Introduction
Integrative therapies have been used for centuries in a variety of cultures to promote health and well-being. The National Center for Complementary and Integrative Health distinguishes two types of integrative approaches: natural products (e.g., dietary supplements) and mind-body practices (e.g., meditation, yoga, and Tai Chi, as well as body-manipulative methods, such as chiropracty, massage, or acupuncture). Interest in mind-body therapies among rehabilitation patients has grown considerably in recent years. Data from the 2002 National Health Interview Survey (NHIS) indicate that roughly one in five individuals with a physical disability, including persons with multiple sclerosis (MS), cerebral palsy, spinal cord injury (SCI), arthritis, and stroke, reported engaging in at least one mind-body therapy (i.e., meditation, yoga, or Tai Chi). NHIS data from 2007 indicate that the use of mind-body therapies nearly doubled for all populations, including those with functional limitations. Recent studies suggest that 40% to 80% of patients with physical disabilities engage in some form of mind-body therapy. This chapter will: (1) review the evidence for in-person and telerehabilitation meditation, yoga, and Tai Chi for persons participating in rehabilitation; (2) highlight areas for future research; (3) present practical strategies to deliver these telerehabilitation mind-body therapies; and (4) present a case study of the delivery of a telerehabilitation meditation program for neurorehabilitation patients.
In-Person Mind-Body Therapies for Rehabilitation Populations
As the use of mind-body therapies has grown, so too has its empirical study. In 2020 over 2800 publications contained the term “mindfulness,” over 600 contained the term “yoga,” and over 300 contained the term “Tai Chi” in the title, which is 15 times greater than the number of publications related to these therapies 20 years before. Evidence of the impact of these therapies for rehabilitation populations, in particular, continues to mount.
Mindfulness-Based Meditation Programs
Mindfulness-based meditation, the most extensively studied type of meditation, refers to the practice of purposefully turning one’s attention to the present moment with a sense of openness, curiosity, and nonjudgment. It can be practiced anywhere in a seated position (preferred) or lying down for any duration. Patients engaging in a mindfulness-based meditation program (MBP) are typically asked to practice daily, with practice lengths ranging from as little as 5 minutes up to 90 minutes. Most MBPs last 4 to 8 weeks, and evidence suggests that at least 4 weeks of practice is needed to impact clinical outcomes. As mindfulness-based meditation involves cultivating a sense of nonjudgment toward the present moment, it may be especially well suited to patients adjusting to a physical disability. In fact, MBPs can lead to increased adaptation to illness, acceptance of physical symptoms, and quality of life (QOL). Unfortunately, research examining MBPs has been plagued by low rigor, resulting in some studies that may seem promising but whose low quality prevents firm conclusions from being drawn. Nevertheless, many studies show the promise of MBPs for improving disease and QOL-related outcomes among individuals with physical disabilities. Specifically, current literature suggests low- to moderate-quality evidence for the effectiveness of MBPs on psychological outcomes (e.g., depression, anxiety, self-efficacy) among individuals with heart failure, stroke, rheumatoid arthritis, SCI, MS, and cancer. There is also some evidence that MBPs are associated with improvement in pain outcomes in individuals with chronic pain and various other rehabilitation populations.
