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Global mapping of interventions to improve quality of life using mind-body therapies during 1990–2018
Complementary Therapies in Medicine 49 (2020) 102350
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Complementary Therapies in Medicine journal homepage: www.elsevier.com/locate/ctim
Global mapping of interventions to improve quality of life using mind-body therapies during 1990–2018
T
Bach Xuan Trana,b,*, Chloe Harijantoc,h, Giang Thu Vud, Roger C.M. Hoe,f,g a
Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Viet Nam Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA c Manchester Medical School, University of Manchester, Manchester, M13 9PL, United Kingdom d Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 700000, Viet Nam e Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore f Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, 119077, Singapore g Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 700000, Viet Nam h Institute for Global Health Innovations, Duy Tan University, Da Nang, 50000, Viet Nam b
ARTICLE INFO
ABSTRACT
Keywords: Scientometrics Content analysis Text mining Interventions Mind-body therapy QoL
Objectives: Mind-body therapies (MBT) are a range of practices which improve well-being and have shown promising results in a variety of illness. To inform the application of MBT in health promotion, and intervention designs, we conducted a global review of publication growth and content analysis of studies examining the impacts of MBT on quality of life (QoL) of different patient groups. Design: Data from 1990 to 2018 was collected from the Web of Science (WoS). They were analyzed with descriptive statistics (publication volume by year, citations, and countries). The development of research areas overtime was structured using Latent Dirichlet Allocation, and co-occurrence of keywords of titles, and abstracts. Results: 3906 studies were obtained, with an exponential increase in recent years. Mindfulness, mental health, cancer, surgery, and QoL are common themes in the literature. Research has explored the efficacy, mechanism, and approaches to deliver MBT in both the general population and the patients. Conclusions: MBT has proven promising in a wide range of medical conditions, not only as a complementary therapy but also been incorporated into health services, especially for chronic diseases. By characterizing the trends in research productivity, and topics, we suggest robust adverse reporting, and guidelines for disease specific MBT should be improved. This global mapping of MBT studies also provides insight for future research, policy, and management direction.
1. Introduction Mind-body therapy (MBT) is a broad group of practices which aim to enhance well-being holistically by focusing on the relationship between mental, and physical processes.1 This relationship has been recognized as bidirectional, where both entities influence mental and physical health.2 They may be broadly categorized into focus-based practices, relaxation therapy, and movement therapy. The former includes mindfulness which emphasizes a non-judgmental focus on the present moment, including thoughts, emotions, and bodily sensations.3 This practice supposes to counter maladaptive coping strategies such as avoidance and rumination.4 Breathing, and relaxation exercises are often used in conjunction and affect the parasympathetic system to
reduce stress.5 Yoga and qigong utilize movement to improve the quality of life (QoL).6,7 These practices encourage self-management and promote diversity and comprehensive treatment of illness.8 The 2002 National Health Interview Survey revealed that 16.6 % of Americans use MBT, mostly concurrent with standard therapy in musculoskeletal chronic pain conditions, insomnia, anxiety, and depression.9 Prevalence of MBT is high in cancer survivors, with one study quoting use in over 40 % of participants.10,11 Users tended to be of higher socioeconomic status and education level.9,11 The literature reflects the popularity of MBT across a wide range of illnesses. Meta-analyses have concluded that programs such as mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT) are effective in mitigating symptoms,4 and relapse in
⁎ Corresponding author at: Institute for Preventive Medicine and Public Health, Hanoi Medical University, No. 1 Ton That Tung Street, Dong Da District, Hanoi, 100000, Viet Nam. E-mail address: [email protected] (B.X. Tran).
https://doi.org/10.1016/j.ctim.2020.102350 Received 18 September 2019; Received in revised form 31 January 2020; Accepted 18 February 2020 Available online 19 February 2020 0965-2299/ © 2020 Published by Elsevier Ltd.
