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Quantitative and Qualitative Effects of Feldenkrais, Progressive Muscle Relaxation, and Standard Medical Treatment in Patients After Acute Myocardial Infarction

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This short-term study examined the effectiveness of the Feldenkrais method of functional integration and of progressive muscle relaxation (PMR) compared with the standard medical treatment during the acute phase after myocardial infarction. Three patient groups (n = 20 each) received 1 of 3 treatment options: 2 sessions of Feldenkrais therapy, 2 sessions of PMR, or no intervention. Evaluations using quantitative and qualitative methods were performed an average of 3.7 and 7.8 days after subjects' myocardial infarction, respectively. Significant improvements, independent of the intervention, were found over the evaluation period in the Perception of Body Dynamics body image scale and in the Physical Well-Being and Emotional Well-Being quality-of-life scales. A statistically significant, differential effect of any one intervention with respect to the control group did not arise in any of the quantitative questionnaire variables examined. However, subjective improvements of varying description were noted by 17 of 20 patients after the 1st Feldenkrais therapy and by 13 of 20 patients after the first PMR treatment. Although the therapeutic doses were probably too small to illustrate a significant effect on the self-rating methods, the qualitative patient statements support using the Feldenkrais method or PMR for particular cases in an acute medical setting and continuing treatment during rehabilitation or on an outpatient basis.
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Psychotherapy Research 12(2) 179–191, 2002
© 2002 Society for Psychotherapy Research
QUANTITATIVE AND QUALITATIVE EFFECTS OF
FELDENKRAIS, PROGRESSIVE MUSCLE RELAXATION,
AND STANDARD MEDICAL TREATMENT IN PATIENTS
AFTER ACUTE MYOCARDIAL INFARCTION
Bernd Löwe
Katja Breining
Stefanie Wilke
Renate Wellmann
Stephan Zipfel
Wolfgang Eich
Department of General Internal and Psychosomatic Medicine,
University of Heidelberg, Medical University Hospital, Heidelberg, Germany
We thank our colleagues at the Medical University Hospital, Heidelberg, for their support, and all the
patients whose contributions made this study possible.
Correspondence concerning this article should be addressed to Bernd Löwe, Department of General
Internal and Psychosomatic Medicine, University of Heidelberg, Medical Hospital, Bergheimer Straße
58, D–69115 Heidelberg, Germany. E-mail: bernd_loewe@med.uni-heidelberg.de.
179
This short-term study examined the effectiveness of the Feldenkrais method
of functional integration and of progressive muscle relaxation (PMR) com-
pared with the standard medical treatment during the acute phase after
myocardial infarction. Three patient groups (n = 20 each) received 1 of 3
treatment options: 2 sessions of Feldenkrais therapy, 2 sessions of PMR,
or no intervention. Evaluations using quantitative and qualitative meth-
ods were performed an average of 3.7 and 7.8 days after subjects’ myo-
cardial infarction, respectively. Significant improvements, independent of
the intervention, were found over the evaluation period in the Percep-
tion of Body Dynamics body image scale and in the Physical Well-Being
and Emotional Well-Being quality-of-life scales. A statistically significant,
differential effect of any one intervention with respect to the control group
did not arise in any of the quantitative questionnaire variables examined.
However, subjective improvements of varying description were noted by
17 of 20 patients after the 1st Feldenkrais therapy and by 13 of 20 pa-
tients after the first PMR treatment. Although the therapeutic doses were
probably too small to illustrate a significant effect on the self-rating meth-
ods, the qualitative patient statements support using the Feldenkrais
method or PMR for particular cases in an acute medical setting and con-
tinuing treatment during rehabilitation or on an outpatient basis.
There is hardly a physical event that interferes so suddenly with the subjective body
experience as an acute myocardial infarction (MI). Severe pain, dyspnea, and fear of
death precede hospital admission, with all the accompanying diagnostic and thera-
180 LÖWE ET AL.
peutic measures, followed by immobilization and the interruption of customary so-
cial and work-related activities. Despite these extensive physical and psychosocial
restrictions, opportunities for body-oriented, psychological interventions, which strive
to promptly overcome the psychosomatic changes after an MI, are available only for
those patients in emergency hospitals in the initial phase after an MI. Such interven-
tions are impeded in emergency hospitals because the short periods of stay do not
allow for continuous patient care. The average length of stay after an MI is, for ex-
ample, in the University Hospital Heidelberg, 2.5 days in intensive care followed by
about 9 days on a normal ward.