Yoga
Yoga combines physical movements and mindful pauses in particular positions (e.g., standing, seated, squatting, lying) with a mental focus on the breath and body. Yoga programs typically last between 4 and 12 weeks, and participants are encouraged to practice at least three times per week. Poses’ difficulty levels can range from low to very intense, and as participants increase their strength and flexibility, they may opt to take on more challenging poses. When working with individuals with physical disabilities, yoga instructors must be experienced and capable of suggesting safe modifications to various poses to allow participation and prevent injuries. Given the importance of physical movement among individuals requiring rehabilitation, yoga is often an ideal complement to traditional rehabilitation therapies. Like MBP research, studies on the effects of yoga have varied quality. Currently, evidence suggests that yoga may improve pain and functional outcomes for individuals with musculoskeletal conditions, including chronic low back pain. Yoga practice has also improved psychological outcomes, sleep, and fatigue for cancer survivors, and cognitive functioning for individuals with mild cognitive impairment or dementia. Yoga has also been found to improve a variety of outcomes among cardiac and stroke patients, including biological cardiovascular risk factors (e.g., blood pressure [BP] and cholesterol), QOL, and functional abilities. In fact, Medicare funds a lifestyle program involving yoga for individuals with heart disease. In individuals with MS, yoga practice was associated with improvement in mood and fatigue. Though yoga for persons with SCI requires considerable individualized modifications from experienced teachers, one small randomized controlled trial (RCT, n=23) found that a 6-week yoga intervention was feasible and associated with reduced depression and increased self-compassion among individuals with SCI.
Tai Chi
Similar to yoga, Tai Chi combines physical movements with attention to the breath and body, but unlike yoga, Tai Chi involves constant movement from one position to the next. Tai Chi is typically done in a standing position, but some programs have been adapted to a sitting position. Programs usually last 4 to 16 weeks, and evidence suggests at least 5 weeks of practice may be necessary to impact clinical outcomes. Given that Tai Chi is a gentle, contemplative exercise that encourages patients to focus on their body’s movement, it can complement traditional rehabilitation therapies. As with MBP and yoga research, studies on the effect of Tai Chi often suffer from low methodological rigor. Nevertheless, current evidence suggests that practicing Tai Chi may significantly improve musculoskeletal pain among individuals with chronic pain, and pain, fatigue, sleep, depression, and QOL among cancer survivors. In individuals with neurological disorders such as MS, stroke, and SCI, Tai Chi practice may improve QOL, balance, functional abilities, and pain. Additionally, Tai Chi modified for wheelchair use among individuals with SCI demonstrated improvement in sitting balance and handgrip strength, enhanced vagal activity, and decreased sympathetic activity.
Physical disabilities are associated with a host of “secondary” effects, including depression, pain, and fatigue, which can, in turn, lead to reduced engagement in activities of daily living and essential rehabilitation therapies. In fact, patients diagnosed with depression are three times more likely to be noncompliant with medical recommendations. Additionally, stress can exacerbate many conditions such as MS and neurocognitive disorders. These mind-body therapies show promise in improving these secondary effects. In particular, mindfulness-based meditation appears to have reasonably robust moderate effects on psychological outcomes and small effects on pain, whereas yoga and Tai Chi may improve pain, QOL, and functional outcomes in a variety of rehabilitation populations. Importantly, these therapies are acceptable and low risk among rehabilitation populations.
Telerehabilitation Mind-Body Therapies
Given the growing interest in and developing evidence supporting the benefits of mind-body therapies for rehabilitation populations, it is important to examine ways to increase access to these therapies. People with physical disabilities face many barriers to accessing health care, especially rehabilitation and integrative therapies. For example, persons requiring rehabilitation are more likely to be unable to drive, and evidence suggests that finding transportation to in-person mind-body classes is a barrier to adherence. Persons needing rehabilitation often juggle many different medical appointments, preventing them from engaging in in-person integrative therapies. Many health care clinics do not have mind-body therapists on staff, making such therapies inaccessible for patients even if they could attend sessions in person. Further, some medical conditions are associated with a high risk of infection (e.g., individuals with cystic fibrosis or posttransplant), preventing these individuals from engaging in in-person group mind-body therapies. The COVID-19 pandemic, which put all patients and providers at risk of infection, dramatically changed the health care landscape, necessitating the move of many therapies to telerehabilitation. Offering telerehabilitation mind-body therapies in the comfort of a person’s own home could increase access and adherence, reduce risk of infection, and potentially result in substantial cost savings. However, more cost-effectiveness research is needed to verify this assertion. Here, we review the existing evidence for and lessons learned from telerehabilitation meditation, yoga, and Tai Chi.