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depression.12 Other psychological benefits are ameliorating anxiety and stress. This effect has also been observed in patients with mental health comorbidities in conditions like multiple sclerosis,13 and cancer.14,15 In addition, MBT alleviates physical symptoms such as chronic musculoskeletal pain 1,16,17 and improves physical function in the rehabilitation of heart failure, 18 and neurological conditions.5 In a cohort of patients with Parkinson’s disease, posture instability, and motor symptoms were improved.19 Additionally, QoL has been consistently measured and enhanced by MBT.20,21 QoL is defined as the disparity between the individual perception of reality, and expectation.22 It is a multi-dimensional subjective measure of a person’s biopsychosocial state. QoL helps focus therapy on the patient and identify issues pertaining on the individual and their health. This activity is crucial in patients with chronic conditions, to understand the compound impact of the illness psychologically, functionally, and socially.23 Since it aims to represent general well-being, it is thought to be more sensitive than other validated scales of function. Consequently, it can be used as an outcome measure of treatment effectiveness and service quality. The advantages of QoL measure also include its patient-centered nature that reflects the perception, and performance of individuals in their life with specific contexts and values, thus, it could inform interventions to improve the ability of patients to cope, concordance, and improve health outcomes in a more comprehensive approach.24–26 Similarly, MBT has been shown to enhance well-being in non-clinical populations. Krasner et al27 demonstrated improvements in emotional stability, burnout, and empathy in physicians. Numerous other studies reflect this impact on well-being, and job performance in healthcare staff.28 The Whitehall studies found that workers under high levels of stress were considerably more inclined to ill-health.29 By improving QoL, MBT may have a role in preventing morbidity. MBT has received a surge in interest over recent years. This accompanies a greater understanding of the relationship between health, and an individual’s psychology, emotions, and socioeconomic environment, and follows from the widespread incorporation of lifestyle improvements in the management of many chronic diseases.30 A concomitant disappointment in conventional medicine, and increase attention to wellness has fueled consumer, and patient interests, along with investment by the US government, and private institutions.30,31 Furthermore, better technology has allowed for breakthroughs in exploring the physiological responses to MBT.30 Evidence also suggest the cost-effectiveness of MBT to the economy, and healthcare system, compared to usual lone care.32 However, systemic factors have impeded integration of MBT into conventional medicine. Often, insurance cover is inadequate for psychosocial therapies, and are separately categorized, and managed which inconveniences all parties involved.8 Time pressures on services may also compromise MBT use, since less emphasis might be placed on the well-being of patients.33 Other barriers include bias toward MBT, which may stem from a traditional distinction between mind and body. As research into the influence MBT has on physiology develops, such a situation may improve.2 More research, and quality evidence may raise physician confidence to promote, and include MBT in clinical practice. Previous studies have been limited in part by the heterogeneous group of practices covered. Several interventions are considered MBT, of which subtypes exist within a practice.21 For instance, variants of yoga emphasize movement, whereas others have a higher element of meditation or relaxation. The lack of standardization extends to duration, and delivery of therapy.21 This limits the volume of studies for a particular therapy and requires caution when practices are analyzed under an umbrella heading. Further, studies often have small sample sizes. A lack of information regarding effect sizes, dropout rates, blinding, and randomization are common methodology deficiencies.34,35 A lack in reporting adverse events, and data on the longterm effects of MBT need to be addressed.15,36 This paper aims to delineate trends of global studies using MBT to improve QoL. It will highlight gaps in the research, and future direction to better inform
