Complementary and integrative health (cih) interventions, as operationalized by the National Center for Complementary and Integrative Health (NCCIH) and the Veteran Health Administration (VHA) (VHA Directive, 2017–1137), includes a diverse group of treatments, many of which are already in use by the public. The World Health Organization has noted that between 65% and 80% of the global population uses some form of alternative or complementary medicine.¹ Oftentimes, such practices are combined with accepted Western medicine practices, and therefore the term “complementary” (as opposed to “alternative” in which the treatment replaces traditional allopathic medical management) has been used. A brief overview of such practices is provided in Table 47–1.

In the United States, the use of natural products, breathing exercises, and meditation seem to be most prevalent (Fig. 47–1).

An understanding of alternative management options by which this restoration takes place is critical in providing the whole continuum of management options to patients. Of note, such practices have become more common in the last decade, with widespread use throughout ambulatory, acute, and postacute care settings. It is also worth considering the utilization of complementary medicine practices in the setting of functional impairments, with a goal of “health or useful and constructive activity.” The present chapter will cover these areas from a rehabilitation framework. The focus of this chapter will be to provide a brief overview of the utilization of CIH in rehabilitation, with an emphasis on neurorehabilitation.

Acupressure refers to fingertip stimulation or light touch at acupoints on the body and does not rely on needles as does acupuncture.^2–4 These points or focal regions on the body have been reported to have significantly reduced electrical resistance (approximately 1/100th of the surrounding area).⁵ Jin Shin, the type of acupressure utilized in the research studies to be discussed, has been practiced since 712 AD.⁶ This form of acupressure was introduced to the United States via Japan in the mid-1900s and now is practiced and taught worldwide.^2,4,5,7,8

Acupressure theory posits a relatively direct connection between the site of stimulation (i.e., points) and the presence and type of illness^2,5 (Fig. 47–2).

Because energy is thought to travel throughout the body via meridians or pathways, energetic imbalance that interferes with or disrupts movement along the meridians can lead to illness. Stimulation at points along the meridians is said to unblock the energetic pathways. In doing so, this leads to energetic balance, healing, and health. Because it can be administered by a trained practitioner and learned by the novice individual, acupressure is unique in its accessibility and promotion of autonomy, both of which are especially important for individuals with chronic health issues.

For individuals with acquired brain injury, acupressure is additionally promising because it is nonpharmacologic, promotes self-care education, is not dependent upon a practitioner, is not reliant on funds or insurance, has no apparent side effects, and is highly tolerable in a variety of populations.

Characterizing an intervention and developing an evidence base for acupressure includes several levels of analyses: dose, control group, efficacy, and underlying mechanism.⁹ Early work showed that an eight-treatment series was an efficacious dose and that a placebo control matched for physical contact, attention, and time allowed for sensitive detection of active treatment–associated effects.¹⁰ For example, in adults postacute stroke, a placebo-controlled, single-blind, crossover trial with random assignment¹¹ showed that active acupressure treatments resulted in a steeper and deeper relaxation response, compared to placebo treatments.

A “relaxation response,” first described by Benson and colleagues as a physiological response with reduced respiration, heart rate, and blood pressure, has been described in conjunction with acupressure treatments.¹² Because the relaxation response may be protective against or a treatment for disease, CIH approaches that engage or enhance the relaxation response show good potential in a variety of important chronic conditions in which enhanced stress sensitivity is a hallmark (e.g., cardiovascular disease, acquired brain injury, etc.).¹³ Potential mechanisms by which the relaxation response may yield benefit include buffering against stress, the stress response, and even against stress-related disease pathology, via alterations in the central nervous system and sympathetic nervous system arousal.^13–17

Similarly promising findings were seen in adults postacute traumatic brain injury (TBI), where a single-blind, placebo-controlled trial with random assignment showed active acupressure treatments significantly improved digit span, reduced Stroop interference, and the concurrent P300 latency and amplitude. This latter finding of a neurophysiological mechanism underlying active acupressure’s cognitive benefits is the first of its type.¹⁸ Taken together with prior findings, there is a strong evidence base for the functional benefits of acupressure treatment in acquired brain injury that is supported by an evidence base of underlying mechanisms (physiological and neurophysiological) for these functional benefits. The level of methodological rigor upon which the evidence base is built (e.g., placebo control, repeated assessment of treatment fidelity, random assignment, blindness, etc.) makes a strong case for acupressure’s efficacy in a rehabilitation setting.

