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Alternative Therapies

Several older reports have suggested an association between dry eye disease (DED) and migraine headaches. Researchers at the Univercity of North Carolina at Chapel Hill just published a large and convincing study confirming this comorbidity.

This was a retrospective study which included 72,969 patients older than 18 years seen over a period of 10 years. The study included 41,764 men and 31,205 women. Of these, 5,352 patients (7.3%) were diagnosed to have migraine headaches and 9,638 (13.2%) had the diagnosis of DED. The odds of having DED and migraine headaches was 1.4 times higher than that of patients without migraine headaches. This association was true for men and women older than 65 and women of all ages. Older age and female sex are both risk factors for the development of DED, probably due to hormonal and age-related changes.

The incidence of migraines and DED in the general population are reversed – about 12% suffer from migraines and 7% from DED, which is probably due to the fact that the study included only patients see at ophthalmology clinics.

The authors conclude that patients with migraine headaches are more likely to have comorbid DED compared with the general population, but this association may not reflect cause and effect. Both conditions do share inflammation as one of the underlying processes.

It is very likely that the eye discomfort from DED can be making migraines more frequent and severe. The diagnosis of DED should be considered in all migraine sufferers, especially in those with difficult to control attacks because effective treatment of DED could lead to an improvement in migraines.

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A study just published in Neurology by the MEGASTROKE project of the International Stroke Genetics Consortium found that “genetically higher serum magnesium concentrations are associated with a reduced risk of cardioembolic stroke…” It is an open access article, so you can download the full text. The study looked at 34,217 cases of strokes and 404,630 noncases, which makes the data highly reliable.

Here are some quotes (some modified) from the paper.

Several observational prospective studies have reported that low circulating magnesium concentrations and low magnesium intake are associated with increased risk of stroke. In the Nurses’ Health Study, low plasma magnesium concentrations were associated with an approximately 70% to 80% increased risk of embolic and thrombotic stroke.

Magnesium may in part reduce the risk of cardioembolic stroke through its antiarrhythmic effects and via atrial fibrillation. Low serum magnesium concentrations are associated with increased risk of atrial fibrillation, which is a strong risk factor for cardioembolic stroke. (My recent post mentioned that the increased risk of strokes in patients with migraines with aura is possibly related to the higher incidence of atrial fibrillation) Two of the magnesium-associated SNPs (genetic variants) were significantly associated with atrial fibrillation, with higher serum magnesium concentrations being associated with lower risk of atrial fibrillation.

Magnesium also has anticoagulant and antiplatelet properties (platelet aggregation is also implicated in migraine). Magnesium is considered to be nature’s calcium blocker as it suppresses many of the physiologic actions of calcium. For example, calcium promotes blood coagulation, whereas magnesium suppresses blood clotting and thrombus formation and reduces platelet aggregation. Antithrombotic effects may lead to reduction in risk of both cardioembolic and large artery stroke.

Other possible mechanisms whereby high serum magnesium concentrations may reduce ischemic stroke risk include improvement of endothelial function and reduction in blood pressure, atherosclerotic calcification, arterial stiffness, oxidative stress, fasting glucose concentration, insulin resistance, and risk of type 2 diabetes. Some of those beneficial e?ects may also lead to a reduction in small vessel stroke, which was not observed in this study.

Magnesium also reduces the size of a hemorrhagic stroke (bleeding into the brain), according a another recent study.

Magnesium has been my main area of research and because I never tire of promoting the role of magnesium in the treatment of migraines some colleagues call me Dr. Magnesium. The evidence is overwhelming – many studies have shown that magnesium deficiency is common in migraine sufferers and that taking magnesium can help. The American Academy of Neurology and the American Headache Society guidelines for the treatment of migraines include magnesium, but it is still underappreciated and underutilized. This is in part because there have been no large-scale (i.e. expensive) trials of magnesium which are done by pharmaceutical companies for new drugs. Another reason is that the trials that have been conducted supplemented migraine patient regardless of their magnesium status – both deficient and non-deficient patients were given magnesium, thus obscuring the great benefit obtained by the deficient cohort.

