According to the NIH, mind-body medicine is the discipline that explores the interactions among the brain, the rest of the body, the mind, and behavior as well as the ways in which emotional, mental, social, spiritual, experiential, and behavioral factors can directly affect health. This definition distinguishes mind-body medicine therapies from therapies that are more established or mainstream but that may have similar mechanisms of action (eg, psychotherapies, behavioral training, support groups, education). Traditionally defined mind-body therapies include biofeedback, hypnosis, meditation, guided imagery, relaxation techniques, yoga, tai chi, and qigong.
The relationship between mind and body and its importance to health has been recognized for thousands of years by all major healing traditions, including the ancient Greek system that gave rise to modern Western medicine. With the ascendancy in the West of the scientific method and the biomedical model of illness, however, the relationship between mind and body has often been neglected. In the 19th century, interest in hypnosis began and later Freud championed the theory of the unconscious mind, which helped establish the paradigm that processes of the mind profoundly affect health. In the early 20th century, the American physiologist Walter Cannon began exploring the physiologic effects of emotional stimuli. In the 1930s, Dr. Clark Hull began studies of hypnosis, and research into hypnosis greatly expanded in the 1950s. The first biofeedback experiments also occurred in the 1950s. In the 1970s, Dr. Herbert Benson coined the term “relaxation response,” describing the counter-stress physiology common to many mind-body medicine practices. Since then, there has been considerable research evaluating the clinical effects of mind-body medicine. Emotions such as anger, anxiety, and depression can affect clinical outcomes (including mortality) for conditions such as cardiovascular disease, cancer, and HIV infection. The field of psychoneuroimmunology has documented, at the physiologic level, the powerful effect of the mind on the nervous, endocrine, and immune systems, and vice versa. In addition, studies have demonstrated that mind-body medicine, in addition to affecting health, can affect brain function and even structure, leading to a reevaluation of previously held beliefs about neuroplasticity.
Clinical Applications of Mind-Body Medicine
Mind-body medicine is popular. According to the 2012 NHIS, over 20% of the US adult population has used one or more mind-body therapies in the past year and this rate increased from prior surveys. The more “conventional” mind-body therapies already are established, supported by evidence, and widely available. For example, multimodal mind-body interventions that use some combination of cognitive behavioral therapies, support groups, education, relaxation and skills training have been proven effective for coronary artery disease, cancer, and chronic pain conditions. Mind-body therapies also work well as adjunctive treatments with surgery, cancer therapy, and stress-exacerbated conditions (Table e4–4). They also offer the psychological benefit of increasing sense of control for the patient. Finally, mind-body therapies can be recommended because they have a very favorable safety profile.
Table e4–4.Overview of mind-body therapies for various clinical conditions. |Favorite Table|Download (.pdf) Table e4–4. Overview of mind-body therapies for various clinical conditions.
|Condition ||Mind-Body Therapy ||Level of Evidence1 ||Comment |
|Surgery/Procedure: Pain || |
|Surgery/Procedure: Anxiety || |
|Cancer: Pain || |
|Guided imagery "B" when combined with other therapies |
|Cancer: nausea and vomiting (chemotherapy) || |
|Guided imagery "A" when combined with other therapies |
|Cancer: Psychological symptoms (eg, mood, anxiety, stress) || |
|Chronic pain (various etiologies) || |
|Fibromyalgia || |
|Migraine headache || |
|EMG biofeedback or thermal biofeedback plus relaxation |
|Tension headache || |
|Irritable bowel syndrome || |
|Hypertension ||Biofeedback ||B ||Thermal, HRV, and electrodermal biofeedback best, add relaxation or cognitive therapy to biofeedback |
|Raynaud phenomenon (primary) ||Biofeedback ||B || |
|Anxiety disorders ||Mindfulness meditation ||A || |
|Depression ||Mindfulness meditation ||A ||MBCT or MBSR |
|Insomnia || |
|Progressive muscle relaxation and combination of mind-body therapies also shown effective |
|Urinary incontinence ||Biofeedback ||A ||Stress, urge, mixed or post-prostatectomy |
|Fecal incontinence ||Biofeedback ||A ||First-line therapy |
|Chronic constipation (pelvic floor dyssynergia) ||Biofeedback ||A ||First-line therapy |
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Meditation is broadly defined as the self-regulation of attention. In healthcare settings, one popular application of mindfulness meditation is the mindfulness-based stress reduction (MBSR) program. This program and its derivatives have been extensively studied in medical populations.
The essential exercise of meditation is focusing one’s full attention on a designated object of meditation, such as one’s breath. When it is noticed that the mind has wandered from this object, attention is returned to the object. Training the mind, beginning with this basic exercise, has many effects including relaxation, metacognition, cognitive flexibility, uncoupling of painful physical sensations from maladaptive cognitive patterns, and revelation of previously subconscious content. In mindfulness meditation, after initial training with the breath, the objects of meditation can include other aspects of human experience, such as physical sensations (eg, pain) or mental and emotional states (eg, anxiety).
Mindfulness meditation is a deliberate, sustained, nonjudgmental way of paying attention to one’s experience that is said to enhance self-awareness, change maladaptive thinking, increase the capacity for skillful response to challenges, and reduce suffering. In 1979, mindfulness meditation practice was introduced into US medical settings with the development of the MBSR program by Jon Kabat-Zinn, PhD. It is an 8-week program that introduces mindfulness practice in a secular, practical form to participants in the context of their life circumstances. There are now hundreds of MBSR programs in the United States and other countries. A close derivative of MBSR, mindfulness-based cognitive therapy (MBCT), was developed exclusively for people with recurrent major depression and has been widely applied to other psychiatric populations. It has also been adapted for use in programs for borderline personality disorder (Dialectical Behavior Therapy), eating disorders, substance abuse, and childbirth preparation.
There have been extensive cardiac, respiratory, metabolic, endocrine, and central nervous system studies of individuals during meditation. Though much remains unknown, it is clear that meditation works in part through modulation of the autonomic nervous system, as demonstrated in the late 1960s and early 1970s by Dr. Herbert Benson. Its effects are different from sleep. From a psychological perspective, it is thought that meditation enables the mind to establish a stable platform from which all events in the field of awareness can be viewed (eg, emotions, thoughts, physical sensations) without reactivity. Proposed mechanisms of mindfulness meditation include metacognition, exposure, uncoupling of maladaptive thoughts from physical stimuli (eg, pain), enhancing cognitive flexibility, relaxation, and self-regulation. At the physiologic level, studies of mindfulness meditation have found effects on the immune system (increased antibody response to vaccination, reduction in pro-inflammatory cytokines, possible slowed decline of CD4+ lymphocytes in HIV infection), nervous system (enhanced cortical thickness in specific brain regions, enhanced prefrontal activation on EEG, neuroplastic changes in the anterior cingulate cortex, insula, temporo-parietal junction and fronto-limbic network, characteristic functional MRI findings), and endocrine system (reduced cortisol, increased melatonin levels).
While certification is not necessarily required to teach MBSR, there are now professional certification programs. An MBSR teacher should have a long-standing daily mindfulness meditation practice, a history of silent meditation retreats, experience with a mindful movement practice (eg, yoga, qigong), experience leading groups, and experience in healthcare settings.
Participation in an MBSR program requires commitment in order to achieve possible health benefits. It requires as much as 28 hours of classroom time over 8 weeks (including an all-day silent retreat) and 30–45 minutes of formal guided mindfulness practice each day. Often, MBSR programs offer free informational sessions that precede the 8-week series so patients can evaluate the program before they decide to enroll.