The primary objective of mind–body medicine is to utilize the mind to positively affect one’s overall health. Historically, relationships between the mind and body have been studied by healers as early as ancient Greece. More recently, studies have suggested that cognitive training techniques may alter neural plasticity.¹⁹ Mind–body medicine has been utilized by up to 20% of the U.S. adult population, and its use continues to grow.²⁰

Traditional examples of mind–body medicine include guided imagery, relaxation techniques, biofeedback, hypnosis, meditation, tai chi, qi gong, and yoga. An overview of mind–body therapies is presented in Table 47–2. These types of treatments have been shown to improve a patient’s sense of autonomy and have a high patient safety profile.

Mindfulness is taught through meditation skills, bringing the body and mind together. Mindfulness can contribute to well-being after a personal crisis and dealing with “who you are” and “who you will become.” Mindfulness can also have an impact on well-being, and could be a therapeutic option for those who had suffered an acquired brain injury and struggle with long-term problems. To date, no consensus definition of mindfulness exists, but one commonly used was introduced by Jon Kabat-Zinn: “paying attention in a particular way; on purpose, in the present moment, and non-judgmentally.”²¹ In short, this means maintaining a moment-by-moment awareness of thoughts, feelings, bodily sensations, and the surrounding environment and paying attention without judging that there is a “right” or “wrong” way to think or feel in a given moment.

Mindfulness is about observation without criticism and being compassionate with oneself.²² The practice of compassion and self-compassion are central parts in mindfulness and have considerable importance for well-being when life is not what it used to be. Compassion is described as opening up to kindness and tenderness toward oneself, rather than self-blame and criticism, with awareness of the suffering of oneself and other beings, coupled with the wish and effort to alleviate it.²³ Research has proven mindfulness to be effective for a wide range of conditions, such as stress, depression, pain, and fatigue, with the potential of helping individuals cope better with their difficulties.^24–27 Mindfulness can also improve attention and cognitive flexibility and result in changes in brain neuronal connectivity.^28,29

When practicing mindfulness, the attitudinal foundations provide a way to hold, investigate, and work with whatever comes up in life, and this can be helpful for many who experience a life crisis. The attitudinal foundations of mindful practices are as follows: (1) beginner’s mind: to see everything as if it is for the first time and not allow illusions of knowing prevent being present to experiences; (2) nonjudging: being open to any experience, not judging or categorizing into good and bad or positive and negative, and to be aware of how easily judging can result in automatic reactions that often have no objective basis; (3) patience: to understand and accept the fact that things unfold in their own time and practicing mindfulness provides the opportunity to give time and space to the individual’s growing insight; (4) trust: developing a basic trust in one’s self and one’s feelings; (5) nonstriving: having no goals other than being one’s self, losing the grip of the attitude “If I only were/had …”; (6) acceptance: seeing things as they actually are; and (7) letting go: releasing unhealthy thoughts, feelings, or activities and listening the inner wisdom of what’s important.³⁰

Many brain injury patients experience emotional distress. If long-term or lasting symptoms remain, life will change in many ways, regardless of injury severity. Coping strategies vary across individuals and may include a habitual automatized pattern. It is not possible to change what has happened, but it is possible to work with how the individual handles life and responds to situations. This strategy to re-pattern responses can be practiced with mindfulness. After an acquired brain injury, mindfulness and specifically mindfulness-based stress reduction (MBSR) can contribute to well-being and improve mental health, and may also have an impact on cognition and brain function. MBSR has been delivered to thousands of patients during the last 35 years and has therefore been well studied.³¹ However, studies of MBSR delivery following an acquired brain injury are few. This has created an increasing awareness of the potential for Mindfulness-Based Program (MBP) delivery to this population.