research focus, and policy. 2. Materials and methods 2.1. Search tools, and search strategy The Web of Science was used as a search engine for collecting data. Web of Science was chosen because of its advantages compared with Scopus or PubMed because it 1) allows extracting a large number of papers, 2) provides cited references since 1900, and 3) covers high impact scientific journals worldwide.37,38 The WoS was produced by the Institute for Scientific Information and is managed by Clarivate Analytics.39 We decided to choose until 2018 because the year of 2019 has not ended yet. Thus, the data of half-year 2019 may not reflect fully the trend this year. Papers of our choice were research articles and research reviews in English. The search strategy was described as follow (see Appendix Fig. A1): - Step 1: an online literature search was conducted using “topic” (title, abstract, keywords, and topic) in WoS with the following terms: “Quality of life”, and “well-being” (See Supplementary Table S1) - Step 2: among papers extracted in the first step, we used the terms “Intervention” or “Trial” to filter all papers using STATA - Step 3: from the dataset in step 2, we filtered papers mentioning “Mind-body therapy” in titles and/or abstracts using STATA. The keywords related to Mind-body therapy were formed by discussing among specialists. The data was downloaded separately by two researchers. Disagreements between the two researchers were solved by discussing with a senior researcher. 2.2. Data exclusion and analysis The data needed for analysis were the title of papers, publication year, the journals title, authors’ keywords, the number of citations, subject areas, and abstracts. After downloading, we excluded papers which were: 1) not article, or review; 2) not in English; 3) anonymous author. The final dataset was transferred to a data file to be further analyzed using STATA. The downloading, and extracting steps were followed by descriptive statistical analysis, in which we used STATA to describe some fundamental characteristics of publications, including years of publication, the number of papers per country/per year, total citations up to 2018, mean citation rate per year, total usage in the last six months/5 years, and mean use rate the last six months/5 years. A network graph showing the co-occurrence network of terms was established by VOSviewer. Latent Dirichlet Allocation was used for classifying papers into similar topics.40–44 Among the most cited papers within each topic, two researchers carefully reviewed the title, and abstracts to label for each topic manually. Besides, we provided the indexes, the total number, and proportion of publications by each topic, and the changes in research interests by ranking these topics based on the total number of publications in the past five years. The analytical techniques applied for each type of data is showed in Table 1: 3. Results Table 2 provides some information about the selected publications. There were 3906 papers mentioned mind-body therapies as a method to improve the quality of life of patients. The first paper was published in 1991, and then the number of studies increased gradually. Although the year 2018 had the highest published work, the highest citation was in 2011. The download times were highest in 2015 and reduced from that year, which shows that the recent interests of readers, was significantly higher within the past five years. 2
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Table 1 Analytical methods and results. Type of data
Unit of analysis
Analytical methods
Presentations of results
Terms, Countries Abstracts WoS classification of research areas
Words Papers WoS research areas
Frequency of co-occurrence Latent Dirichlet Allocation Frequency of co-occurrence
Map of keywords clusters Ten classifications of research topics Dendrogram of research disciplines (WoS classification)
Table 2 General characteristics of publications. Year published
2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1993 1991
Total number of papers
Total citations
597 564 488 452 361 289 260 197 136 118 101 86 60 45 36 21 29 13 19 12 7 5 2 4 3 1
528 2,088 3,268 6,139 7,004 6,954 8,821 8,913 6,733 5,766 7,800 6,259 2,905 2,661 3,630 4,483 2,031 691 1,060 1,039 504 152 15 197 205 30
Table 3 Number of papers by countries as study settings (total 658).
Mean cite rate per year
Total usage last 6 month
Total usage last 5 years
Mean use rate last 6 month
Mean use rate last 5 year
0.9 1.9 2.2 3.4 3.9 4.0 4.8 5.7 5.5 4.9 7.0 6.1 3.7 4.2 6.7 13.3 4.1 3.0 2.9 4.3 3.4 1.4 0.3 2.1 2.6 1.1
3,560 1,976 1,304 1,204 1,050 458 544 494 327 211 262 164 61 35 98 188 27 5 9 8 6 3 0 2 1 0
5,457 9,266 11,538 14,437 13,260 9,557 9,261 7,337 4,536 2,895 3,846 2,649 962 829 1,749 1,874 478 149 175 186 55 22 5 38 23 11
6.0 3.5 2.7 2.7 2.9 1.6 2.1 2.5 2.4 1.8 2.6 1.9 1.0 0.8 2.7 9.0 0.9 0.4 0.5 0.7 0.9 0.6 0.0 0.5 0.3 0.0
1.8 3.3 4.7 6.4 7.3 6.6 7.1 7.4 6.7 4.9 7.6 6.2 3.2 3.7 9.7 17.8 3.3 2.3 1.8 3.1 1.6 0.9 0.5 1.9 1.5 2.2
Rank
Country settings
Frequency
%
Rank
Country settings
Frequency
%
1
United States Australia India Oman Ireland China United Kingdom Canada Iran Hong Kong (China) Brazil New Zealand Taiwan (China)
104
15.8 %
31
Belgium
3
0.5%
75 45 35 34 33 30
