1. OVERVIEW AND DESCRIPTION
Integrative Approaches to Therapeutic Exercise
The National Center for Complimentary and Integrative Health (NCCIH) of the National Institutes of Health (NIH) uses the term “complementary health approaches” to refer to non-mainstream health care practices. When these complementary health approaches are used in combination with allopathic mainstream health care, the practice is referred to as “integrative medicine” or “integrative healthcare”. The NCCIH provides two further subgroups: natural products and mind-body practices. 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 (arthritides2-4, neck pain3,5, low back pain3,5-7), repetitive use injuries8, chronic pain5, fibromyalgia2,9, Parkinson’s Disease10-13, cardiovascular disease2,14-16, cancer2,5,17,18, chronic lung disease19, anxiety2,4,18,20, depression2,9,18,21, and chronic headaches22.
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.5,23
Complementary movement therapies are adaptable and can fit numerous specialized niches. Movement therapies can be quite individualized to fit the needs of any participant. For example, individuals with cancer have a complex constellation of factors that influence their pain experience, including “neuropathic, psychological, social, and spiritual components”, which determine the patient’s pain experience.18 Each of these components of pain may potentially be addressed with movement therapy, given the combination of body, mind, and spiritual focus as noted in the therapy descriptions below. These therapies can be adjusted to the needs of individual patients who may have injuries, significant co-morbidities, or other limiting conditions. For example, individuals with paraplegia or with lower extremity amputations can participate by modifying the exercise to accommodate a seated position.
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.
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 2012.24 There 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.5 Several clinical trials have concluded that yoga yields improvements in chronic low back pain4-6 and neck pain.4 It may be efficacious in populations over 50 years of age with yoga practice as infrequent as once weekly.25 The American College of Rheumatology and Arthritis Foundation 2019 guidelines conditionally recommend yoga for individuals with knee osteoarthritis.3
Yoga may help to lessen the severity of symptoms and treatment side effects associated with cancer, as well as promote well-being and quality of life (QOL).18 Nine studies included in a systematic review by Behzademehr et al, demonstrated that yoga may improve cancer-related pain.17 Yoga can also effect cardiovascular benefits, with similar physiological changes as with aerobic exercise.5,15 A meta-analysis of 44 randomized controlled trials showed that yoga improved blood pressure, heart rate, respiratory rate, waist circumference, cholesterol levels, and hemoglobin A1c levels.15 Regular yoga practice may also yield a reduction in episodes of atrial fibrillation in affected individuals.16
Yoga boasts numerous mental health benefits, including stress reduction,4,21 development of cognitive coping strategies,5,23 and elevations in both immediate and long-term mood.4,18 A systematic review by Gothe et al, showed positive impacts of yoga on brain health.26 Improvements in sleep, QOL, and depression have been associated with yoga practice.18 Improved levels of pain intensity and tolerance can also be achieved through yoga via improved emotional responses to painful sensory input.4,5,23
Qi Gong and Tai Chi
Both Qi Gong and Tai Chi originate in Chinese medicine and incorporate flowing movement or static postures with a focus on relaxed awareness and breathing. There are many forms of both of these meditative practices, which are meant to balance the energy or “Qi” in the body. Disease is thought to occur when the flow of Qi is blocked. Qi Gong is typically composed of a shorter set of movements which are simpler and easier to learn as compared to traditional Tai Chi, which involves a longer series of more complex movements.
Qi Gong and Tai Chi have demonstrated positive health benefits such as increased bone mineral density, improvements in physical function, reduction in blood pressure and heart rate, improved biomarkers of heart health, and reduction in depression and anxiety.2 Individuals with fibromyalgia who practice Qi Gong or Tai Chi have demonstrated improvements in their ability to manage pain.2 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 effects18.
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.4 The American College of Rheumatology and Arthritis Foundation 2019 guidelines strongly recommend Tai Chi for individuals with knee and/or hip osteoarthritis.3 Both Qi Gong and Tai Chi may improve balance and fall risk in older populations2,4,18 and balance and motor function in individuals with Parkinson’s Disease13.
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 disorders6,8 via changes in functional reach, breathing capacity, sit-to-stand ability, and perceived effort associated with movement.6 It may also improve upright posture and step initiation in individuals with Parkinson’s Disease.10
- 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 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 problems4, including chronic low back pain7.
- 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,9,27,28 and it may improve physical function, QOL, and sleep quality29. Pilates can also be useful in reducing pain in individuals with chronic low back pain28 and fibromyalgia9.
- Dance/Movement Therapy: Dance/Movement Therapy is “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual”.30 This form of therapy may help individuals cope both physically and psychologically with the treatment experience of radiotherapy.31
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.32 Paced or slowed breathing may have benefits for relieving insomnia and anxiety as well as addressing autonomic instability, hypertension, and pulmonary disease.9,33 Breathing exercises and inspiratory muscle training improve exercise and functional performance in individuals with heart failure.14 Breathing exercises may also reduce gastroesophageal reflux disease (GERD) symptoms.34
- 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.35 The underlying perspective is that gravity affects body alignment, structure, and function.36 Rolfing may help improve pain and active range of motion in individuals with cervical spine dysfunction19; sleep, posture, and pain37 as well as balance38 in chronic fatigue syndrome; gait parameters in young individuals with cerebral palsy39; and anxiety20,40.
