Author(s): Irene Estores, MD, Rosalynn Ruzica Conic, MD, PhD, MPH
Originally published: September 10, 2015 Last updated: May 16, 2024
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Overview and Description

Integrative Approaches to Therapeutic Exercise

The National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health (NIH) defines “integrative health” as a coordinated intentional way of combining conventional allopathic healthcare with non-mainstream (complementary) health approaches to  achieve whole person health through addressing biological, behavioral, social and environmental domains.1 The NCCIH further subdivides complementary health approaches into natural products (e.g. diets, dietary supplements, herbs and probiotics), and mind-body practices (i.e. psychological, physical and combination). Complementary health approaches to exercise or movement therapy fall under the category of mind-body practices, as they commonly integrate physical and mental exercises.1

Mind-body practices: movement therapy

Movement therapy involves active engagement of the participant both physically and mentally. The mental component may consist of focus on body awareness, mindfulness, and/or meditation. The physical component involves the proper execution of the activity. Movement therapy is useful in maintaining long-term wellness and symptomatic relief from a variety of medical conditions, including musculoskeletal pain (arthritides,2-4 neck pain,3,5 low back pain3,5-7), repetitive use injuries,8 chronic pain,5 fibromyalgia,2,9 Parkinson’s disease,10-14 cardiovascular disease,2,15-17 cancer,2,18-28 chronic lung disease,29 anxiety,2,19,30,31 depression,2,9,31,32 chronic headaches,33,34 traumatic brain injury35 and Post-Acute COVID-19 Syndrome.36 The use of movement therapies is increasing, rising from 5.8% in 2002 to 14.5% in 2017 according to National Health Interview Survey.37

Exercise prescriptions: complementary approaches to exercise

Complementary movement therapies differ from most mainstream healthcare practices in that they focus on the development of lifestyle changes for sustainable wellness and management of health conditions. Because of this, motivation is a requirement for successful treatment with these modalities. Movement therapies indirectly address pain by inducing physical changes and by teaching the individual pain-coping mechanisms and body awareness.5,38

Special populations

Complementary movement therapies are adaptable and can fit the needs of any patient.

Pediatric

Use of complementary medicine in pediatric populations is of interest due to the impact of medication on childhood development and possible toxicities and due to the rising prevalence of children with chronic illness.39 According to the 2012 National Health Interview Survey, 12% of people <18 years of age used complementary therapies in the last year. Parental use is the most common predictor for complementary medicine use among the pediatric population, followed by higher parental education, income, living in the western United States, and higher healthcare utilization in the year prior. Conditions treated include anxiety/depression, asthma, irritable bowel syndrome,40 juvenile idiopathic arthritis, fibromyalgia, chronic pain,41 obesity,42 sleep disorders and ADHD.

Pregnancy

Complementary medicine is of interest in pregnancy due to avoidance of teratogenic substances; however, data is scarce.43 Yoga in particular may reduce rates of intrauterine growth restriction, preterm labor, low birth weight, pregnancy-related discomfort and improve sleep.44

Elderly

According to the World Health Organization, patients over the age of 65 are considered elderly, a rapidly growing patient population throughout the United States and developed countries. Physical and mental function generally decline with age and complementary medicine provides a therapeutic option with less side effects, is less invasive and more cost-effective.45 According to the National Health Interview Survey, use of yoga, tai-chi and qigong in those >65 rose from 0.3% to 1.5% between 2002 and 2017 and is predicted to continue rising.37 It has been studied for anxiety, depression, cognition, reduce frailty and improve fall risk.45

Cancer

Use of complementary medicine is common among cancer patients with up to 80% including it in their treatment.27 Pain is one of the largest challenges, with a complex constellation of “neuropathic, psychological, social, and spiritual components”, which determine the patient’s pain experience.19 Movement therapy may be used to address each of these components, by reducing fatigue, anxiety, depression and insomnia.19,24,26 For breast cancer patients with lymphedema, yoga could lead to improved range of motion and quality of life.25

Relevance to Clinical Practice

Complementary movement therapies stimulate health improvements from which a variety of clinical populations can benefit as described below. Moreover, access to these therapies is generally less restricted; some of these therapies require no equipment or specialized facilities and are low cost. Movement therapies are typically low-intensity exercises with slow, controlled movements. Yoga and Tai Chi are examples of these therapies, and these can be modified to suit any ability level, whether that is regarding physical fitness level or accounting for active illness or co-morbidities. Exercises can often be performed in any position: lying down, seated, standing or with ambulation. The following sections provide insight on a few key movement therapies including yoga, Tai Chi and other specialized therapies. The majority of existing evidence is limited to level 2-4, with few level A studies, and those were generally focused on yoga, with several addressing Tai Chi and Qigong. Table 1 summarizes relevant findings by type of therapy and disease.