As mentioned in several previous posts, magnesium also helps asthma, palpitations, feeling cold or having cold hands and feet, muscle twitching, cramps or diffuse muscle aches (fibromyalgia), premenstrual symptoms (PMS), brain fog, and many other symptoms. If you have any of these symptoms you may want to have a blood test for magnesium. And even if you don’t have symptoms, the next time you have any kind of a routine blood test, ask your doctor to add a test for “RBC magnesium”, which is more accurate than the usual “serum magnesium”.

If you have any of the above symptoms, you can also just start taking 400 mg of magnesium glycinate, which is the daily recommended allowance for magnesium. If oral magnesium does not help and the RBC magnesium level is low we usually give monthly infusions of magnesium. They take 10 minutes to do, have no side effects and are covered by most insurance plans.

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Having conducted and published research on magnesium and seeing dramatic improvement from magnesium in many of my patients, I try to write about magnesium at least once a year. Up to half of migraine sufferers are deficient in magnesium and could greatly benefit from it.

Magnesium supplements are considered “probably effective” for the prevention of migraine headaches, according to the American Headache Society and American Academy of Neurology guidelines. The reason magnesium is listed as only probably effective is poor design of most clinical trials. There was no selection of patients – magnesium was given to all without any regard to their magnesium status. Obviously, those who did not have a deficiency did not benefit from taking magnesium and they diluted positive results seen in those who were deficient.

A study conducted by researchers at George Mason University looked at the dietary and supplement data of 2,820 American adults between 20 and 50 years old. They found that higher dietary intake of magnesium led to lower risk of migraines in both men and women. This relationship was even stronger in women, but not men who took magnesium supplements.

They also found that the average consumption of magnesium in these 2,820 Americans was only 70%-75% of the Recommended Dietary Allowance. Obviously, it is better to get your magnesium from food, such as whole grains, dark leafy vegetables, avocados, legumes, and other. However, changing your diet is not easy, so the second best choice is to take a supplement. I recommend 400 mg of magnesium glycinate, but other magnesium salts can also help.

About 10%-20% of our patients who are deficient in magnesium either do not absorb magnesium (we check their RBC magnesium levels) or do not tolerate it and get diarrhea. They do very well with a monthly intravenous infusion of magnesium.

Magnesium has many benefits besides relieving migraines, including possibly preventing Alzheimer’s disease, reducing the size of a stroke, post-concussion syndrome, fibromyalgia, palpitations, asthma, muscle cramps, “brain fog”, and other symptoms.

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We’ve been prescribing medical marijuana for migraines and other painful conditions since it was legalized in the state of New York four years ago. While it does not seem to help most of our patients, it does benefit a significant minority. The benefits may include relief of pain, nausea, anxiety, and improved sleep. Various ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD) produce different effects and often neither one alone is as effective as a combination of the two (so called entourage effect). Although marijuana is a very effective medicine for some patients, there is no good science to explain how it works, in what combination of ingredients and for what types of pain.

A very interesting study that sheds some light on the possible mechanism of action of THC was just published in a leading neurology journal, Neurology by Israeli researchers. They enrolled fifteen patients with chronic neuropathic pain in the leg (like sciatica) in a double-blind placebo-controlled crossover study. Nine patients were given THC in the first part of the study and placebo in the second and six were given placebo first and then THC. In addition to measuring the effect of THC on pain the researchers performed functional MRI (fMRI) scans before and after administering THC or placebo.

THC was significantly better than placebo at relieving pain and the fMRI scans showed THC-induced changes in the way pain may be processed in our brains. They found that THC produced a reduction in functional connectivity between the anterior cingulate cortex (ACC), a major pain-processing region that is rich in cannabinoid receptors and the sensorimotor cortex. This reduction correlated with the reduction in the subjective pain ratings after THC treatment, meaning that patients who did not have pain relief usually did not have a decrease in the connectivity between the two regions.

