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Submission: December 14, 2016; Published: January 03, 2017
*Corresponding author: Susanna Maddali Bongi, Department of Experimental and Clinical Medicine, Division Rheumatology, University of Florence, Largo Brambilla 3, 50134 Florence, Italy, Tel: +39-055-2751868; E-mail: email@example.com
How to cite this article: Maddali Bongi S, Piemonte G, El Aoufy K, Landi M. Feldenkrais-Core Integration Method In Patients With Ankylosing Spondylitis:
A Pilot Study. J Complement Med Alt Healthcare. 2017; 1(2): 555556.
Background: It is widely accepted that rehabilitation combined with pharmacological approach could improve pain, spinal mobility and functional status in ankylosing spondylitis (AS). Feldenkrais-Core Integration (FCI) method is a mind body therapy based on low impact exercises focusing on better body organization, postural re-education and balance improvement.
Aims:Our aim was to assess in a pilot study the utility and feasibility of FCI approach in the treatment of AS.
Setting: Outpatient Clinic of the Division of Rheumatology, Department of Experimental and Clinical Medicine, University of Florence.
Methods: Ten AS patients were recruited to perform a FCI physiotherapic program of 10 supervised group sessions (60 min, twice a week). Clinic and clinimetric measurements including pain, fatigue, global health status (VAS), disease effect on wellbeing (BAS-G), functional status (BASFI, HAQ-S), disease activity (BASDAI), enthesitis (MASES) and anthropometric measurements of lumbar mobility and cervical mobility were assessed at baseline (t=0) and at the end of the study (t=1). At t=1 patients’ satisfaction, attendance rate and attrition rate were assessed. Only descriptive statistics was performed.
Results:Our results showed improvements in pain, fatigue, global health status, BAS-G, BASFI, HAQ-S, MASES, BASDAI, lumbar lateral flexion and cervical range of motion (cervical forward flexion, extension, lateral flexion and rotation) at the end of the study compared to the baseline. Greater improvements in percentage are found in pain, fatigue, self perceived health status, functionality and tenderness on enthesial sites. No dropouts were registered
Keywords: Ankylosing spondylitis; Rehabilitation; Mind body therapies; Feldenkrais-core integration
Abbrevations: AS: Ankylosing Spondylitis; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; BASFI: Bath Ankylosing Spondylitis Functional Index; BAS-G: Bath Ankylosing Spondylitis Global Score; CI: Core Integration; CNS: Central Nervous System; FCI: Feldenkrais-Core Integration; FFD: Finger Floor Distance; GPR: Global Posture Reeducation; HAQ-S: Health Assessment Questionnaire-Spondyloarthropathies; ISTAP: The Institute of Postural Analysis, Florence, Italy; MASES: Maastricht Ankylosing Spondylitis Enthesitis Score; MBT: Mind Body Therapies; NRS: Numerical Rating Scale; OSWDQ: Oswestry Low Back Pain Disability Questionnaire; SF36: Short Form 36 Health Survey; TNF: Tumor Necrosis Factor; VAS: Visual Analogue Scale; WDI: Waddell Disability Index
Ankylosing spondylitis (AS) is a chronic, progressive, immuno-inflammatory disease that predominantly affects the sacroiliac joints and the whole spine . AS may be associated with extra-spinal manifestations, such as peripheral arthritis, uveitis, and cardiovascular complications with functional impairment , disability and poor quality of life . The estimated prevalence in european-caucasian population ranges from 0.1 to 1.4 , in Italy is about 0.37% . AS is mainly characterized by chronic
inflammatory sacroiliac pain, spinal stiffness, loss of motility of the spine and serious postural abnormalities.
Postural changes associated with AS include loss of lumbar lordosis, accentuation of the thoracic kyphosis, inversion of cervical lordosis and hip flexion . Such condition may affect the global functional status and social wellbeing restricting interpersonal communication and basic activities of daily living . Moreover, fixed thoracolumbar hyperkyphosis induces the forward and downward shift of the body’s centre of mass with
respect to the base of support. Consequently in AS patients the
extension of the hips, flexion of the knees and plantar flexion of
the ankles occur to maintain balance .
AS subjects may have balance alterations associated with
poor posture, joint deformities, muscle atrophy and pain . The
reduction of the range of movement of the head and neck may
worsen balance problems hampering gaze stability .
