
Interventio
nCon
trol
Outcome
Results
Com
ments
Laum
eretal.
(1997)[14]
RCT
2parallelgroup
s30
patie
ntsw
itheatin
gdisorder
FM:9-hou
rcou
rse
C:didno
tpartic
ipatein
FM
Body
CathexisS
cale;
Body
PartsS
atisfactio
nScale;
Body
perceptio
n;em
otion
inventory;Ano
rexia-
Nervosa-Inventory
for
Self-Ra
ting;
eatin
gdisorder
inventory-2
FMparticipantsshow
edincreasin
gcontentm
entw
ithregard
toprob
lematiczoneso
ftheirb
odyandtheiro
wnhealth
andacceptance
andfamiliarity
with
theirb
ody
Fullarticlein
German
James
etal.
(1998)[15]
RCT
3parallelgroup
s
48healthy
undergradu
ate
students
FM:4×45-m
inute
sessions
over
2weeks
of4different
ATM
lesson
srecordedon
audiocassette
Relaxatio
n:4×45min
sessions
over
2weeks
listenedto
relaxatio
ntraining
audiocassette
C:no
supervise
dles
sons
Ham
stringleng
th(m
odified
AKE
test)
NSD
Insufficientexp
osure,low
statisticalpo
wer
Hop
pere
tal.
(1999)[16]
Stud
y1:RC
T2parallelgroup
sStud
y2:subsam
pleo
fStudy
1
Stud
y1:75
undergradph
ysio
students
Stud
y2:39
participantsfro
mStud
y1
Stud
y1:FM
:single
ATM,45m
inaudio
cassetteles
son(no
priorF
Mexperie
nce)
Stud
y2:4different
ATM
lesson
sover2
weeks
Stud
y1:C:
listenedto
softno
nverbalm
usic
Stud
y2:sameA
TMles
sons
over
4sessions
in2weeks
when
subjectshadpriorF
Mexperie
nce
Mod
ified
AKE
test(ham
string
leng
th);
Sitand
Reachtest;
Borg’s6–
20ratin
gof
perceivedexertio
n(duringsit
andreachtest)
Stud
y1:NSD
Stud
y2:forp
erceived
exertio
nsig
nificantm
aineffect
𝑃=0.0003.
NSD
others
Inbo
thstu
dies
therew
asa
significantd
ifference
inexertio
nlevelsbetween
males
andfemales
with
males
exertin
gmore
irrespectiveo
fgroup
Koltand
McC
onville
(200
0)[17]
RCT
2parallelgroup
s
54un
dergrad
physiotherapy
studentsw
ithno
priorF
Mexperie
nce
FM:4×45min
ATM
lesson
svia
audiocassette
over
a2-weekperio
d
Relaxatio
n:4×45min
relaxatio
nsessions
via
audiocassette
over
a2-weekperio
dC:
nospecifictasks
over
2-weekperio
d
Bipo
larform
ofthep
rofileo
fmoo
dstates
(POMS-BI)
NSD
Com
posed-anxiou
sscoreso
fthe
POMS-BI
didvary
significantly
over
time(𝑃=0.001)for
all
participants.
Females
inFM
and
relaxatio
ngrou
psrepo
rted
significantly
lower
anxietyscores
atcompletioncomparedwith
control
Nodifferences
betweenFM
andrelaxatio
ngrou
ps
Lowee
tal.
(2002)
[18]
Pseudo
rand
omized,
consecutivea
llocatio
n
60patie
nts
transfe
rred
tono
rmalward
after
acute
treatmentfor
MI
FM:2×30min
individu
alsessions
Relaxatio
n:2×30min
individu
alPM
RC:
nobo
dy-orie
nted
interventio
ns
Body
imageq
uestion
naire
(FKB
-20,German
version);
HospitalA
nxietyand
DepressionScale-German
version(H
ADS-D);
Mun
ichQualityof
Life
Dim
ensio
nsList(M
LDL);
German
versionGeneralized
Self-Effi
cacy
Scale(GSE
S)
NSD
Overallim
provem
entswere
seen
inMLD
L,GSE
S,and
FKB-20
Stephens
etal.
