An integrated mind-body approach to arthritis: a pilot study.

Arthritis affects both the physical and psychological abilities of people in all walks of life. There are currently no recommended effective 'disease-modifying' remedies. Therapists and physicians are therefore exploring possible benefits from non-conventional therapeutic approaches. The purpose is to assess the changes in fitness and psychosocial outcomes of six doctor-referred patients as a result of participating in the I Can Move Again (ICMA) program. Six female participants diagnosed with arthritis were recruited from a local family practitioner. The subjects participated in a series of daily classes for 12 weeks including massage, mindfulness, bounce-back chairs, resistance chairs, aerobic and anaerobic training, rebounders, and whole body vibration platform Tai Chi. Demographic, psychosocial, and physical data were collected at the ICMA and at Y-Be-Fit (Provo, UT). Significant pre to post mean differences were found for sit-ups (F (1,8) =5.42 P =0.048), chair stand (F (1,10) =6.622 P =0.028), arm curl (F (1,10) =14.379 P =0.004), six-minute walk test distance (F (1,9)= 19.188 P=0.002), and speed (F,(1,8) =13.984 P =0.006), and rotation right (F (1,10) =8.921 P =0.014) and left (F (1,10) =11.373 P =0.007), in 27 of the 61-item questionnaire. The preliminary data on the six subjects lacked sufficient statistical power to detect the significant differences that could exist, thus committing a Type II error, but it is important to note an overall, substantial trend in improvement in the patients' physical outcomes and psychosocial perceptions associated with improvements in activities of daily living.

INTRODUCTION

Arthritis is a disease that affects both the physical (e.g. walking, standing, and other activities of daily living or ADLs) and psychological (i.e. well-being, self-image, and productivity) abilities of people in all walks of life. Persons suffering from arthritis experience symptoms ranging from mild inconvenience and discomfort to complete debilitation due to joint immobility and pain caused by joint inflammation and cartilage degeneration (as in osteoarthritis). The etiology of joint inflammation may be due to factors such as, autoimmune disease or traumatic injury. Regardless of the cause, arthritis can impose severe restrictions on one's quality of life. It is estimated that 50 million[1] Americans are living with some form of arthritis, and of those, 27 million[2] are suffering from osteoarthritis (OA). The cost to the US[3] is estimated to be nearly $128 billion — some $81 billion in medical care expenditure and an additional $47 billion in lost earnings. Despite these massive medical-related costs (virtually everyone intended to mitigate the symptoms rather than cure arthritis) there are currently no recommended effective ‘disease-modifying’ remedies.[4] Therapists and physicians are therefore exploring the possible benefits of non-conventional therapeutic approaches, both pharmacological and non-pharmacological.

The American College of Rheumatology report, the 2012 Recommendations for the Use of Non-pharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip and Knee,[5] suggests the following non-pharmacological interventions: Emphasis on muscular strength and aerobic exercise (for example, Tai Chi [TC], land- or aquatic-based activities) in combination with manual or modality therapies, weight management, self-management skills, and psychosocial interventions. The report's pharmacological recommendations include over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDS) in the topical or oral variety, acetaminophen, or corticosteroid injections.[5]

Complementary alternative medicine

The current conventions for treating OA include physical therapy, pharmacological interventions, and complementary alternative medicine (CAM) (non-mainstream approaches [e.g. acupuncture, dietary supplements, massage, meditation, Tai Chi,[6] etc.] used in conjunction with conventional medical treatment [e.g. physical therapy, NSAIDs, and corticosteroid injections]). In developed countries, it is estimated that approximately 30-70% of the people with OA use CAM.[7] More pertinent to this study, the following forms of CAM will be discussed in depth.

