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Review ArticleClinical Review

Mind-Body Medicine: State of the Science, Implications for Practice

John A. Astin, Shauna L. Shapiro, David M. Eisenberg and Kelly L. Forys
The Journal of the American Board of Family Practice March 2003, 16 (2) 131-147; DOI: https://doi.org/10.3122/jabfm.16.2.131
John A. Astin
PhD
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Shauna L. Shapiro
PhD
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David M. Eisenberg
MD
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Kelly L. Forys
MA
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    Table 1.

    Description of Mind-Body Therapies (MBTs).

    ModalityDescriptionUse by the Public17 (%)
    Relaxation techniquesRelaxation techniques, broadly defined, include those practices whose primary stated goal is elicitation of a psychophysiological state of relaxation or hypoarousal. In certain practices, the goal might be to reduce muscular tension (as in progressive muscle relaxation in which muscles are alternatively tensed and relaxed). In other cases, the primary goal is to achieve a hypometabolic state of reduced sympathetic arousal. The most prominent example of the latter is Benson’s relaxation response18,1916.3
    MeditationMeditation has been defined as the “intentional self-regulation of attention,” a systematic mental focus on particular aspects of inner or outer experience.20–23 Unlike many approaches in behavioral medicine (eg, biofeedback, relaxation strategies), most meditation practices were developed within a religious or spiritual context and held as their ultimate goal some type of spiritual growth, personal transformation, or transcendental experience. It has been argued that as a health care intervention, meditation can be taught and used effectively regardless of a patient’s cultural or religious background.24 The two most extensively researched forms are transcendental meditation,25 in which practitioners repeat a silent word or phrase (a mantra) with the goal of quieting (and ultimately transcending) the ordinary stream of internal mental dialogue, and mindfulness meditation,26 in which practitioners simply observe or attend to (without judgment) thoughts, emotions, sensations, perceptions, etc, as they arise moment by moment in the field of awareness10.0
    Guided imageryGuided imagery involves the generation (either by oneself or guided by a practitioner) of different mental images. Using the capacities of visualization and imagination, individuals evoke images, usually either sensory or affective. These images are typically visualized with the goal of evoking a psychophysiological state of relaxation or with some specific outcome in mind (eg, visualizing one’s immune system attacking cancer cells, imagining oneself feeling healthy and well, exploring subconscious themes, etc)4.5
    HypnosisHypnosis has been defined as “a natural state of aroused, attentive focal concentration coupled with a relative suspension of peripheral awareness.”27 Primary components of the hypnotic trance experience include (1) absorption, or the intense involvement of a central object of concentration; (2) dissociation, in which experiences that would ordinarily be experienced consciously occur outside of normal conscious awareness, in part owing to the intense absorption; and, (3) suggestibility, in which persons are more likely to accept outside input (ie, instructions, guidance) without cognitive censor or criticism271.2
    BiofeedbackDeveloped in the 1960s, biofeedback involves the use of devices that amplify physiological processes (eg, blood pressure, muscle activity) that are ordinarily difficult to perceive without some type of amplification. Participants are typically guided through relaxation and imagery exercises and instructed to alter their physiological processes using as a guide the provided biofeedback (typically visual or auditory). Examples of prominent forms of this therapy are electromyographic biofeedback, in which patients with a condition, such as tension headaches, are provided with feedback regarding the degree of tension in the frontalis muscle, or temperature biofeedback, in which patients with migraine headache disorder are instructed to warm their hands using as their feedback cue sounds or tones indicating temperature changes in this region of the body1.0
    Cognitive behavioral therapyAmong more traditional psychological interventions, one of the more prominent MBTs is cognitive-behavioral therapy. It emphasizes the role of cognitive processes in shaping affective experience and argues that problematic emotions, such as anger, depression, and anxiety, result from irrational or faulty thinking.28,29 Behavior therapy (as distinguished from cognitive behavior approaches) tends to emphasize the use of environmental reinforcements (eg, not rewarding certain behaviors) to change or elicit certain behavioral changes.N/A
    Psychoeducational approachesThese approaches typically combine certain psychological strategies (eg, cognitive behavioral coping skills training, relaxation, meditation, and imagery for stress reduction) with patient education (ie, teaching patients about their disease, appropriate treatments, self-care behaviors, and communicating with health care providers). A prototype is the Arthritis Self-Management Program developed by Lorig and colleagues30N/A
    • N/A = not available.

      Note: In describing MBTs, researchers have used a number of broad, interrelated terms, including “behavioral,” “psychosocial,” “psychoeducational,” and so on. Such variations in terminology can reflect differing approaches and emphases. Often, however, the terms simply reflect the particular theoretical orientations of the investigators (eg, those working in the complementary and alternative medicine field might refer to meditation as a mind-body therapy, whereas researchers within behavioral medicine might refer to it as a behavioral intervention). For simplicity of presentation, we have tried to use the broader term mind-body therapies throughout the article to refer collectively to these different approaches.

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    Table 2.

    Summary of Systematic Reviews of Mind-Body Therapies (MBTs).