(200
6)[19
]RC
T2parallelgroup
s38
graduate
students
FM:5×15min
ATM
sessions/w
k,audiotapeo
ver
3-weekperio
d
C:regu
lard
aily
activ
ities
AKE
(ham
stringmuscle
leng
th)
Sign
ificant
increase
inhamstr
ing
muscle
leng
th(𝑃=0.005)in
ATM
grou
pcomparedwith
control
Participantsvarie
dgreatly
inthed
urationandnu
mbero
fho
mes
essio
nscompleted
Quinteroetal.
(200
9)[20]
RCT
2grou
p(crossover
desig
nfor
control)
3-to
6-year-old
child
renwith
sleep
brux
ism
FM:3
hrsessions×
10du
ring10-w
eek
perio
dbasedon
ATM
C:no
details
Vario
usmeasureso
fjoint
functio
n;no
cturnalbruxism
Statisticallysig
nificantincreaseo
fCV
Aangle(𝑃=0.0)for
FMc.f.C
.Afte
rintervention77%parentsin
FMrepo
rted
nono
cturnal
brux
ismc.f.15.38%forC
Atbaselin
etwogrou
pswere
comparable
Evidence-Based Complementary and Alternative Medicine 7
Table3:Con
tinued.
Author
(year)
Stud
ydesig
nSample
Interventio
nCon
trol
Outcome
Results
Com
ments
Vrantsidise
tal.
(200
9)[21]
RCT
2grou
ps(crossover
desig
nfor
control)
55participants
aged≥55
years
FM:gettin
ggrou
nded
gracefully
program
(based
onAT
M)2×40–6
0min
sessions/w
kover
8weeks
C:continue
with
usual
activ
ity
Frenchay
Activ
ityIndex;
Hum
anAc
tivity
Profi
le;
Assessm
ento
fQualityof
Life;
Mod
ified
Falls
Efficacy
Scale;
AbbreviatedMentalTestS
core;
four-squ
ares
teptest;
timed
upandgo
test;
theS
tepTest;
Timed
Sit-T
o-StandTest;
ClinicalStrid
eAnalyzer;
force-platform
measureso
fgait,
mob
ility,and
functio
n;satisfactionsurvey
Sign
ificant
effectsforg
aitspeed
(𝑃=0.028)a
ndMod
ified
Falls
Efficacy
Scale(𝑃=0.003)for
FMgrou
p;near
significanteffectfor
timed
upandgo
test(𝑃=0.056)
Positivefeedb
ackfro
msurvey
Nosig
nificantb
aseline
differences
betweengrou
ps.
Highclassa
ttend
ance
Ullm
annetal.
(2010)
[22]
RCT
2grou
ps
47relativ
elyhealthy
independ
ently
living
≥65-year-olds
FM:1
hour
ATM
sessions
3x/w
eekfor
5weeks
(providedby
instr
uctor)
C:waitlist
Falls
Efficacy
Scale;
Activ
ities
SpecificB
alance
Con
fidence
Scale;
timed
upandgo
andTU
Gwith
addedcogn
itive
task;G
AITRite
Walkw
aySyste
m;
tand
emsta
nce
Balance(𝑃=0.030)a
ndmob
ility
(𝑃=0.042)increased
forF
M,
whilst
fear
offalling
decreased
(𝑃=0.042).
Atbaselin
egroup
scomparablee
xceptfor
high
erBM
Iininterventio
ngrou
p
Hilliere
tal.