The study also showed that pretreatment functional connectivity between the ACC and the sensorimotor cortex positively correlated with the improvement in pain scores induced by THC, that is, the higher the positive functional connectivity at baseline, the more benefit was gained from THC administration.

The authors also commented that THC combined with CBD may have stronger pain-relieving properties. Hopefully, the researchers will figure out the best combination of THC and CBD, but it is possible that other ingredients in marijuana contribute to the therapeutic effects. This could be why some of our patients prefer products from one dispensary and not the other and why some find that the whole plant is more effective than THC with CBD in any ratio. Most patients also find that products made from different strains of marijuana plant (sativa vs indica) have different effects.

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Medical marijuana (MM) is now legal in 30 states. Most states approve its use for specific medical conditions and severe pain and nausea, which are symptoms of migraine, are usually on the list.

I’ve been prescribing MM since it was legalized in the State of NY four years ago. My estimate is that one out of three patients find it useful. Some take it daily for the prevention of migraine attacks, but the majority use it as needed, whenever an attack occurs. MM sometimes relieves all of the symptoms of migraine, but sometimes only pain or only nausea. Some patients find that it helps them to go to sleep and when they wake up, the headache is gone. A few patients have told me that they take it regularly for insomnia and that it often works better than prescription drugs, such as zolpidem (Ambien) and does not cause side effects. The calming effect of MM is also useful when dealing with a very upsetting and debilitating condition such as migraine.

Most states require an analysis of the amount of active ingredients in every MM product by an independent laboratory. The two main ingredients are tetrahydrocannabinol (THC) and cannabidiol (CBD). This is one of the advantages of going the legal route – you know that the product will be the same each time you buy it. However, my patients have told me that they prever products from one or another dispensary even when using products with the same concentration of THC and CBD. This can be explained by the fact that all MM products contain other supposedly inactive ingredients, which in fact may also have various positive or negative effects.

CBD oil made from hemp is legal to buy without a doctor’s prescription and is available for purchase online. For many it works well by itself to relieve pain, nausea, and inflammation. THC is responsible for the sedating and calming effect. However, even a small amount of THC often makes CBD more effective. Raphael Mechoulam, a Hebrew University professor who discovered THC, calls this the entourage effect.

Many patients take low THC/high CBD products during the day to avoid euphoric and cognitive effects, while at night they might take a high THC/low CD combination.

For faster onset of actionvaping MM is optimal, while for the prevention, taking a pill or a tincture can be more convenient. These are the three types of products that are approved in NY.

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Almost everyone has an occasional pain in the upper back and shoulders, often caused by prolonged sitting in front of a computer or just by stress. The pain is due to muscle spasm and keeping those muscles in good shape helps prevent this problem. It also helps to be aware of your body through regular meditation practice or Awareness Through Movement method developed by an Israeli physicist Moshe Feldenkrais. I’ve posted Feldenkrais exercise videos for neck pain here and here. Most people are shocked at the immediate improvement in the range of movements they notice even after the first set of exercises.

I recently had a tight knot in one of my shoulders which did not go away after 90 minutes of hot yoga. Lying on the floor at the end of the yoga session I did a 5-minute Feldenkrais exercise which made the knot melt away. In this video I demonstrate this exercise that relaxes tight muscles and stops shoulder and upper back pain. Instead of watching the video you can follow these written instructions:

Lie down on your back with a thin pillow or a soft pad under your head. Spend a minute paying attention to spots where your head, shoulders, back, arms and legs touch the ground. Then, bend your knees and keep your feet flat on the floor. Stretch your arms in front of you and put your palms together with your arms forming a tall triangle. Keep your eyes on the thumbs and slowly lift the right shoulder off the ground with your head rolling to the left. Press down the left foot to make the movement easier. Keep the shoulder lift small to avoid straining and time it with exhalation. Repeat this shoulder lift and head turn five times while maintaining the gaze on the thumbs. Then, do another five of these movements in exactly the same way, except now move your eyes from the thumbs as far as you can in the opposite direction from the head roll. It may be difficult at first because your head may want to move with the eyes. When you come back to the midline, your eyes return to the thumbs. Put your arms and legs down and again spend a minute noticing the areas of pressure where various parts of your body touch the floor. Now, repeat the same two sets of 5 movements to the left side and then rest for a minute to feel your body contact the floor.
Try to maintain regular slow breathing throughout this exercise.

