Mind-Body Interventions Utilize the Mind’S Capacity to Affect the Body and Its Physiological Responses

Home , Effects of meditation, Hypnotherapy

In Brief Integrative Medicine & Complementary / From Research to Practice

Mind-body interventions utilize the mind’s capacity to affect the body and its physiological responses. They thereby influence health. The response to stress (the “fight or flight” reaction) may be automatic, but recovery toward relaxed parameters (“the relaxation response”) can be learned through self-regulation and the regular use of mind-body interventions. Many of these interventions originate from Eastern healing practices. Western science has found some of them to be helpful as adjunct modalities in the treatment of disease, and their use is increasing.

Mind-Body Interventions

Mind-body medicine focuses on the pens even without our planning or communication between mind and effort. In scientific studies, it has been body and the powerful ways in which shown to interfere with clinical out- Birgitta I. Rice, MS, RPh, CHES emotional, mental, social, and spiritu- comes. It is often looked upon as puz- al factors can directly affect health. zling or confusing and unfortunately Western, or allopathic, medicine tends has thereby been undervalued.2 A to consider the scientific, or medical, positive placebo response typically model of medicine superior to mind- improves a patient’s trust and hope body therapies. It often has negated for an affirmative outcome. the fact that one’s mind has any affect Mind-body therapies regard as on the body. But in the last genera- essential an approach that acknowl- tion, with the meeting of Eastern and edges each person’s capacity for self- Western healing practices, we have knowledge and self-care. It empha- come to accept and understand that sizes the person’s openness to partici- mind and body are powerfully related. pate and his or her desire to succeed. Between 1990 and 1997, the num- It often has been said that mind-body ber of patients using alternative prac- medicine views illness not as an obsta- tices increased from 36 to 46%.1 cle but as an opportunity for personal Quality clinical research has grown growth and transformation. steadily since 1970. The National Further training of medical health Center for Complementary and professionals is needed to improve Alternative Medicine (NCCAM), understanding of the benefits of the founded in 1998 as part of the mind-body therapies. Likewise, practi- National Institutes of Health, is now a tioners of spirituality and mind-body vital organization for disseminating interventions need to be more appre- information and providing funding ciative of the successes that the scien- options for complementary or alterna- tific practice of medicine has made tive medical research. available. Together, they can help Mind-body interventions include augment clinical outcomes whenever relaxation, imagery, biofeedback, possible. meditation, hypnosis, tai chi, yoga, Dean Ornish, MD, a cardiologist and others. They often help patients and founder of the Preventive experience healing for their illnesses in Medicine Research Institute in new and different ways. Sausalito, Calif., has done just that. A mind-body modality we often He showed that comprehensive experience, many times unbeknownst lifestyle changes (low-fat vegetarian to us, is the placebo response. It hap- diet, smoking cessation, stress-man- 213 Diabetes Spectrum Volume 14, Number 4, 2001 agement training, and moderate exer- facilitating the uptake of oxygen. The ing with two interdependent variables cise) for patients with heart disease body achieves a sleep-like rest (an here, mind and body, which then have can actually reverse coronary heart altered state of consciousness) in a to interact with all the other bodily disease.3 brief period of time. functions. Table 1 lists many of the mind- Conversely, the stress response, or It is not easy to design research body therapies and offers a brief the “fight or flight” response, includes methodologies that produce signifi- description of their potential physio- increased levels of heart rate, breath- cant outcomes in such challenging sit- logical benefits. ing, blood pressure, blood glucose, uations. Grant opportunities have How do these therapies work? and stress hormones. Excess stress- been few compared to those available What is the trigger? In many, if not induced levels of adrenaline or corti- for drug research, reflecting the limit- all, methodologies, the basic dynamic sol may damage the blood vessels and ed profit potential of complementary feature is the “relaxation