(2010)
[23]
Pseudo
rand
omized
control
trial
2grou
ps
22healthypeop
lepo
stretire
ment
FM:A
TMclass,
1hr/weekfor8
weeks
C:generic
balancec
lass
1hr/weekfor8
weeks
SF-36;
Patie
ntSpecificF
unctionalScale
(PSFS);tim
edup
andgo
test;
functio
nalreach
test(FRT
);Sing
leLegStance
Time(SL
S);
Walkon
Floo
rEyesc
losed
(WOFE
C)
Sign
ificant
timee
ffectfora
llmeasurese
xceptfor
WOFE
CSign
ificant
improvem
entsforb
oth
grou
psforS
F-36,P
SFS,andFR
T.SL
Sim
proved
FM(𝑃=0.016)
Postho
cind
ividualanalysis
comparis
onsm
ade
Bitte
retal.
(2011)[24]
RCT
3arms
29healthy
university
students
FM1:AT
Mlesson
1×40min,
dominanth
and;
FM2:sameb
utno
ndom
inanth
and
C:relaxatio
nlesson
1×40min
Purdue
Pegboard
Test;
Grip
-lift
test;
subjectiv
echang
es
FM1significantg
roup
bytim
einterventio
neffectw
hen
comparedto
controlgroup
for
dexterity
Nam
bietal.
(2014)
[25]
RCT
3arms
60 institu
tionalized
ageing
peop
le
FM:A
TMclasses
3×6weeks
PI:P
ilatesc
lasses3×6
weeks
C:sham
walking3×6
weeks.
Functio
nalreach
test;
timed
upandgo
test;
Dyn
amic
gaitindex;RA
ND-36forq
uality
oflife
Both
FMandPI
improved
all
measures(𝑃<0.000);C
improved
TUGandDGIo
nly
RCT:
rand
omise
dcontrolledtrial;FM
:Feldenk
raisMetho
d;MS:multip
lesclerosis
;L:left
;R:right;C
:con
trol;pw
:per
week;VA
S:visualanalogue
scale;mCT
SIB:
Mod
ified
ClinicalTestof
SensoryIntegrationand
Balance;NSD
:nosig
nificantd
ifference;STA
I:State/TraitA
nxietyIndex;EM
G:electromyography
;UL:up
perlim
b;AT
M:awarenessthrou
ghmovem
ent(lesson
);min:m
inutes;A
KE:activek
neee
xtensio
ntest;
MI:
myocardialinfarct;P
MR:
progressivem
uscler
elaxation;
c.f.:comparedwith
;SF-36:sho
rtform
36;P
I:Pilates.
8 Evidence-Based Complementary and Alternative Medicine
Rand
om se
quen
ce g
ener
atio
n (s
elect
ion
bias
)
Bitter et al. 2011
Brown and Kegerreis 1991
Chinn et al. 1994
Hillier et al. 2010
Hopper et al. 1999
James et al. 1998
Johnson et al. 1999
Kolt et al. 2000
Laumer et al. 1997
Lundblad et al. 1999
Nambi et al. 2014
Quintero et al. 2009
Ruth and Kegerreis 1992
Smith et al. 2001
Stephens et al. 2001
Stephens et al. 2006
Ullman et al. 2010
Vrantsidis et al. 2009
Allo
catio
n co
ncea
lmen
t (se
lect
ion
bias
)
Blin
ding
of p
artic
ipan
ts an
d pe
rson
nel (
perfo
rman
ce b
ias)
Blin
ding
of o
utco
me a
sses
smen
t (de
tect
ion
bias
)
Inco
mpl
ete o
utco
me d
ata (
attr
ition
bia
s)
Sele
ctiv
e rep
ortin
g (r
epor
ting
bias
)
Oth
er b
iase
s+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
−
−
−
−
Lowe et al. 2002
Grubel et al. 2003
Figure 3: Risk of bias summary: review authors’ judgements abouteach risk of bias item for each included study.
therewas a clear risk of bias (given a red status) orwhether theauthors had simply not stated the process in sufficient detailfor a judgement to be made; hence the risk of bias indicatorwas left blank.
