Beyond the Mind-Body Exercise Hype

Jeffrey C. Ives, PhD; Jacob Sosnoff

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 3 - MARCH 2000

In Brief: Mind-body exercise methods are spreading rapidly throughout the health, fitness, and rehabilitation fields. Many of the claimed benefits for these activities are not supported by clinical evidence, and, as alternative therapies, they carry legal and professional ramifications. Understanding the nature of mind-body exercise and knowing the scientific evidence behind claims for its benefits can help clinicians make appropriate recommendations to patients. For example, yoga and tai chi can reduce stress, decrease hypertension, and exert cardiorespiratory benefits, and tai chi can improve balance in seniors. However, there is not enough evidence to support replacing conventional medical treatments with somatic methods.

The rapid growth of alternative and complementary therapies has influenced sports medicine (1). Mind-body exercise has become widely popular in fitness facilities for performance enhancement and general wellness, and it is sometimes combined with conventional physical therapy for patients who require musculoskeletal rehabilitation (2,3).

Mind-body exercise methods may have benefits that are different from traditional exercise; however, important differences and precautions should be considered before recommending the activities to patients. Unlike conventional exercise, most types of mind-body exercise lack a strong research base. In addition, disclaimers, contraindications, precautions, and guidelines—widely documented for traditional exercise (4)—are rarely mentioned or standardized in the mind-body exercise literature. Practicing clinicians should also be aware that recommending mind-body activities, which can be considered alternative or complementary medicine, may raise medicolegal questions.

What Is Mind-Body Exercise?

The fundamental premise behind the mind-body connection is that thoughts, emotions, attitudes, and behaviors affect physiologic function, and vice-versa (5). Empiric data support some mind-body methods, such as meditation, for various clinical problems (5,6). Mind-body exercise, however, is distinct from meditation and related methods such as relaxation training in that it is purported to "unify" the mind and body through the training of motor coordination and somatosensory function. Some proponents suggest that "effective" movement is essential to nervous system development, including cognition and consciousness (7).

Also called somatic education, somatics, or psychophysical education, mind-body exercise encompasses many exercise and movement methods. The oldest are ancient Eastern practices such as yoga and tai chi, but many Western methods have developed over the past century. The diversity of somatic methods ranges from those that are vigorous enough for strength training (eg, Pilates-based training) to others that represent a somatic approach to psychotherapy (eg, Hakomi integrative somatics). Most methods fall between these two extremes.

Though each somatic technique has its own terminology and style, our review of nearly 20 different methods reveals a similar philosophy and core of techniques. Essentially, motor function cannot be separated from psychological processes, and by simultaneously training psychological and neuromuscular systems, one can meet psychological and physiologic demands more efficiently and appropriately. For example, many proponents suggest that motor dysfunction often results from deep psychological trauma. Emotional tension is thought to create abnormal muscle tone that may lead to poor posture, dysfunctional movement patterns, or chronic musculoskeletal discomfort (8).

Somatic programs emphasize educating people about their own bodies and feelings and developing self-empowerment rather than physical conditioning. A key component of mind-body exercise is awareness: awareness of one's internal bodily environment, awareness of thoughts and emotions, and awareness of one's body relative to the environment. Common somatic techniques include slow performance of unique or exploratory movements, regulated breathing and relaxation, and imagery. Eastern-based methods generally have a meditative component. In nearly all methods, instructors use verbal or tactile guidance to lead clients through various movement patterns and instruct clients to concentrate on kinesthetic and perceptual awareness. Though movements are often choreographed, clients are instructed to explore how the movement feels or to perform the movement differently.

For example, practitioners of the Alexander technique believe that a primary cause of postural and musculoskeletal dysfunction is a habitual startle response developed over years of improper use of the body. Resultant head and neck misalignment can be corrected by lightly touching the client's head and neck to direct the head forward and up, putting the head and neck in a neutral position that requires minimal exertion to maintain an erect posture (9,10). Instructors verbally cue their clients to free the neck, move the head forward and up, and allow the back to widen and lengthen. In contrast, yoga students regulate breathing while performing various vertical, horizontal, and spiral postures. They focus on how and what they are doing and on identifying any movement constraints. Each posture has a specific objective and a verbal descriptor. For example, the aim of the cobra posture is to strengthen the abdominal muscles, upper body, and the spinal extensors and focus the student's attention on spinal movement.