There are few reported adverse effects of mindfulness meditation specifically reported in experimental trials. For example, meditation can allow previously subconscious, distressing psychic content to come into consciousness. Patients with psychiatric disorders should consult with a mental health care professional before starting a program of meditation. However, a recent perspective by expert researchers in meditation and mindfulness have sought more critical inquiry into the adverse effects associated with these practices and to be careful that these practices do not degrade into a panacea for all.
Untreated psychosis, mania, and active substance abuse are relative contraindications because these conditions may impair the fundamental exercise required for mindfulness training (ie, repeatedly returning one’s attention to a desired object of awareness).
Clinical Uses of Mindfulness Meditation
There are over 200 experimental trials assessing mindfulness-based interventions. Most of the research examines the efficacy of MBSR programs, but there are also studies of MBCT, other MBSR-derived programs, and shorter mindfulness interventions. Two meta-analyses of MBSR show average effect sizes of 0.5–0.6. The most comprehensive meta-analysis found mindfulness-based treatments to be especially effective for reducing symptoms of anxiety, depression, and stress.
A. Cancer-related Symptoms
There are more than 35 studies of mindfulness meditation in patients with cancer, including at least 25 randomized controlled trials examining over 2300 patients. More than two dozen studies that measured psychological variables have all shown significant improvements in a variety of outcomes such as mood disturbance, anxiety, stress, and quality of life. Several studies assessed sleep problems and all found improvement; however, one found that the improvement from sleep-focused CBT was superior to MBSR and one found that the benefit of MBSR was lost at 1-year follow-up. One study specifically examined cancer-related fatigue and found benefit from MBSR. Three meta-analyses and a 2016 systematic review corroborate the beneficial mental health effect of mindfulness in cancer patients. In a nonrandomized comparison of MBSR and a healing-through-creative-arts program, the mindfulness intervention was superior in reducing the symptoms of stress, anxiety, and mood disturbance, and in increasing the sense of spirituality. The two groups were equal in increasing a measure of posttraumatic growth. One study looked at couples who went through the MBSR program together, where one member of the couple had cancer, and found improved psychological functioning for both members of the couple. Two other cancer studies showed that psychological benefits from MBSR were sustained at 6-month and 12-month follow-up, respectively.
Ten studies, seven of which were randomized controlled trials, specifically examined the effect of MBCT on patients with major depression. Several of these trials specifically looked at relapses of depression; they demonstrated a reduction of almost 50% in relapses in patients with a prior history of more than two relapses. One study compared MBCT to standard CBT and found the two modalities to be equally effective in treatment of recurrent depression. MBCT is recommended as a treatment for recurrent depression in the United Kingdom’s National Institute for Clinical Guidelines.
There have been three randomized controlled trials of MBCT for bipolar affective disorder. One showed improvement in depression and anxiety in bipolar patients with suicidal ideation or behavior, one showed no mood benefit from MBCT, and one showed benefit if participants performed mindfulness meditation 3 or more days per week. A randomized controlled trial of MBSR for women with fibromyalgia showed improvement in depression maintained at 2-month follow-up. One randomized controlled trial of 76 patients with traumatic brain injury and depression found patients randomized to mindfulness had statistically significant improvement in mood compared to those in the wait-list control group. Multiple other MBSR studies show improvement in mood in various populations, including military personnel with depression or posttraumatic stress disorder (PTSD); however, two studies found mindfulness interventions to be equal to comparison groups (CBT and relaxation therapy).
C. Anxiety and Stress Disorders
Several randomized controlled trials have been conducted, all of which have shown a benefit. A controlled trial of patients with generalized anxiety disorder or panic disorder, all of whom were receiving pharmacotherapy, compared MBCT to an anxiety education program and found MBCT superior for relieving anxiety and depression symptoms. A 2013 randomized controlled trial of MBSR in 93 patients with generalized anxiety disorder showed improved anxiety symptoms. A randomized controlled trial of 31 pregnant women showed reduction of anxiety and perceived stress, and an improvement in mood. Other study populations where randomized controlled trials have shown the effectiveness of mindfulness to diminish anxiety include patients with obsessive-compulsive disorder, with intellectual disabilities, with implanted cardiac defibrillators, and with coronary artery disease. A randomized controlled trial studying patients with social anxiety disorder categorized patients into three groups: mindfulness, CBT, and control; results showed that the mindfulness-based intervention group and CBT group were both superior to the control group but equal to each other. Four controlled studies have been published on PTSD; two showed clear benefit for PTSD symptoms, one showed mixed results, and one showed benefit in mood. Finally, a 2014 systematic review of 17 MBSR studies published since 2008 concluded that MBSR is an effective modality for stress management in otherwise healthy individuals.
A 2013 systematic review and meta-analysis of MBSR for fibromyalgia identified six trials totaling 674 patients and concluded that there is favorable though low quality evidence supporting its use and that “only a weak recommendation can be made at this point.” Two 2013 studies of an online mindfulness intervention for fibromyalgia, showed improved social functioning, positive affect, and coping with pain and stress. A 2017 randomized, controlled trial of 74 patients with fibromyalgia found significant improvements in pain, sleep quality, and psychological distress with an 8-week mindfulness-based intervention.
Nineteen studies, including over 1200 patients, have been conducted using MBSR in chronic pain populations. All studies showed significant improvement in mental health parameters, such as quality of life, acceptance, pain tolerance, and mood. Although many studies have looked at the effect of mindfulness on the psychological and functional status of chronic pain patients, a 2013 review deliberately chose to answer the specific question of whether mindfulness led to significant reduction of pain intensity itself. It concluded that in 10 of the 16 studies reviewed there was significant pain reduction. One follow-up study showed that improvements were maintained up to 4 years later. A randomized controlled trial of MBSR for patients with rheumatoid arthritis showed improvement in psychological distress and well-being at 6-month follow-up despite no improvement in disease activity. A second randomized controlled study of patients with rheumatoid arthritis compared a mindfulness-based intervention (that was much less intensive than standard MBSR) with a CBT intervention and an education control group. Both experimental groups were significantly superior to the control group, although overall the CBT group showed the greatest reduction in pain and IL-6 levels. In the subset of patients with a history of recurrent depression, however, the mindfulness-based intervention yielded greatest reduction in pain and improvement in mood. Benefit of mindfulness meditation was demonstrated in two randomized controlled trials in patients with headache, one in 2013 and one in 2014. A 2016 randomized controlled trial comparing MBSR to CBT in 342 people with chronic low back pain found that MBSR or CBT, compared with usual care, both resulted in significant improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT. Study authors concluded that MBSR is an effective treatment option for patients with chronic low back pain.
Other studies have been conducted involving patients with chronic insomnia, psoriasis, tinnitus, irritable bowel syndrome, inflammatory arthritis, type 2 diabetes mellitus, organ transplants, eating disorders, hot flashes, and female sexual arousal disorder, as well as with inner city residents, nursing home residents, incarcerated individuals, smokers, physicians, nurses and nursing students, medical students, and college students. Nearly all of these studies showed a mental health benefit from meditation and most showed symptom reduction of the condition being studied. Interestingly, a randomized controlled trial of psychotherapists in training showed improvement in the patients of those therapists who were taught mindfulness, and a multicenter study of physicians showed greater patient satisfaction with physicians who had higher mindfulness scores.