Meditation
Several studies have examined telerehabilitation MBPs for rehabilitation populations, including individuals diagnosed with cancer, MS, SCI, prehypertension, and osteoarthritis.
Cancer
Telerehabilitation MBPs have been most extensively studied in individuals with cancer. A systematic review of telerehabilitation MBPs for cancer survivors found that these programs were associated with small-to-medium effects on anxiety, depression, and pain, which is generally consistent with in-person studies of MBP. This review also pointed out that delivery methods varied considerably: about one-third of the MBPs reviewed were delivered via a website, one-third via mobile app, and one-third via videoconference or telephone. Typically, patients were provided with audio- and/or video-recordings of mindfulness exercises to support practice in between sessions. Interestingly, few reviewed studies used reminder systems (e.g., email, text messages), which is surprising given that reminder messages may increase adherence to MBPs by eight times. Though attrition seems to be higher in telerehabilitation MBP (13%–48% for telerehabilitation compared with <25% for in-person), participants tend to complete at least four sessions, which is consistent with the adherence to in-person MBPs. Thus reminder systems may be critical to keep participants engaged, but evidence generally suggests it is feasible, acceptable, and effective for cancer survivors.
Multiple Sclerosis
One study found that individuals diagnosed with MS who were randomly assigned to an 8-week group mindfulness-based stress reduction (MBSR) program led by a trained MBSR facilitator via Skype video chat reported a higher QOL and lower depression, anxiety, and sleep disturbance at the end of intervention compared with those randomly assigned to an 8-week asynchronous online psychoeducation program (n = 139). The effect sizes observed in this study were smaller than those observed in a similar study examining an in-person MBSR intervention for patients with MS. Thus more research is needed to discern if the effects of telerehabilitation MBPs may be weaker than in-person approaches among MS patients and if sustained support (e.g., “booster sessions”) is necessary for long-term change. Regarding feasibility, this study noted that at least one participant experienced difficulty with their internet connection each session. However, participants were able to reconnect quickly. Additionally the vast majority of participants (98%) completed the intervention, and dropout rates were similar in both conditions, suggesting that this intervention is acceptable and feasible. Minor adaptations to traditional MBSR were made to meet the needs of individuals with MS in this study (e.g., sessions included a discussion of acceptance of MS-related symptoms), and home exercises were supported by a study-specific website that contained guided meditations instead of physical CDs, which have often been provided to patients in MBSR. Thus telerehabilitation MBPs may need to be adapted to the needs of the particular rehabilitation populations and the online environment.
Spinal Cord Injury
Preliminary evidence also supports the use of telerehabilitation MBPs among persons with SCIs. Individuals with SCI and chronic pain who were randomly assigned to an 8-week individual, asynchronous online mindfulness course reported reduced depression, anxiety, and pain catastrophizing at the end of the intervention and 3 months later compared with those randomly assigned to an 8-week psychoeducation program (n = 67). Specifically, the mindfulness course involved listening to two 10-minute guided meditations available on the study’s website for 6 out of 7 days a week for 8 weeks. The guided meditations were adapted to an SCI population (e.g., encouraging participants to consider head tilts or wrist rotations in a mindful movement exercise), again highlighting the need to adapt interventions to the target population. Though the majority (72%) of participants completed the intervention, dropout rates were higher in the intervention group than in the psychoeducational program group, particularly among older, more depressed individuals. Thus strategies to retain older and more severely depressed individuals may be necessary for telerehabilitation MBPs.