Yoga

Yoga is both a mind-body practice and a movement therapy combining physical movements or postures, breathing exercises, and mindfulness or meditation.1 It is one of the most commonly utilized complementary movement therapies; on the 2017 National Health Interview Survey, 14.3% of U.S. adults reported practicing yoga, an increase from 9.5% in 2012.46There are numerous schools of yoga. For example, Hatha yoga utilizes static postures, while vinyasa or “power yoga” consists of controlled movements linked with breathing to “flow” from one posture to the next. Postures can be modified for the individual’s ability level, allowing all levels of experience and physical ability to participate safely together.

Benefits of yoga include improvements in overall physical fitness, strength, and flexibility.5Several clinical trials have concluded that yoga yields improvements in chronic low back pain16 and neck pain. It may be efficacious in populations over 50 years of age with yoga practice as infrequent as once weekly.47The American College of Rheumatology and Arthritis Foundation 2019 guidelines conditionally recommend yoga for individuals with knee osteoarthritis.4

There is a substantial evidence base supporting the physiological effects of yoga and its benefits for several health conditions; however current studies are limited by the challenges of performing a double-blind study, possible differential effects of different types of yoga on the condition, and lack of diversity in studies (for example, very few studies evaluate older populations or veterans).48

Qigong and Tai Chi

Tai Chi and Qigong are exercises in Traditional Chinese Medicine.  Both are aimed at cultivating and balancing “Qi” or energy through slow flowing movement, rhythmic breathing, and imagery. Tai Chi is one form of Qigong exercises and typically involves a longer series of more complex movements.  Qigong can be practiced with simple movements of the arms and legs or with almost no movement, focusing mainly on the breath and visualization.49 Both have demonstrated benefits for health promotion and disease management and are often studied as a combined intervention, typically in an Asian population. Tai Chi and Qigong can effectively reduce depression and anxiety in substance use disorders,31 and blood pressure in essential hypertension.50 It has beneficial effects on physical and cognitive functions in older adults.51 Both Qi Gong and Tai Chi may improve balance and fall risk in older populations2,4,19 and balance and motor function in individuals with Parkinson’s Disease.14

Pain and function may also be improved through these practices. Tai Chi may be used to improve function in the context of a variety of arthritides; the U.S. Arthritis Foundation endorses Sun Style Tai Chi as appropriate low-impact exercise for individuals with knee and/or hip osteoarthritis.4 In a randomized trial, Tai Chi performed with the same intensity and duration as aerobic exercise provided greater benefit in fibromyalgia.52 Some small studies have indicated that individuals with cancer who practice Tai Chi showed improved aerobic capacity2 and decreased severity of cancer symptoms and chemotherapy side effects.19 Similarly to yoga, while promising, the evidence regarding Qi Gong and Tai Chi is limited by heterogeneity between studies, lack of patient diversity, and possible publication bias.53

Other movement therapies

Alexander Technique: The Alexander Technique is a psycho-physical technique that uses verbal cueing and therapeutic touch between provider and recipient to improve automatic postural balance and coordination as well as tonic muscle activity.6 The Alexander Technique may reduce musculoskeletal pain and repetitive strain disorders via changes in functional reach, breathing capacity, sit-to-stand ability, and perceived effort associated with movement.8,54 Efficacy of Alexander technique has been studied in few conditions, including Parkinson’s disease where it may improve upright posture and step initiation.13

Feldenkrais Method: The Feldenkrais method is a form of movement therapy that is primarily used for musculoskeletal pain and dysfunction and, arguably, does not incorporate a spiritual or meditative component as do many of the aforementioned therapies; however, participants must focus during the therapy in order to effect changes in neuromuscular recruitment patterns.4 Therapy consists of slow and simple movements with the goal of using minimal muscle effort to evoke positive neuromuscular changes without stretching or straining, which makes this an excellent option for all age groups and most medical conditions. Individuals with Parkinson’s Disease may have improvements in motor function, gait,10 QOL and depression with use of Feldenkrais method-based exercise.12 Feldenkrais method has also been associated with a decreased perception of pain in individuals with chronic headaches and/or musculoskeletal problems,4 including chronic low back pain.7 While there are several randomized controlled trials, the diversity of conditions treated and variations in protocol used, limit the robustness of meta-analyses.55