- 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 Trager therapy may provide reduced chronic shoulder pain in individuals with spinal cord injuries.41 Chronic headache sufferers may experience reduced headache symptoms as well as decreased medication usage with the use of Trager therapy.22 Positive effects on respiratory measures have also been noted in individuals with restrictive chronic lung disease who utilize the Trager approach.42 One study also suggests that Trager therapy holds promise in reducing the rigidity experienced by individuals with Parkinson’s Disease.11
CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
Integrative medicine is becoming more widespread in the United States. Various forms of complementary health approaches such as Yoga and Tai Chi are more commonplace in healthcare. Emphasis on preventive care and maintenance of good health and wellbeing is of increasing emphasis in the healthcare community, though there are still significant obstacles to overcome before healthcare practices that encourage preventive healthcare and daily healthcare maintenance might be fully covered under health insurance plans. Integrative therapies also offer opportunities for patient empowerment and self-management of comorbidities and mental health.
GAPS IN KNOWLEDGE/EVIDENCE BASE
There are several unique challenges that have to 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 honed 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.43 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
- NCCIH: What is complementary and alternative medicine (CAM)?. 2014 National Institutes of Health/National Center for Complementary and Integrative Healthcare. Available at: https://nccih.nih.gov/health/whatiscam. Accessed March 1, 2015.
- Jahnke R, Larkey L, Rogers C, Etnier J, Lin F. A comprehensive review of health benefits of Qigong and Tai Chi. Am J Health Promot. 2010;24(6):e1-e25.
- Plastaras CT, Schran S, Kim N, et al. Complementary and alternative treatment for neck pain: Chiropractic, acupuncture, TENS, massage, yoga, Tai Chi, and Feldenkrais. Phys Med Rehabil Clin N Am. 2011;22:521-537.
- Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology. 2020;72(2):220-233.
- Wren AA, Wright MA, Carson JW, Keefe FJ. Yoga for persistent pain: new findings and directions for an ancient practice. Pain 2011;152:477-480.
- Cacciatore TW, Horak FB, Henry SM. Improvement in automatic postural coordination following Alexander Technique lessons in a person with low back pain. Physical Therapy. 2005;85(6):565-578.
- Paolucci T, Zangrando F, Iosa M, et al. Improved interoceptive awareness in chronic low back pain: a comparison of back school versus Feldenkrais method. Disabil Rehab. 2017;39(10):994-1001.
- Reddy PP, Reddy TP, Roig-Francoli J, et al. The impact of the Alexander Technique on improving posture and surgical ergonomics during minimally invasive surgery: pilot study. J Urol. 2011;186:1658-62.
- Rakel D. “Chapter 89: Breathing Exercises” and “Chapter 90: Prescribing Movement Therapies”. Integrative Medicine. Philadephia, PA: Elsevier Saunders, 2012. 814-827. Print.
- Cohen RG, Gurfinkel VS, Kwak E, Warden AC, Horak FB. Lighten Up: Specific postural instructions affect axial rigidity and step initiation in patients with Parkinson’s Disease. Neurorehabil Neural Repair. 2015. [ePub ahead of print]
- Duval C, Lafontaine D, Hebert J, Leroux A, Panisset M, Boucher JP. The effect of Trager therapy on the level of evoked stretch responses in patients with Parkinson’s disease and rigidity. J Manipulative Physiol Ther. 2002;25(7):455-64.
- Teixeira-Machado L, Araujo FM, Cunha FA, Menezes M, Menezes T, Melo DeSantana J. Feldenkrais method-based exercise improves quality of life in individuals with Parkinson’s disease: a controlled, randomized clinical trial. Altern Ther Health Med. 2015;21(1):8-14.
- Zhou J, Yin T, Gao Q, Yang XC. A meta-analysis on the efficacy of Tai Chi in patients with Parkinson’s Disease between 2008 and 2014. Evidence-Based Complementary and Alternative Medicine. 2014;2015:1-9.
- Cahalin LP, Arena RA. Breathing exercises and inspiratory muscle training in heart failure. Heart Failure Clinics. 2015;11(1):149-172.
- Cramer H, Lauche R, Haller H, Steckhan N, Michalsen A, Dobos G. Effects of yoga on cardiovascular disease risk factors: A systematic review and meta-analysis. International Journal of Cardiology. 2014;173(2):170-183.
- Kanmanthareddy A, Reddy M, Ponnaganti G, et al. Alternative medicine in atrial fibrillation treatment- Yoga, acupuncture, biofeedback and more. Journal of Thoracic Disease. 2015;7(2):185-192.