Massage

Massage has been used as a pain modality for years. In a study conducted by Perlman,[8] massage was found to be a beneficial treatment for OA. A meta-analysis conducted in 2011, found several studies on the benefits of massage for management of pain associated with knee OA.[9]

Topical aids

Topical aids (e.g. celadrin, capsaicin, menthol, NSAIDs, etc.) have been used for the treatment of arthritis. Some of the ingredients most salient to this study are first, celadrin, a COX 2 inhibitor, used to improve range of motion (ROM) and function during activity in the arthritic joints.[1011] Next, methylsulfonylmethane (MSM), organic sulfur, was shown to be effective in OA model mice,[12] by decreasing the degeneration of the cartilage at the knee's joint surfaces. MSM used in humans, Debbi, et al.,[13] demonstrated a decrease in pain (via the Visual Analog Scale; [VAS]) and an increase in physical function (via the Western Ontario and McMaster University Osteoartirhits Index; [WOMAC]) compared to a placebo. Capsaicin is a neuromodulator and has been recommended as ‘an add-on therapy for patients with persistent local pain and inadequate response or intolerance to other treatments’.[14] Lastly, Arnica is commonly recommended for external use for rheumatic muscle and joint problems, inflammation, and for symptomatic relief in OA of the hands[15] and knees.[1617]

Vitamins and minerals

Diets deficient in trace minerals, such as zinc, magnesium, selenium, and copper, may lead to joint disease and arthritis.[18] Ross,[17] argues that proper nutrition should always be the focus when combating inflammation in the body. Eating foods that contain anti-inflammation properties can give you a proper balance of macronutrients (e.g. omega-3 fatty acids), which in turn are effective in fighting inflammation.[17] Ross advocates that, ‘nutritional supplementation in addition to eating high-quality food helps build a strong foundation for optimal health,’[17] including a high-potency multiple vitamin/mineral formula and an antioxidant complex of nutrients (including Vitamin C and E), and Omega-3 fatty acids (fish oil with EPA/DHA).[17]

Tai Chi

Wang[4] suggests that Tai Chi has both physical and mental components that combine to decrease pain and increase strength, cardiovascular health, and balance. Yan,[19] states that, “Tai Chi is a low-impact physical activity with slow and gentle movements associated with health benefits, including increased flexibility and lower extremity muscle strength, improved fitness and cardiovascular health, better gait, balance, functional performance, and decreased arthritic symptoms, for a variety of conditions, including OA.” Tai Chi is especially helpful for OA patients, because it is easy and gentle on the body. The fluid and graceful motions of Tai Chi require muscular strength, joint mobility, and overall body balance from participants, without worsening the OA symptoms.[20] Hence, this may be an ideally suited OA intervention.

Meditation

Davidson[21] found that meditation (i.e. altering one's level of consciousness to achieve a specific benefit, such as pain reduction or psychological well-being) produced positive effects in the body's immune functions. The effects of mindfulness (a western, non-sectarian, research-based form of meditation, as a means of increasing awareness of both the sick toward or the healthy to maintain optimal health and well-being) have been shown to mitigate the pain and barriers to psychological well-being for persons who suffer from various rheumatic conditions, including OA.[22]

Exercise

Exercise is often recommended as the first intervention against OA. There are several forms of exercise that are possible. For example, Golightly[23] found that, “strong evidence supports that aerobic and muscle strengthening exercise programs are beneficial for improving pain and physical function in adults with mild-to-moderate knee and hip OA.” On account of the correlation between cardiovascular disease and arthritis (perhaps due to weight reduction), it may also be beneficial to focus on low impact interval training to work the cardiovascular system as well.[24]

Adopting an integrated approach

With no clear evidence that arthritis can be cured, physicians are recommending one or more therapies or medicines hoping to find some relief for their patients. This trial-and-error approach can be lengthy and expensive. It may be prudent to take an integrated approach, by combining many of the recommended treatments with CAM treatments into one comprehensive treatment protocol.

The I Can Move Again (ICMA) Wellness Center has created a 12-week program that combines both medical-practitioner recommended and CAM treatments, to help provide therapeutic and psychosocial benefits to individuals with arthritis. The program includes massage, heat modalities, mindfulness and visualization, stretching, daily supplements, and topical aids (ingredients in the nutritional supplements and topical aids are listed in the appendix). Exercise routines include aerobic exercise (i.e. bounce back chair, a rebounder, and stationary biking), strength training (resistance bands), low-impact anaerobic interval training (stationary bike), core training, and a Tai Chi routine on a whole body vibration platform.

The purpose of this pilot study is to assess the changes in health-related fitness (HRF) (comprising of body composition, cardiovascular endurance, muscle strength and endurance, and flexibility) and psychosocial outcomes of six doctor-referred arthritis patients, as a result of participating in the 12-week, ICMA program. The researchers hypothesized that the participants would experience positive changes in muscular strength and endurance, flexibility, body composition, and cardiovascular endurance along with a positive change in the psychosocial perceptions (including perceived decrease in pain) about their arthritis condition, after participation in the program.