Prehypertension
Even relatively low-intensity interventions, such as having an individual use a mobile app, may impact physical health outcomes. One study examined the effect of using the publicly available app, TensionTamer, on BP among patients diagnosed with prehypertension (systolic blood pressure [SBP]: 121–139; n = 64). Participants attended an in-person orientation session to download the app and were randomly assigned to use the Breathing Awareness Meditation sessions for 5-, 10-, or 15-minute intervals twice daily over 6 months. A greater dose (i.e., the 15-minute condition) was associated with reduced adherence, particularly as the program continued. Nevertheless the 15-minute condition was also associated with the greatest reduction in SBP at the 3- and 6-month follow-up. However, all conditions were associated with a significant drop in SBP from baseline, and the effect sizes observed were similar to or greater than in-person meditation studies. Thus app-based MBPs may be an effective alternative to in-person MBPs for prehypertensive individuals. Additionally, longer mobile app–guided meditation (i.e., 15 minutes twice daily) may be ideal during the initial weeks of an MBP and shorter and/or less frequent meditation sessions may be ideal in the following months, which is consistent with preferences reported by stroke survivors enrolled in an at-home MBP. Interestingly, this study measured adherence using built-in photoplethysmography in the TensionTamer app, which collected heart rate throughout each meditation session as the participant placed their index finger on the rear-facing camera on their smartphone. This illustrates just one of the many ways that existing technology can be used to assess adherence to and effects of telerehabilitation mind-body interventions.
Osteoarthritis
Remotely delivered MBPs may also enhance the effectiveness of other rehabilitation therapies. Participants with knee osteoarthritis who were randomly assigned to self-administer transcranial direct current stimulation (tDCS) and listen to a CD of guided mindfulness-based meditation for 20 minutes per day for 10 days reported less pain compared with those assigned to a sham tDCS and sham mindfulness condition (i.e., listening to a CD instructing them to breathe in and out) (n = 30). Though it is not possible to disentangle the effects of mindfulness from those of tDCS in this study, it does suggest that MBPs may be used to augment other telerehabilitation practices.
Summary
Telerehabilitation MBPs lasting at least 4 weeks and involving daily practice for 5 to 15 minutes may lead to improved psychological outcomes, which can have important implications for health and QOL among rehabilitation populations. Unfortunately, much like the in-person research on MBPs for rehabilitation populations, little is known about the direct impacts of telerehabilitation MBPs on functional outcomes. Nevertheless, telerehabilitation MBPs are safe, seem to be feasible even in the face of some technology challenges (e.g., inconsistent internet connection), and may be incorporated with other rehabilitation therapies.
Yoga
Fewer studies have examined telerehabilitation yoga interventions, but initial evidence suggests it is safe and potentially beneficial for individuals diagnosed with heart failure/chronic obstructive pulmonary disease (COPD) and cancer.
Heart Failure/COPD
One nonrandomized trial examined qualitative feedback from six participants with dual heart failure/COPD who participated in a yoga program adapted for heart failure/COPD patients delivered twice weekly for 8 weeks via multipoint videoconference technology (i.e., DocBox). Results suggested the intervention was feasible, as all six participants who began the yoga program attended at least 13 sessions of 18 possible sessions. Qualitative feedback indicated that it was acceptable and motivating, and may be particularly helpful in decreasing breathlessness. Interestingly the technology used in this study (DocBox) allowed participants to livestream yoga classes to their televisions, which had the benefits of presenting the instructor on a relatively large screen, did not require participants to own a tablet or computer, and allowed participants to interact with their instructor, but not other participants. However a member of the research team was required to come to each participant’s home to install the videoconference technology (i.e., camera and software), which may not be practical for all rehabilitation settings. Additionally, half of the participants reported having difficulty with their internet connection during classes that prevented them from following the instructor. Participants were divided on their impressions of the group dynamics; half preferred to be able to interact with others and half appreciated the privacy. Thus providing patients with stable internet access and options of attending group or individual yoga classes may be ideal.