response.” also compromise the immune sys- and alternative medicine research. The Herbert Benson, MD, of the Mind- tem.5,6 remainder of this article describes Body Medical Institute at Harvard Keeping excess stress hormones in some of the therapies that have been University4 coined the phrase “relax- check with relaxation may help stabi- researched and published in peer- ation response” after carrying out lize glucose levels and at the same reviewed journals. As expected, there research on the effects of meditation time provide some protection for the are a variety of studies both with and in collaboration with national and heart.3 These are both very important without positive results regarding international scholars. The relaxation issues for people with diabetes. their effect on diabetes. response is a state in which the body Mind-body therapies work for slows down and heart rate, blood some people, but they may not work Relaxation and Biofeedback-Assisted pressure, and breathing slow down, for everyone. Remember, we are deal- Relaxation Techniques Feelings of stress raise blood glucose Table 1. Overview of Mind-Body Interventions levels in people with diabetes. This is because of an increased production 7 Modality Description and potential physiological benefits of stress hormones, which reduces insulin action. In addition, patients Relaxation A state of altered consciousness, a slowing of breath and under perceived stress may find that heart rate. caring for their diabetes is less of a Meditation A process of training one’s mind to be attentive, to focus priority, leading to poor glycemic in a nonanalytical way, an attempt to refrain from rumi- 4 control, which further exacerbates the nation, as in relaxation. situation. Hypnosis The induction of trance states by therapeutic suggestion, It is therefore important for dia- a state of altered consciousness. Facilitates behavior and betes health professionals to be aware lifestyle changes, overcoming addictions. of and to check with their patients Imagery The formation of images in perception, thought, feeling, about how stress may be affecting memory, and fantasy, all in the absence of sensory stim- their lives. Health care professionals ulants (seeing, hearing, feeling, smelling, tasting). May can then offer advice specific to their improve immune function, speed surgical recovery. patients’ situation. Perhaps some Visualization Active imagery to influence attitude, behavior, or physi- additional lifestyle changes could be ological responses. Even faint intentional imagery of recommended for stress reduction. As thought activates the brain to release neurotransmitters noted earlier, decreasing stress reac- to the corresponding neural and hormonal pathways. tions may lead to better glucose con- Autogenic Training Relaxation and self-hypnosis using a specific, tested trol and improvement in immune sys- sequence of wording. tem function. Aromatherapy Stimulation of the sense of smell to encourage relax- Glucose management. With in- ation, well-being, or other physiological benefits. creased glycemic control, there is Biofeedback Adjustment of thinking processes and regulation of always a risk for hypoglycemia. When physiological functions with feedback from monitoring in a relaxed state, the body metabo- instruments. Helps to control blood pressure, muscle lizes carbohydrate more efficiently, tension, heart rate, brain waves, and skin temperature. thereby lowering blood glucose Psychotherapy Treatments ranging from simple listening to combina- levels.8,9 Patients with type 1 diabetes tions of medication, counseling, and discussion, using may potentially develop hypoglycemia behavioral/emotive approaches. following relaxation.9,10 Therefore, Support Groups Group interventions that promote bonding and belong- such patients should be told of the ing, being understood, self-expression, learning, stress possibility for low blood glucose lev- relief, and longevity. Decreases anxiety and isolation.35 els after relaxation and instructed to Dance and Exercise Movement to improve self-esteem, facilitate attention, promptly treat it as directed by their express anger, and develop a more positive body image. health care professional. Yoga A system of developing discipline to achieve body pos- In published, peer-reviewed re- tures, control breathing, and reduce stress and stress search studies featuring diabetes and hormones, thereby boosting the immune system. blood glucose, the most common Music and Art Pursuits that help in developmental disabilities and are alternative treatment is relaxation effective as an analgesic