3.5. Effects of Interventions. Sufficiently homogenous data(same population, intervention, comparator, and outcomemeasure) were able to be extracted to performmeta-analysesin the areas of balance training in ageing populations.
Four studies [21–23, 25] reported on the timed up andgo assessment for balance and mobility, just failing to find infavour of Feldenkrais classes (Figure 4(a)); pooling postinter-vention measures gave a mean difference of −0.78 s (95% CI−1.69, 0.13), 𝑃 = 0.09. However, heterogeneity was high (𝐼2 =49%). Therefore, a sensitivity analysis was performed as onestudy by Hillier et al. [23] compared Feldenkrais to anotherbalance class whereas the other three studies compared theFM class to wait list control or no class. Removal of Hillieret al. [23] (Figure 4(b)) revealed a larger effect size with amean difference of −1.13 (95% CI −1.7, −0.56), 𝑃 = 0.0001,and heterogeneity reduced to a negligible level (𝐼2 = 5%). Itwas also noted that Nambi et al. [25] had narrow outcomevariability which led to a heavier weighting in the meta-analysis.
Two studies [21, 22] evaluated balance confidence usingthe Falls Efficacy Scale after FM classes (Figure 5). Pooledresults trended in favour of the FM, however, failed to reachsignificance (MD 0.59, 95% CI −0.08, 1.26; 𝑃 = 0.08).
Two studies [23, 25] evaluated balance using the func-tional reach test after FM classes (Figure 6)—pooled resultsfound in favour of the FM classes (compared to nothingor another generic balance class) with a mean difference of6.08 cm (95% CI 3.41,8.74), 𝑃 < 0.00001.
Meta-analysis was also able to be performed using threestudies measuring the influence of FM classes on hamstringlength in healthy populations [15, 16, 19]. The authors allreported the measure as an active knee extension test; how-ever, on visual inspection, the results appeared heterogeneousin terms of magnitude and range; therefore, a standardizedmean difference (rather than MD) was calculated. No sig-nificant effect was found after the intervention comparedto control (SMD 0.15, 95% CI −0.49, 0.79; 𝑃 = 0.65) andstatistical heterogeneity was unacceptably high (𝐼2 = 73%)(Figure 7).
Single randomised controlled studies reported statisti-cally significant, positive benefits compared to control inter-ventions and included the following:
(i) greater neck flexion and less perceived effort aftera single FM lesson for neck comfort [6]; reducedprevalence of neck pain and disability in symptomaticwomen after FM (individual and group sessionscompared to conventional care or home exercises) [8];reduced perceived effort in FM group for people withupper torso/limb discomfort [13];
(ii) improved balance in people with MS after eight FMsessions [9];
(iii) improved body image parameters in people witheating disorders after a nine-hour FM course [14];
(iv) reduction in nocturnal bruxism in young childrenafter 10-week course of FM lessons [20];
(v) improved dexterity in healthy young adults after asingle session of FM class [24].
Seven of the 20 studies failed to show any superior posi-tive effects of FM compared to other comparison modalities.See Table 3 for details. No studies reported adverse events.