MBSR for Acquired Brain Injury

The majority of studies assessing mindfulness-based interventions in acquired brain injury have utilized MBSR programs with a clear curriculum and high-quality standards. The data thus far support mindfulness-based interventions as having potential to improve mental health and cognitive function and relieve fatigue after acquired brain injury. Mindfulness-based approaches are intended to teach practical skills that can help with physical and psychological health and ongoing life challenges.

Quality of Life

Improved quality of life after an MBSR (slightly modified) program has been reported in adults with TBI, and the improvement held constant irrespective of injury severity. Specifically, the Perceived Self-Efficacy Scale and the SF 36 were used to assess quality of life in a pre- and post-intervention study design with no control group.^32,33 A follow-up one year later indicated that improved quality of life was maintained, as was a continued improvement in energy level. The study was however limited by a small sample size. Studies in populations other than acquired brain injury show similarly positive findings and in functional domains that may be relevant to TBI patient outcomes (e.g., stress, pain, coping).

A large study with a pre-/post-intervention design with nine MBSR groups, each including 20 to 25 participants with a broad range of challenges including illness-related stress, chronic pain, personal, and employment-related stress, showed improvement in measures of well-being and a reduction in stress.³⁴ A meta-analysis concluded that MBSR may be useful in a broad range of chronic disorders (fibromyalgia, chronic pain, cancer, coronary artery disease) to cope better with the distress and disability associated with everyday life.³⁵

Depression and Anxiety

In uncontrolled trials, mindfulness-based cognitive therapy (MBCT) and MBSR seem promising for reducing the impact of depression and anxiety in acquired brain injury. This has been found in pre- versus post-intervention studies in adults with TBI where MBCT was associated with reduced depression symptoms and reduced pain intensity.³⁶ Similarly, a reduction in depression symptoms (using the Beck Depression Inventory) was reported after an MBSR program in adults with TBI or subarachnoid hemorrhage (SAH).^37,38 Both studies utilized a pre- versus post-intervention design with no control group.

PTSD

Veterans with mild TBI and chronic cognitive complaints, as well as comorbid post-traumatic stress disorder (PTSD) reported reduced PTSD symptoms after participating in an MBSR program, and this was sustained 3 months following MBSR completion.³⁹ Though no control group was used in the study, the potential sustainability of the effects is promising. MBSR delivered live on the Internet also reduced the level of depression and anxiety symptoms as measured by the Comprehensive Psychopathological Rating Scale (CPRS) for participants who had suffered a TBI and stroke.⁴⁰

Fatigue

Because fatigue can persist beyond the traditional rehabilitation period, a study was conducted to determine whether MBSR could reduce mental fatigue. Using the Mental Fatigue Scale in adults with TBI or stroke, a reduction in their persistent, long-term mental fatigue was reported after an MBSR program.^41,42 Reduced mental fatigue was also found when MBSR was delivered live on the Internet for participants suffering from mental fatigue after stroke and TBI.⁴⁰

Cognitive Function

Processing speed and attention are the most susceptible cognitive functions to a brain injury.⁴³ These are also cognitive functions that may improve with mindfulness-based practices, particularly given that MBSR is associated with changes in brain activity involved in attention.^28,29,44 MBSR in mild TBI was associated with significant improvements in working memory and regulation of attention.³² Improved processing speed and attention were reported after an MBSR program in those with persistent mental fatigue after TBI or stroke, compared to a control group.^40,42

Biofeedback

Biofeedback has been defined as “a mind–body technique in which individuals learn how to modify their physiology for the purpose of improving physical, mental, emotional and spiritual health.”⁴⁵ Health care professionals utilize custom equipment to record physiological data and convert it to visual and auditory cues for a patient. Commonly recorded data include skin temperature, pulse, respirations, and skin conductance.⁴⁶ Most importantly, the results of the recording are provided in real time to the patient.⁴⁷ One of the most common variables used is surface electromyography. Painful conditions in which anxiety or stress are prevalent are examples of conditions in which biofeedback is used. The therapists often employ operant conditioning, data are conveyed to the patient, and therefore the patient is given tools by which to make changes.⁴⁸