The primary goal in the treatment of AS patients is to
reduce pain and inflammation, to prevent permanent structural
damages, and to maintain the highest possible functional status
and health related quality of life.
ASAS/EULAR recommendations for the management of
ankylosing spondylitis state that the optimal management
of AS requires a combination of pharmacological and nonpharmacological
treatments. TNF blocker agents have been
shown to improve significantly spinal pain, function and
peripheral joint arthritis in the short term and in the long term
follow up in patients with persistently high disease activity
despite conventional therapies . Non pharmacological
treatment include patient education and exercise both
individually and in groups . Patient education and behavioral
therapy seem to improve anxiety and motivation, but there are
no evidences of their effectiveness on disease’s symptoms and
disability. Individual and group exercises play an important role
in all stages of the disease owing to associated improvements
in function and pain. Global assessment is better in AS patients
involved inphysiotherapic group treatments . Although
benefits of combination treatment including rehabilitation and
TNF inhibitors are well described in literature [13,14] current
evidence shows that a specific exercise protocol has not been
validated yet .
Feldenkrais-Core Integration (FCI) method developed by
Josef Della Grotte  derives from Feldenkrais® method
principles  and integrates them with the my ofascialchain
concepts . The concept of myofascial chain originates from
the assumption that the muscles of the human body do not
function as independent units. Instead, they are regarded as part
of a tensegrity-like, body-wide network, with fascial structures
acting as linking components .
Feldenkrais® method is a movement pedagogy designed to
improve function in activities of daily living, work and recreation
through an increasing awareness about movement habits, as well
as to find alternative ways of using the body . Feldenkrais®
method aims to help people become self-directed learners
through specific use of sensimotor experiences and exploratory
processes of moving .
FCI approach emphasizes the importance of postural
re-education, balance improvement and promotes active
involvement of the patient in the rehabilitation program. It
provides for a global approach in order to take care of the overall
health of a patient, treating not only the districts affected, but
the whole musculoskeletal system. FCI offers a new mapping
system to re-organize movements and to remove incorrect
Although clinical studies focused on the efficacy of FCI in AS
patients are still lacking, many authors show beneficial effects
of Feldenkrais® method in improving balance  and mobility
 and in reducing pain (VAS - Visual Analogue Scale) 
and disability (WDI- Waddell Disability Index)  in patients
with chronic low back pain . A tailored FCI intervention in
posturopatic patients improved significantly the global postural
score and had positive effects both on tonic postural state and
dynamic postural parameters . The sum of twenty-five
postural parameters, assessed applying the ISTAP (The Institute
of Postural Analysis, Florence, Italy) diagnostic protocol, affords
the global postural score. Postural parameters were evaluated
with a specific kinematic examination in addition to the
assessment of static and dynamic forces while walking .
Based on these results, we hypothesized that FCI may have
positive effects on signs and symptoms of spondyloartrhitis.
Therefore in this pilot study the main aim was to evaluate the
utility of FCI method in the treatment of AS patients, focusing
on pain, fatigue, global health status, disability, spinal range of
motion and disease activity.
Ten AS patients, 5 men and 5 women, were recruited,
consecutively from January 2016 to June 2016, from the
outpatient clinic of the Division of Rheumatology, Department
of Experimental and Clinical Medicine, University of Florence.
Inclusion criterion was the diagnosis of ankylosing spondylitis
according to modified New York criteria . Patients recruited
signed a written informed consent for all the procedures in
accordance with Helsinki Declaration of 1975/83. The study was
approved by local Ethical Committee.
All patients continued their pharmacological treatments and
throughout the period of the study they were asked not to start
any new pharmacological and non pharmacological therapy.
AS patients were included in a FCI physiotherapic program
of 10 sessions (maximum 5-6 participants) each lasting about
60 minutes, twice a week. The lessons were conducted by a
physiotherapist (LM) who is experienced and trained in FCI
method. The physiotherapic protocol included home exercises
chosen by the therapist and tailored on the patient, performed
daily (30minutes/day) during the whole treatment period.