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et al. Brief mindfulness-based therapy for chronic tension-type headache: a randomized controlled pilot study. Behav Cogn Psychother. 2014 Jan;42(1):1–15.
et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016 Mar 22–29;315(12):1240–9.
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et al. Mindfulness-based stress reduction in addition to usual care is associated with improvements in pain, fatigue, and cognitive failures among veterans with Gulf War Illness. Am J Med. 2016 Feb;129(2):204–14.
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Guided imagery uses the imaginative capacity of the mind to affect one’s physical, emotional, or spiritual state. As is the case with psychotherapeutic techniques, guided imagery can be applied in a variety of ways. It may be directive, with the therapist providing specific images, or it may be more receptive, inviting the patient to find their own images. It may be supportive, with the intention to create a relaxed, pleasant or specifically positive feeling (eg, trust or patience) or it may intend to directly work with an area of active challenge (eg, anxiety or pain). Classically, in guided imagery, the therapist is less directive and the patient has a more active role than in hypnosis; however, this distinction is not always true in clinical practice and guided imagery can closely resemble hypnosis, especially when suggestion is used. Guided imagery can be conducted live with a therapist one-on-one, in a group setting (less common), or via audio recording.
Imagery has been used throughout history and can be found in the origins of all ancient healing systems still extant today. In contemporary Western medicine, the psychiatrist Dr. Carl Jung recognized the importance of imagery as an expression of the subconscious and in 1915 developed a psychotherapeutic technique called “active imagination.” With the similar intention to aid psychoanalytic exploration, the French psychotherapist Dr. Robert Desoille in the late 1930s created a method he called “directed daydreaming,” and in the 1950s Dr. Hanscarl Leuner introduced “guided affective imagery.” Medical research on guided imagery began in the 1970s and increased greatly in the 1980s. In 1989, the physician Dr. Martin Rossman and the psychologist Dr. David Bresler founded the Academy for Guided Imagery which began certifying health professionals. One modern application of guided imagery has been through technology and virtual reality. A recent pilot study of 34 patients with Parkinson disease found that treadmill training augmented by virtual reality (in which participants were presented obstacles and real-life challenges in a virtual environment) resulted possibly improved function, perhaps reflecting increased brain efficiency.
The mechanism of action of guided imagery is not well known, but some physiologic effects have been demonstrated. Three of five studies examining cortisol levels in relation to guided imagery have found that serum levels decreased after the intervention. Studies of the effect of guided imagery on immune function have shown mixed results. However, a 2009 randomized controlled trial of women with breast cancer showed improved NK cell cytotoxicity and increased IL-2-activated NK cell activity. One study documented reduced physiologic arousal around chemotherapy sessions, as measured by heart rate and systolic blood pressure. Some proposed psychological mechanisms postulated to explain the effects of guided imagery include cognitive restructuring, increased sense of control, increased adaptive coping, distraction, and relaxation.
The leading certifying organization, the Academy for Guided Imagery, generally limits certification to licensed health care professionals or health professional students, but exceptions are allowed. To obtain the certification known as “interactive guided imagery,” 150 total hours of training is required, including 52 hours of small group supervision. Applicants are also required to adhere to the American Psychological Association code of ethics. Another major certifying organization is Beyond Ordinary Nursing, which requires 110 total hours of training, including ten documented imagery sessions.
The length of a typical guided imagery session with a therapist is 50 minutes, with 20–30 minutes spent in active imagery. The imagery portion of the appointment often begins with imagining a place of comfort and safety, then proceeding to the desired area of specific clinical attention. Polysensory recruitment is often used (ie, the patient is asked to imagine visual, auditory, tactile, and olfactory cues in the image scenario). Examples of specific clinical techniques used by the therapist might include dialoging with the symptom (“If your back pain had a voice, what would it say?”), consulting a wisdom figure or inner advisor (“What does your wisdom figure say about how to approach this cancer treatment?”), and visualizing a desired outcome (“Imagine yourself waking up after surgery feeling calm and comfortable.”). Interactive Guided Imagery is a type of imagery that more deliberately aims to enhance awareness of subconscious content.
Predictors of favorable outcome from guided imagery, based on three studies, are previous experience with guided imagery, imaging ability of the patient, perceived credibility of the therapist, and rapport of the patient with the therapist. Age, gender, and education level have not shown significant correlation with outcomes, suggesting that this technique can be applied widely.
Adverse events have not been reported with guided imagery. However, as is the case with any psychotherapeutic technique, distressing psychological content can arise.
There are no contraindications based on outcomes studies. However, due to the potential risk of reexperiencing original trauma, caution is advised in using guided imagery in patients with posttraumatic stress disorder or history of severe trauma or abuse.
Clinical Uses of Guided Imagery
There are many studies examining the use of guided imagery on outcomes related to such surgeries and procedures as heart surgery, colorectal surgery, abdominal surgery, laparoscopic gynecologic surgery in adults, bone marrow aspiration, lumbar puncture, burn wound debridement, and administration of immunizations in children. Although many of the studies have methodologic limitations, reviews and meta-analyses have found overall benefit of small to moderate effect sizes for reducing psychological distress and reducing postoperative pain. A 2013 systematic review of the effect of mind-body therapies on postoperative outcomes concluded there was strong evidence that guided imagery improved psychological well-being measures and moderate evidence that it reduced analgesic intake. Two of the three randomized controlled trials assessing effect on average length of hospital stay found a significant decrease with guided imagery intervention. Other studies have shown significant decreases in total opioid use and average pharmacy costs. An interesting 2012 randomized controlled trial on guided imagery’s effect on wound healing found that the intervention reduced perceived stress and increased hydroxyproline deposition in the surgical wound, a measure of the healing response. The most significant negative trial of the perioperative use of guided imagery was a randomized controlled trial of guided imagery for periprocedural pain and anxiety conducted with 170 women undergoing colposcopy which did not show significant effect in the experimental group. Also, a small 2016 three-arm randomized controlled trial of patients undergoing colorectal surgery did not find benefit from guided imagery or progressive muscle relaxation on quality of life after surgery.
B. Cancer-related Symptoms
Most of the studies in patients with cancer that use guided imagery do so in combination with another modality, such as progressive muscle relaxation, meditation, hypnosis, biofeedback, or music therapy. These studies vary in methodologic quality. There are at least 20 randomized controlled trials in this category and all show benefit for psychological outcomes, such as quality of life, anxiety, and depression. Studies that assessed the effect of guided imagery in combination with other modalities on nausea and vomiting also showed uniform benefit. For example, in a 2016 randomized controlled trial of 208 patients receiving a combination of guided imagery and progressive muscle relaxation once a week for 4 weeks while undergoing chemotherapy, the experimental group experienced significant improvements in fatigue, pain, and health-related quality of life when compared with usual-care control group. With respect to nonprocedural, cancer-related pain, there are at least 6 randomized controlled trials using guided imagery as part of a combination intervention. Three studies showed significant pain reduction with guided imagery intervention, 2 showed no pain reduction, and 1 showed significant benefit in patients’ self-reported ability to decrease pain but not in measured pain intensity.
There are also several randomized controlled trials of guided imagery used alone, as a sole adjunctive treatment for patients with cancer. All of these studies again showed that guided imagery led to improvement in psychological outcomes, and in approximately half of the studies, the improvement was superior to other comparison interventions, such as progressive muscle relaxation or hypnosis. The evidence for guided imagery alone in preventing chemotherapy-related nausea and vomiting is mixed.