- Behzadmehr R, Dastyar N, Moghadam MP, Abavisani M, Moradi M. Effect of complementary and alternative medicine interventions on cancer related pain among breast cancer patients: a systematic review. Complementary Therapies in Medicine. 2020;49:1-12.
- Singh P, Chaturvedi A. Complementary and alternative medicine in cancer pain management: A systematic review. Indian Journal of Palliative Care. 2015;21:105-115.
- James H, Castaneda L, Miller ME, Findley T. Rolfing structural integration treatment of cervical spine dysfunction. Journal of Bodywork and Movement Therapies. 2009;13(3):229-238.
- Weinberg R, Hunt VV. Effects of Structural Integration on state-trait anxiety. J Clin Psychol. 1979;35:319-322.
- Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med. 2004;10:60-63.
- Foster KA, Liskin J, Cen S, et al. The Trager approach in the treatment of chronic headache: a pilot study. Altern Ther Health Med. 2004;10(5):40-6.
- Villemure C, Ceko M, Cotton VA, Bushnell MC. Insular cortex mediates increased pain tolerance in yoga practitioners. Cereb Cortex. 2014;10:2732-40.
- Clarke TC, Barnes PM, Black Li, Stussman BJ, Nahin RL. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and over. NCHS Data Brief. 2018;(325):1-8.
- Grabara M, Szopa J. Effects of hatha yoga exercises on spine flexibility in women over 50 years old. J Phys Ther Sci. 2015;27:361-365.
- Gothe NP, Khan I, Hayes J, Erlenbach E, Damoiseaux JS. Yoga effects on brain health: a systematic review of the current literature. Brain Plasticity. 2019;5:105-122.
- Hyun J, Kwangbo K, Lee CW. The effects of pilates mat exercise on the balance ability of elderly females. J Phys Ther Sci. 2014;26:291-293.
- Wells C, Kolt GS, Marshall P, Hill B, Bialocerkowski A. The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review. PLos One. 2014;9(7):1-14.
- Garcia-Soidan JL, Giraldez VA, Cachon Zagalaz J, Lara-Sanchez AJ. Does pilates exercise increase physical activity, quality of life, latency, and sleep quantity in middle-aged people? Percept Mot Skills. 2014;119(3):838-50.
- American Dance Therapy Association. Available at: http://www.adta.org. Accessed March 6, 2015.
- Ho RT, Lo PH, Luk MY. A good time to dance? A mixed-methods approach of the effects of dance movement therapy for breast cancer patients during and after radiotherapy. Cancer Nurs. 2015. [ePub ahead of print]
- Vieira DSR, Mendes LPS, Elmiro NS, Velloso M, Britto RR, Parreira VF. Breathing exercises: influence on breathing patterns and thoracoabdominal motion in healthy subjects. Braz J Phys Ther. 2014;18(6):544-552.
- Borge CR, Hagen KB, Mengshole AM, Omenaas E, Moum T, Wahl AK. Effects of controlled breathing exercises and respiratory muscle training in people with chronic obstructive pulmonary disease: results from evaluating the quality of evidence in systematic reviews. BMC Pulmonary Medicine. 2014;14(184):1-15.
- Qiu K, Wang J, Chen B, Wang H, Ma C. The effect of breathing exercises on patients with GERD: a meta-analysis. Annals of Palliative Medicine. 2020;9(2):405-413.
- Jacobsen E. Structural Integration, an Alternative Method of Manual Therapy and Sensorimotor Education. The Journal of Alternative and Complementary Medicine. 2011;17(10):891-899.
- Jones TA. Rolfing. Phys Med Rehabil Clin N Am. 2004;15(4):799-809.
- Pratt T. Psychological effects of Structural Integration. Psychol Rep. 1974;35:856.
- Findley T, Quigley K, Maney M, et al. Improvement with structural integration (Rolfing) in persons with chronic fatigue syndrome. In: Findley T, Schleip R, eds. Fascia Research. Munich: Elsevier GmbH, 2007:242-243.
- Perry J, Jones MH, Thomas L. Functional evaluation of Rolfing in cerebral palsy. Dev Med Child Neurol. 1981;23:717-729.
- Spielberger CGR, Lashene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, 1970.
- Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE, Druin EL. Acupuncture and Trager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individual’s with spinal cord injury. Arch Phys Med Rehabil. 2001;82(8):1038-1046.
- Witt PL, MacKinnon J. Trager Psychophysical Integration: A Method to Improve Chest Mobility of Patients with Chronic Lung Disease. Physical Therapy Journal. 1986;66:214-217.
- Veziari Y, Leach MJ, Kumar S. Barriers to the conduct and application of research in complementary and alternative medicine: a systematic review. BMC Complementary and Alternative Medicine. 2017;17(166):1-14.
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
Sara N. Raiser, MD
Nothing to Disclose
Daniel C. Herman MD, PhD
Nothing to Disclose