11.4% 6.8% 5.3% 5.2% 5.0% 4.6%
32 33 34 35 36 37
France Uganda Colombia Cuba Estonia Iceland
3 3 2 2 2 2
0.5% 0.5% 0.3% 0.3% 0.3% 0.3%
28 26 20
4.3% 4.0% 3.0%
38 39 40
Jordan Myanmar Norway
2 2 2
0.3% 0.3% 0.3%
17 16
2.6% 2.4%
41 42
Poland Argentina
2 1
0.3% 0.2%
16
2.4%
43
1
0.2%
14 12 12 11 10
2.1% 1.8% 1.8% 1.7% 1.5%
44 45 46 47 48
Central African Republic Chad Chile Croatia Georgia Ghana
1 1 1 1 1
0.2% 0.2% 0.2% 0.2% 0.2%
9 8 7 7 7 6 6 5 5 5
1.4% 1.2% 1.1% 1.1% 1.1% 0.9% 0.9% 0.8% 0.8% 0.8%
49 50 51 52 53 54 55 56 57 58
Greece Guinea Haiti Hungary Jersey Kenya Niger Nigeria Peru Portugal
1 1 1 1 1 1 1 1 1 1
0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%
4
0.6%
59
1
0.2%
4
0.6%
60
Puerto Rico Slovenia
1
0.2%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
29
Sweden Japan Turkey Netherlands South Africa Thailand Iraq Germany Malaysia Singapore Israel Spain Italy Switzerland Wallis and Futuna Afghanistan
30
Austria
19 20 21 22 23 24 25 26 27 28
*Total usage: Total number of downloads; ** Mean use rate: Total number of downloads/Total number of papers.
Table 3 shows the number of papers by the locations of study settings mentioned in the abstracts. In total, there were 658 times the bibliography included country settings, of those, the number of studies set up in the United States of America accounted for 15.8 %. Half of the countries in the list were developed countries. In the top ten countries, five Asian countries/ regions with the highest proportions of involvements as study settings, they were China (mainland, Hong Kong, and Taiwan), Oman, Iran, and India. By analyzing the content of abstracts, and titles, we scrutinized the terms to characterize the scope of studies, and co-occurrence of terms. Fig. 1 describes the co-occurrence of the most common terms. Four major clusters emerged from 286 most common keywords with co-occurrence of at least 800 times. The four major clusters are: Cluster 1 (red) refers to the application of mindfulness in mental health treatment (depression). Cluster 2 (blue) focuses on applying this therapy for cancer patients. Cluster 3 (yellow) points out that mind-body therapies were used for QoL improvement to the patient with gastroenterology or surgery. Cluster 4 (green) illustrates the kind of mind-body therapies applied to improve QoL, including Tai Chi, or Qigong. Table 4 shows the most cited papers among those each paper has been assigned to a topic referring to Table 5. The papers mentioned mindfulness ranked first in the total citation of six topics (topic 1, topic 2, topic 3, topic 5, topic 7, and topic 8), that shows the concern of scientific researchers to this method due to the benefits it could bring to health.
Using Latent Dirichlet Allocation of texts in the abstracts, we constructed research topics into ten major groups (Table 5). Topics with the highest volumes of publications include “Randomised Controlled Studies on MBT efficacy”, and “Benefits of MBT in non-clinical populations, and digital delivery of MBT”. Rehabilitation of chronic conditions (e.g., COPD, CVD) using MBT (Topic 9), and biofeedback therapy (topic 10) has gained traction in publications. Meanwhile, the interest in topic 1, and 2 have been decreasing in recent years. This change could indicate the increased understanding of the psychological, and physical impact of various MBT in clinical, and non-clinical populations (Fig. 2). Fig. 3 presents the hierarchical clustering of research disciplines in using mind-body therapies to improve quality of life. The horizontal axis of the dendrogram illustrates the dissimilarity between clusters while the vertical axis shows the research disciplines. It can be seen that the research landscapes in using mind-body therapies to improve quality of life rooted in the following disciplines: 1) Psychology, and 2) Biomedical Social Sciences as the first chunk in the bottom the dendrogram. This method had a close relationship with other research areas in Behavioral Sciences or clinical (Surgery, and Clinical 3
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Fig. 1. Co-occurrence of most frequent terms in the titles and abstracts. Note: the strength of the links between items were automatically calculated by VOSviewer using the fractionalization method. The size of a term is determined based on the weight of the item. Cluster 1 (red) refers to the application of mindfulness in depression. Cluster 2 (blue) focuses on applying this therapy for cancer patients. Cluster 3 (yellow) points out that mind-body therapies were used for QoL improvement to the patient with gastroenterology or surgery. Cluster 4 (green) illustrates the kind of mind-body therapies applied to improve QoL, including Tai Chi, or Qigong. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
Neurology). However, this method had not a close connection with Psychiatry, Clinical Psychology, or Family Studies.