Though the philosophies behind mind-body unification are often unorthodox, conventional scientific principles support some somatic techniques, such as the neuroanatomical theory behind the Alexander technique (11). In addition, traditional motor learning and motor control theories have been used to describe coordination acquisition in tai chi (12) and as a basis for somatic education in general (7,13).

Physicians and allied health professionals cannot rely on theory and peripheral evidence, however, to support mind-body exercise. Basic science and clinical data are necessary to validate its use in a professional setting.

The Scientific Evidence

Somatic methods have been purported to improve a wide range of parameters such as low-back pain, sports performance, central nervous system pathology, and emotional health (14). Movement efficiency, better posture, reduced musculoskeletal pain, and "mind-body harmony" are the most common claims. Only tai chi (including related methods such as qigong), yoga, the Feldenkrais method, the Alexander technique, and Pilates-based methods are supported with research; the work, however, varies widely in quality and quantity.

Our intent is not to provide an extensive literature review of these methods, but rather to report recent review article conclusions from peer-reviewed scientific journals. When necessary, we report the recent primary research.

The disparity of clinical findings among the somatic methods and the technical and stylistic differences that characterize them make it inappropriate to extrapolate the benefits of one method to another. For example, yoga and tai chi have meditative aspects not found in other methods presented here. Feldenkrais and Alexander programs offer a greater emphasis on one-to-one, hands-on instruction (9) that fosters a deep relationship between the client and the instructor that may be responsible for some of the positive psychological effects.

Yoga and tai chi. Yoga and tai chi share many features, including precisely choreographed movements, breathing regulation, and meditation. Critical reviews on yoga (15), tai chi (12), and both (6,16,17) provide ample evidence that both methods can positively influence flexibility, hypertension, ventilation, and, for tai chi, cardiovascular performance. Biochemical changes include increased urinary norepinephrine excretion and decreased salivary cortisol levels (17).

As might be expected, most cardiorespiratory benefits have been seen in elderly and sedentary persons. However, the finding that the cardiorespiratory benefits of tai chi are similar to that of brisk walking prompted Wolf et al (12) to conclude that these benefits can be achieved in younger people, as well, if training is long term and progressively more intense.

Yoga and tai chi have also been shown to improve mood states and lower stress, which may produce some of the biochemical changes (6). These reviews all suggest that the physiologic and psychological effects of yoga and tai chi can benefit people who have cardiovascular disease.

Tai chi has received much attention recently as a way to improve balance and posture, and it has been shown to be more effective than traditional exercise in preventing falls in seniors (12). Some reports have shown that tai chi and yoga improve muscle strength in unfit persons and reduce symptoms of carpal tunnel syndrome and rheumatoid arthritis (16).

The regulated breathing techniques in yoga have been found to reduce asthma symptoms (18,19), but the rigor of this research has been questioned (6,19). It is important to note that different styles of tai chi and yoga vary markedly in their physiologic intensity and that results may not apply to all styles (16,17).

Feldenkrais method and Alexander technique. The Feldenkrais method and Alexander technique emphasize posture and movement re-education. Movements address specific (eg, altering pelvic angle) and general (eg, kinesthetic awareness, muscle tension) needs of clients. Like yoga and tai chi, Feldenkrais and Alexander exercises can be done in group settings but are perhaps most effective with one-on-one, hands-on instruction (9).

Case and anecdotal reports have claimed improvements in conditions ranging from hysterical paralysis and brain damage to a vast array of neuromusculoskeletal problems such as scoliosis and knee pain (20). However, few controlled trials have been conducted, and the findings are inconclusive. Reviews on Feldenkrais (20) and Alexander (21) have commented that strong conclusions could not be drawn about clinical effectiveness because of conflicting data, poor-quality studies, small sample sizes, lack of control or comparison groups, potential Hawthorne effects, or because some studies used multimodal interventions.

Even the most recent Feldenkrais (22-24) and Alexander (25-27) studies have lacked randomized control groups. For example, improvements in ventilatory function (28) and elders' functional reach (29) have been reported, but without control groups it is impossible to rule out placebo effects or determine if these methods work better than conventional treatments.