or relaxant. training or biofeedback-assisted relaxation training. Many case and con- 214 Diabetes Spectrum Volume 14, Number 4, 2001 trolled studies using biofeedback- sion to the peripheral blood vessels, thermal biofeedback. On the other Integrative Medicine & Complementary / From Research to Practice assisted relaxation training with type thereby increasing blood flow to the hand, in mind-body therapies, “think- 1 diabetic patients showed significant- extremities.18 With the improved ing of warmth” may surpass or be ly lower average blood glucose levels blood flow comes increased oxygena- more accurate than “feeling warmth.” in experimental groups or at post-test tion and nutrition of the tissues. The beneficial effects of thermal in the instance of case studies.11–13 In the studies of Rice et al.,19,20 this biofeedback-assisted relaxation have These differences could not be hypothesis was proven valid. A within- been demonstrated for several addi- explained by increased insulin doses.11 subjects design study of 40 people tional vascular disorders, including It is suggested that stress management with diabetes19 demonstrated that sub- hypertension,22 migraine,23 and be considered as an adjunct to the jects responded positively to thermal Raynaud’s syndrome.24 medical management of people with biofeedback-assisted relaxation by Claudication. This is a disease type 1 diabetes. increasing peripheral vasodilation. process involving inadequate periph- In studies of patients with type 2 This increased blood flow by an aver- eral blood flow. Thermal biofeedback diabetes, no significant lowering of age change score of 22.5% (blood vol- has been tested as a therapy to glycemic levels were observed at post- ume pulse [BVP] measured with pho- improve vascular flow and walking test.14,15 However, with relaxation toplethysmography). Change scores tolerance in patients with peripheral training, patients may have experi- were expressed as a percentage of the vascular disease.25 Improvements were enced other benefits, such as increased optimal BVP change (100%) as fol- seen in ankle-brachial index, walking self-management abilities, improved lows for each participant: [(post-BVP distance, walking speed, and stair sense of well-being, increased coping score pre-BVP score)/(100 pre- climbing. Thermal biofeedback pro- skills, lowered incidence of depres- BVP score)] 100. Similarly, for the vided an improved vascular and sion, and less perceived stress. Some temperature change score, the optimal ambulatory function for a diabetic studies have not been designed to pro- value used was 98.6 Fahrenheit. The patient with claudication.25 vide statistically significant results for average increased toe temperature Another case study of a patient more than one or two variables. change score was 31.4%, (P < 0.001). with diabetes reported that attacks of Depression. Depression is a fre- A multi-center, controlled clinical intermittent claudication were reduced quent comorbidity of chronic illness trial of patients with chronic non- to zero after 12 sessions of thermal and diabetes.16 People with diabetes healing foot ulcers20 produced signifi- biofeedback. The patient’s daily walk- who suffer from depression or anxiety cant results in healing. Of participants ing distance increased by about a mile struggle more to control their blood in the experimental group who were over the course of the treatment.26 glucose levels, even if they are taught taught thermal biofeedback-assisted Thus, it appears that thermal biofeed- biofeedback and relaxation tech- relaxation (increased blood flow to back and autogenic training are poten- niques. A small, controlled study fol- the feet), 14 out of the 16 ulcers, or tially promising therapies for people lowed 18 insulin-dependent diabetic 87.5%, healed. In the control group, with diabetes and peripheral vascular patients with depression.17 Four weeks 7 out of 16 ulcers, or 43.75%, healed disease. after the treatment ended, researchers (P < 0.009). found little difference in the daily Neuropathy pain. Diabetic periph- Hypnosis blood glucose measurements between eral neuropathy affects the sensory This modality has been used to help patients who were taught to practice nerves in the feet with pain and, later, people with eating disorders and those relaxation at home and those who with loss of feeling. The additional in need of assistance with smoking were not. Depressed patients often oxygenation and available nutrients to cessation and other lifestyle changes.27 have difficulty executing the self-care the tissues following the effects of Adolescents with type 