FCI intervention has at least three functional and structural
A. Better body organization and postural equilibrium;
B. Greater efficiency and energy conservancy;
C. Greater kinetic energy by gathering potential energy in
The main assumption of this training is that central nervous
system (CNS) can best track and organize efficient movement
when there is a recognition of clear direction to, and perceived
connection with, functional-structural pathways. The process
leads to static and dynamic equilibrium through muscular and
myofascial integration. Core integration method has identified
and mapped six core movement pathways to describe and
account for the transmission of forces in any biomechanical
system. The core pathways are a mapping construct of how the
body system organizes itself through movement for appropriate
The pathway used is defined with the following concepts:
A. It contains a vector of force, direction, and myofascial
tensegrity; it passes through the center of gravity and
represents the most efficient expenditure of energy
B. It has specific anatomical features and can be tracked
through specific joint angles, actions of levers, muscle chains
and fascial tensile spread
C. It requires lengthening by virtue of mechanical levering
and the physiology of myofascial actions
D. Muscles in the sequential contracting-lengthening phase
stimulate tensile fascial spread [15,26].
In each lesson the FCI approach consisted in:
A. Core integration (CI) group exercises aimed at
strengthening deep muscle, improving body flexibility and
stability. They consist in an application of a movement map
based on six core movement pathways which enables the
patient to organize movements with better efficiency and
less expenditure of energy.
B. Feldenkrais®-based Awareness Through Movement
group lessons aimed at gaining control of how the body
system organizes itself through movement and constructing
correct motor patterns. The key is in identifying the paths,
assessing movement and posture, tracking how movement
is transmitting, and determining through client response
whether CNS receives and fixes the image [15,26].
C. The lessons were sequential, and each lesson dealt with
themes from the previous session. FCI kinetic protocol would
be interrupted in case of clinical worsening (increased pain,
stiffness or fatigue).
D. The exercise program proposed is further detailed in
At baseline (t=0), patients were evaluated for demographic
characters (sex, age), disease duration and type of joint
involvement. Presence of sacroiliac pain, arthritis, enthesitis,
thoracic pain, dactylitis and uveitis was also assessed. Previous
physiotherapy treatments and sportive activities were evaluated.
All patients were assessed by clinic and clinimetric tools at t=0 and
at the end of the study (t=1) for pain, fatigue, global health status,
effect of AS on patients’ wellbeing, functional status, disability,
disease activity and enthesitis. Anthropometric measurements
of lumbar and cervical mobility were also documented. At the
end of the physiotherapic treatment (t=1) patients’ satisfaction,
attendance rate and attrition rate were assessed.
A. Pain was rated with an auto-administered Visual
Analogue Scale (VAS 0-10), which measures current pain
intensity on a 0-10 scale (0 = no pain, 10 = worst pain ).
B. Fatigue was rated with an auto-administered Visual
Analogue Scale (VAS 0-10), which measures current fatigue
intensity on a 0-10 scale (0 = no fatigue, 10 = worst fatigue).
B. Fatigue was rated with an auto-administered Visual
Analogue Scale (VAS 0-10), which measures current fatigue
intensity on a 0-10 scale (0 = no fatigue, 10 = worst fatigue).
Disease effect on wellbeing was rated by Italian version of
Bath Ankylosing Spondylitis Global Score (BAS-G) which asks
patients to indicate the effect of AS on their well-being over
the last week and the last 6 months, using a 100 mm horizontal
visual analogue scale, where none = 0 and very severe = 100. The
mean of the two scales affords the BAS-G score a value between 0
and 100, with a lower score indicating less disease burden .
Functional status was rated by Italian version of Bath
Ankylosing Spondylitis Functional Index (BASFI) which is
composed by ten questions elaborated to determine the degree
of functional limitation in patients with AS. Each question is
answered using an 11-points numerical rating scale (NRS),
with a recall period of the past week. The mean of the ten scales
affords the BASFI score a value between 0 and 100, with a lower
score indicating less functional limitation [29,30].
Disability was rated by Italian version of Health Assessment
Questionnaire-Spondyloarthropathies (HAQ-S) which is a selfreport
questionnaire referring to global disability, ranges from 0
(no difficulty) to 3 (unable to do) .
Disease activity was rated by Italian version of Bath
Ankylosing Spondylitis Disease Activity Index (BASDAI) which
has six 11-points NRS to measure the severity of fatigue, spinal
and peripheral joint pain, localized tenderness, and morning
stiffness in patients with AS. Each item is provided using a 0-100
horizontal NRS, to extremes the adjectival descriptors “none”
and “very severe”. Item six (duration of morning stiffness) is
related to a time scale (0-2 h). The mean of items five (severity of
morning stiffness) and six is calculated separately. The BASDAI,
a number from 0 to 100, is obtained with the mean of this result
with the previous four items. Lower scores are indicating lower
disease activity. The cut-off of four is used to define the presence
of an active disease .