Pilates: Pilates is a movement therapy that particularly focuses on core stabilization. Breathing and posture are important aspects of Pilates with the goal of bringing the body into muscular balance. Studies have shown that the regular practice of Pilates increases flexibility, strength, and balance,9,56,57 and it may improve physical function, QOL, and sleep quality.58 Pilates can also be useful in reducing pain in individuals with chronic low back pain57 and fibromyalgia.9 Studies are limited by variable methodology, limited blinding, and heterogeneity of conditions studied.59

Dance/Movement Therapy: Dance/Movement Therapy (DMT) is “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual”.60In a systematic review, persons with Parkinson’s disease (PD), mild- cognitive impairment (MCI) and Alzheimer’s disease (AD), positive benefits on balance, gait and general disease condition was noted in persons with PD who received DMT compared to the non-dance group.61 Benefits on global cognitive function, memory and executive function were noted in persons with MCI. With the 4 studies on AD included in this review, there was insufficient evidence of efficacy. The feasibility, acceptability and effects of dance therapy has also been reviewed, but data are inconclusive on the positive effects on post-stroke body functions.62  Protocols that integrate movement in standard therapies for persons with psychological trauma,63 autism spectrum disorder,64 schizophrenia65 and cerebral palsy66 exist but further refinements of the protocols and the trials are warranted. This form of therapy may help individuals cope both physically and psychologically with the treatment experience of radiotherapy.22 Evidence regarding efficacy of DMT is limited by methodologic quality and quantity, cultural variations in dance, variety in practitioner certification across different countries and the variety in disease processes that it is used for.67

Other complementary exercise therapies

Complementary movement therapies overlap with several additional manual manipulation and meditative therapies, each of which incorporate active movement into their practices.

Breathing exercises: such as diaphragmatic breathing, paced or slow breathing, and yogic breathing have been shown to improve breathing patterns.68 Paced or slowed breathing may have benefits for relieving insomnia and anxiety as well as addressing autonomic instability, hypertension, and pulmonary disease.9,69 Breathing exercises and inspiratory muscle training improve exercise and functional performance in individuals with heart failure16 and spinal cord injury.70,71 In a proof-of-concept trial, ten persons with spinal cord injury followed a 4- week intervention of weekly group sessions and daily home practice of a specific breathing exercise, the WimHof Method.72 This protocol was feasible, safe and demonstrated improvements in self- reported physical and mental health outcomes.72 Breathing exercises may also reduce gastroesophageal reflux disease (GERD) symptoms.73 Studies to date are generally smaller, prospective with variable randomization, and with heterogeneous design and intervention, in various populations, limiting ability to identify an optimal breathing approach.74

Structural Integration or Rolfing: is a form of sensorimotor education that utilizes manual therapy and movement education to address the biomechanical efficiency of the body as a whole.75-78 The underlying perspective is that gravity affects body alignment, structure, and function.75,76 Rolfing may help improve pain and active range of motion in individuals with general pain symptoms,79 cervical spine dysfunction;80 sleep, posture, and pain77 as well as balance78 in chronic fatigue syndrome80; gait parameters in young individuals with cerebral palsy;81 and anxiety.30,82 While it has been studied in various conditions, overall sample sizes were small, and access is limited due to provider availability.79

Trager Psychosocial Integration: is a muscle education system that consists of soft tissue manipulation sessions and incorporates active movement exercises referred to as “mentastics”.9 Chronic headache sufferers may experience reduced headache symptoms as well as decreased medication usage with the use of Trager therapy.33  Positive effects on respiratory measures have also been noted in individuals with restrictive chronic lung disease who utilize the Trager approach.29 One study also suggests that Trager therapy holds promise in reducing the rigidity experienced by individuals with Parkinson’s Disease.11It could be a valuable tool to improve pain following spinal cord injuries83 or spinal surgery.84 Studies regarding Trager approach are limited to small cohort studies or case series, and patient access is limited.

Integrative-Approaches-to-Therapeutic-Exercise-Table-1

Table 1. Summary of available data by type of integrative exercise and disorder

Cutting Edge/Unique Concepts/Emerging Issues

Integrative medicine is steadily gaining acceptance in the United States. As an “approach to care an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health,”134 integrative therapies also offer opportunities for patient empowerment and self-management of comorbidities and mental health. Although preventive care and promotion of health and wellbeing are now increasingly being emphasized, significant obstacles remain in performing research, patient and physician perception and insurance coverage.