Reflecting this situation, the existing studies on body-orientated psychological in-
terventions or relaxation techniques after MI address only the rehabilitation phase and
not the acute phase. These studies describe positive effects of relaxation techniques
with respect either to frequency of hospital admission and cardiac events over a
5-year period (van Dixhoorn & Duivenvoorden, 1999) or to psychological variables
such as anxiety or depression (Collins & Rice, 1997; van Dixhoorn, Duivenvoorden,
Pool, & Verhage, 1990) and physical parameters such as heart rate, blood pressure,
breathing rate, and cardiovascular reactivity in response to stress (Cole, Pomerleau, &
Harris, 1992; Collins & Rice, 1997; van Dixhoorn, 1998). To our knowledge, the only
study conducted during the acute phase did not demonstrate any significant effects
from two 30-min sessions of listening to recorded relaxation instructions and classical
music in patients with unstable angina pectoris or a recent MI (Elliott, 1994). These
results, however, were criticized by the author because of the shortness of the inter-
vention and the limited sample size.
Progressive muscle relaxation (PMR) is the predominant body-oriented method
both in rehabilitation after MI and in the studies described previously (e.g., Jacobson,
1938; Ohm, 1992; Olschewski, 1994). This technique centers on gradually gaining
the voluntary control of certain muscle groups through targeted contraction and re-
laxation of individual muscle groups. Muscle tension can be substantially reduced
through alternated contraction and relaxation, in which muscular and cognitive pro-
cesses are key. Once the technique is sufficiently mastered, muscular relaxation brings
about a subjective feeling of relaxation. The efficiacy of PMR is well substantiated by
follow-up studies of different patient groups, such as those suffering from headaches
and hypertension in terms of psychological variables (e.g., anxiety and depression)
and physiological variables (e.g., blood pressure and pulse rate; Carlson & Hoyle,
1993).
Studies on the effects of other relaxation therapies or body-oriented interven-
tions after MI are rare. For example, no studies have been published in the last 15
years that examine the effects of “autogenic training” (e.g., Eberlein, 1987; Schultz,
1928), or of “functional relaxation” (e.g., Fuchs, 1989) in patients after an MI. Whereas
the role of psychosocial factors in the engendering of an MI is widely accepted
(Hermann-Lingen, 2000), conducting body-oriented interventions in patients after MI
may also have secondary prevention aspects. It is also worth noting that functional
relaxation has been shown to have a positive effect on airway obstruction in asthma
patients (Loew, Siegfried, Martus, Tritt, & Hahn, 1996).
Body-oriented therapies using the Feldenkrais method (Feldenkrais, 1949; Russell,
1999) have been offered in our clinic for the past few years. The treatments occur in
either individual or in group settings. The course of individual treatment, used in
this study for patients after a MI, is termed “functional integration.” The course of
group therapy, based on the same principles, is termed “awareness through move-
ment.” The method is usually performed with the patient lying down in a comfort-
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 181
able position, not bothered by physical distractions such as pain sensations. In the
individual setting, passive movements are conducted by the patient with the aid of
the Feldenkrais tutor. The tutor gets the individual patient settled and begins the
lesson with the smallest possible movements. The patient does not need to expend
any energy against gravity. According to the underlying theory, reducing the motor
stimuli to a minimum increases the sensitivity to a maximum (Feldenkrais, 1949). In
this way, the patient’s own, possibly restricted, movement patterns can be perceptu-
ally discriminated, and alternative movement patterns can be developed. The pa-
tient can thus regain the ability to select an appropriate pattern of movement to suit
the situation. By working on his or her physical posture and learning new patterns
of movement, the patient should develop the ability to react in a flexible way to
everyday situations. The posture is interpreted as the expression of the subjective
psychological condition. Changes in physical posture serve to reach the goal of de-
veloping not only motor freedom but also inner freedom and freedom on the behav-
ioral level as well. The Feldenkrais method, by means of physical awareness, ultimately
aims to clarify, complete, and differentiate the body image and thus to influence
movement, sensory perception, cognition, emotions, and behavior.
In our experience and according to clinical studies, the method is well accepted
by patients and readily practiced (Klinkenberg, 1996a, 1996b; Olbrich, Kern, Burkhard,
Hupfer, & Strotkötter, 1997). However, controlled studies examining the efficiency
of this method in MI patients are lacking. The few studies investigating the effects of
the Feldenkrais method by means of a control group design almost exclusively use
the group setting (awareness through movement). One control group study on mul-
tiple sclerosis patients receiving more than 8 weeks of Feldenkrais therapy showed
a reduction in anxiety and a reduced perception of stress. The disease symptoms and
the physical level of function remained unchanged, however (Johnson, Frederick, &
Mountjoy, 1999). Laumer, Bauer, Fichter, and Milz (1997) based their study on fe-
male eating-disorder patients and, for the patients of Feldenkrais group, showed an
increasing contentment with the problem areas of their own bodies, a greater accep-
tance of their bodies, and a decline in feelings of helplessness. Olbrich et al. (1997)
also showed in psychosomatic rehabilitation inpatient members of a Feldenkrais group
a more positive assessment of their body image in comparison to a control group.