A single study has examined the effect of guided imagery directly on cancer disease regression using clinical (UICC criteria) and pathologic (biopsy) measures and found no effect.
There are several studies of guided imagery for various chronic pain conditions, such as osteoarthritis, headache, low back pain, fibromyalgia, and interstitial cystitis. Some of the studies are controlled and all but one show benefit in either pain, psychological distress, or both. A rigorous systematic review found 8 of 9 randomized controlled trials showed benefit of guided imagery for musculoskeletal pain, but due to variable quality of these studies the review concludes that the evidence is encouraging but inconclusive. Similarly, a 2012 review of 15 randomized controlled trials on guided imagery for nonmusculoskeletal pain concluded that the evidence of benefit is encouraging but inconclusive. A 2012 systematic review and meta-analysis of studies on fibromyalgia concluded that low methodologic quality of existing studies precludes definitive conclusion on any benefit that guided imagery may have for this painful condition; however, a subsequent 2014 randomized controlled trial of 72 women with fibromyalgia showed significant decreases in stress, fatigue, pain, and depression. Finally, in a 2014 randomized, controlled trial of nursing-guided imagery relaxation therapy among 60 women with fibromyalgia, the treatment group reported statistically significantly lower levels of pain and depression than the control group at 4 weeks post-intervention (but the benefit for pain was no longer present at 8 weeks post-intervention).
In at least two dozen trials, a variety of imagery techniques have been shown effective for stroke rehabilitation. These usually involve having the patient practice imagining the movement or function they wish to execute, in a sense cognitively rehearsing. There are positive studies on hand function, upper extremity function, gait and lower extremity function, and balance.
et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.
et al. Guided imagery for total knee replacement: a randomized, placebo-controlled pilot study. J Altern Complement Med. 2016 Jul;22(7):563–75.
et al. Effects of psychological interventions and patients' affect on short-term quality of life in patients undergoing colorectal surgery. Cancer Med. 2016 Jul;5(7):1502–9.
et al. Effects of guided imagery on biobehavioral factors in women with fibromyalgia. J Behav Med. 2014 Feb;37(1):70–80.
et al. Effectiveness of guided imagery relaxation on levels of pain and depression in patients diagnosed with fibromyalgia. Holist Nurs Pract. 2015 Jan–Feb;29(1):13–21.
Biofeedback is a behavioral therapy method that teaches a patient to gain greater awareness and control over physiologic functions, including some not normally under conscious control. This is achieved by using technology that presents to the patient in visual or auditory form the level of activity of a physiologic parameter, such as muscle tension, skin temperature, sweat gland activity, respiratory muscle activity, PCO2, heart rate variability, or brain wave pattern.
Biofeedback began in the 1950s with the work of the experimental psychologist Dr. Neil Miller. He demonstrated that rats could learn to regulate autonomic functions when motivated by painful or pleasurable stimuli. The idea that autonomic function could be volitionally controlled was contrary to the scientific dogma of the time. In the 1960s, other researchers began to examine the human ability to consciously alter physiologic function.
Certification is obtained through the Biofeedback Certification International Alliance (BCIA) and is open to professionals from clinical health care areas including, but not limited to, psychology, nursing, and counseling. Requirements for certification are: (1) 48 hours of didactic education, (2) 20 hours of contact spent with a BCIA approved mentor, 50 patient/client sessions, and case conference presentations, and (3) successful completion of a written certification examination. There is also a continuing education requirement.
When treating a medical or psychological disorder, biofeedback practitioners are required to hold a current state license in a BCIA-approved health care field or, if without this license, work under the supervision of an appropriately credentialed health care professional. Separate, additional certificates are required for electroencephalographic (EEG) biofeedback (neurofeedback), and pelvic muscle dysfunction work.
Since biofeedback is a taught, self-regulatory skill, the patient should be motivated; prepared to take an active role in their treatment; respond well to visible, quantifiable information; or have aptitude or familiarity with technology. Typical biofeedback sessions last 50 minutes, with half or more of that time in active monitoring. To begin a biofeedback session, the therapist applies sensors to the patient that monitor the physiologic parameters of interest. For example, in a case of chronic tension headache, an electromyographic (EMG) sensor may be applied to the skin of the forehead. Information from the sensor feeds back to the patient as sound or as an image on a computer screen in real time, so he or she can begin to learn to reduce tension in the forehead muscle. Multiple sessions are usually required and the patient is asked to practice the learned skills between sessions. The goal of biofeedback is to help the patient train himself to produce the desired response at other times. Some biofeedback software programs and sensors are available for use on a home computer or with portable electronic devices.
Adverse Events & Contraindications
There are no reported adverse effects of biofeedback therapy. Benzodiazepines, opioids, other sedating medicines, and even caffeine can have undesirable effects on biofeedback training.
Clinical Uses of Biofeedback
The American Heart Association 2013 Scientific Statement paper on complementary therapies for blood pressure lowering conferred a “Class IIB, level of evidence B” designation for the efficacy of biofeedback for treating hypertension, and stated that “biofeedback may be considered in clinical practice to lower blood pressure.” Studies on the blood pressure lowering effect of biofeedback have been published for over 40 years. Meta-analyses consistently show that compared with wait-list or other inactive control groups, biofeedback can significantly lower patients’ systolic and diastolic blood pressures (approximately 5–8 mm Hg systolic and 3–5 mm Hg diastolic pressure). In many of the older studies when biofeedback is compared with an active control group (eg, sham biofeedback or nonspecific behavioral control), it is usually not statistically superior in its effect on blood pressure except when coupled with relaxation training or cognitive therapy. On the other hand, follow-up studies suggest that biofeedback is indeed superior to active controls. For example, a 2012 randomized controlled trial of 43 prehypertensive persons compared heart rate variability biofeedback with slow abdominal breathing and treatment as usual. The biofeedback group experienced significantly greater blood pressure reductions than either control group as well as increased baroreceptor sensitivity. In general, the degree of blood pressure reduction with biofeedback strongly correlates with pretest blood pressure. Persons with higher baseline blood pressures show larger beneficial effects from biofeedback.
Because most patients in studies of nonpharmacologic treatment of hypertension have only mild hypertension, the effect of treatments like biofeedback are more difficult to detect. Also, it is worth noting that, as is the case for all antihypertensive therapies, small reductions in blood pressure yield important clinical benefits.
There is also research on respiratory biofeedback training for blood pressure reduction. A particular pattern of device-assisted respiration practiced for 15 minutes daily has been shown in seven of nine small studies to lower ambulatory blood pressure. A thorough 2012 meta-analysis concluded that both diastolic and systolic blood pressure may be reduced with short-term use of device-guided breathing. However, because five of the eight trials were sponsored by or involved the manufacturers of the device, they were excluded. With their exclusion, no overall effect was found. Longer-term, independent trials are required. A 2013 randomized controlled trial involving 48 type 2 diabetic patients found no blood pressure benefit to using this device-guided breathing technique. A 2015 review of 15 published studies of this device concluded that it does significantly lower blood pressure (but one of the review’s authors may have had a financial conflict of interest).