Evidence-Based Complementary and Alternative Medicine 9
Study or subgroup
Total (95% CI)
Mean
7.0615
11.5312.15
SD
1.721
4.062.9
Total
11202526
82
Mean
6.9216.1
11.5114.34
SD
0.881
4.134.3
Total
11202229
82
Weight
29.2%43.1%11.8%15.9%
100.0%
IV, random, 95% CIFeldenkrais Control Mean difference Mean difference
IV, random, 95% CI
0 5 10Favours Feldenkrais Favours control
−10 −5Heterogeneity: 𝜏2 = 0.40; 𝜒2 = 5.90, df = 3 (P = 0.12); I2 = 49%Test for overall effect: Z = 1.67 (P = 0.09)
0.14 [−1.00, 1.28]−1.10 [−1.72, −0.48]0.02 [−2.33, 2.37]
−2.19 [−4.11, −0.27]
−0.78 [−1.69, 0.13]
Hillier et al. 2010Nambi et al. 2014Ullman et al. 2010Vrantsidis et al. 2009
(a)
Study or subgroup
Total (95% CI)
Mean
7.0615
11.5312.15
SD
1.721
4.062.9
Total
11202526
71
Mean
6.9216.1
11.5114.34
SD
0.881
4.134.3
Total
11202229
71
Weight
81.7%7.4%
10.9%
100.0%
IV, random, 95% CI
Not estimable
Feldenkrais Control Mean difference Mean differenceIV, random, 95% CI
Favours Feldenkrais Favours control0 5 10−10 −5
−1.10 [−1.72, −0.48]0.02 [−2.33, 2.37]
−2.19 [−4.11, −0.27]
−1.14 [−1.78, −0.49]
Heterogeneity: 𝜏2 = 0.03; 𝜒2 = 2.10, df = 2 (P = 0.35); I2 = 5%Test for overall effect: Z = 3.45 (P = 0.0006)
Hillier et al. 2010Nambi et al. 2014Ullman et al. 2010Vrantsidis et al. 2009
(b)
Figure 4: (a) Effect sizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance and mobility). (b) Effectsizes of Feldenkrais versus control for the timed up and go test (measured in seconds; balance andmobility) withHillier 2010 removed (controlgroup was alternate balance class).
Study or subgroup
Total (95% CI)
Mean9.6
8.63
SD1.71.6
Total2526
51
Mean9.357.73
SD1.71.9
Total2229
51
Weight
47.4%52.6%
100.0%
IV, random, 95% CIFeldenkrais Control Mean difference Mean difference
IV, random, 95% CI
Favours control Favours Feldenkrais
0.25 [−0.72, 1.22]0.90 [−0.03, 1.83]
0.59 [−0.08, 1.26]
0 5 10−10 −5Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 0.90, df = 1 (P = 0.34); I2 = 0%Test for overall effect: Z = 1.73 (P = 0.08)
Ullman et al. 2010Vrantsidis et al. 2009
Figure 5: Effect sizes of Feldenkrais versus control for the Falls Efficacy Scale (balance confidence).
Study or subgroup
Total (95% CI)
Mean31.8936.7
SD3.982.7
Total1120
31
Mean27.6229.6
SD4.974.7
Total1120
31
Weight
36.2%63.8%
100.0%
IV, random, 95% CI4.27 [0.51, 8.03]7.10 [4.72, 9.48]
6.08 [3.41, 8.74]
Feldenkrais Control Mean difference Mean differenceIV, random, 95% CI
Favours control Favours Feldenkrais0 5 10−10 −5
Heterogeneity: 𝜏2 = 1.43; 𝜒2 = 1.55, df = 1 (P = 0.21); I2 = 36%Test for overall effect: Z = 4.47 (P < 0.00001)
Hillier et al. 2010Nambi et al. 2014
Figure 6: Effect sizes of Feldenkrais versus control for the functional reach test (measured in cm; balance).
10 Evidence-Based Complementary and Alternative Medicine
Study or subgroup
Total (95% CI)
Mean
20.933.5149
SD
11.12.417.4
Total
751418
107
Mean
21.534.4
141.8
SD
13.72.567.6
Total
751715
107
Weight
41.6%29.4%29.0%
100.0%
IV, random, 95% CIFeldenkrais Control Std. mean difference Std. mean difference
IV, random, 95% CI
0 1 2Favours control Favours Feldenkrais
−0.05 [−0.37, 0.27]−0.35 [−1.07, 0.36]0.94 [0.21, 1.66]
0.15 [−0.49, 0.79]
−2 −1Heterogeneity: 𝜏2 = 0.23; 𝜒2 = 7.31, df = 2 (P = 0.03); I2 = 73%Test for overall effect: Z = 0.46 (P = 0.65)
James et al. 1998Stephens et al. 2006
Hopper et al. 1999
Figure 7: Effect sizes of the Feldenkrais Method on the active knee extension test.
