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Modality Description Use by the Public17 (%) Relaxation techniques Relaxation 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 response18,19 16.3 Meditation Meditation 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 awareness 10.0 Guided imagery Guided 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 Hypnosis Hypnosis 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 criticism27 1.2 Biofeedback Developed 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 body 1.0 Cognitive behavioral therapy Among 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 approaches These 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 colleagues30 N/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.
First Author, Year Condition Number and Type of Studies Reviewed Total Number of Subjects Interventions Results Quality Rating13 Anderson & Lyttkens35 Tinnitus 8 randomized controlled trials 700 Cognitive-behavioral, relaxation, hypnosis, biofeedback, education, problem solving Effect sizes:* Annoyance = 0.86 Loudness = 0.68 Negative affect = 0.48 Sleep = 0.26 Effects diminished at follow-up 4 Astin et al36 Rheumatoid arthritis 24 randomized controlled trials 1,189 Psychological-psychosocial approaches Effect sizes: Pain = 0.22 (0.06 at follow-up) Disability = 0.36 (0.20 at follow-up) 5 Berghmans et al37 Urinary incontinence 11 randomized controlled trials 240 Pelvic floor muscle exercises with or without biofeedback No evidence that addition of biofeedback is helpful 4 Brown38 Diabetes 82 trials (26 single group design) Not provided Patient education including relaxation, stress reduction, and cognitive-behavioral counseling Metabolic control (0.16–0.41) 5 Carroll & Seers39 Chronic pain 9 randomized trials 414 Relaxation Insufficient evidence to support use of relaxation 4 Devine & Pearcy40 Chronic obstructive pulmonary disease 65 studies (54% controlled; 34% randomized) 3,642 Psychoeducational care (see Table 1) Endurance = 0.77 Functional status = 0.63 7 Devine41 Asthma 31 studies (58% randomized) 1,860 Psychoeducational care Asthma attacks = 0.56 Respiratory volume = 0.34 Expiratory flow rate = 0.29 Functional status = 0.46 Medication use = 0.62 5 Devine42 Presurgery 191 studies (69% randomized) Not available Presurgical psychoeducational interventions Recovery = 0.43 Pain = 0.38 7 Dusseldorp43 Coronary heart disease 37 studies (75% randomized) 9,699 Health education and stress management 34% reduction in cardiac mortality 29% reduction in recurrent events 5 Eisenberg et al44 Hypertension 26 randomized trials 1,264 Cognitive 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 condition 5 Glanz et al45 Post stroke rehabilitation 8 randomized trials 180 Biofeedback Lower extremity range of motion = 0.5 Upper extremity = 2.3 7 Haddock et al46 Chronic benign headache 20 randomized trials Not available Home and clinic-based behavioral treatments 46% (home based) and 53% (clinic based) showed significant improvement (ie, 50% reduction in headache activity) 5 Hadhazy et al47 Fibromyalgia 13 randomized trials 802 Mind-body therapies including autogenic training, relaxation, meditation, biofeedback, cognitive therapy, hypnosis Limited evidence that MBTs are effective in fibromyalgia 5 Hermann et al48 Pediatric migraine 17 studies (9 control group design) 92 Behavioral 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 effective 4 Holyrod & Penzien49 Migraine 35 studies (63% used between-group comparisons) 2,445 Biofeedback and/or relaxation Relaxation and biofeedback appear equally effective compared with pharmacologic approaches (43% reduction in migraine activity) 3 Johnston & Vogele50 Surgery 34 randomized trials 1,774 Psychological preparation Pain = 0.85 Pain medication = 0.60 Length of stay = 0.65 Recovery = 0.61 2 Linden & Chambers51 Hypertension 89 randomized trials 1,651 Psychologically based nonpharmacologic treatments Individualized therapy appears most effective, ES = 0.65 for systolic blood pressure Multicomponent ES = 0.51 Single method ES = 0.47 2 Linden et al52 Coronary artery disease 23 randomized trials 2,024 Addition of psychosocial treatment to standard cardiac rehabilitation Patients not receiving psychosocial adjunct had adjusted odds ratio for 2-y mortality of 1.7 and 1.84 for recurrence—effects weakened at follow-up 3 Meyer & Mark53 Cancer 45 randomized trials 2,840 Psychosocial interventions (eg, cognitive behavioral, social support, educational, and multimodal interventions) Effect sizes: Functional adjustment = 0.19 Treatment and disease-related symptoms = 0.26 3 Moreland et al54 Stroke 8 randomized trials Not available Biofeedback Significant changes in ankle muscle strength, ES = 1.2 7 Morin et al55 Insomnia 59 controlled trials 2,102 Psychological interventions (eg, stimulus control, relaxation) Significant changes in sleep latency, ES = 0.88 Time awake after sleep, ES = 0.65 3 Morley et al56 Chronic pain 25 randomized trials 1,672 Cognitive behavioral and behavioral therapy (including biofeedback, relaxation) Mean ES = 0.5 across all domains (eg, pain, function, mood) 7 Mullen et al57 Arthritis 15 controlled trials (13 randomized) Not available Psychoeducational interventions Effect sizes: Pain = 0.20 Disability = 0.06 2 Murtagh & Greenwood58 Insomnia 66 controlled trials 1,907 Psychological treatments Sleep latency = 0.87 Total sleep time = 0.49 Awakenings = 0.63 Sleep quality = 0.94 5 Scott et al59 Childbirth 11 randomized trials 4,230 Emotional support Continuous 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 & Carroll60 Acute pain 7 randomized trials 821 Relaxation Some weak evidence (3/7 studies) suggesting positive effect of relaxation 5 Superio-Cabuslay61 Osteoarthritis 19 controlled trials 3,148 Patient education (eg, arthritis self-management program) Effect sizes: Pain = 0.17 Disability = 0.03 Tender joints (RA) = 0.28 1 van Tulder et al62 Low back pain 20 randomized trials 1,349 Behavioral and cognitive-behavioral treatments Effect sizes: Pain = 0.62 Functional status = 0.35 7 * 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.
Clinical Condition Level of Evidence Source of Evidence (Total Number of Patients) Implications for Practice After myocardial infarction Strong Two 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) Strong Positive 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 disorders Strong Positive 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 outcomes Strong Positive 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 Insomnia Strong Positive results from meta-analyses (4,009); NIH Consensus Panel MBTs (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 Headache Strong Positive 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 pain Strong Positive 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 arthritis Moderate-strong Positive 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 Hypertension Moderate Positive results from 1 meta-analysis (1,651)51 but contradictory findings in 2 others44,108 MBTs (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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