considerable work has been done to elucidate the mechanism of MBT. Conceptually, attention and emotional regulation are thought to mediate mindfulness.48 Another aspect investigated is the neurophysiological basis of MBT. Hölzel et al. reported an increase in brain grey matter in areas for considering perspectives, and emotional regulation in participants of MBSR.49 Other parameters include electroencephalogram (EEG), cortisol levels, and immune function.50,51 However, the mechanisms remain poorly understood. Consolidation of this subfield would accelerate the integration of MBT into conventional medicine by promoting understanding, and acceptance by the public, and healthcare professionals. Furthermore, it is essential for directed use, research, and policy advancement, where therapy technique and clinical end-points are better defined and tailored to individual illness.2 LDA analysis has revealed research into the use of MBT as rehabilitation for chronic conditions (Table 5). While publications of these themes remain low, they have burgeoned in recent years (Fig. 2). There may be an increased exploration into the physical benefits of MBT, and their expanding role in medicine. This study has several implications. First, it highlights the substantial research focus on mindfulness and comparative lack of other MBT practices. This is concerning since meta-analyses, and systematic reviews have consistently identified a lack of strength in trials. MBT has full origins,5 and some may be more acceptable in certain cultures. For example, Tsang et al. noted a preference of ‘Chinese’ activities among the elderly community in Hong Kong.7 Hence, more work is required in these areas to capitalize on the potential benefits and provide evidencebased care across cultures. This suggestion is in lieu of a barrier to integrating MBT into conventional medicine – physician-perceived lack of evidence. Second, the adverse effects of MBT are not well represented in the literature. A meta-analysis noted more than two-thirds of trials included did not evaluate the safety profile of yoga52 while a mere 2 of 19 studies reported side effects of aromatherapy, and massage therapy in a systematic review.36 One reason may be the lack of established methods for determining adverse events of MBT.53 Some negative effects of MBT reported include relaxation-induced anxiety,53 psychotic symptoms,
4. Discussion This study has investigated the research landscape for MBT, and their impact on QoL in terms of the distribution of the publications, the terms co-occurrence, and LDA topic modeling. The increase of publications, and readership of peer-reviewed literature, particularly in the last five years, has demonstrated the growing academic, and public interest in the field. This phenomenon might be explained by the promising results of MBT in enhancing QoL in both clinical, and nonclinical populations. Publications have predominantly been spearheaded by the USA, and Australia, and have seen the significant contribution from India, Oman, China, UK, and Canada. Fig. 3 shows the interdisciplinary nature of the research. While previous bibliometric analyses have focused on single MBT practices, this is the first study to encompass the variety of therapies, in attempt to inform future research, and policy on this vast, and complex area. Analysis of keywords and abstracts highlighted mindfulness as the primary MBT extensively studied. Researchers have investigated the effectiveness of mindfulness in a multitude of illnesses, mainly mental health,4,45 chronic pain,1,17 cancer,46 and gastrointestinal conditions,47 as reflected by Fig. 1. The focus on chronic conditions may indicate inadequate management by conventional medicine in these conditions, perceived efficacy,9 and the nature of MBT as a long-term commitment. As highlighted in the introduction, measures include the psychological, physical, and social function and QoL. The volume of papers in this area could be due to the existence of structured programs such as MBSR, and MBCT, allowing for studies to be replicated and improved. It indicates the need for standardization of research in other MBT practices (components, duration, frequency, outcome measures). It might also indicate the heterogeneity of practices considered as mindfulness, including religious meditation, acceptance-based interventions, self-compassion mindfulness, and mindfulness as a trait. Some of the most highly cited articles and LDA analysis shows that 4