4. Discussion
4.1. Summary of Main Results. The majority of the 20included studies reported significant positive effects of FM ina variety of populations and outcomes of interest. A high riskof bias/poor methods reporting does temper the interpreta-tion of these findings.The low amount of confirmed/reportedadherence to best practice conduct of RCTs may be partiallyattributable to the age of the studies when knowledge in thearea of trial conduct was less.
Neverthelessmeta-analyses in the area of balance trainingin ageing populations were found in favour of the FM classesfor clinical measures such as the timed up and go andfunctional reach tests. Both of these measures are predictiveof falls risk. Whilst the TUG effect size was probably notclinically significant (1- to 2-second change), the functionalreach test effect size would arguably indicate a clinicallymeaningful change (able to reach further 6 cm).
Given the positive effects in particular outcome domainsit is interesting to speculate on themechanism of action of theFM; however, it is to be noted that this was not the purpose ofthe review. The favourable evidence for reduced perceptionsof effort, improved dexterity, improved comfort and reducedbruxism all support the proposed mechanism of action viapromotion of awareness, relaxation andmore efficient action.Inconsistent results were found for improving hamstringslength indicating that a “relaxation” effect may be variable.
The populations varied in age and diagnosis indicatingthat a beneficial effect is possible across different domains;again this is consistent with the use of the FM in diversepopulations and also consistent with the notion that it is nota healing or disease-specific mechanism of action but ratherone based on more generic learning and self-improvement.
The findings of this updated review have strengthenedsince the 2005 review by Ernst and Canter [4]. We were alsoable to locate studies prior to 2005 that were not found by theoriginal SR authors, presumably due to improved databaseaccess. As the previous authors reported, the studies arestill highly varied and of often questionable quality. Thereis an ongoing issue of poor reporting, resulting in risksbeing judged “unclear”; it is unknown whether this hidesundeclared risk or is simply an omission of reporting.
This review is not without its own limitations.This reviewincludes all trials aimed at improving health and/or function
so we have trials of healthy individuals as well as peoplewith a clinical presentation.We have not included an analysisof publication bias, though we are confident that by usingexperts in the field and checking grey literature (organi-zational websites) we have made every effort to captureunpublished (negative) trials. We attempted to account forstatistical heterogeneity and can conclude that the analysis forthe timed up and go ismore robust with the removal ofHillieret al. [23] (Figure 4(b)) because the comparator group differsfrom the other studies (alternate balance class versus nointervention) and secondly this studywas pseudorandomized(allocation based on enrolment day).The question of inactivecontrols is vexed and permissible when proof of conceptor pilot/phase 1 trials are being conducted. We encouragereaders to take the stage of research and the design intoaccount in their interpretation.
4.2. Implications for Practice. There is promising evidencethat FM may be considered for balance classes in ageingpopulations, both as a preventative approach and for peopleat risk of falls. There is also some evidence for the use of FMwhere reduced effort, efficiency of movement, and awarenesscan play a part in reducing pain or discomfort.
4.3. Implications for Research. Further high quality researchis required comparing FM to other modalities. Investigationsshould focus on the impact on self-efficacy, functional inde-pendence, and ease and efficiency of functioning, both asstrategies for promotion of wellness and wellbeing and alsofor people with impairment who wish to improve their senseof ease. Mechanisms of effect also need to be investigated.Particular attention needs to be paid to the reporting of bestpractice trial design and to controlling for a potential placeboeffect.
5. Conclusions
There is further promising evidence that the FM may beeffective for a varied population interested in improvingfunctions such as balance. Careful monitoring of individualimpact is required given the varied evidence at a group leveland the relatively poor quality of studies to date.
Evidence-Based Complementary and Alternative Medicine 11
Disclosure
Funding was from professional bodies involved in promotingFM but the bodies were not involved in the conduct of thereview other than to identify experts within their member-ship to identify any missed/unpublished trials.