As a result of encouraging clinical experience with the Feldenkrais method and
the lack of existing studies, we wanted to investigate specifically the efficacy of the
Feldenkrais method during the acute phase after an MI compared with both the more
frequently used PMR and a control. Special attention was paid to the development
of depression in patients because a depressive symptomatology after acute MI is now
considered to be an independent risk factor for cardiovascular mortality over the
course of the disease (Ariyo et al., 2000; Frasure-Smith et al., 2000; Welin, Lappas, &
Wilhelmsen, 2000), quality of life (Mayou et al., 2000), and compliance (Ziegelstein
et al., 2000). The second independent variable studied was patient anxiety, because
anxiety-reducing effects are to be expected from both PMR and the Feldenkrais
method, and this variable is also likely to exhibit an effect on the postinfarct process
(Januzzi, Stern, Pasternak, & DeSanctis, 2000). Body image was also incorporated as
a possible theoretical and empirical measure of the body-oriented relaxation tech-
niques. Quality of life was taken as a general outcome parameter. Because the
Feldenkrais method explicitly aims to develop and adopt new behavioral alterna-
tives, the patients’ perceived self-efficacy was also studied.
This study was limited to being a short-term intervention study with a low “thera-
peutic dose” because of the short inpatient stays in the admitting hospital. To portray
182 LÖWE ET AL.
the specific therapeutic effects of the Feldenkrais method meaningfully, a comparison
was made with (a) a control group not receiving body-oriented interventions and (b)
a second group receiving an established body-oriented method at the same frequency
and intensity. The PMR method was chosen as the second intervention because of the
proven efficacy of this method. This design—two intervention groups and a control
group—should permit the identification of method-specific effects. We chose a design
that contained quantitative and qualitative methods equally because the assumption
that the existing questionnaire scales exhaustively cover the specific, subjective thera-
peutic effects was not met. Several issues were formulated:
1. To date, not all of the available assessment methods have been applied to a
sample group of patients shortly after an MI. Therefore, the reliability of these
methods, in terms of internal consistency, should be checked at two evalua-
tion times: before or after the intervention period.
2. Any improvement during the treatment period with respect to changing body
image, anxiety, depression, quality of life, and perceived self-efficacy should
be investigated in patients after a recent MI. As the patients on a normal ward
became increasingly more active and mobile, we expected positive changes
even within the short time span of a few days. Differential therapeutic effects
were expected in that the groups of patients receiving either Feldenkrais or
PMR therapy would show significant improvement over the control group in
the areas of body image, anxiety, depression, quality of life, and perceived
self-efficacy. The empirical and theoretical bases of the two intervention
methods are not, however, sufficient to formulate sound hypotheses in favor
of either of the two methods. The comparison of the Feldenkrais group with
the PMR group was, therefore, conducted as a hypothesis-generating estima-
tion of the extent and type of therapeutic effects.
3. Using a qualitative interview with open answer options, certain questions
should be investigated such as the patients’ previous experiences, how ac-
ceptable the method is, whether and how the patients subjectively profited,
and their interest in pursuing the method. By way of response frequency in
certain answer categories, it should also be examined whether patients in the
Feldenkrais group or the PMR group described positive, subjective effects of
the treatments more than expected by chance (null hypothesis: positive and
negative comments occur with the same frequency).
Methods
Participants
The study group was composed of patients at the Medical University Hospital,
Heidelberg who were transferred to a normal ward from intensive care after acute
treatment for MI. The patients were informed about the study on the normal ward
and were included after giving written consent. Sixty patients were consecutively
assigned to the Feldenkrais group (n = 20), the PMR group (n = 20), or the control
group (n = 20). Nine patients declined to take part before the start of the study (13%
of the total). No patients declined further treatment once the study was in progress.
Table 1 shows the age, gender, length of stay, and the most important sociodemo-
graphic characteristics of the two intervention groups and the controls. The three
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 183
study groups were identical with respect to gender distribution and were not signifi-
cantly different in terms of age, length of admission, profession, and family status.
Procedure
After granting their consent, all patients were given the initial questionnaire. This
first evaluation point was, on average, 3.7 days (SD = 1.4 days) after the MI. The inter-
vention groups each received two approximately 30-min individual treatments according
to the functional integration Feldenkrais method or PMR. The first treatment occurred
the day after the initial evaluation point and the second treatment 2 days later. Ques-
tionnaires were again distributed on the day after the second treatment, and an inter-
view was conducted (second evaluation point). The second evaluation point was on
average 7.8 days (SD = 1.8 days) after MI. No body-oriented interventions were con-
ducted on the control group, although the evaluation points were the same as for the
intervention groups. All patient groups received the usual medical and physiotherapy
treatments prescribed for patients after MI, independent of the study.