B. Coronary Artery Disease
There have been clinical studies of the effect of biofeedback on heart rate variability. Heart rate variability is considered to be an indicator of autonomic tone and has been postulated to be the mediator of the effects of cognitive and mind-body therapies on cardiovascular conditions. Cardiac electrophysiology studies have shown that decreased heart rate variability is predictive of both short-term and long-term mortality after myocardial infarction. One randomized controlled trial of 154 patients with established coronary artery disease showed that biofeedback significantly increases heart rate variability. Another randomized controlled trial showed an 86% reduction in post-myocardial infarction mortality at 2 years from a psychosocial intervention that included biofeedback training of heart rate variability. However, this study did not show a significant change in heart rate variability with the intervention unless individuals with high heart rate variability at baseline were excluded. Thus, it remains unanswered whether improved heart rate variability from biofeedback training indeed affects important cardiovascular outcomes.
There have been eight randomized controlled trials of the efficacy of biofeedback on Raynaud phenomenon. Three show biofeedback to be superior to active control (eg, autogenic training), and four show benefit from biofeedback but equal to active control. One large study showed thermal biofeedback to be equivalent to EMG biofeedback treatment and to treatment with sustained-release nifedipine.
Biofeedback and other behavioral techniques have been extensively studied in prevention of recurrent migraine and tension headaches, with more than 50 studies including many randomized controlled trials. Several meta-analyses concur there is a significant reduction (30–55%) in headache frequency with biofeedback and other behavioral interventions. Other outcomes with significant improvement in several headache studies are anxiety, depression, self-efficacy and medication usage. The American Academy of Neurology practice guidelines state that there is grade “A” evidence for the use of thermal biofeedback with relaxation or EMG biofeedback for prevention of migraine. Biofeedback compares favorably with pharmaceutical treatments in several studies. There are also studies showing enhanced efficacy from adding medications to biofeedback therapy. The American Academy of Neurology practice guidelines state that there is grade “B” evidence for behavioral therapy (eg, biofeedback and relaxation techniques) when combined with prophylactic drug therapy (eg, propranolol and amitriptyline) to achieve additional clinical improvement for migraine relief. Finally, a 2016 randomized controlled pilot study of 27 patients suggested that biofeedback may have a role in treating medication-overuse headache.
Pelvic floor muscle training is an effective treatment for incontinence in women. According to a 2011 Cochrane review of 24 trials, biofeedback-assisted pelvic floor muscle training yields even greater benefit for incontinence in women, but a 2012 review questioned whether observed effect could be related to the amount of health professional contact. A 2013 randomized controlled trial supported the use of biofeedback for urinary incontinence in premenopausal women. In 2016, a randomized controlled trial involving 58 women with overactive bladder symptoms showed significantly improved symptoms and quality of life with EMG biofeedback-assisted pelvic muscle therapy after 9 weeks of treatment. In men with urinary incontinence post-prostatectomy, a 2016 systematic review and meta-analysis of 13 randomized controlled trials involving a total of 1108 patients found the immediate-, intermediate-, and long-term effects of biofeedback-assisted pelvic floor muscle training on urinary incontinence were significantly better than pelvic floor muscle training alone. Small-to-moderate immediate- and intermediate-term effects were also observed on the quality of life. A 2012 randomized controlled trial of 52 post-prostatectomy men showed pelvic floor biofeedback significantly improved erectile function.
There are more than 40 experimental trials of biofeedback for fecal incontinence in adults and all but 2 of these report moderate to large benefit. However, the methodologic quality of some of these studies is low. A 2012 Cochrane review of biofeedback and sphincter exercises for fecal incontinence included 21 randomized trials and concluded that there was evidence that biofeedback enhanced treatment outcomes; however, because of methodological weaknesses of many of the trials, a definitive conclusion was not possible. A 2013 systematic review of 13 trials was more positive, noting that biofeedback plus electrical stimulation was particularly effective. A report of 513 consecutive patients seen at a tertiary colorectal referral clinic showed that more than 70% of patients received benefit. Skeptics have noted that most of the studies on biofeedback for fecal incontinence were performed in tertiary referral centers with specialization in this modality. However, a 2017 retrospective study of 205 patients with fecal incontinence using low intensity biofeedback therapy at a secondary care center found success rates comparable to tertiary referral centers: a 71% response rate, with 47% achieving continence. Good anal sphincter exercise technique, longer in-home practice and more sessions were significantly associated with a favorable outcome. Another important “real world” study in 2013 showed less than half of patients with fecal incontinence referred for pelvic biofeedback actually received this therapy due to lack of insurance coverage or geographic distance to treatment facility but of those that did ultimately receive biofeedback therapy the success rate was high (80%), consistent with previous positive study reports. Another 2013 trial found significant quality of life benefit for fecal incontinence patients undergoing biofeedback therapy. Many authors and clinicians in this field consider pelvic biofeedback to be first- or second-line therapy for fecal incontinence. American College of Gastroenterology Practice Guidelines consider biofeedback safe and effective and recommend it for treatment of fecal incontinence.
Some 30–50% of cases of chronic constipation are due to pelvic floor dyssynergia, a failure of the pelvic floor and anal muscles to relax during straining. Pelvic floor dyssynergia may be less amenable to laxative and fiber treatment but appears to be successfully treated with biofeedback. This indication has been studied in adults in at least 11 randomized controlled trials. In 6 trials, biofeedback was superior to sham biofeedback, polyethylene glycol, diazepam, usual care, and placebo. Because of its success rate (70–80%) and safety, biofeedback is widely recommended as first-line therapy alone or in combination with other measures. A 2012 report of 226 patients referred to a tertiary care center also showed over two-thirds of patients with dyssynergic defecation had improved symptoms with pelvic biofeedback therapy. A randomized controlled trial of 157 patients with a related phenomenon, the levator ani syndrome, showed similar results; patients responded more often to biofeedback than to massage or electrostimulation.
Biofeedback for stroke rehabilitation has a sound theoretical basis but has been difficult to evaluate for several reasons, including nonstandardized outcome measures, multiple different versions of biofeedback therapies and variability in the time post-stroke at which biofeedback is offered. There are more than 30 randomized controlled trials, all with small sample sizes, and although the majority of studies show benefits such as improved motor strength, gait quality, and functional recovery, results are mixed. A Cochrane review concludes EMG biofeedback cannot be recommended as a routine treatment but due to its safety and possible efficacy its use can be reasonably considered. A comprehensive 2009 review on motor recovery from stroke similarly points out the limitations of the biofeedback literature but concludes there are positive results for recovery of arm function and standing balance though not for sit-to-stand transfer ability. At least four trials have concluded that there is significant benefit of biofeedback for gait training after stroke. A 2013 randomized controlled trial showed improvement in hand function with biofeedback and a 2014 randomized controlled trial showed improvement in lower extremity function. In two 2016 trials, visual biofeedback did not enhance outcomes of gait symmetry and postural balance beyond what was achieved with conventional treadmill training and physical therapy, but in a third trial conducted in patients with poststroke dysphagia, laryngeal elevation training combined with game-based biofeedback increased the removal rate of nasogastric tubes.