MATERIALS AND METHODS

Participants and setting

This is a pilot study wherein six female participants (each was diagnosed with either OA or Rheumatoid Arthritis [RA]) were recruited from a local family practitioner. Each participant received a briefing on the ICMA program and signed a document of informed consent. The subjects were included in the pilot study based on the following criteria:

Diagnosis of OA or RA

Clearance from personal physician to participate

Willingness and ability to provide informed consent

Age ≥ 19 years.

Subjects were excluded based on the following criteria:

Recent (less than six months) joint surgery

Other significant medical or psychiatric conditions, including other inflammatory conditions and epilepsy

Women who were pregnant or plan on becoming pregnant during the course of the study

Hypermobility or unstable disease that could compromise participation in the study.

The ICMA facility [Figures 1 and 2] is an activity space fitted with massage tables; bounce-back chairs, vibration platforms, and rebounders — five of each. There are also nine resistance chairs with bike attachments, and two hand cycle ergonometers. The room has six large screen TVs to display Tai Chi or other exercise routines.

Figure 1

Exercise gym floor

Figure 2

Massage tables with music player

Instrumentation

Program instrumentation included, the massage table, bounce-back chair, resistance chair, rebounder, WBV platform, Deep Healing CD, and Tai Chi routine video (see appendix for the specifications of each instrument). The testing instrumentation included a ruler, a 4 lb dumbbell, a 100 ft measuring tape, and a stopwatch. The testing was done according to Rikli and Jones’ valid and reliable Senior Fitness Test Manual.[25] The Y-Be-Fit instrumentation included a Precor Treadmill c90064 (Woodinville, WA 98072-4002), a seated Cybex chest press and seated leg press machine (Cybex International, Inc., Medway, MA 02053), and a BOD POD (COSMED USA, Inc.; Concord, Ca).

The ICMA questionnaire was based on the valid and reliable Health Assessment Questionnaire by the Stanford University School of Medicine that has been used since 1978.[2627] The questionnaire was slightly modified and additional items were added for more specificity. No evidence of validity or reliability for the modified version used in this study is available at this time.

Procedures

The subjects participated in a series of daily classes for each of the 12 weeks. The activities were prearranged in a consistent weekly rotation [Table 1]. The activities included: massage, relaxation, mindfulness, visualization, the use of bounce-back chairs for expansion and contraction of several joints in the body, the use of resistance chairs for strength training, core strengthening, aerobic and anaerobic training, the use of rebounders for the benefit of aerobic exercise with low impact on the joints, the use of whole body vibration platforms for strength and proprioception while doing Tai Chi.

Table 1

Daily class activities

Due to facility limitations, the class sizes were kept to a maximum of five participants. Each activity was tailored to the limitations of each participant including, modifications of bolsters, props, steps, chairs, and hand ergonometers. The patients were able to choose to participate in each activity, and were not pressured to participate if they felt they did not want to or could not participate.

Participants came to the ICMA facility at the same time for one hour a day, five days a week. The daily schedule of activities is listed in Table 1. Each day began with a mindfulness activity, while on a heated massage table, listening to relaxing music using headphones. The music was interlaces with subliminal messaging (Jonet Inc, 2010). The remainder of the activities varied daily [Table 1]. Each treatment session lasted one hour.

The other routines were conducted as follows: The bounce-back chair routine consisted of sitting on the chair and bouncing for the time allotted. The patient determined the bouncing rhythm and direction. Stretching on the bounce-back chair consisted of a light stretching routine listed in Table 2. The warm-up routine on the resistance bike is also listed in Table 2. Each warm-up/stretching routine took approximately four minutes. The Monday, wednesday, friday warm-up/stretching routine was done on the bounce-back chair. The Tuesday, Thursday warm-up/stretching routine was done on the resistance chair.

Table 2

Warm up and stretching routines

The rebounder routine consisted of a gentle health bounce for the allotted time. The patients determined the bouncing rhythm, magnitude, and direction of their bouncing.

The strength training routine consisted of an upper body resistance bands routine. The entire routine is listed in Table 3.