Psychological Assessment
To describe the subjective body image of the patients, we used the Body Image
Questionnaire (FKB-20; Clement & Löwe, 1996; Löwe & Clement, 1996; original
TABLE 1. Sociodemographic Data
Feldenkrais PMR Control
Variable (n = 20) (n = 20) (n = 20) pa
Age (years)
M63.1 63.1 65.0 0.81
SD 10.5 11.8 9.8
Length of stay on normal ward (days)
M8.6 8.7 9.1 0.77
SD 1.9 2.9 2.6
nnnp
Gender
Female 4 4 4 Idem
Male 16 16 16
Professional qualification
Apprenticeship 7 5 8
Craftsman/technical school 9 5 8 0.37
Technical college/university 1 6 2
No graduation 3 4 2
Marital status
Single/no partner 1 0 0
Married 16 15 13
Divorced/separated 1 1 2 0.88
Widow/widower 1 3 4
Stable relationship 1 1 1
aThe group differences were calculated using one-way analysis of variance according to the general
linear model (age, length of stay) or using Fisher’s exact test (gender, professional qualification, marital
status).
184 LÖWE ET AL.
German version: Fragebogen zum Körperbild), which assesses the body image by
means of the two dimensions designed by factor analysis: negative evaluation of the
body and perception of body dynamics. The stability of the factor construction as
well as good internal consistency and good clinical validity were demonstrated in
replicated studies.
The assessment of anxiety and depression was conducted using the Hospital
Anxiety and Depression Scale–German version (HADS-D; Hermann, Buss, & Snaith,
1995). Extensive clinical experience and validation results exist for this short ques-
tionnaire (14 items), which was devised especially for use in somatic medicine
(Hermann, 1996).
The patients’ quality of life was standardized with the Munich Quality of Life
Dimensions List (MLDL; Heinisch, Ludwig, & Bullinger, 1988). The two subscales,
Physical Well-Being and Emotional Well-Being, were selected from this question-
naire because they most easily covered the relevant areas of quality of life in the
early phase after MI.
Because one of the postulated effects of the Feldenkrais method is an improved
self-efficacy, this was assessed in patients at both evaluation points using the Ger-
man version of the Generalized Self Efficacy Scale (Schwarzer & Jerusalem, 1993).
This scale has been proven to be sensitive with respect to measurement of changes.
A qualitative interview was conducted at the second evaluation point so that the
assessment was not limited to the fixed scope of an a priori questionnaire. This in-
terview was composed of 21 questions, with open answer options, on previous ex-
periences, expectations, misgivings, perceptions, and desires of the patients, as well
as the acceptance of the treatments the patients received. Additionally, questions
regarding treatment satisfaction were posed. The untreated control group was only
asked about their satisfaction with the inpatient treatment.
Analyses
Scale reliability was calculated at both evaluation points as internal consistencies
(Cronbach’s a coefficients) for the total sample population. In addition to a descriptive
presentation of the scale statistics, repeated measures analyses of variance (ANOVA;
Class III design) were conducted, which represent changes over time and the differen-
tial therapeutic effects in terms of significant interactions (SAS Institute, 1994a, 1994b).
Evaluation of the qualitative interviews occurred in four successive steps, which relied
on the concept of qualitative content analysis by Mayring (1995). The statistical com-
parison of the frequency in special answer categories was performed using Fisher’s
exact test or chi-square test (SAS Institute, 1994a, 1994b). For the sake of brevity, only
a selection of the most important results from the qualitative analyses are presented
here (for a comprehensive presentation, see Breining, 2000).
Results
Quantitative
Table 2 shows the internal consistencies of the questionnaires used at both evalu-
ation points: before and after the intervention phase. Cronbach’s a coefficients ranged
from .76 to .93 and can, therefore, be considered good. As such, the use of our ques-
tionnaires in our sample population after MI was deemed justified.
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 185
Table 3 shows the quantitative results of body image, anxiety, and depression at
both evaluation points. Also shown is the respective repeated measures ANOVA.
Significant changes, in terms of improvement, over the 4-day evaluation period were
only seen with the body image scale Perception of Body Dynamics (FKB-20). No
significant changes were found in the areas of anxiety (HADS) and depression (HADS).
Significant group effects or interactions that would have indicated differential thera-
peutic effects could not be demonstrated for any variable.