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper.
Authors’ Contribution
Anthea Worley conducted the search and preliminary inclu-sions. Both authors contributed to the review of all papersand constructed the final report. One of the authors (SusanHillier) was also author for two included studies; these wereindependently scrutinized.
Acknowledgments
The authors wish to acknowledge the financial assistanceof the Australian Feldenkrais Guild and the InternationalFeldenkrais Federation in supporting the costs of the searchand appraisal.
References
[1] M. Feldenkrais, Awareness through Movement: Health Exercisesfor Personal Growth, Arkana, London, UK, 1990.
[2] K. A. Connors, M. P. Galea, C. M. Said, and L. J. Remedios,“Feldenkrais Method balance classes are based on principlesof motor learning and postural control retraining: a qualitativeresearch study,” Physiotherapy, vol. 96, no. 4, pp. 324–336, 2010.
[3] P. A. Buchanan and B. D. Ulrich, “The Feldenkrais Method:a dynamic approach to changing motor behaviour,” ResearchQuarterly for Exercise and Sport, vol. 72, no. 4, pp. 315–323, 2001.
[4] E. Ernst and P. H. Canter, “The feldenkrais method—a system-atic review of randomised clinical trials,” Physikalische MedizinRehabilitationsmedizin Kurortmedizin, vol. 15, no. 3, pp. 151–156,2005 (German).
[5] D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and ThePRISMA Group, “Preferred reporting items for systematicreviews and meta-analyses: the PRISMA statement,” PLoSMedicine, vol. 6, no. 7, Article ID e1000097, 2009.
[6] S. Ruth and S. Kegerreis, “Facilitating cervical flexion using aFeldenkrais method: awareness through movement,” Journal ofOrthopaedic and Sports Physical Therapy, vol. 16, no. 1, pp. 25–29, 1992.
[7] S. K. Johnson, J. Frederick, M. Kaufman, and B. Mountjoy,“A controlled investigation of bodywork in multiple sclerosis,”Journal of Alternative and Complementary Medicine, vol. 5, no.3, pp. 237–243, 1999.
[8] I. Lundblad, J. Elert, and B. Gerdle, “Randomized controlledtrial of physiotherapy and Feldenkrais interventions in femaleworkers with neck-shoulder complaints,” Journal of Occupa-tional Rehabilitation, vol. 9, no. 3, pp. 179–194, 1999.
[9] J. Stephens, D. DuShuttle, C. Hatcher, J. Shmunes, and C.Slaninka, “Use of awareness through movement improves bal-ance and balance confidence in people withmultiple sclerosis: arandomized controlled study,” Neurology Report, vol. 25, no. 2,pp. 39–49, 2001.
[10] A. Smith, G. Kolt, and J. McConville, “The effect of theFeldenkraismethod on pain and anxiety in people experiencingchronic low back pain,”NewZealand Journal Physiotherapy, vol.29, no. 1, pp. 6–14, 2001.
[11] R. Grubel, G. Erbacher, and A. Larisch, “Die wirksamkeitder feldenkrais-methode bei krebs-betroffenen,” Erfahrung-sheilkunde, vol. 52, no. 02, pp. 71–83, 2003 (German).
[12] E. Brown and S. Kegerreis, “Electromyographic activity oftrunk musculature during a Feldenkrais awareness throughmovement lesson,” Isokinetics and Exercise Science, vol. 1, no. 4,pp. 216–221, 1991.
[13] J. Chinn, D. Trujilo, S. Kegerreis, and T. Worrel, “Effect of aFeldenkrais intervention on symptomatic subjects performinga functional reach,” Isokinetics and Exercise Science, vol. 4, no.4, pp. 131–136, 1994.
