Originally published in Massage Bodywork magazine, December/January 2007. Copyright 2007. Associated Bodywork and Massage Professionals. All rights reserved.
Contemporary treatment for low-back pain runs the gamut, from the conventional to the alternative, with sufferers seeking relief any way they can. What if it were simply a matter of mindfulness and attention to the breath? In a small pilot study from the Osher Center of Integrative Medicine in San Francisco, California, a research team led by Wolf Mehling, MD, used just such a concept for comparison of breath therapy and physical therapy for treatment of low-back pain. The results showed comparable clinical benefits for both groups, but for breath therapy subjects there also emerged a "new and improved relationship to the body," with accompanying insight into the role of stress in back pain and improved coping skills for most of the group.1
At the heart of breath therapy is the importance of body awareness, or proprioception. "If you have back pain," Mehling says, "the normal situation for a patient is they don't really focus well in the body area where they have lots of pain. They can have difficulty in perceiving subtle sensations that are not pain. The therapist teaches that they can perceive in that pain area the subtle movements that are related to breathing. If you learn those perceptions, that seems to be one of the mechanisms where enhanced body awareness helps in reducing pain."Breath Therapy
As a mind-body approach, breath therapy integrates body awareness, breathing, meditation, and movement. Mehling says much of what happens during the therapy is not easily visible, "similar to the 'body scan' in meditation or mindfulness-based stress reduction or qi gong. It is a Western method, however," he says, "developed since the 1920s in Germany, where all the other approaches such as Feldenkrais, Alexander Technique, eutony, sensory awareness, functional relaxation, autogenic training, bioenergetics, Else Gindler work, etc., have their European roots."
Similar to meditation, breath therapy emphasizes awareness in the present, but also adds hands-on techniques and verbal cues to focus on distinct body areas. For example, with the client lying prone on the table, the therapist places her hands on the sacrum and asks the client to perceive subtle changing movements occurring in that area. "The verbal cues hook the patient's attention to a certain region," Mehling says. With the therapist keeping firm but gentle contact, the client is asked to feel how the movement pushes the hand or to feel the breath movement approaching the hand. The approach can also include stretching at the back, legs, or neck, with the intention of enhancing awareness and allowing for less restricted movement where pain is held.2
"Breath movements happen in the entire body," Mehling says. "The therapy concept is you enhance diaphragmatic breathing in order to promote relaxation. One of the striking things is you really feel, all of a sudden, movement of the breath in a part of the body you never were aware of, for example in the pelvis, the sacrum, or the thighs."Diverse Treatments, Comparable Results
According to Mehling's team, "Recent studies report that patients with chronic low-back pain suffer from a deficit of trunk proprioception." They note that the causal relationship between the two is unclear. "Is lack of proprioception a byproduct of chronic pain following an injury, or is lack of body awareness and proprioception a risk factor for low-back pain, particularly chronic low-back pain?" the team writes. Building on preliminary data that has shown benefits of breath therapy for improved body-awareness as well as improvement in postural control and low-back pain, the research team developed a randomized controlled trial to compare this mind-body approach to a neuromuscular-biomechanical approach. Behind this is the hypothesis that "an improvement in low-back pain could be paralleled by a measurable improvement in proprioception."3
For the control intervention, they chose physical therapy, considered the gold-standard treatment for this condition.4
Initially, thirty-six patients were randomized equally to the two study groups, but the numbers dropped by the posttest measurement date, with fourteen remaining for breath therapy and twelve for physical therapy. The participants were primarily women, with an average age of forty-nine years and an average of one-year history of moderate low-back pain. Both groups began treatment with a one-hour introductory evaluation session, followed by twelve intervention sessions, forty-five minutes each, over a six to eight week period. All sessions took place in the same setting. Therapists for breath therapy and physical therapy treatment came from faculty at the Middendorf Breath Institute in Berkeley, California, and the Department of Physical Therapy and Rehabilitative Science at University of California, respectively. In addition to following the specified treatment protocol for their particular group, the therapists provided instruction to their subjects for a home-based daily exercise program. Subjects were also asked to keep a diary of their experience, including their thoughts and feelings related to the therapy or therapist, and whether or not their thinking had changed in relationship to their body, back, pain, or life in general.5
Measurements taken at baseline and following the treatment course included a pain intensity scale (10 cm VAS), a low-back pain-specific functional disability scale (Roland Morris Scale), and a form measuring functional overall health status (Short Form-36 or SF-36). At the six-month follow-up, a recovery scale was added to these same measurements. Researchers also sought to document changes in whole-body proprioception and body awareness by assessing postural stability with the use of a sensory organization test and various positioning on a static force plate. Both of these tests involve having participants attempt to maintain balance on a platform while conditions related to sensory input vary.6
