Author(s): Sara N. Raiser, MD, Daniel C. Herman MD, PhD
Originally published: September 10, 2015 Last updated: April 19, 2020
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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

Special Populations

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

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

  1. 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
  2. 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.
  3. 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.
  4. 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.

  1. 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
  2. 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.
  3. 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

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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

Author Disclosure

Sara N. Raiser, MD
Nothing to Disclose

Daniel C. Herman MD, PhD
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