TABLE 2.Reliability of the Scales Used (Internal Consistency)
Evaluation point 1 Evaluation point 2
Variable (N = 60) (N = 60)
Body Image Questionnaire
Negative Evaluation of the Body 0.77 0.81
Perception of Body Dynamics 0.88 0.87
Hospital Anxiety and Depression Scale
Anxiety 0.79 0.81
Depression 0.78 0.76
Munich Quality of Life Dimensions List
Physical Well-Being 0.78 0.82
Emotional Well-Being 0.89 0.88
Generalized Self-Efficacy Scale
Generalized Self-Efficacy 0.92 0.93
aCronbach’s a coefficient.
TABLE 3. Quantitative Results on Body Image, Anxiety, and Depression
FKB-20 HADS-D
Negative evaluation Perception of
of the body body dynamics Anxiety Depression
Feldenkrais (N = 20)a
Evaluation point 1 18.4 ± 6.5 29.5 ± 9.4 6.9 ± 4.0 6.1 ± 4.4
Evaluation point 2 17.6 ± 5.5 30.4 ± 9.0 7.6 ± 4.8 5.8 ± 3.8
PMR (N = 20)a
Evaluation point 1 17.6 ± 6.9 28.5 ± 9.8 5.2 ± 3.4 4.6 ± 3.5
Evaluation point 2 17.6 ± 6.0 30.3 ± 8.7 5.5 ± 3.6 5.1 ± 3.4
Control (N = 20)a
Evaluation point 1 19.0 ± 7.2 26.5 ± 6.2 4.6 ± 2.9 5.5 ± 3.4
Evaluation point 2 18.9 ± 6.8 27.8 ± 7.1 4.8 ± 3.8 5.1 ± 3.7
ANOVA with repeated measurements
Fp Fp Fp Fp
Time (df = 57) 0.25 ns 7.70 ** 2.59 ns 0.06 ns
Time × group (df =57) 0.17 ns 0.33 ns 0.47 ns 0.97 ns
Group (df = 2) 0.27 ns 0.66 ns 2.64 ns 0.48 ns
Note. FKB-20 = Body Image Questionnaire; HADS-D = Hospital Anxiety and Depression Scale; ns = not
significant; ANOVA = analysis of variance.
aValues represent mean ± standard deviation.
*p < .05. **p < .001. ***p < .0001.
186 LÖWE ET AL.
Table 4 shows the results with respect to quality of life and self-efficacy in the
three sample groups. The ANOVA demonstrated improvements in the Physical Well-
Being (MLDL), Emotional Well-Being (MLDL), and the Generalized Self-Efficacy Scales.
Significant interactions in terms of differential therapeutic progress or group differ-
ences also were not shown with these scales.
Qualitative
To demonstrate the results of the qualitative analyses, we concentrated on a
comparative representation of the three sample populations (n = 20 patients each).
First, a categorization system for answers to the individual questions was set up because
of the open nature of the patients’ answers. The results are described according to
the topic areas of the interview questions.
Previous experience, misgivings, and expectations. The 60 patients had very little
previous experience with body-oriented interventions and relaxation techniques.
Autogenic training was familiar to 7 of the study patients, and only 1 patient had
previous experience of either the Feldenkrais method or PMR. None of the patients
had any kind of misgiving before the start of the intervention. Similarly, the majority
in both intervention groups (n = 14 per group) had no concrete expectations.
Treatment experiences. After the first therapy session, 17 Feldenkrais group pa-
tients felt subjectively better, 2 experienced no change, and 1 felt worse. After the second
session, a majority of patients (n = 16) felt subjectively better and 4 were indifferent.
According to our study protocol, the control group received no treatment, and so the
TABLE 4. Quantitative Results on Quality of Life and Self-Efficacy
Munich Quality of Life Generalized
Dimensions List (MLDL) Self-Efficacy Scale
Physical Emotional Generalized
Well-Being Well-Being Self-Efficacy
Feldenkrais (N = 20)
Evaluation point 1 30.2 ± 3.4 22.6 ± 13.6 30.0 ± 7.8
Evaluation point 2 34.1 ± 12.8 26.6 ± 12.3 30.6 ± 7.4
PMR (N = 20)
Evaluation point 1 31.3 ± 7.2 24.0 ± 8.4 28.8 ± 6.9
Evaluation point 2 33.8 ± 6.6 25.2 ± 8.4 30.7 ± 7.6
Control (N = 20)
Evaluation point 1 33.8 ± 7.8 28.3 ± 8.7 30.8 ± 4.9
Evaluation point 2 37.8 ± 7.2 29.6 ± 7.7 32.1 ± 4.9
ANOVA with repeated measurements
Fp Fp Fp
Time (df = 57) 24.96 *** 9.58 ** 13.32 **
Time × group (df = 57) 0.56 ns 1.71 ns 1.08 ns
Group (df = 2) 0.95 ns 1.34 ns 0.36 ns
Note. ANOVA = analysis of variance; ns = not significant.