1 diabetes have activities associated with diabetes. The relaxation provide improved sensory been reported to have a nonadherence additional demands of a relaxation function in the nerve fibers that corre- rate of ~20% to diet, exercise, and treatment plan may have been similar- spond to touch.20 This was shown by other self-care behaviors.28 In a hyp- ly difficult to follow. measuring the Current Perception nosis study,28 six adolescents served as Blood circulation and healing. The Threshold (CPT) levels by electrical their own controls, and no changes autonomic nervous system is com- stimulation of the great toe. The were made in insulin, diet, or exercise posed of the sympathetic branch change in CPT levels pre- to post- for 6 months. Then hypnosis, admin- (active in response to stress), and the intervention indicated a significant istered individually, was added with parasympathetic branch (active during difference between the experimental all of the usual modalities for 6 relaxation and digestion). Relaxation, and control groups. A significant months. Posttreatment tests showed or self-regulation of the sympathetic improvement (increased sensation in that average HbA1c dropped from nervous system activity, can be accom- the feet) was noted in the large myeli- 13.2 to 9.7%, and average fasting plished in various ways including nated nerve fiber functioning in the blood glucose (FBG) dropped from hand- and foot-warming. In a general experimental groups, which used 426 to 149 mg/dl. way, this may be thought of as quiet- biofeedback-assisted relaxation, com- ing the emotions. pared to the control groups who did Yoga When relaxing, the sympathetic not (P < 0.02). In yoga, people with diabetes may nervous system tone is lessened. In another study by Fiero et al.,21 it have found an important “new” tool Muscles relax—not only the large was suggested that diabetic neuropa- that is thousands of years old. ones, but also the musculature sur- thy might interfere with the ability to Research has shown Hatha yoga rounding the capillary blood vessels. self-regulate peripheral temperature (physical movements and postures) This relaxation allows a reduction in and that assessing neuropathic status and meditation to be excellent exam- blood pressure and improved perfu- may be important before prescribing ples of the mind-body connection at 215 Diabetes Spectrum Volume 14, Number 4, 2001 work. Yoga may provide real benefits Practitioners and providers who For insurance companies, covering in stabilizing blood glucose.29 If done want to incorporate mind-body mind-body therapies can be financially properly, yoga also counts as an aero- interventions may need to educate beneficial because these therapies are bic exercise. their hospital and clinic administra- cost-effective, nonpharmacological, Jain and associates30 studied the tors about these therapies. They noninvasive, and safe. Naparstek37 response patterns of people with type need to see and be convinced by and Rice et al.20 have shown how 2 diabetes to yoga therapy. Their positive results when mind-body relaxation and imagery have increased study showed 70% of participants to therapies are used in clinical appli- healing in clinical application. have a fair to good response to yoga cations. These therapies could be Educated clients become more preven- therapy. After 40 days of yoga, there made available to their patients. tion-oriented and stay healthier. was a significant reduction in hyper- Mindfulness meditation36 as a form glycemia measured by FBG and oral of stress management therapy has References glucose tolerance test. It has been sug- made inroads in many health sys- 1 gested that yoga, a simple and eco- tems. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC: Trends nomical therapy, might be considered in alternative medicine use in the United States, a beneficial adjunctive and self-admin- Table 2. Resources for 1990–1997. JAMA 280:1569–1575, 1998 istered therapy to medical treatment. Reference and Training in 2Harrington A: The Placebo Effect: An Regular practice is the most important Mind-Body Interventions Interdisciplinary Exploration. Cambridge, Mass., variable with all these mind-body thera- Harvard University Press, 1999 Center for Mind-Body Medicine pies. They are all inherently noninvasive, 3 inexpensive, and safe. Furthermore, James Gordon, MD, Director Ornish D, Brown SE, Scherwitz LV, Billings JH, 5225 Connecticut Ave., NW, Suite 414 Armstrong WT, Ports TA, McLanahan SM, many studies have noted that patients Kirkeelde RL, Brand RJ, Gould KL: Can lifestyle Washington, DC 20015 using them experience