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The New York Headache Center participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in Neurology and the American Academy of Neurology endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex), where it had to pass strict safety studies. However, Germany does not allow butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur is still made in Germany and is sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany.

The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their manufacturing plant in Germany. However, my concerns about butterbur have not been addressed. Here is my email response to the manufacturer:
“Thank you for this additional information. It is good to see that the FDA conducted a “comprehensive inspection” of the manufacturing facility in Germany. However, my concerns about the safety of Petadolex are not due to possible deficiencies in manufacturing, but are related to the extraction process. As far as I know, this is why German and UK governments still do not allow the sale of Petadolex and this is why I do not recommend Petadolex to my patients. I am also concerned that because Petadolex is fairly expensive, many patients will decide to buy a cheaper brand of butterbur, which can be truly dangerous. Once Petadolex is cleared for sale in Germany I will be happy to resume recommending it to my migraine patients”.

Some of the above text is from my previous posts a few years ago, but I still do not routinely recommend butterbur. If a patient expresses an interest in it and if other herbal treatments and supplements fail, I will provide directions for its use and will emphasise the importance of not substituting Petadolex for a cheaper brand.

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Boswellia serrata is not a drug, but a plant, but I am including herbal products as well if a serious scientific journal has published articles on it. Most of the available information on Boswellia is in mentioned in my previous post. I would only add that of all herbal products, Boswellia is the first one I recommend because it is very safe and I continue to see many patients who respond well to it. My preferred brands of Boswellia are Nature’s Way and Pure Encapsulations, although Nature’s Way is cheaper.

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Jan Mundo, who is a Somatic and Headache Coach, and Bodyworker just wrote a book, The Headache Healer’s Handbook, which was published by the New World Library. I’ve known Jan and her wonderful work with headache patients for many years and was happy to write a foreword to her very readable and useful book. Here is the foreword:

Headaches afflict close to half of the US population with 40 million suffering from migraines, which can be very disabling. Many books have been written for the general public, including two of my own, but Jan Mundo’s Headache Healer’s Handbook brings a unique perspective to this problem.
When I treat patients in the office, they are usually reassured by the fact that I am also a migraine sufferer and so it is with Jan’s book – she knows first-hand what it feels like to have a migraine. More importantly, she has discovered ways to relieve her own attacks and those of other countless migraineurs.
Like Jan, I am a big proponent of non-drug treatments and this is what she details in her book. I also like her hands-on approach, both literally and figuratively. Psychologists have proven that active treatments, where people are doing things to improve their condition, are much more effective than passive treatments, such as massage, chiropractic, and acupuncture, where things are done to them. This leads to the transfer of external locus of control to internal locus of control or in other words, a shift from a passive and helpless victim of external circumstances, to being an active participant in the events with a significant degree of control.
Jan begins with the basics – identifying your type of headache and finding possible triggers that make headaches worse. She does recommend at least one visit to the doctor to confirm the diagnosis. This is important not because a brain tumor or an aneurysm is likely to be found since those are very rare, but a routine blood test could detect magnesium or thyroid deficiency, anemia, or another medical problem that could be contributing to headaches.
Once your diagnosis is confirmed, with Jan’s help you can take an inventory of your diet, sleeping habits, your physical environment, and posture, and try to find triggers, which can be corrected. Then Jan recommends breathing exercises which to me had echoes of the Feldenkrais method – becoming aware of how you breathe and improve not only your breathing, but also the movements of your chest, spine, and the rest of your body.
In the chapter, Being still: Mindfulness and Headaches Jan describes another powerful tool in combating not only headaches, but many other physical and mental ailments. Yes, everyone is talking about the proven benefits of meditation, but it is surprising how few people actually practice it.
Posture, Ergonomics, and Sleep is followed by a chapter on physical exercise, which is proven to not only be good for you, but to specifically reduce the frequency and the severity of headaches.
A large portion of the book is devoted to the Mundo method, Jan’s unique hands-on therapy, which she has developed to treat her own headaches and which has helped many sufferers she has worked with. The healing power of touch is scientifically proven to dramatically improve outcomes in premature babies and without a doubt, can be also harnessed to relieve a variety of headache conditions. Just follow Jan’s advice and watch your headaches go away.