Outcome measures showed a clinically and statistically significant improvement for both groups, from baseline to end of treatment period, in pain intensity (VAS) and functional overall health status (SF-36). Slight differences emerged in some components of the SF-36, with significant improvement in physical and emotional role for breath therapy and in vitality for the physical therapy group. Breath therapy subjects also showed significant improvement in low-back pain-related functional disability.7
Although anticipated improvements were found in balance measures, the team notes these changes were not clinically or statistically significant. In previous studies with breath therapy, these measures have been administered before and immediately following treatment, showing clinical benefit. But in this study measurements were taken one week following the last session and may indicate, according to the team, that the measured effect is short-term rather than significant in long-term benefit. The lack of correlation of these measures to the clinical outcome casts doubt, they say, on whether these are valid measures for chronic low-back pain research. Self-reports of the home exercise program also showed no correlation to the clinical improvements noted, but the authors point out a limitation in documentation of compliance.8
In terms of numbers, outcome at the six to eight week intervention period showed clinically meaningful improvement for seventy-one percent of the breath therapy subjects and fifty percent of physical therapy subjects (VAS and Roland Morris measurements). At the six-month follow-up, that trend had reversed with more of the breath therapy participants evidencing a relapse or exacerbation of their condition. Improvement scores for the breath therapy group dropped to 40 percent (VAS) and 67 percent (Roland Morris) with the physical therapy group at 45 percent (VAS) and 73 percent (Roland Morris). However, the six-month measurement was a single point in time and was at variance with monthly pain scores over that time period which showed no difference in relapse numbers between the two groups for the cumulative period.9
"Relapse rate, as well as responsiveness of treatment for chronic low-back pain, is dependent on psychosocial as much as musculoskeletal, bio-mechanical, and neuro-motor predictors," the authors write. Noting a study limitation in that these factors were not independently assessed, they suggest future studies examine the role of psychosocial, cultural, and functional patient characteristics in regard to responsiveness to the two therapeutic approaches.10
While clinical benefits for the two groups were shown to be comparable, a major difference emerged for breath therapy subjects in regard to their relationship to their body and their chronic pain. As contrasted with few or no entries regarding emotional effects, insights about pain, and coping with stress for those in the physical therapy group, there were "rather rich entries" in the diaries of breath therapy subjects. Examples given by the team include: "Breath therapy has taught me how to relax and be in touch with my own being," "I look at my body a little more friendly and understanding," " ... through breath therapy I am trying to incorporate the painful part into the rest of my body." This qualitative data, the team writes, suggests the breath therapy subjects experienced "a different kind of learning" that improved their relationship to their body, gave them insight into the connection between their stress and pain, and for most, improved their coping skills.11Toward a Combination Approach
Although the breath therapy and physical therapy interventions differed in their application, both were hands on and administered by highly trained, empathic, and motivated practitioners. In light of the findings that both are of equal benefit, the team suggests two interpretations. It may be that improvement can be found with "any individual, hands-on, highly motivated or empathic attention" regardless of the approach and its orientation. Additionally, with these two methods each providing "equally valuable elements," combining the approaches may prove superior to either approach alone and is suggested for further study.12
"The physical therapists who treated the control group were very qualified, particularly for chronic pain," Mehling says. "They were the very best physical therapists you could get in San Francisco." It was learned that one of the practitioners also incorporated some breath techniques in the treatment, he says, thus introducing an element of body awareness. And as stated in Mehling's published article, physical therapy treatment for chronic pain is adapted to the individual, and it is not uncommon for the therapist to include diaphragmatic breathing and mental imagery education in their approach.13
While it is noted that this may have reduced the chance of finding a difference in benefits between the two groups, it would also seem to bolster the idea that combining a mind-body learning element with physical therapy would only enhance the results.
"There's a big discussion in medicine," Mehling says. "Should you put your attention into the pain or distract yourself? There's a confusion." What is emerging in newer studies, he says, is that it seems to depend on the type of attention. If it's hypervigilance or fear, the answer is no. But if awareness is applied in a meditative way, there can be benefit. "The type of attention seems to be the key. There seems to be a crucial difference between thinking, worrying, mental ruminating about your back pain versus feeling and sensing, deeply exploring your pain in a non-judgmental, embodied, immediate fashion." Notes
1. Wolf E. Mehling, "Breath Therapy for Chronic Low Back Pain," Journal of Bodywork and Movement Therapies 10 (2006), 98.
2. Wolf E. Mehling et al., "Randomized, Controlled Trial of Breath Therapy for Patients with Chronic Low-Back Pain," Alternative Therapies in Health and Medicine 11, no. 4 (July/Aug 2005): 46.
3. Ibid, 45.
4. Ibid, 50.
5. Ibid, 45-47.
6. Ibid, 46.
7. Ibid, 47-48.
8. Ibid, 49, 51.
10. Ibid, 51.
12. Ibid, 50.