Cancer
Another open pilot study collected qualitative feedback from four women undergoing radiation or chemotherapy for breast cancer who participated in a cancer-adapted yoga program twice weekly for 6 weeks using multipoint videoconference software (GoToMeeting), which allowed participants to see and interact with the instructor and other participants. Participants were provided with printed instructions on using the software, and staff were available to provide technical assistance during each class. Recruitment and retention for this study was difficult; a third of those screened did not have internet access, and only half of those who consented attended more than 4 of the 12 possible classes. Thus telerehabilitation programs may need to provide additional support to patients in the form of assistance with internet access and synchronous (i.e., live) orientation to the technology (either in person or via video chat). Additionally, providing telerehabilitation yoga during active chemotherapy/radiotherapy may not be feasible. Indeed, participants suggested the program be offered after active treatment was completed. Qualitative feedback indicated several other areas for improvement, including a more streamlined/user-friendly videoconferencing technology, more class times to accommodate busy schedules, and reduced survey lengths. Thus a user-friendly interface (such as an app) that contains all program content, some of which can be viewed asynchronously in the absence of an internet connection, may be ideal.
Multiple Sclerosis
One ongoing study will examine the effectiveness of a 12-week yoga, Pilates, and neurorehabilitation intervention via 20 prerecorded videos on an app for participants with MS. Though the results of this RCT have not yet been published, the protocol provides several ideas for ways that a yoga intervention may be provided via telerehabilitation. For example, participants are asked to attend an in-person orientation meeting in the clinic with a family or friend present so that they may have assistance in using the app at home. Additionally, participants are classified into four exercise levels, based on their performance on the Timed 25-Foot Walk Test, and are only provided with videos containing exercises/poses appropriate for their functional abilities. As was recommended in previous studies, participants are provided with a tablet, on which the app with appropriate videos is already available, to allow participants to use the program in the absence of internet connection. Additionally, participants will receive regular automated phone calls to encourage adherence. One limitation of this study is the absence of any synchronous yoga instruction, which may be important for sustained interest and adherence.
Heart Disease
Telerehabilitation may also be used to enhance adherence to a home practice of mind-body therapies delivered in person. For example, one study found that cardiac patients discharged from an inpatient rehabilitation program that included yoga training who received four motivational phone calls over the course of 6 months were twice as likely to continue their yoga practice at home postdischarge compared to usual care (n = 228). Participants receiving the motivational phone calls also reported higher mental health-related QOL and had lower SBP compared with usual care 6 months postdischarge. Thus even a very low-intensity telerehabilitation intervention can lead to increased use of rehabilitation techniques, which may in turn lead to improved mental and physical health-related outcomes.
Summary
Telerehabilitation of yoga is novel but shows promise. Reminder phone calls, provision of technological resources (e.g., tablets and/or internet access), and hands-on orientation to technology may increase the feasibility of remotely-delivered yoga.
Tai Chi
Similar to yoga, few studies have examined telerehabilitation Tai Chi interventions for rehabilitation populations, but initial evidence suggests it is safe and potentially beneficial for individuals with cystic fibrosis and elevated fall risk.
Cystic Fibrosis
One RCT compared a Tai Chi program consisting of eight sessions delivered over 3 months via videoconferencing software (Skype) to in-person delivery of the same program for adults and children with cystic fibrosis (n = 40). Both programs had very good engagement and retention rates and both resulted in improved sleep, cough, breathing, and gastrointestinal symptoms. No differences between the telerehabilitation and in-person delivery were observed. Though most participants reported being surprised at how much they benefited from the telerehabilitation, a few reported difficulty with inconsistent internet connection as well as difficulty seeing their instructor clearly on the small screen of their device. Thus assistance with technology (i.e., providing internet access or larger screens) may help increase accessibility for participants.