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Medical marijuana appears to be very effective for the treatment of pain, according to a new study just published in the European Journal of Internal Medicine.

The study was conducted by researchers at the Soroka University Medical Center, Ben-Gurion University of the Negev, in Be’er-Sheva, Israel. Israeli scientists have been at the forefront of the research of medical applications of cannabis, starting with the discovery of THC in 1964 by a Hebrew University professor Raphael Meshulam.

In the current study, the researchers evaluated 2736 patients above 65 years of age who received medical cannabis from January 2015 to October 2017 in a specialized medical cannabis clinic. The mean age was 74 years. The most common indications for cannabis treatment were pain (67%) and cancer (61%). After six months of treatment, 94% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0-10 to a median of 4. Most common adverse events were dizziness (9.7%) and dry mouth (7.1%). After six months, 18.1% stopped using opioid (narcotic) analgesics or reduced their dose.

The authors concluded that “the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids.” Even though it was a very large study, it was an observational study with its obvious limitations. They also stressed the need for double-blind prospective trials to confirm the safety and efficacy of medical cannabis for the treatment of pain in the elderly.

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An electric stimulation device, gammaCore has received clearance from the U.S. Food and Drug Administration (FDA) as an acute treatment of pain associated with migraine in adult patients. gammaCore is a hand-held device that stimulates the vagus nerve in the neck through the skin and was developed following and based on my 2005 publication describing the use of implantable vagus nerve stimulator for refractory chronic cluster and migraine headaches. This adds to the approval gammaCore received for the acute treatment of pain associated with episodic cluster headache in adult patients in April 2017. The clearance is limited to pain of migraine, rather than migraine attacks, meaning that the device relieves pain and may not relieve other migraine symptoms, such as nausea and sensitivity to light and noise.

The FDA clearance of gammaCore for the acute treatment of pain associated with migraine was supported by the results of the multicenter, randomized, double-blind, sham-controlled trial that demonstrated that “treatment with gammaCore for the acute treatment of pain associated with migraine was superior to sham, and also enabled patients to reach pain freedom more frequently by 30, 60, and 120 minutes compared with sham treatment”. Just like with all other studies with gammaCore, the therapy was found to be well tolerated by patients.

gammaCore is also available outside of the U.S., including in Canada and the European Economic Area. The manufacturer offers a free trial of the device, which cannot be purchased, but only rented. Some insurance plans may pay for the rental.

Here are a few disclaimers and warnings from the manufacturer:

The safety and effectiveness of gammaCore (non-invasive vagus nerve stimulator) has not been established in the acute treatment of chronic Cluster Headache.
This device has not been shown to be effective for the prophylactic treatment of chronic or episodic cluster headache.
The long-term effects of the chronic use of the device have not been evaluated.
Safety and efficacy of gammaCore has not been evaluated in the following patients, and therefore is NOT indicated for:
Patients with an active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device
Patients diagnosed with narrowing of the arteries (carotid atherosclerosis)
Patients who have had surgery to cut the vagus nerve in the neck (cervical vagotomy)
Pediatric patients
Pregnant women
Patients with clinically significant hypertension, hypotension, bradycardia, or tachycardia

Patients should not use gammaCore if they:
Have a metallic device such as a stent, bone plate, or bone screw implanted at or near their neck
Are using another device at the same time (eg, TENS Unit, muscle stimulator) or any portable electronic device (eg, mobile phone)

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A recent article in the New York Times by the health columnist, Jane Brody, Trying the Feldenkrais Method for Chronic Pain, described her very positive experience with the Feldenkrais method. Then, at about the same time a patient told me that Feldenkrais lessons made a big difference in her neck and back pain. I started to read about Feldenkrais (download an article from the Smithsonian Magazine), took a lesson with my patient’s teacher, and then invited this teacher to work in our office.