*p < .05. **p < .001. ***p < .0001.
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 187
incidences of subjective change in the intervention groups could only be evaluated
by comparison to a random distribution (null hypothesis). With respect to the random
distribution, the positive effects were significantly more frequent after the first as well
as the second therapy sessions (Fisher’s exact test: ps < .001). For the PMR method, 13
patients reported a clear improvement after the first therapy session and 7 experienced
no change. After the second session, 12 patients reported an improvement and 8 pa-
tients described no change. The PMR group also reported positive effects after both
therapy sessions that were more frequent than by chance alone (Fisher’s exact test: ps
< .05). A direct comparison of the two intervention methods did not yield any signifi-
cantly different appraisal with respect to the effects of the two therapy sessions.
Subjective effects of the treatments. Regarding how patients noticed feeling better
or worse,1 the Feldenkrais patients reported that they felt more lighthearted (n = 8),
more relaxed (n = 5), more easy going (n = 4), or warm (n = 3). Furthermore, a posi-
tive effect on mood (n = 6) or an improvement in the disease symptoms (n = 3) were
reported. Patients in the PMR group similarly described improvement in the disease
symptoms (n = 3), a feeling of relaxation (n = 3), or a comfortable feeling (n = 3). The
total number of positive answers given was significantly greater in the Feldenkrais group
than the PMR group (ns = 45 and 25, respectively, c2 = 5.7, p < .05).
Interest in pursuing the treatment. Sixteen Feldenkrais group patients would have
liked to continue the treatment after discharged. Two patients were indifferent, and
2 patients showed no interest. For the PMR group, 9 patients wished to continue
treatment, 4 were indifferent, and 7 declined further treatment. The desire to con-
tinue treatment was greater than by chance alone in the Feldenkrais group (Fisher’s
exact test: p < .05); this effect could not be demonstrated for the PMR group.
Inpatient treatment. The factors contributing to improvement in the state of health
during inpatient treatment were essentially the same for both intervention groups and
the control group. The most important factor in all three groups was a friendly and
competent staff. The second, again in all groups, was proficient medical treatment.
Discussion
In this study, we presented the effects of the Feldenkrais method functional in-
tegration, or PMR, in comparison with a control group for three homogeneous sample
groups of 20 patients each after recent MI. Thus, we provide the first investigation of
the efficacy of the Feldenkrais method using a design comprising two intervention
groups and a control group. Moreover, this is also the first study to investigate the
effects of the Feldenkrais method and PMR in the early stages (not the rehabilitation
phase) after MI. Performing the study in an admitting hospital, with an average inpa-
tient stay of 9 days on a normal ward, permitted only a short intervention period and
low intervention frequency. The sample groups can be considered representative of
patients in the acute phase after MI because there was no patient preselection be-
fore inclusion in the study and only a minimum number who declined (13%). Good
1Multiple answers were possible. Here we only report the answer categories mentioned by patients at
least three times.
188 LÖWE ET AL.
internal consistencies were demonstrated for the scales chosen for use (FKB-20, HADS,
MLDL, and Generalized Self-Efficacy Scale).
In this short-term study of two evaluation points at 3.7 and 7.8 days after re-
cent MI, progressive improvements were observed, particularly in physical- and
activity-related areas, specifically, the dynamic and health-related aspects of the
body image, quality of life (physical and emotional), and generalized self-efficacy.
These improvements corresponded well to increasing mobility after MI. Although
a near-total imobilization existed at the first evaluation point (sitting on the edge
of the bed, cautious standing up), the majority of patients were again almost com-
pletely mobile and independent (unassisted walking, extensive freedom of move-
ment) at the second evaluation point. In contrast, no improvement could be shown
when appraising anxiety and depression. Obviously, these areas are more stable
and less influenced by partially regained autonomy during the course of health
stabilization after MI.
A differential therapeutic effect, which demonstrated the advantage of the Feldenkrais
method or PMR over the control group, could not be shown by the quantitative analysis
of the questionnaire results. Thus, the sole consideration of the questionnaire results
yielded a similar picture to that of the study by Elliott (1994), in which significant
beneficial effects in patients with unstable angina pectoris or recent MI could not be
shown from two 30-min tape recordings of relaxation instructions and classical music.
To explain the absence of efficacy proof for the Feldenkrais method or PMR in our
study, as in the study mentioned previously, the low therapeutic dose of two ses-
sions and the short evaluation interval of 4 days should be taken into consideration.