Table 3

Strength training routine

The bike or hand ergonometer interval training routine consisted of a three-minute warm up followed by eight, 30-second sprints and eight, 90-second recovery periods. The participants determined their resistance and speed according to their target heart rate zones of 90-95% of maximum heart rate (HRmax), depending on their physician's recommendations. The researchers calculated the maximum heart rates, and therefore, the training zones, using four methods — the traditional (220-age), the Miller (217-.85[age]), the Londeree and Moeschberger (206.3-.711[age]), and the Inbar (205.8-.685[age]). The lowest, most conservative training zone from among all scales was chosen and communicated to the participants.

The Tai Chi routine on the whole body vibration (WBV) platform consisted of standing on the platform and following the video playing at the front of the room. The WBV platform was set at an oscillation rate of 30 Hz. Each participant was also given a home practice copy (DVD) of the Tai Chi routine and was encouraged to use it to learn the poses.

In addition to the one-hour session at the ICMA, the participants were instructed to develop a home practice of deep healing meditation at least once a week, which was provided via a CD during the baseline visit.

The subjects were encouraged to self-select whether to participate in any of the activities. Subjects also self-selected the resistance and repetitions of the activities each week and were then allowed to increase both the following week, as they wished, up to the maximum allowance of exercises for that week (e.g. for resistance training week one, only one sprint was allowed, week two, two were allowed etc.).

The subjects took a daily dose of a multivitamin, vitamin C with zinc, borage oil, Celadrin, fish oil, and a protein shake. In addition the subjects used the topical aids daily. Some participants were unable to take the fish oil and protein shakes because of contraindications. The participants were told to stop all other supplementations during the 12-week program, but were to continue their prescribed medications, unless otherwise directed by their physician.

Data collection

At the baseline, demographic and clinical data were collected via a computerized and in-person interview conducted by the same tester. The patient-reported outcomes were recorded via a questionnaire at both the baseline and end of the study. Physical measurements were also collected at the baseline and at the end of the study by the same tester at ICMA and also by an outside resource. Y-Be-Fit at Brigham Young University collected the physical measurement data on each individual at the baseline and within one week of the last class period. No other data were collected during the class periods.

Data analysis

Preliminary data on the six people lacked sufficient statistical power to detect the significant differences that could exist, thus committing a Type II error. Therefore, the data were analyzed as individual case studies as well as by means of a cohort. All data were imported into SPSS (SPSS 20 IBM Software) and analyzed.

RESULTS

Dependent variables

The descriptive data is listed in Table 4. Pre-to-post changes in the dependent variables are listed according to the components of HRF, namely body composition, muscular strength and endurance, cardiovascular health, and flexibility. It must be noted that inability to detect significance in these outcomes is likely due to lack of sufficient power on account of the low number of subjects. In such instances, we ask the reader to consider pre-to-post differences for each of the subjects as an individual case rather than as a part of the group mean. Significant group means will also be listed.

Table 4

Descriptive data

Body composition

There were no significant pre-to-post differences in the body fat percentages according to the Bod Pod measurements or waist-to-hip ratio.

Muscular strength and endurance

Assessment in each of the six tests associated with muscle strength and endurance indicated notable, but non-significant pre-to-post improvements for chest press, leg press, and push-ups. Significant pre-to-post mean differences were found for sit-ups, chair stands, and arm curls. Results are shown in Table 5.

Table 5

Strength pre-to-post improvements

Cardiovascular

Assessment in each of the three tests associated with cardiovascular endurance indicated notable, but non-significant pre-to-post improvements for VO2. Significant pre-to-post mean differences were found for Six Minute Walk Distance and Six Minute Walk Test Speed. Results can be found in Table 6.

Table 6

Cardiovascular pre-to-post improvements

Flexibility

Assessment in each of the ten tests associated with flexibility indicated notable, but not significant pre-to-post improvements for middle fingertip to floor test, lateral flexion right thigh, lateral flexion left thigh, chair sit and reach, calf flexibility right, calf flexibility left, back scratch right, and back scratch left. Significant pre-to-post mean differences were found for rotation right and rotation left. Results are shown in Table 7.