An emerging theme in the preponderance of the data, though, is that these methods may promote lower stress levels (23,24,30) and elevate mood states (27,29). Kinesthetic feelings of lightness or perceptions of movement are also commonly reported (24,29,31,32).

Pilates-based training. Pilates-based training is especially popular among dancers, and all peer-reviewed studies have involved dancers. Pilates-based training is distinguished by the use of specially designed resistance training devices. Exercises follow specific and ordered sequences and emphasize core movements and body balancing. Participants focus on concentration, control, movement flow, precision, "body centering," and breathing. Strength and flexibility gains have been demonstrated (33), but data on jump-height increases are equivocal (33,34). Static (33) and dynamic (35) posture improvements and various dance aesthetic qualities (36) have been found, but, like Alexander and Feldenkrais data, the validity of some reports has been questioned (35). One case study (37) suggests that Pilates-based exercise may be useful for knee rehabilitation.

Anticipating Practice Issues

Though there is not enough evidence to support replacing conventional medical treatment with somatics, the demonstrated benefits of yoga and tai chi for certain medical conditions and the promising outlook for other somatic methods increase the likelihood that more physicians will consider recommending the activities to patients. First, several legal and professional issues should be considered (table 1).

TABLE 1. Important Considerations When Recommending Mind-Body Exercise Educate yourself, your staff, and your clients on all aspects of a somatic technique before prescribing it Promote only those specific benefits supported by sound peer-reviewed data, and remember that not all benefits can be attributed to all methods Be wary of treading in the psychological domain; if so, make sure the somatic instructors have the appropriate credentials and that informed consent documents and waiver forms address these issues Make sure that the somatic practitioner has adopted and fulfills rigorous standards of practice, and verify fulfillment with careful documentation Thoroughly review a somatic instructor's experience, education, and references

Contraindications. The slow and gentle movements of most somatic methods suggest that the activities are safe and carry few contraindications. However, Pilates-type movements can be vigorous, and even the gentle movements of tai chi can be intense enough to elicit cardiovascular and strength-training responses (12). Jim Stephens, PhD, PT, assistant professor of physical therapy at Widener University in Chester, Pennsylvania, and research director of the Feldenkrais Guild, cautions that some of the lessons may be difficult for some people and that some people may exert too much effort when performing the movements; hence, teachers should be aware of cardiac problems among participants (written communication, July 1999).

Many methods can challenge range-of-motion limits, especially in overly enthusiastic clients. Yoga postures have been implicated in certain central nervous system infarcts (15). Consequently, people who participate in mind-body exercise programs should undergo the same level of preexercise screening as for any other exercise program.

Compliance. Many clients express positive attitudes toward mind-body exercise, but adherence does not appear to differ markedly from traditional exercise or therapeutic interventions (38-40). Wolfson et al (41) described the 72% attendance rate of their tai chi participants as "moderately good" and reported that at-home practice was infrequent and inconsistent. Wolf et al (42) noted that about 60% of their subjects discontinued tai chi after the study ended. The cognitive effort and challenge required of methods such as Feldenkrais can pose barriers to some clients (24).

Liability risk. Somatic methods are most often promoted as learning systems rather than medical or psychological therapies, but their actual pattern of use blurs this distinction. Cohen (43) noted that somatic and other holistic practitioners routinely offer diagnosis and treatment suggestions that could be viewed as unlicensed medical practice. Somatic methods can be considered complementary or alternative medicine (10) and, as such, carry a liability risk. Among the complex ethical and medicolegal issues, the most important points to keep in mind include:

• Physicians and other licensed healthcare providers may be liable under certain circumstances for referring patients to alternative providers (44). The lack of licensure among somatic practitioners and the absence of universally recognized care standards further complicate this issue (see "How Are Instructors Trained?" below).
• Malpractice insurers may not cover alternative methods (44).
• Because the legal and scope-of-practice issues surrounding alternative medicine are not clear (44,45), it is advisable to recommend alternative methods only when efficacy has been established for certain conditions (46). Brooke (45) advised that clients be fully informed about the physical and philosophical nature of the method used, and that informed consent be obtained if necessary.