    First Author, YearConditionNumber and Type of Studies ReviewedTotal Number of SubjectsInterventionsResultsQuality Rating13
    Anderson & Lyttkens35Tinnitus8 randomized controlled trials700Cognitive-behavioral, relaxation, hypnosis, biofeedback, education, problem solvingEffect sizes:* Annoyance = 0.86 Loudness = 0.68 Negative affect = 0.48 Sleep = 0.26 Effects diminished at follow-up4
    Astin et al36Rheumatoid arthritis24 randomized controlled trials1,189Psychological-psychosocial approachesEffect sizes: Pain = 0.22 (0.06 at follow-up) Disability = 0.36 (0.20 at follow-up)5
    Berghmans et al37Urinary incontinence11 randomized controlled trials240Pelvic floor muscle exercises with or without biofeedbackNo evidence that addition of biofeedback is helpful4
    Brown38Diabetes82 trials (26 single group design)Not providedPatient education including relaxation, stress reduction, and cognitive-behavioral counselingMetabolic control (0.16–0.41)5
    Carroll & Seers39Chronic pain9 randomized trials414RelaxationInsufficient evidence to support use of relaxation4
    Devine & Pearcy40Chronic obstructive pulmonary disease65 studies (54% controlled; 34% randomized)3,642Psychoeducational care (see Table 1)Endurance = 0.77 Functional status = 0.637
    Devine41Asthma31 studies (58% randomized)1,860Psychoeducational careAsthma attacks = 0.56 Respiratory volume = 0.34 Expiratory flow rate = 0.29 Functional status = 0.46 Medication use = 0.625
    Devine42Presurgery191 studies (69% randomized)Not availablePresurgical psychoeducational interventionsRecovery = 0.43 Pain = 0.387
    Dusseldorp43Coronary heart disease37 studies (75% randomized)9,699Health education and stress management34% reduction in cardiac mortality 29% reduction in recurrent events5
    Eisenberg et al44Hypertension26 randomized trials1,264Cognitive behavioral techniques (including meditation, relaxation, biofeedback, stress management)Significant blood pressure declines compared with usual care or wait-list control, but not significant compared with placebo or sham condition5
    Glanz et al45Post stroke rehabilitation8 randomized trials180BiofeedbackLower extremity range of motion = 0.5 Upper extremity = 2.37
    Haddock et al46Chronic benign headache20 randomized trialsNot availableHome and clinic-based behavioral treatments46% (home based) and 53% (clinic based) showed significant improvement (ie, 50% reduction in headache activity)5
    Hadhazy et al47Fibromyalgia13 randomized trials802Mind-body therapies including autogenic training, relaxation, meditation, biofeedback, cognitive therapy, hypnosisLimited evidence that MBTs are effective in fibromyalgia5
    Hermann et al48Pediatric migraine17 studies (9 control group design)92Behavioral treatments (typically biofeedback or relaxation, or multi-component MBT)All behavioral treatments more effective than placebo or wait-list although thermal biofeedback alone or in combination with relaxation appeared most effective4
    Holyrod & Penzien49Migraine35 studies (63% used between-group comparisons)2,445Biofeedback and/or relaxationRelaxation and biofeedback appear equally effective compared with pharmacologic approaches (43% reduction in migraine activity)3
    Johnston & Vogele50Surgery34 randomized trials1,774Psychological preparationPain = 0.85 Pain medication = 0.60 Length of stay = 0.65 Recovery = 0.612
    Linden & Chambers51Hypertension89 randomized trials1,651Psychologically based nonpharmacologic treatmentsIndividualized therapy appears most effective, ES = 0.65 for systolic blood pressure Multicomponent ES = 0.51 Single method ES = 0.472
    Linden et al52Coronary artery disease23 randomized trials2,024Addition of psychosocial treatment to standard cardiac rehabilitationPatients not receiving psychosocial adjunct had adjusted odds ratio for 2-y mortality of 1.7 and 1.84 for recurrence—effects weakened at follow-up3
    Meyer & Mark53Cancer45 randomized trials2,840Psychosocial interventions (eg, cognitive behavioral, social support, educational, and multimodal interventions)Effect sizes: Functional adjustment = 0.19 Treatment and disease-related symptoms = 0.263
    Moreland et al54Stroke8 randomized trialsNot availableBiofeedbackSignificant changes in ankle muscle strength, ES = 1.27
    Morin et al55Insomnia59 controlled trials2,102Psychological interventions (eg, stimulus control, relaxation)Significant changes in sleep latency, ES = 0.88 Time awake after sleep, ES = 0.653
    Morley et al56Chronic pain25 randomized trials1,672Cognitive behavioral and behavioral therapy (including biofeedback, relaxation)Mean ES = 0.5 across all domains (eg, pain, function, mood)7
    Mullen et al57Arthritis15 controlled trials (13 randomized)Not availablePsychoeducational interventionsEffect sizes: Pain = 0.20 Disability = 0.062
    Murtagh & Greenwood58Insomnia66 controlled trials1,907Psychological treatmentsSleep latency = 0.87 Total sleep time = 0.49 Awakenings = 0.63 Sleep quality = 0.945
    Scott et al59Childbirth11 randomized trials4,230Emotional supportContinuous support resulted in shorter labor (mean difference of −1.64 h), less analgesia (OR = 0.64), oxytocin (OR = 0.29), forceps (OR = 0.43) and cesarean section (OR = 0.49)4
    Seers & Carroll60Acute pain7 randomized trials821RelaxationSome weak evidence (3/7 studies) suggesting positive effect of relaxation5
    Superio-Cabuslay61Osteoarthritis19 controlled trials3,148Patient education (eg, arthritis self-management program)Effect sizes: Pain = 0.17 Disability = 0.03 Tender joints (RA) = 0.281
    van Tulder et al62Low back pain20 randomized trials1,349Behavioral and cognitive-behavioral treatmentsEffect sizes: Pain = 0.62 Functional status = 0.357
    • * Effect sizes are typically derived from Cohen’s d statistic,34 which represents the difference of the group means divided by their pooled standard deviation. Effect sizes therefore represent the difference between groups expressed in standard deviation units (ie, an effect size of 1.00 signifies a difference of one standard deviation in the outcome measure between the treatment and control groups). As suggested by Cohen, effect sizes between 0.20 and 0.50 are considered small, those between 0.50 and 0.80 moderate, and those greater than 0.80 large. Effect sizes in the behavioral sciences tend to be in the small to moderate range. In addition, even small effect sizes can represent important clinical phenomena, particularly when they represent changes in an outcome, such as mortality, or could potentially effect large numbers in the population.