Table 7

Flexibility pre-to-post improvements

One-way analysis of variance

Results from the repeated measures One-way Analysis of Variance (ANOVA) revealed significant differences across time (baseline to post testing) for 27 items of the following psychosocial measurement via the ICMA questionnaire, [Table 8]: Dress and grooming, grip, eating, arising, walking and activities, and psychosocial. All other comparisons were found to be non-significant at the P ≤ 0.05 level.

Table 8

Significant pre-to-post differences on the disability questionnaire

Mindfulness meditation

In addition to the mindfulness meditation routine in the daily classes, each participant self-reported doing one hour or more of deep healing meditation per week at home with the provided CD. The majority of the participants reported doing it every day.

DISCUSSION

Arthritis affects both the physical and psychological abilities of people in all walks of life. There are currently no recommended effective ‘disease-modifying’ remedies with American traditional medicine.[4] The authors are therefore exploring possible benefits of non-conventional therapeutic approaches including complementary medicine.

“Traditional Medicine is the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.”[28] Traditional medical practices in American culture include recommendations such as emphasis on muscular strength and aerobic exercise, in combination with manual or modality therapies, weight management, self-management skills, and psychosocial interventions, OTC or topical prescription or oral NSAIDS, acetaminophen, and supplements including glucosamine, or corticosteroid injections.[5] This can become expensive and has varying success among persons suffering from arthritis. Many persons who suffer continue looking for other treatment options, including complementary medicine. “Complementary medicine, also sometimes referred to as non-conventional or parallel medicine, is used to refer to the broadest of healthcare practices that are not part of a country's own tradition, or not integrated into its dominant healthcare system.”[28] I Can Move Again has created an intervention program that embodies both traditional and complementary medical practices to help arthritis suffers. The traditional medicine approach includes exercise, nutritional supplements, and topical aids. The complementary medicine approach includes massage, mindfulness and meditation. The combination of both traditional and complementary medicine has proven effective in several health- related fitness components.

The authors grouped fitness outcomes into HRF components, namely body composition, muscular strength and endurance, cardiovascular health, and flexibility.

Body composition

This is not a weight loss program, because there is no nutritional component. although excess weight aggravates arthritis[5] the measured body composition measurements were the same pre-to-post. Therefore, any improvements cannot be attributed to changes in body composition. There were some non-significant trends in changes to lean body mass. Had there been a nutritional component, decreases in weight and body fat may have resulted in amelioration of arthritis.

The authors are recommending additional diet-modification components, to make the most of the ICMA program. Not only would diet modification increase nutrients to the joint, but also a weight reduction would decrease the load on the joints. The authors believe that, had a nutritional component been introduced the results would have been more dramatic.

Cardiovascular component

Even though there was a cardiovascular component, it was insufficient to elicit significant changes in the VO2 Max. The authors believe this was due to the lack of power as there was a significant difference in the six-minute walk test distance and speed.

Muscular strength and endurance

Pre-to-post improvements were found in several variables. This is beneficial to improve overall physical function, mobility and lessen pain.[29]

Flexibility indicators

Pre-to-post improvements were found in several of the variables. Joint flexibility is important to persons with OA. Joint lubrication occurs as the joint moves and expands and contracts the fluid throughout the joint. This delivers nutrients and provides waste removal.[30]

Questionnaire

The questionnaire was based on the validated instrument of the Health Assessment Questionnaire.[27] Nine of the original 49 questions were modified for specificity purposes for this study (e.g. questions 29 and 30 added the words “or descend” to the original questions; questions 46 and 47 are the result of splitting a single, compound question into two individual questions). The goal of the researchers was to achieve greater specificity, while maintaining the integrity of the original questionnaire. The authors recommend caution in the interpretation of the results from these specific nine questions, but it is important to note an overall, substantial trend in improvement in patient perceptions associated with improvements in ADLs.

Preliminary data on the six subjects lacked sufficient statistical power to detect significant differences that could exist, thus committing a Type I error, but it is important to note an overall, substantial trend in improvement in patient physical outcomes and psychosocial perceptions associated with improvements in ADLs. Out of the 96 variables, tested, 86 (89.6%) saw a mean improvement, four (4.2%) of the variables saw no mean improvement, and six (6.2%) had a sight mean decline in outcome. Therefore, the authors recommend the ICMA program, because it seems to produce positive results for its OA and RA patients, in both physical and psychosocial outcomes.