Enthesitis was documented by Maastricht Ankylosing
Spondylitis Enthesitis Score (MASES) which evaluates the
presence or the absence of tenderness in 13 enthesial sites
Tenderness on physical examination is recorded as either
present (1) or absent (0) for each of the 13 sites, for an overall
score range of 0 -13 .
A. Forward flexion was documented by Schöber test and
finger floor distance (FFD).
Schöber test - Two reference points (spinous process of L5
and 10 cm above) were marked on the patients’ low back
region while they stood in erect position with feet together.
Then the patients bent maximally forward and the new
distance between the upper and lower marks was measured.
Distances of 14.5-15 cm are considered normal . FFD
- The patients bent maximally forward trying to touch the
floor. The distance between fingers and floor was reported
B. Lateral flexion - The patients bent laterally to the right
and to the left. The distance between fingers and floor was
reported for each side (cm).
Patient satisfaction with physiotherapic treatment was
evaluated with a questionnaire measuring seven items (self
perceived wellbeing, pain and stiffness reduction, movement
fluency and easiness, enjoyableness of the physiotherapic
program and willingness to continue the treatment) each one
rated with an auto-administered Visual Analogue Scale (VAS),
reporting the measure on a 0-10 scale (0 =no satisfaction, 10
=best satisfaction). The overall satisfaction, a number from 0 to
70, is obtained summing VAS scores of the previous seven items.
Lower scores are indicating lower satisfaction. Attendance rate
was reported as total hours of patients’ attendance/total hours
patients’ treatment ratio (%); Attrition rate was reported as
Dropouts/Patients recruited ratio (%).
Descriptive statistics for nominal data were expressed in
percentages. Continuous variables were described as mean and
standard deviation (M±SD). To assess improving parameters over
the period of study differences between means and percentage
changes were evaluated (SPSS statistical package, version 20.0
for Windows, SPSS, Chicago, USA).
Ten AS patients, 5 men and 5 women, were enrolled and
assessed. Their baseline characteristics are summarized in
Table 2. The differences between the means of the clinical
and clinimetric evaluations at t=0 and at t=1 show that FCI
physiotherapic sessions had positive effects on pain, fatigue,
global health status, BAS-G, BASFI, HAQ-S, BASDAI, MASES,
lumbar (lateral flexion) and cervical mobility (flexion/extension,
lateral flexion and lateral rotation of the head) (Table 3). The
adherence to FCI physiotherapic program was complete. No
dropouts were registered. The attendance rate was 78,6%. The
patients’ satisfaction score was 58,0 ± 6,75.
AS is a systemic, chronic rheumatic disease that predominantly
affects axial skeleton with severe sacroiliac pain and impaired
spinal mobility leading to disability  and reduced quality of
life . Modifications in spinal posture begin at early stages of
the disease and become more marked over the time  and
account for balance problems . The optimal management of
AS requires a combination of tailored pharmacologic and nonpharmacologic
interventions aiming at treating inflammation
and pain, preventing structural deformities, increasing spinal
motion [10,12] and improve overall function and quality of
life . Despite the evidences about the effectiveness of
physiotherapy in AS, a specific physical exercise protocol has not
been established yet .
Global Posture Reeducation (GPR) method, a form of
active overall muscle stretching working on strengthening and
improving flexibility of specific muscle chains offered promising
results in restoring spinal mobility (BASMI) and functional
capacity (BASFI) in AS patients group sessions managed
by a trained physiotherapist . GPR group intervention
demonstrated to maintain improved parameters after 6 months
and one year follow-up . GPR individual treatment in AS
showed significantly greater improvement in morning stiffness
duration, spinal mobility parameters (chin to chest distance,
occiput to wall distance, cervical rotation, modified Schöber
test ), chest expansion and self perceived physical wellbeing
(SF36 - Short Form 36 Health Survey ) than the control group
treated with segmental stretching and breathing exercises .
Pilates body conditioning method, a well known formula
of over 500 physical exercises focusing on stretching and
strengthening body core muscles  was suggested as a
beneficial exercise therapy in patients with musculoskeletal
spinal problems increasing proprioceptive balance (Stork stand
test) and flexibility (Sit and reach test) , reducing disability
(OSWDQ - Oswestry Low Back Pain DisabilityQuestionnaire
) and pain intensity (VAS) [48,49]. In AS patients Pilates
showed positive outcomes on chest expansion, Bath Ankylosing
Spondylitis Metrology Index (BASMI) and BASDAI in a short term
follow up, and significant improvements of functional status and
BASMI after 6 months compared to the baseline .