These two factors were predetermined by the short inpatient period in our institu-
tion and parallel the situation in other admitting hospitals. It is also possible that the
predetermined questionnaire scales were not suitable for demonstrating the specific
effects of the interventions.
The results of the qualitative interviews are important in the further interpreta-
tion of the overall results. It was apparent that the patients had only limited previous
experience and no misgivings concerning the methods employed in this study. Sub-
jectively, most of the patients in both the Feldenkrais and the PMR groups felt better
after the treatments. The Feldenkrais patients classified this improvement as light-
heartedness, a sense of being more easy-going, relaxation, warmth, mood improve-
ment, and a reduction in symptoms. The subjective intervention effects described by
the patients in the PMR group were overall less differentiated and significantly less
frequent. The majority of patients in the Feldenkrais group expressed a desire for
continued and more frequent treatment after discharge. Taken together, the qualita-
tive analyses showed that the patients very likely profited subjectively from the
Feldenkrais method and also, although to a lesser extent, from PMR. Because the
patients were able to describe the subjective effects very well, it appears that these
effects go beyond those of general attentive care.
Looking at both the qualitative and quantitative methods, it seems that patients,
in general, are ready to accept the offer of treatment without reservation. The lack of
observed, differential, therapeutic effects of the Feldenkrais method or PMR can be
attributed primarily to the low therapeutic dose. The beneficial subjective use, as
reported by the patients, suggests that for individual cases therapy with PMR or the
Feldenkrais method should already be initiated in an acute medical setting. A con-
tinuation of therapy should then be undertaken preferably during rehabilitation or
on an outpatient basis. Further studies are necessary to investigate the efficiency of
these methods under acute inpatient, rehabilitation, and outpatient conditions.
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 189
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Zusammenfassung
Diese Studie überprüft in einem Kurzzeitdesign die Wirksamkeit der Feldenkrais-Methode “Funktionale
Integration” und der Progressiven Muskelrelaxation (PMR) im Vergleich zur medizinischen Standard-
behandlung in der Akutphase nach Myokardinfarkt. Drei Interventionsgruppen zu je N=20 Patienten
erhielten entweder zweimalige Feldenkrais-Therapie, zweimalige Progressive Muskelrelaxation oder keine
Intervention. Die Erhebungen mittels quantitativer und qualitativer Methoden fanden durchschnittlich 3,7
Tage und 7,8 Tage nach Myokardinfarkt statt. Signifikante Verbesserungen über den Messzeitraum fanden
sich unabhängig von den Interventionen in der Körperbildskala “Vitale Körperdynamik” (FKB-20) sowie
in den Lebensqualitätsskalen “Physis” und “Psyche” (MLDL). Ein statistisch signifikanter differentieller Effekt
zugunsten einer Intervention gegenüber der Kontrollgruppe ergab sich bei keiner der untersuchten
quantitativen Fragebogenvariablen. In den qualitativen Interviews gaben 17 von 20 Patienten nach der
ersten Feldenkraisintervention bzw. 13 von 20 Patienten nach der ersten PMR-Intervention subjektive
Besserungen an, die differenziert beschrieben wurden. Auch wenn die Therapiedosis vermutlich zu gering
war, um einen signifikanten Effekt auf den Selbstratinginstrumenten abzubilden, ermutigen die qualitativen
Patientenangaben dazu, im Einzelfall mit der Feldenkrais-Methode bzw. der Progressiven Muskelrelaxation
im akutmedizinischen Setting zu beginnen und im Rehabilitations- bzw. ambulanten Bereich fortzusetzen.
Résumé
Cette brève expérience a examiné l’efficience de la méthode Feldenkrais d’intégration fonctionnelle et
de relaxation musculaire progressive (PMR) comparées avec un traitement médical standard en phase
aigue suite à un infarctus du myocarde. Trois groupes de patients (n = 20 chacun) ont bénéficié d’une
des trois options thérapeutiques: 2 séances de Feldenkrais, 2 séances de PMR, ou aucune intervention.
Les évaluations quantitatives et qualitatives étaient effectuées à 3.7 resp. à 7.8 jours, en moyenne, après
l’infarctus. Des améliorations significatives indépendamment de l’intervention ont été trouvées, au cours
de la période d’évaluation, à l’échelle d’image corporelle (Perception of Body Dynamics) et aux échelles
de qualité de vie (Physical Well-Being et Emotional Well-Being). Un effet différentiel statistiquement
significatif d’une des interventions par rapport au groupe contrôle ne s’est montré dans aucune des
variables des questionnaires quantitatifs examinées. Cependant, des améliorations subjectives, décrites
de façon variée, ont été relevées par 17 des 20 patients après le premier traitement Feldenkrais et par
EFFECTIVENESS OF TREATMENTS IN MI PATIENTS 191
13 des 20 après le premier traitement PMR. Même si les doses thérapeutiques étaient probablement
trop petites pour montrer un effet significatif sur les échelles d’auto-évaluation, les avis subjectifs des
patients sont encourageants pour commencer par les méthodes Feldenkrais ou PMR, dans des cas
particuliers, dans le setting médical aigu et pour continuer le traitement en réhabilitation ou en
ambulatoire.