EEG biofeedback, also known as neurofeedback, was first used to reduce seizure frequency in epilepsy in the 1970s. Since then, it has been applied to psychoses, substance use disorders, anxiety disorders, affective disorders, traumatic brain injury, attention-deficit hyperactivity disorders, and other psychiatric conditions. However, there are few methodologically rigorous trials investigating this form of biofeedback in adults. A 2012 case series report of 51 patients with schizophrenia showed neurofeedback led to improvements in the Positive and Negative Syndrome Scale score in the majority of patients. A 2016 randomized controlled trial of 84 patients with psychotic symptoms who underwent heart-rate variability biofeedback sessions showed that no group differences occurred in paranoid symptoms or subjective stress, although paranoia was diminished in the subset of participants who were breathing per protocol. A small 2013 randomized trial of 20 people with opiate addiction undergoing neurofeedback showed improvement in somatic symptoms, mental health, relief from withdrawal, and reduced desire to use opioids. A 2016 review of neurofeedback for PTSD examined five studies and found that neurofeedback had a statistically significant effect in three studies.
et al. An update on anorectal disorders for gastroenterologists. Gastroenterology. 2014 Jan;146(1):37–45.e2.
et al. RESPeRATE: the role of paced breathing in hypertension treatment. J Am Soc Hypertens. 2015 Jan;9(1):38–47.
et al. Effect of preoperative pelvic floor muscle therapy with biofeedback versus standard care on stress urinary incontinence and quality of life in men undergoing laparoscopic radical prostatectomy: a randomised control trial. Neurourol Urodyn. 2015 Feb;34(2):144–50.
et al. Beneficial effects of biofeedback-assisted pelvic floor muscle training in patients with urinary incontinence after radical prostatectomy: a systematic review and metaanalysis. Int J Nurs Stud. 2016 Aug;60:99–111.
et al. Swallowing training combined with game-based biofeedback in poststroke dysphagia. PM R. 2016 Aug;8(8):773–9.
et al. Randomized controlled trial of heart rate variability biofeedback in cardiac autonomic and hostility among patients with coronary artery disease. Behav Res Ther. 2015 Jul;70:38–46.
et al. Diagnosis and treatment of dyssynergic defecation. J Neurogastroenterol Motil. 2016 Jul 30;22(3):423–35.
et al. Biofeedback in the prophylactic treatment of medication overuse headache: a pilot randomized controlled trial. J Headache Pain. 2016 Dec;17(1):87.
et al. Integrated low-intensity biofeedback therapy in fecal incontinence: evidence that "good" in-home anal sphincter exercise practice makes perfect. Neurogastroenterol Motil. 2017 Jan;29(1).
et al. The effect of EMG biofeedback assisted pelvic floor muscle therapy on symptoms of the overactive bladder syndrome in women: a randomized controlled trial. Neurourol Urodyn. 2017 Sep;36(7):1796–803.
et al. Effect of biofeedback cycling training on functional recovery and walking ability of lower extremity in patients with stroke. Kaohsiung J Med Sci. 2014 Jan;30(1):35–42.
Hypnosis is a procedure that induces an altered state of consciousness in which the patient’s mind is more accepting of suggestion. It is believed that during hypnosis the usual evaluative, critical function of the conscious mind is bypassed and more direct communication with the subconscious mind occurs.
Hypnotic phenomena, including trancelike states for medical purposes, have been practiced around the world throughout human history. It was the Scottish surgeon, James Braid, in 1843, however, who coined the term “hypnosis” and laid the foundation for the use of hypnosis in modern medicine. Braid believed the effects of hypnosis were mediated by the mind of the patient. Important early research was conducted in the 1930s by Dr. Clark Hull and his student, Dr. Milton Erickson. In the mid-1950s, the British and American Medical Associations suggested that hypnosis be incorporated into the medical curriculum. In 1960, the American Psychological Association endorsed hypnosis as a branch of psychology. In 1996, an NIH Technology Assessment Panel judged hypnosis to be an effective intervention for alleviating pain.
The mechanism of action of hypnosis has not been fully elucidated, but its effects are seen at multiple levels, including somatosensory cortex, anterior cingulate cortex (modulation of pain affect via limbic system), spinal cord and autonomic nervous system (eg, reduction of colonic motility in irritable bowel syndrome). Additional evidence about the mechanism includes upregulation of immune-related gene expression (eg, effects on TNF) and reduction of mucosal inflammatory response (in ulcerative colitis). Hypnotic trance is a state distinct from sleep or relaxation, and hypnotic analgesia is distinct from placebo analgesia.
Certification for hypnosis, granted through the American Society of Clinical Hypnosis, has the following requirements: (1) health professional degree, (2) 40 hours of workshop training, (3) 20 hours of supervised clinical training, and (4) 2 years of independent practice using clinical hypnosis.
Other certification programs exist. Patients and clinicians should inquire about the training and certification of any practitioner of hypnosis because there are no restrictions limiting its use to licensed health care practitioners.
The procedure of hypnosis can be divided into three phases: induction (or pre-suggestion), suggestion, and post-suggestion. The induction of a trance is accomplished in a variety of ways with the intention of developing relaxation and focused attention. Once the trance is induced, therapeutic suggestions are offered. In the post-suggestion phase, the patient returns to their usual state of consciousness and the suggestions may be discussed and reinforced. Self-hypnosis may be taught to further reinforce the therapeutic suggestions between sessions.
Although most people can respond to hypnosis, there is great variability in hypnotic susceptibility (“suggestibility”) in the population. This can be measured with standard instruments such as the Harvard Group Scale of Hypnotic Susceptibility and the Stanford Hypnotic Susceptibility Scale. Studies have shown a positive correlation between hypnotic susceptibility and its efficacy.
The ideal candidate for hypnosis is a patient with high suggestibility and motivation, with a condition for which hypnosis has proven benefit. Course of treatment can vary from a single session to several. Sessions are usually 45–60 minutes, with the first session typically lasting 90–120 minutes. It is helpful when referring patients to dispel common myths about hypnosis. For example, it is not true that one loses consciousness in trance nor that one cedes control to the hypnotist. Trance state may best be described as a voluntary state of mind not unlike the one experienced when absorbed in reading a book or when daydreaming. It may be useful to explain to patients that the purpose of referral to hypnosis is to learn skills to use the mind-body connection.
Adverse events from hypnosis have not been well studied. As with any psychological therapy, distressing emotions or thoughts may occur. These can manifest as somatic symptoms, such as dizziness, headache, or nausea. Occasionally, uncovering repressed psychic content can evoke strong emotional response, known as abreaction. A minority of hypnosis practitioners believe abreaction is therapeutic. Also, as with other mind-body medicine modalities that include deliberate relaxation, paradoxical anxiety reactions can rarely occur.
There is no consensus on contraindications to hypnosis; however, the use of hypnosis in patients with severe psychiatric disease is controversial. Also, patients who have very low scores on hypnotic susceptibility scales are less likely to derive therapeutic benefit.
Clinical Uses of Hypnosis
There are at least 40 controlled studies of variable methodologic quality on the use of hypnosis for treating acute pain in adult and pediatric populations. All but 3 studies show superiority of hypnosis over a control condition (usual care, no treatment, or attentional control). Hypnosis has been shown effective for periprocedural and perioperative pain in patients undergoing breast lumpectomy, excisional and core breast biopsy, bone marrow aspiration, pectus excavatum repair (Nuss procedure), percutaneous transluminal coronary angioplasty and other percutaneous vascular and renal procedures, burn wound care, dental procedures, and plastic surgery. Many studies also report less procedure-related anxiety and lower analgesic medication requirement. According to a 2013 meta-analysis, additional documented benefits include reduced recovery and surgical procedure times. A 2014 meta-analysis concludes that hypnosis is superior to some other psychological interventions for the treatment of chronic pain. A small 2013 three-arm randomized controlled trial suggests live hypnosis is superior to both recorded hypnosis and placebo for reducing anxiety during dermatologic procedures. A 2016 randomized controlled trial of 53 older hospitalized patients (mean age 80 years) found that hypnosis caused a greater reduction in pain than massage, and it also significantly improved mood.