In a recent study involving early AS patients in a specific
McKenzie kinetic program aimed at assessing and treating
spinal and postural problems, significant improvements in pain,
metrology (BASMI, FFD, chest expansion, modified Schöber test),
function (BASFI) and disease activity (BASDAI) were registered
compared to the baseline and to the control group . Moreover
a specific protocol combining McKenzie, Pilates & Heckscher
 conducted in a group setting and followed by a maintaining
home exercise regimen registered significantly beneficial effects
on pain, spinal mobility, BASDAI, BASMI and chest expansion in
AS patients .
Aquatic exercises have been used for many years in the
treatment of musculoskeletal conditions. In this context
hydrotherapy effectiveness is widely reported . The
benefits of aquatic exercise arise from the physiological effects
of immersion and hydrodynamic principles of exercise in the
aquatic environment [55-57]. An in-patient rehabilitation
program including hydrotherapy, basic exercises for movement,
muscle strength and stability, balance and coordination improved
disease activity (BASDAI), spinal mobility (BASMI, FFD), chest
expansion and gait velocity (6m gait velocity test) in AS patients
. A randomized trial exploring three exercise regimens in AS
showed beneficial effects of hydrotherapy on pain and stiffness.
However any significant improvement was found at 6 months
follow up .
Feldenkrais Core Integration method is a somatic
rehabilitation technique with low physical impact and few side
effects. FCI is counted among mind body therapies (MBT) and is
focused on gaining perception and body awareness in order to
recognize and correct abnormalities such as muscle contractions
and posture misalignments and consequently to reduce antalgic
and non functional posture. Several studies demonstrate that
MBT, increasing the abilities of the mind to influence body
characteristics and disease symptoms, are effective and useful
in the rehabilitation of chronic rheumatic patients, especially in
improving function, pain and reducing social and psychological
problems [60-63]. Despite their potential utility, few MBT were
evaluated in AS.
The present study is the first aimed at assessing the
feasibility and the utility of Feldenkrais Core Integration method
in the treatment of AS. Our results showed improvements in pain,
fatigue, global health status, BASDAI, BAS-G, BASFI, MASES, HAQ-S,
lumbar lateral flexion and cervical range of motion (cervical
forward flexion, extension, lateral flexion and rotation) at the end
of the study compared to the baseline. Greater improvements
in percentage are found in pain, fatigue, self perceived health
status, functionality and tenderness on enthesial sites. This
suggests the utility of FCI in improving flexibility and movement
fluency and in re-organizing body schemas trying to eliminate
antalgic postures. Effects on clinimetric parameters were
scanty probably due to the short duration of the physiotherapic
interventions and the exiguous number of sessions performed.
Moreover the wide range of disease duration in our sample may
explain the different response to the therapy and may affect the
results of the study.
FCI method provides for a global approach and focuses on the
close relationships between mental and somatic dimensions .
Therefore it allows to reach physical and emotional well-being
and to increase the patient’s overall health. Our results seemed
to confirm these concepts, in fact the greatest improvement in
percentage was found in self perceived global health status.
FCI, characterized by low physical impact approach, is
always respectful of the pain threshold. These latter guarantees
a high adherence to the rehabilitation program and reduces the
probability of dropouts. In fact in our study no dropouts were
registered and the patients’ satisfaction was adequate.
Owing the exploratory nature of the present study, the
small sample size and the short term intervention, inferential
statistical tests were not performed. Further investigations on
wider cohorts of patients and longitudinal design are required
to confirm the utility of FCI as an important rehabilitation tool
Feldenkrais Core Integration method is a movement based
MBT with potential effects on muscle contractures, pain and
stiffness. Its global approach recognizes the interactions between
mind and body in supporting health and allows the patients
to achieve physical and psychological wellbeing. The present
study showed that FCI approach may be a useful and feasible
non-pharmacologic approach in the treatment of patients with
ankylosing spondylitis. FCI had positive effects on pain, fatigue,
global health status, disease activity, functional status and
enthesitis. Our results should be validated by prospective studies
with larger sample size.