[14] U. Laumer, M. Bauer, M. Fichter, and M. Helmut, “Thera-peutische Effekte der Feldenkrais-Methode ’Bewusstheit durchBewegung’ bei Patienten mit Essstorungen [Therapeutic effectsof the Feldenkrais Method (Awareness through Movement) ineating disorders],” Psychotherapie Psychosomatik MedizinischePsychologie, vol. 47, no. 5, pp. 170–180, 1997 (German).
[15] M. James, G. Kolt, J. McConville, and P. Bate, “The effects of aFeldenkrais program and relaxation procedures on hamstringlength,” Australian Journal of Physiotherapy, vol. 44, no. 1, pp.49–54, 1998.
[16] C. Hopper, G. S. Kolt, and J. C. McConville, “The effects ofFeldenkrais awareness throughmovement on hamstring length,flexibility, and perceived exertion,” Journal of Bodywork andMovement Therapies, vol. 3, no. 4, pp. 238–247, 1999.
[17] G. S. Kolt and J. C. McConville, “The effects of a Feldenkrais(ATM) Awareness Through Movement program on state anxi-ety,” Journal of Bodywork and MovementTherapies, vol. 4, no. 3,pp. 216–220, 2000.
[18] B. Lowe, K. Breining, S. Wilke, R. Wellmann, S. Zipfel, andW. Eich, “Quantitative and qualitative effects of Feldenkrais,progressive muscle relaxation, and standard medical treatmentin patients after acute myocardial infarction,” PsychotherapyResearch, vol. 12, no. 2, pp. 179–191, 2002.
[19] J. Stephens, J. Davidson, J. DeRosa, M. Kriz, and N. Saltzman,“Lengthening the hamstring muscles without stretching using‘awareness through movement’,” Physical Therapy, vol. 86, no.12, pp. 1641–1650, 2006.
[20] Y. Quintero, C. C. Restrepo, V. Tamayo et al., “Effect ofawareness through movement on the head posture of bruxistchildren,” Journal of Oral Rehabilitation, vol. 36, no. 1, pp. 18–25, 2009.
[21] F. Vrantsidis, K. D. Hill, K. Moore, R. Webb, S. Hunt, andL. Dowson, “Getting grounded gracefully: effectiveness andacceptability of feldenkrais in improving balance,” Journal ofAging and Physical Activity, vol. 17, no. 1, pp. 57–76, 2009.
[22] G. Ullmann, H. G. Williams, J. Hussey, J. L. Durstine, andB. A. McClenaghan, “Effects of feldenkrais exercises on bal-ance, mobility, balance confidence, and gait performance incommunity-dwelling adults age 65 and older,” Journal of Alter-native and Complementary Medicine, vol. 16, no. 1, pp. 97–105,2010.
12 Evidence-Based Complementary and Alternative Medicine
[23] S. Hillier, L. Porter, K. Jackson, and J. Petkov, “The effects ofFeldenkrais classes on the health and function of an ageingAustralian sample: pilot study,”TheOpen Rehabilitation Journal,vol. 3, no. 1, pp. 62–66, 2010.
[24] F. Bitter, S. Hillier, and L. Civetta, “Change in dexterity withsensory awareness training: a randomised controlled trial,”Perceptual and Motor Skills, vol. 112, no. 3, pp. 783–798, 2011.
[25] G.Nambi, P. S. Trivedi, S.M.Momin, S. Patel, andD. P. Pancholi,“Comparative effect of Pilates and Feldenkrais intervention onfunctional balance and quality of life in ambulatory geriatricpopulation: a randomized controlled study,” International Jour-nal of Health Sciences and Research, vol. 4, no. 3, pp. 71–77, 2014.
[26] J. P. T. Higgins and S. Green, Eds., Cochrane Handbook forSystematic Reviews of Interventions Version 5.1.0, The CochraneCollaboration, 2011, http://www.cochrane-handbook.org/.
Submit your manuscripts athttp://www.hindawi.com
Stem CellsInternational
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Disease Markers
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014
Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014
Parkinson’s Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com