For chronic pain, individual studies have shown efficacy for headache, orofacial pain, dyspepsia, low back pain, vulvodynia, sickle cell crisis, fibromyalgia, multiple sclerosis, and spinal cord injury.
B. Cancer-Related Symptoms
There are at least 15 randomized controlled trials that have specifically evaluated the efficacy of hypnosis for cancer-related pain, distress, fatigue, nausea, and hot flashes in adults, usually involving adults with breast cancer. All trials showed benefit compared with no treatment or usual care. In addition, 3 of 4 trials showed significant benefit of hypnosis for reducing anticipatory nausea and vomiting from chemotherapy. Other randomized controlled trials concluded (1) hypnosis decreased hot flash scores by 68% in breast cancer survivors; (2) self-hypnosis plus empathic attention was superior to empathic attention alone for reducing pain, anxiety, and medication usage in 201 patients undergoing percutaneous tumor treatment; (3) hypnosis preoperatively reduced institutional costs for breast cancer patients; (4) hypnosis reduced the doses of anesthesia medications required and reduced pain, fatigue, nausea, and emotional upset in breast cancer patients; and (5) a combined intervention of hypnosis with CBT reduced fatigue in one study of breast cancer patients undergoing radiation therapy and in another study reduced negative affect and increased positive affect in a similar patient population.
C. Irritable Bowel Syndrome
There are 17 studies of hypnosis for irritable bowel syndrome in adults, 7 of which are controlled (placebo pill, CBT, or wait-list control). All 7 controlled studies show reduction in pain and bowel symptoms and some show improved quality of life and reduced anxiety. There are also 5 follow-up studies showing maintenance of benefits for 1–7 years in duration. Two large studies (1 prospective randomized controlled trial and 1 retrospective trial) examined refractory IBS patients and found efficacy for hypnosis. The American College of Gastroenterology includes hypnosis among its recommended behavioral therapies for the treatment of irritable bowel syndrome. Among the pediatric population, a 2017 prospective randomized controlled study of 250 children with irritable bowel syndrome and functional abdominal pain found that home-based hypnotherapy with an audio file was noninferior to individual hypnotherapy performed by therapists. This study adds another treatment option for these patients.
A 2012 Cochrane review of eleven trials concluded that whether hypnosis is superior to other interventions or to no treatment for smoking cessation cannot be determined because of conflicting results and statistical weaknesses in head-to-head trials. Similarly, a 2012 meta-analysis found hypnosis may possibly aid smoking cessation but a large confidence interval in the final statistical analysis, prevented the authors from stating any definitive conclusion. More recently, a 2016 randomized controlled three-arm trial in 164 hospitalized patients concluded that hypnotherapy was superior to nicotine replacement therapy as measured by abstinence rates at 12 and 26 weeks post-hospitalization (however, the statistical significance of this conclusion was questionable).
et al. A meta-analysis of hypnosis for chronic pain problems: a comparison between hypnosis, standard care, and other psychological interventions. Int J Clin Exp Hypn. 2014;62(1):1–28.
et al. Hypnosis can reduce pain in hospitalized older patients: a randomized controlled study. BMC Geriatr. 2016 Jan 15;16:14.
et al. Hypnosis in breast cancer care: a systematic review of randomized controlled trials. Integr Cancer Ther. 2015 Jan;14(1):5–15.
et al. Hypnotherapy is more effective than nicotine replacement therapy for smoking cessation: results of a randomized controlled trial. Complement Ther Med. 2014 Feb;22(1):1–8.
et al. Randomized controlled trial of a cognitive-behavioral therapy plus hypnosis intervention to control fatigue in patients undergoing radiotherapy for breast cancer. J Clin Oncol. 2014 Feb 20;32(6):557–63.
OS. Hypnosis treatment of gastrointestinal disorders: a comprehensive review of the empirical evidence. Am J Clin Hypn. 2015 Oct;58(2):134–58.
et al. Home-based hypnotherapy self-exercises vs individual hypnotherapy with a therapist for treatment of pediatric irritable bowel syndrome, functional abdominal pain, or functional abdominal pain syndrome: a randomized clinical trial. JAMA Pediatr. 2017 May 1;171(5):470–7.
et al. A randomized controlled trial of hypnosis compared with biofeedback for adults with chronic low back pain. Eur J Pain. 2015 Feb;19(2):271–80.
Definition & Epidemiology
According to the National Center for Complementary and Integrative Health, yoga is a mind-body practice with origins in ancient Indian philosophy. The various styles of yoga typically combine physical postures, breathing techniques, and meditation or relaxation. There are numerous schools of yoga in the United States and around the world. Hatha yoga emphasizes postures (asanas) and breathing exercises (pranayama). Some of the famous styles of hatha yoga are Iyengar, Ashtanga, Viniyasa, and Kundalini.
According to the 2012 NHIS survey data, the percentage of adults who practice yoga in the United States has increased substantially, from 5.1% in 2002 to 6.1% in 2007 to 9.5% in 2012.
There are many yoga teacher training programs in existence. To standardize yoga teacher training in the United States the nonprofit Yoga Alliance provides a set of educational standards for yoga schools. A teacher trained through a Yoga Alliance-certified school has “RYT” (“registered yoga teacher”) after their name according to the following hierarchy:
RYT 200 (this is the minimum level of teacher training signifying that the teacher graduated from a Yoga Alliance-approved 200-hour training).
RYT 500 (this level signifies graduating from a 500-hour training plus having 100 hours teaching experience).
E-RYT 200 (“E” stands for “experienced.” This designation level means the teacher has 1000 hours teaching experience and has taught for at least 2 years).
E-RYT 500 (2000 hours teaching experience and has taught for at least 5 years).
There are also two specialty designations, RCYT (“Registered Children’s Yoga Teacher”) and RPYT (“Registered Prenatal Yoga Teacher”), with specific training requirements. All RYTs must complete continuing education hours every 3 years.
As there are many different styles of yoga, when referring patients to a yoga program, keywords that suggest the yoga class may be safe and gentle for medical/surgical patients are “restorative yoga,” “therapeutic yoga,” and “gentle yoga.” Other styles can also be appropriate but are more teacher-dependent. The term “hatha yoga” is non-descript. “Hatha” is a classic yoga term denoting the postures (“asanas”) that are a central element of most yoga practice. When referring patients to a program identified as “hatha yoga” often the connotation of “hatha” is that the class is classic, appropriate for beginners and not too strenuous; however, this should be verified before participation.
Like any physical activity, there is a risk of injury with yoga practice. There is no comprehensive study assessing the detailed risks of practicing yoga, but strains, injuries to the trunk, and to older participants appear to be most common. The most common type of adverse event was musculoskeletal (mostly minor sprains and strains), followed next by neurologic (mostly transient paresthesias and headache). The headstand posture caused the most reported injuries (10), followed by the shoulder stand (3), and lotus position (3).
There are 25 randomized controlled trials examining the effects of yoga on cancer patients. Most of these studies exclusively enrolled breast cancer patients. The early studies are heterogeneous and have various methodologic shortcomings; however, there have been higher quality studies more recently. Overall, the psychological outcomes in these studies are very consistent, beneficial, and have large effect sizes. Physical outcomes are less consistent and demonstrate smaller effect sizes. Fatigue in particular has been studied in 14 randomized controlled trials and a systematic review concluded: “Yoga may be beneficial for reducing cancer-related fatigue in women with breast cancer; however, conclusions should be interpreted with caution as a result of bias and inconsistent methods used across studies."