First, while the body of evidence on efficacy of integrative medicine approaches, historically these treatments were rooted in experiential evidence.135 Many of the existing studies are poor, unreliable and involve specific populations, and regulations regarding practitioners of integrative approaches are limited to non-existent.136 Furthermore, there is limited access to research funding, a paucity of researchers trained in integrative medicine or those interested in this type of research.137 A secondary research barrier is that true blinding or true control/experimental group is challenging as potential research participants could easily identify if they are in the experimental group or not which could affect findings depending on patient bias.137 In addition, once research is published, application can be limited due to practitioner’s ability to locate the evidence, lack of knowledge in interpreting studies, bias towards a “traditional” approach, lack of monetary incentive to follow evidence-based medicine, and the time required to stay up to date with current practices. This could be addressed in several ways:

  • Increase grant funding or add additional grant mechanisms to research integrative approaches in medicine.
  • Improve practitioner education on research. Integrating training on research concepts during practitioner training could both encourage research and improve practitioner’s ability to interpret research.
  • Establish collaborative practices and practice-based research networks.
  • Presenting and publishing research to a broad audience (general public and medical) could improve knowledge dissemination.

Patient perception of integrative treatment is another important factor in its growth; however, it has become more widespread. The major detractors are the beliefs that complementary approaches are ineffective, lack scientific evidence and regulation.138 If the patient has a negative perception, explaining current evidence base may help.

Next, physician perception of practices and lack of knowledge regarding integrative medicine may be a barrier to recommending integrative therapeutic care. Sometimes, physicians have a negative perspective of integrative medicine due to lack of scientific proof, suspicion for practitioner’s qualifications, and personal or cultural bias against integrative approaches.139  Furthermore, a survey found that even though the majority of patients asked for integrative options 90% of pediatrics residents felt their knowledge is insufficient to direct the patients.140 In a national survey conducted among adults between ages 50-80 querying the use and interest for integrative medicine, fewer than one in five discussed it with their providers, yet 87% would be comfortable discussing it, and those who did were more likely to use it.141 Both of these barriers can be addressed by improving physician education and including integrative medicine teaching in the medical school curriculum or by having a specialized consultative service.142 Furthermore, having a rigorous standard for practitioner’s qualification, and physician knowledge of these standards could address some personal hesitancies.

Finally, integrative therapeutic approaches can range from free videos to costly in person one-on-one sessions, and access to more individualized treatment is variable. These approaches are rarely covered by health insurance, in part due to limited robustness of existing evidence regarding their efficacy. Some recommendations to overcome these barriers include changing financial incentives that prioritize health promotion instead of disease management and improving the current evidence base.143

Gaps in Knowledge/Evidence Base

There are several unique challenges that must be addressed with respect to complementary healthcare practices. Evidence-based knowledge is difficult to obtain when considering complex healthcare practices that incorporate physical as well as mental and spiritual components. Standardized and sufficiently powered studies are not plentiful in the realm of complementary movement therapies. One systematic review homed in on barriers to research conduct and evidence-based practice in Complementary and Alternative Medicine (CAM) that include access, competency, and bias of practitioners who would engage in this research.137  In a scoping review, these investigators listed strategies to address these that includes use of practice-based research networks of integrative medicine practices and customized educational programs that expand collaborations between health researchers CAM researchers.135 Standardizing musculoskeletal therapies often tends to deemphasize spiritual and/or mental aspect of the practices by focusing on the physical benefits rather than the holistic benefits of the therapy. There are also limitations in the populations that have actually been studied. For example, most of the yoga research is performed on Caucasian, middle-aged women of upper socioeconomic classes.4  An increasing global interest in diversity and inclusion in academic medicine, science and research from funders, scientists, researchers, and journals has led to the development of a diversity index to increase the diversity of populations and researchers.144

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Original Version of the Topic

Daniel C. Herman MD, PhD, Sara N. Raiser, MD, Kevin R. Vincent, MD, PhD, Heather K. Vincent, PhD. Integrative Approaches to Therapeutic Exercise. 9/10/2015

Previous Revision(s) of the Topic

Sara N. Raiser, MD, Daniel C. Herman MD, PhD. Integrative Approaches to Therapeutic Exercise. 4/19/2020

Author Disclosure

Irene Estores, MD
Nothing to Disclose

Rosalynn Ruzica Conic, MD, PhD, MPH
Nothing to Disclose