      ES = effect size, OR = odds ratio, RA = rheumatoid arthritis.

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    Table 3.

    Mind-body Therapies: Best Clinical Evidence.

    Clinical ConditionLevel of EvidenceSource of Evidence (Total Number of Patients)Implications for Practice
    After myocardial infarctionStrongTwo positive meta-analyses43,52 (12,879)In addition to the current emphasis on exercise and nutrition, MBTs (that focus on the development of self-regulation skills, such as relaxation and the management of anger, hostility, and general stress reactivity) should be included as part of cardiac rehabilitation
    Cancer symptoms (disease and treatment related)StrongPositive results from 2 meta-analysis53,71 (∼6,166)MBTs (eg, relaxation, hypnosis, supportive group therapy) should be strongly considered as adjunctive therapy for cancer patients, given these therapies’ showed efficacy in improving mood, quality of life, and coping with both the disease and treatment-related side effects
    Incontinence disordersStrongPositive results from 1 meta-analysis98; AHCPR guidelines (240)Biofeedback-assisted muscle retraining in the treatment of urinary incontinence. Can also be effective for fecal incontinence, although additional research is needed
    Surgical outcomesStrongPositive findings from 2 meta-analyses42,50 (∼6,904)MBTs (eg, relaxation, guided imagery, hypnosis, instructional interventions) can be recommended as part of presurgical preparation, although additional research is needed to determine the relative efficacy and cost-effectiveness of these different approaches
    InsomniaStrongPositive results from meta-analyses (4,009); NIH Consensus PanelMBTs (eg, muscle relaxation, cognitive-behavioral and behavioral therapies, such as stimulus control) should be considered in the treatment of insomnia. Additional research is required to determine how MBTs might be effectively combined with pharmacotherapy
    HeadacheStrongPositive results from 2 meta-analyses46,49 (∼3,083)The combination of relaxation and thermal biofeedback can be recommended as treatment for recurrent migraine, while the use of relaxation or muscle biofeedback can be recommended as adjunctive or stand-alone therapies for tension headaches
    Chronic low back painStrongPositive findings from 1 high-quality meta-analysis62 (1,349)Multi-component MBTs that include some combination of stress management, coping skills training, or cognitive restructuring should be strongly considered as adjunctive therapies in medical management of chronic low back pain
    Osteoarthritis, rheumatoid arthritisModerate-strongPositive findings from meta-analyses36,61 (though effect sizes generally small and frequently diminished with time) (4,337)Multimodal MBTs (that combine education with such approaches as relaxation, imagery, biofeedback, and cognitive behavioral counseling) should be considered as potentially effective adjunctive treatments for osteoarthritis and rheumatoid arthritis
    HypertensionModeratePositive results from 1 meta-analysis (1,651)51 but contradictory findings in 2 others44,108MBTs (particularly multi-component as opposed to single-component interventions, such as stand-alone relaxation therapies) can be potentially useful adjuncts in the medical management of hypertension
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The Journal of the American Board of Family Practice: 16 (2)
The Journal of the American Board of Family Practice
Vol. 16, Issue 2
1 Mar 2003
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Mind-Body Medicine: State of the Science, Implications for Practice
John A. Astin, Shauna L. Shapiro, David M. Eisenberg, Kelly L. Forys
The Journal of the American Board of Family Practice Mar 2003, 16 (2) 131-147; DOI: 10.3122/jabfm.16.2.131

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Mind-Body Medicine: State of the Science, Implications for Practice
John A. Astin, Shauna L. Shapiro, David M. Eisenberg, Kelly L. Forys
The Journal of the American Board of Family Practice Mar 2003, 16 (2) 131-147; DOI: 10.3122/jabfm.16.2.131
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