Resumen
Esta breve experiencia comparó la efectividad del método Feldenkrais de integración funcional y de
relajación muscular progresiva (PMR) con el tratamiento médico estándar de la fase aguda del infarto
de miocardio. Tres grupos de pacientes (n = 20 cada uno) recibieron uno de tres tratamientos: dos
sesiones de terapia Feldenkrais, dos sesiones de PMR o ninguna intervención. Las evaluaciones por
medio de métodos cuanti y cualitativos se efectuaron, en promedio, entre 3.7 y 7.8 días después del
infarto, respectivamente. Se encontraron mejorías significativas, independientes de la intervención,
durante el período de evaluación en la escala de imagen corporal de la Percepción de la dinámica
corporal y en las escalas de Bienestar físico y de Bienestar emocional. En ninguna de las variables de
los cuestionarios cuantitativos de las intervenciones se registró efecto diferencial estadísticamente
significativo respecto del grupo de control. Sin embargo, diecisiete de los veinte pacientes notaron
mejorías subjetivas diversas luego de la primera terapia Feldenkrais y trece de veinte pacientes luego
del primer tratamiento PMR. Si bien las dosis terapéuticas fueron probablemente demasiado pequeñas
para mostrar un efecto significativo en los métodos de autoevaluación, las declaraciones cualitativas de
los pacientes estimularon a comenzar con el método Feldenkrais o con el PMR en casos particulares en
hospitales de agudos y a continuar el tratamiento durante la rehabilitación o en externación.
Received February 14, 2001
Revision received August 28, 2001
Accepted October 11, 2001
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Zusammenfassung Herzerkrankungen sind seit jeher auch auf psychische Ursachen zuruckgefuhrt worden. Aufgrund ihrer auserordentlichen gesundheitspolitischen Bedeutung hat insbesondere die koronare Herzkrankheit (KHK) grose wissenschaftliche Beachtung gefunden. Einer kaum mehr uberschaubaren Fulle von Publikationen zu ihren somatischen, psychischen und sozialen Entstehungsbedingungen steht ein eklatanter Mangel an integrativer Verarbeitung der Einzelbefunde gegenuber. Die vorliegende Arbeit gibt einen kurzen Uberblick uber den aktuellen Stand der Forschung zur KHK-Psychogenese. Entgegen dem vorherrschenden Versuch, jeweils voneinander unabhangige psychische beziehungsweise soziale Risikofaktoren zu identifizieren, betont sie die Bedeutung dynamischer biopsychosozialer Prozesse, die letztlich in die manifeste Koronarerkrankung munden. Der Beitrag skizziert Moglichkeiten der Integration klinischer und empirischer Befunde in einem bio-psycho-soziodynamischen Modell. Dieses durchaus erweiterungsfahige Modell ka...
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Based on the movement-pedagogical concept of Feldenkrais and the findings of disturbed body perception by eating disordered patients this research aimed at studying the therapeutical effects of the Feldenkrais Method 'Awareness through Movement' with eating disorder patients. 15 eating disordered patients treated at the Roseneck hospital for behavioural medicine rated - by means of a questionnaire consisting of scales of the Body Cathexis Scale (BCS), the Body Parts Satisfaction Scale (BPSS), the questionnaire for body perception (Fragebogen zum Korpererleben; FKE), the Emotion Inventory (Emotionalitatsinventar; EMI-B), the Anorexia-Nervosa-Inventory for Self-rating (ANIS) and the Eating Disorder Inventory-2 (EDI) - various aspects of their eating disorder before and after participating in a nine hour course of the Feldenkrais Method. The data of these patients were compared to those of the members of a control group, also consisting of 15 eating disordered patients who did not participate in a Feldenkrais course. The participants of the Feldenkrais-course showed increasing contentment with regard to problematic zones of their body and their own health as well as concerning acceptance and familiarity with their own body. Other results were a more spontaneous, open and self-confident behaviour, the decrease of feelings of helplessness and decrease of the wish to return to the security of the early childhood, which indicates the development of felt sense of self, self-confidence and a general process of maturation of the whole personality. The outcome points to the therapeutical effectiveness of the Feldenkrais Method with eating-disorder patients within a multimodal treatment program.