A unique 2017 pilot study examined the effects of a patient-caregiver dyadic yoga program for high-grade glioma patients who were undergoing radiation therapy and their family caregivers; it found significant improvements in patients’ sleep disturbance as well as quality of life for both patients and caregivers.
There have been 17 randomized controlled trials that in aggregate show a significant reduction of systolic blood pressure of 4.17 mm Hg and a significant reduction of diastolic blood pressure of 3.62 mm Hg, although some of the studies were of low quality. Importantly, when only including studies in which the yogic intervention contained all three basic elements of yoga practice (postures, meditation, and breathing), the blood pressure reduction effect was almost doubled. Yoga has been consistently superior to no treatment but has not been clearly superior to aerobic exercise.
A 2017 Cochrane review of 12 trials involving 1080 patients with chronic low back pain concluded that there is low to moderate certainty evidence that yoga results in small to moderate improvements in function at 3 and 6 months, but it was not shown whether yoga was superior to other exercises for back pain. A previous systematic review and meta-analysis concluded that there was strong evidence for short-term benefit on pain, long-term benefit on pain, reduced back-specific disability, and increased global improvement and moderate evidence for a long-term benefit on back-specific disability. Furthermore, an additional randomized controlled trial concluded that a 6-week yoga intervention is a cost-effective early treatment for low back pain. No serious adverse events occurred in any of these studies. Lastly, a 2017 randomized controlled study of 320 patients with nonspecific low back pain, found that yoga was noninferior to physical therapy with regard to disability and pain.
A systematic review and meta-analysis of five randomized controlled trials with a total of 233 COPD patients found that yoga training significantly improved FEV1, FEV1 %predicted, and 6-minute walking distance. However, yoga training had no significant effects on PaO2 and PaCO2. In a 2016 randomized, controlled trial of 81 coal miners with COPD, yoga significantly reduced dyspnea and fatigue and improved measured oxygen saturation.
et al. Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med. 2015 Feb;47(2):167–73.
et al. Trends in the use of complementary health approaches among adults: United States, 2002–2012. Natl Health Stat Report. 2015 Feb 10;(79):1–16.
et al. Salute to the sun: a new dawn in yoga therapy for breast cancer. J Med Radiat Sci. 2017 Sep;64(3):232–8.
et al. Effects of yoga training in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Thorac Dis. 2014 Jun;6(6):795–802.
et al. Yoga program for high-grade glioma patients undergoing radiotherapy and their family caregivers. Integr Cancer Ther. 2017 Jan 1:1534735417689882.
et al. Yoga for hypertension: a systematic review of randomized clinical trials. Complement Ther Med. 2014 Jun;22(3):511–22.
et al. Yoga-based pulmonary rehabilitation for the management of dyspnea in coal miners with chronic obstructive pulmonary disease: a randomized controlled trial. J Ayurveda Integr Med. 2016 Jul–Sep;7(3
et al. Physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med. 2017 Jul 18;167(2):85–94.
et al. Effects of yoga on cancer-related fatigue and global side-effect burden in older cancer survivors. J Geriatr Oncol. 2015 Jan;6(1):8–14.
et al. Yoga-related injuries in the United States from 2001 to 2014. Orthop J Sports Med. 2016 Nov 16;4(11):2325967116671703.
et al. Application of an integrative yoga therapy programme in cases of essential arterial hypertension in public healthcare. Complement Ther Clin Pract. 2014 Nov;20(4):285–90.
et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017 Jan 12;1:CD010671.
Tai chi chuan is a martial art that can be practiced as a gentle, meditative exercise that consists of flowing movements, balance and weight shifting, breathing and body awareness.
The exact origin of tai chi is obscure, but it likely began between 300 and 800 years ago and developed in monastic settings in China.
There is no widely recognized, standardized teacher training or certification in tai chi. Teachers are established through a lineage tradition of master-to-student transmission. When referring patients to tai chi programs it is helpful to inquire about the characteristics of that lineage and how many years of experience the teacher has.
There are four major styles of tai chi, but the majority of publicly available classes in the United States are in the Yang style. Yang style uses slow, flowing movements of medium excursion. Wu style uses smaller, more compact movements. The Chen style is the most physically demanding, especially on the knees and low back. Some of the movements in the Chen style are rapid and forceful. The Hao style emphasizes internal chi movement more than external visible movements.
Tai chi practice appears to be very safe. A systematic review of adverse events in the tai chi literature was conducted in 2014 and found 50 of 153 eligible randomized controlled trials reported any adverse events. Most of these trials found no adverse effects. Of the events that did occur none were serious. The most common events were minor musculoskeletal pains (knees, ankles, low back). Nine falls were reported but out of thousands of patients, many of whom are referred to tai chi for problems with balance, this is probably neither surprising nor alarming.
Tai chi improves balance and reduces falls. A 2017 systematic review and meta-analysis of 18 studies and 3824 patients concludes that Tai chi experimental group subjects experienced a significantly lower chance of falling at least once and a lower rate of falls altogether than control group subjects.
B. Cognitive Function in Elders
There are 21 studies (including 12 randomized controlled trials) of tai chi in elders, examining the impact on cognitive function. A meta-analysis demonstrated a large effect size (0.9) when comparing tai chi with nonintervention controls and a moderate effect size (0.5) when comparing with exercise controls. Randomized controlled trials of cognitively impaired adults (mild cognitive impairment and dementia) showed smaller (0.3) but statistically significant effect size when tai chi was compared with other active interventions. A 2016 randomized controlled trial in older adults with mild cognitive impairment showed both a significantly reduced fall risk and significantly improved cognitive function.
A meta-analysis of seven randomized controlled trials and one nonrandomized controlled trial concluded that there were beneficial effects of tai chi in improving motor function, balance and functional mobility in patients with Parkinson disease. A three-arm randomized controlled trial of 195 patients with Parkinson disease found significant reduction in falls in the tai chi group compared to the stretching group.
A 2017 meta-analysis of 13 randomized controlled trials found evidence that Tai chi significantly improved 6-minute walking distance, left ventricular ejection fraction, serum BNP, and quality of life.
et al. Tai Chi exercise for patients with chronic heart failure: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil. 2017 Oct;96(10):706–16.
et al. Improvement of balance control ability and flexibility in the elderly Tai Chi Chuan (TCC) practitioners: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2015 Mar–Apr;60(2):233–8.
et al. Systematic review and meta-analysis: Tai Chi for preventing falls in older adults. BMJ Open. 2017 Feb 6;7(2):e013661.
et al. Tai Chi and postural stability in patients with Parkinson's disease. N Engl J Med. 2012 Feb 9;366(6):511–9.
et al. Effects of Tai Chi on cognition and fall risk in older adults with mild cognitive impairment: a randomized controlled trial. J Am Geriatr Soc. 2017 Apr;65(4):721–7.
et al. Effect of tai chi on cognitive performance in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2014 Jan;62(1):25–39.
et al. What do we really know about the safety of tai chi? A systematic review of adverse event reports in randomized trials. Arch Phys Med Rehabil. 2014 Dec;95(12):2470–83.
et al. Tai Chi for improvement of motor function, balance and gait in Parkinson's disease: a systematic review and meta-analysis. PLoS One. 2014 Jul 21;9(7):e102942.