Increased Fall Risk
Another RCT compared a thrice weekly 15-week group Tai Chi program for older adults at risk for falls delivered in three different ways: synchronously via telerehabilitation (DocBox installed in their home by the research team), synchronously in person at a community center (local YMCA), or asynchronously via prerecorded videos to view at home (n=64). Close to half of participants in the asynchronous condition discontinued the program due to loss of interest, suggesting some synchronous contact with the instructor is important. Both the telerehabilitation and community center Tai Chi programs were associated with significant reduction in falls, improved balance, and increased health-related QOL. This suggests that telerehabilitation Tai Chi may be a feasible, acceptable, and effective intervention for older adults. However, it is important to note that the study team set up DocBox in participants’ homes and the instructor viewed participants from three large screens, which may be a challenge for rehabilitation providers in the absence of research funding.
Stroke
Finally, one ongoing study will compare a twice weekly 8-week Tai Chi program for poststroke patients delivered via telerehabilitation versus in person. Though results of this study are not yet available, it is noteworthy that patients are being recruited before they are discharged from an inpatient stay, highlighting the importance of integrating telerehabilitation mind-body programs into patients’ larger rehabilitation care.
Summary
Telerehabilitation Tai Chi is novel, but preliminary evidence suggests it may be as effective as in-person Tai Chi at improving health and QOL-related outcomes. Participants may prefer synchronous instruction and may benefit from technological assistance (i.e., sufficiently sized screens and reliable internet connections).
Research Recommendations
Preliminary research suggests that delivering mind-body therapies via telerehabilitation is feasible and acceptable to rehabilitation populations. Though relatively more evidence supports the effectiveness of telerehabilitation MBPs compared to yoga or Tai Chi, more rigorous investigation of each of these integrative approaches is needed. Specifically, high-quality RCTs comparing telerehabilitation mind-body therapies with active control conditions, including in-person mind-body therapies, are essential to determining the effects of these interventions. Additionally, due to the impact of expectancy on outcomes, single-, double-, or triple-blind RCTs are needed. Research is also needed to compare the effects of different program elements (e.g., synchronous vs. asynchronous; individual vs. group; app vs. website platform; text message vs. email vs. automated phone call reminders) on adherence, satisfaction, and clinical outcomes. Additionally, future research should consider including common adherence measures (i.e., logins to the program, time spent viewing the app, etc.) and common outcome measures that include functional limitations, QOL, and disease severity.
Practical Considerations
Ideally, telerehabilitation for integrative health should be integrated as part of the individual’s inpatient or outpatient rehabilitation program. This allows for communication among the treatment team, increases trust and safety on the part of the participant, and may also lead to higher patient engagement. However, if a clinic does not have a mind-body therapist on staff, telerehabilitation allows the clinic to partner with a trained individual in any location who can offer these therapies. Providers must also consider whether content will be delivered synchronously (i.e., live sessions that allow for interaction), asynchronously (i.e., prerecorded audio or videos), or both ways (e.g., synchronous weekly sessions with asynchronous content to support daily practice). Previous studies suggest that commonly available videoconferencing programs such as Zoom, GoToMeeting, Webex, or DocBox can be effective methods to providing synchronous sessions. Though DocBox requires equipment be installed in patients’ homes, it does allow patients to view the instructor on a larger screen (television). Asynchronous sessions may best be delivered via user-friendly program-specific apps or websites.
Previous research also highlights the importance of live orientation to the chosen technology, so an initial meeting in-person or over video chat, possibly even involving family members who can provide additional assistance, may be particularly useful. If delivering content synchronously, providers will also need to consider whether they prefer their therapy to be delivered in a group or individual format. Evidence suggests both may be beneficial, though a group format may provide much-needed social support to patients who are open to meeting others and may be more cost-effective for providers. Mind-body therapy content should also be adapted to the particular patient population, as evidenced by in-person studies of mind-body therapies. Practice between sessions is essential for any rehabilitation therapy. Telerehabilitation provides patients with reminders via phone call, text message, or smart messaging (i.e., a notification pushed to a device from an app). These types of reminders appear quite effective at increasing home practice and may even increase therapeutic alliance. Thus providers may want to build in reminders to their patients.