secondary bene- changes reverse coronary heart disease? Lancet fits, such as an increased ability to cope Phone: 202-966-7338 336:129–133, 1990 Fax: 202-966-2589 with daily stressors, adherence to pre- E-mail: [email protected] 4Benson H: The Relaxation Response. Boston, scribed treatments, increased ambulation, Website: www.cmbm.org Mass., Morrow, 1975 13,31–34 and positive outlook on life. 5Frichione GL, Stefano GB: The stress response Mind/Body Medical Institute and autoimmunnoregulation. Adv Strategies for Including Mind-Body Herbert Benson, MD Neuroimmunol 4:13–27, 1994 110 Francis St. Therapies 6Kamei T, Toriumi Y, Kimura H, Ohno S, Educational interventions are different Boston, MA 02215 Kumano H, Kimura K: Decrease in serum corti- from drug therapy and other medical Phone: 617-632-9592 sol during yoga exercise is correlated with alpha interventions in that patients must Fax: 617-632-7383 wave activation. Perceptual Motor Skills accept a much greater personal respon- E-mail: [email protected] 90:1027–1032, 2000 Website: www.mindbody.com sibility for the conduct and success of 7McEwen BS: Protective and damaging effects of these treatments. Most of the mind- stress mediation. N Engl J Med 329:1246–1253, The Center for Mindfulness in 1998 body therapies involve patient educa- Medicine tion, supervised practice, and regular Jon Kabat-Zinn, PhD 8Curtis JD, Deter RA, Schindler JV, Zirkel J: practice at home. Professional Training Information Teaching Stress Management & Relaxation Both educator and patient are the Center for Mindfulness Skills: An Instructor’s Guide. La Crosse, Wisc., Coulee Press, 1985 beneficiaries of the lifestyle changes University of Massachusetts Medical and positive attitudes resulting from Center 9Guthrie D, Moeller T, Guthrie R: Biofeedback the mind-body interventions. In addi- 419 Belmont Ave., 2nd floor and its application to the stabilization of dia- Worcester, MA 01604 betes. Am J Clin Biofeedback 2:82–87, 1987 tion to providing the education and Website: www.mindfulnesstapes.com 10 teaching the techniques, the thera- McGrady A, Bailey BK, Good MP: Controlled pist/educators serve as mentors and study of biofeedback-assisted relaxation in type I San Francisco Preventive Medicine diabetes. Diabetes Care 5:360–365, 1991 human connections to the modality, Institute 11 providing hope and encouragement Dean Ornish, MD Bailey BK, McGrady AV, Good M: for patients. Instruction and super- 900 Bridgeway, Suite #1 Management of a patient with insulin- depen- dent diabetes mellitus learning biofeedback- vised practice of mind-body skills can Sausalito, CA 94965 assisted relaxation. Diabetes Educ 16:201–204, be conducted individually or in group or 1990 settings, which can provide the New Medicine Tapes 12McGrady A, Gerstenmaier L: Effect of biofeed- strength of community.35 1308 Gilman St. Berkeley, CA 94706 back-assisted relaxation training on blood glu- Diabetes educators and other Phone: 510-527-3600 cose levels in a type I insulin dependent diabetic: health care professionals have been at a case report. J Behav Ther Exper Psychiatr E-mail: [email protected] 21:69–75, 1990 the forefront of including proven Website: mind-body therapies in their practices. www.ccnet.com/~newmed/ornish.htm 13Cox DJ, Taylor AG, Holley-Wilcox P, Pohl SL, Continuing education courses and cer- Guthrow E: The relationship between psycholog- tifications in mind-body interventions Life Sciences Institute of Mind-Body ical stress and insulin-dependent diabetic blood- Health glucose control: preliminary investigations. are available for health care profes- Health Psychol 3:63–75, 1984 sionals who want to become familiar 2955 SW Wanamaker Dr. 14 with mind-body skills and learn how Topeka, KS 66614 Jablon SL, Naliboff BD, Gilmore SL, Rosenthal to instruct patients in these therapies. Phone: 785-271-8686 MJ: Effects of relaxation training on glucose tol- Fax: 785-271-8698 erance and diabetic control in type II diabetes. Table 2 offers a list of resources for E-mail: [email protected] Appl Psychophysiol Biofeedback 22:155–169, reference and training. 1997 216 Diabetes Spectrum Volume 14, Number 4, 2001 15 32

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17 25 Ed. New York, Springer-Verlag, 1990, p. McGrady A, Horner J: Role of mood in out- Aiken JE: Thermal biofeedback for claudica- 184–197 come of biofeedback assisted relaxation therapy tion in diabetes: a literature review and case in insulin dependent diabetes mellitus. Appl study. Altern Med Rev 4:104–110, 1999 34Stein M, Miller AH, Trestman RL: Depression,

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