Though recommending somatic methods seems legally risky, the activities appear to have a low malpractice risk (44). Cohen (43) also noted that holistic and somatic practitioners may be relatively free from liability because they are not practicing traditional biomedicine. Nonetheless, we advise those who are unsure of where they stand to get legal advice from a medical malpractice attorney.

Philosophical conflicts. Many Eastern and Western methods involve more than movement re-education and exercise methods—they are lifestyles replete with their own spiritual and philosophical tenets; however, one need not make dramatic lifestyle changes to benefit from these techniques. Tai chi, yoga, and other Eastern methods are firmly rooted in Eastern mysticism, which commonly holds that a vital life force or energy (called chi) unifies mind, body, and nature. The movement patterns in tai chi and yoga were designed to balance life energies, an underlying philosophy that remains despite Western adaptations that de-emphasize the spiritual aspect. Some Western somatic methods contain elements of Eastern mysticism, fringe psychology, or new-age spirituality. For example, the Nia technique is "a lifestyle blueprint that offers personal and professional growth." (47 )

We make no value judgments regarding these philosophical aspects, but clients should be made aware of them before participating. Casual participants often do not know of these philosophical and religious bases, but could find them contrary to their own belief systems. Respect and good business practice mandate that clients are not unwittingly placed in situations that may be stressful or uncomfortable. Therefore, we advise that potential belief system incompatibilities be recognized and respected, and that clients be educated on the philosophical origins of a somatic method before participation.

Psychotherapeutic scope. Somatic methods are often used directly or indirectly as psychotherapeutic tools, and blurring the line between psychotherapy and exercise raises scope-of-practice questions. Certainly, traditional exercise has been used to improve mood states (48), yet it is rarely used to explore consciousness and emotions, as is common with many somatic methods (7).

Even when not used as a direct psychotherapeutic tool, somatic sessions can elicit strong emotional responses (8). Clients have been reported to weep (49), and, as one somatic instructor reported, past traumatic experiences may resurface and cause distress, anxiety, or rage (8). Instructors must be able to handle such incidents, and clients should be informed about potential psychological outcomes. The use of touch that is common in many somatic methods raises sexual harassment concerns (50).

Tread Carefully

There is little question that some mind-body activities enhance wellness. We believe that, in certain instances, mind-body exercise can offer some benefits not easily obtained with traditional exercise. Physicians and allied health professionals, though, have ethical and legal responsibilities to advocate or use these methods in accord with the clinical evidence and scientific rationale (46).

The field of mind-body exercise is wide open, unregulated, and filled with grand promises. Our advice is to thoughtfully consider these methods but not to the exclusion of traditional strength, aerobic, and flexibility exercises.

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How Are Instructors Trained?

Somatic instructors often have certification of their qualifications, but their credentials may mean little. There is no single regulatory agency, no standard certification, and no standard educational requirement to become a mind-body or somatic professional. Each method has its own training system, which can range from a few days to years.

Numerous certification programs are available for yoga teachers, each with its own criteria. Programs range from correspondence courses and 2-day residential workshops to multiyear intensive training with a yoga master in India. A typical program is a 2-week workshop followed by 2 to 3 months of home study. Despite more than 4,000 tai chi schools and organizations worldwide, there are few mainstream teacher certification programs. Qualification to teach tai chi commonly consists only of getting approval from a master teacher or the master teacher's organization.

Training for the Alexander technique (1,600 hours over 3 years) and the Feldenkrais method (800 to 1,000 hours over 3 to 4 years) is the most extensive of Western somatic methods. Training in either method includes lectures and discussions on anatomy and physiology, kinesiology, motor control principles, method philosophy, and interpersonal communication skills. Extensive practical experiences in observing and modifying human movement pattern rounds out the training. In comparison, clinical exercise specialists certified by the American Council on Exercise may gain specialty recognition in mind-body integration with 15 hours of training. Many other somatic training programs exist within this range.

Dr Ives is an assistant professor and Mr Sosnoff is a student in the Department of Exercise and Sport Sciences at Ithaca College in Ithaca, New York. Address correspondence to Jeffrey C. Ives, PhD, Ithaca College, Dept of Exercise and Sport Sciences, Hill Center, Ithaca, NY 14850; address e-mail to jives@ithaca.edu.