This method was developed by a Russian-born Israeli engineer Dr. Moshe Feldenkrais (1904-1984). He was a physicist who was educated at Sorbonne and worked with Frédéric Joliot-Curie, then worked in the British survey office and during the war, as a science officer in the Admiralty. In 1936, while in France, he became one of the first Europeans to earn a black belt in judo.

A knee injury led Feldenkrais to develop a movement method named after him. He did not call it therapy and always insisted that he did not treat patients, but rather taught lessons on how to move naturally. At the same time, his lessons often led to a dramatic relief of pain, improved movement and functioning in individuals who suffered from cerebral palsy, strokes, multiple sclerosis, back, and neck pains. He felt that the key to healing was to become aware of what one is doing. Dancers, artists, and athletes have been using Feldenkrais lessons to improve their performance and to heal and avoid injuries. In the early 1950s Feldenkrais worked with the first Prime Minister of Israel, David Ben-Gurion, whose decades-long chronic back pain dramatically improved. Feldenkrais quit his position as the first director of the electronics department of the Israeli Defense Force and decided to devote all of his time to teaching his movement method. He had trained hundreds of practitioners all around the world and they in turn trained the next generation of teachers.

Feldenkrais emphasizes gentle and often small movements that re-educate and re-establish the connection between the body and the brain. It also makes you do movements that do not come naturally and that we never do, such as turning your head to one side and moving your eyes in the opposite direction. It is difficult to describe this method in words, but even a single lesson can show its dramatic potential. Try this simple exercise. Check the range of movements in your neck – how far can you turn your head to one side, then the other without straining. Then, put palms of your hands on your cheeks and attach your arms to the body. Now, turn your body at the waist from the midline to the left and back to the midline, again only as far as you can comfortably do it. Repeat this 10 times and then 10 times from the midline to the right. Now, put down your arms and test your range of movements again. Most people, including those who have very tight neck muscles, will noticed a significant and a very surprising improvement. Surprising, because it happened without moving your neck. You can watch me doing this exercise on youtube; I also show another exercise that improves the lateral flexion of your neck.

A possible explanation is that our brains get visual cues indicating that our head moved far to one side, but the brain cannot tell if the movement came from turning the torso or the neck. Repeating the move 5-10 times trains our brain to allow such movement even when we only move the neck. This explanation has some scientific support. When vision and proprioception were incongruent, participants were less accurate and initially relied on vision and then proprioception over time.

This explanation has some scientific support. The authors of an article in the Experimental Brain Research, Untangling visual and proprioceptive contributions to hand localisation over time, conclude that “When vision and proprioception were incongruent, participants were less accurate and initially relied on vision and then proprioception over time” (proprioception is our sense of the relative position of our body parts).

Another fascinating phenomenon that provides Feldenkrais method additional scientific support is the observation that when we cross our hands, we feel less pain in the hand. The Journal of Pain published an article “Seeing One’s Own Painful Hand Positioned in the Contralateral Space Reduces Subjective Reports of Pain…” Scientific research using functional MRI images of the brain led to the publication of another article in the same journal: Crossing the line of pain: FMRI correlates of crossed-hands analgesia.

It appears that our visual cues are very important to our ability to move and feel pain and this may be one of the ways the Feldenkrais method improves movement and relieves pain.

Individual lessons can be expensive ($100-$200 an hour), but Feldenkrais is often taught in groups, which makes it more affordable. You can also learn it by reading books, such as Awareness Heals: The Feldenkrais Method For Dynamic Health , audio recordings – The Feldenkrais Lessons: Awareness Through Movement by Bruce Holmes , and youtube videos

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