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Table 4 Most cited papers. Title
Topica
Total citation
Publication year
Cite rate
Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study Randomized trial of a meditation-based stress reduction program, and cognitive behavior therapy in generalized social anxiety disorder A randomised comparative trial of yoga, and relaxation to reduce stress, and anxiety Yoga for chronic low back pain in a predominantly minority population: a pilot randomized controlled trial Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia Mindfulness-Based Stress Reduction for Failed Back Surgery Syndrome: A Randomized Controlled Trial A mindfulness course decreases burnout, and improves well-being among healthcare providers Mindfulness-Based Stress Reduction (MBSR) for Primary School Teachers Teaching mindfulness in medical school: where are we now, and where are we going? Emotional intelligence mediates the relationship between mindfulness, and subjective well-being Mindfulness, self-compassion, and happiness in non-meditators: A theoretical, and empirical examination A mindfulness model of affect regulation, and depressive symptoms: Positive emotions, mood regulation expectancies, and self-acceptance as regulatory mechanisms A Systematic Review, and Meta-analysis of Yoga for Low Back Pain Mind-body therapies for the treatment of fibromyalgia. A systematic review A systematic review, and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome Cognitive behavioural therapy for tinnitus The Effects of Yoga on Physical Functioning, and Health Related Quality of Life in Older Adults: A Systematic Review, and Meta-Analysis Exercise therapy for schizophrenia Efficacy, and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review, and meta-analysis of randomized controlled trials Mindfulness, and Acceptance Models in Sport Psychology: A Decade of Basic, and Applied Scientific Advancements Migraine prevalence, and treatment patterns: The global Migraine, and Zolmitriptan Evaluation survey Integrative oncology: Complementary therapies for pain, anxiety, and mood disturbance Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society Guidelines for trials of behavioral treatments for recurrent headache, first edition: American Headache Society Behavioral Clinical Trials Workgroup Clinical Practice Guidelines on the Evidence-Based Use of Integrative Therapies During, and After Breast Cancer Treatment Mindfulness-Based Cognitive Therapy to Prevent Relapse in Recurrent Depression Impact of Mindfulness-Based Stress Reduction (MBSR) on sleep, mood, stress, and fatigue symptoms in cancer outpatients An open trial of an acceptance-based behavior therapy for generalized anxiety disorder Effectiveness, and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial Systematic review, and meta-analysis of transdiagnostic psychological treatments for anxiety, and depressive disorders in adulthood The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health, and quality of life: A randomized controlled study Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD Mindfulness-Based Stress Reduction Compared with Cognitive Behavioral Therapy for the Treatment of Insomnia Comorbid with Cancer: A Randomized, Partially Blinded, Noninferiority Trial Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms, and symptom clusters Mindfulness-Based Cognitive Therapy for Nonremitted Patients with Bipolar Disorder Qigong Improves Quality of Life in Women Undergoing Radiotherapy for Breast Cancer Results of a Randomized Controlled Trial Mindfulness practice leads to increases in regional brain gray matter density The underlying anatomical correlates of long-term meditation: Larger hippocampal, and frontal volumes of gray matter Mindfulness meditation, well-being, and heart rate variability: A preliminary investigation into the impact of intensive Vipassana meditation The neural substrates of mindfulness: An fMRI investigation Rapid changes in histone deacetylases, and inflammatory gene expression in expert meditators Meditation (Vipassana), and the P3a event-related brain potential Improvement in physiological, and psychological parameters after 6 months of yoga practice Respiratory muscle endurance training in chronic obstructive pulmonary disease - Impact on exercise capacity, dyspnea, and quality of life Exercise training in COPD patients: the basic questions Functional anorectal disorders Dyssynergic defecation, and biofeedback therapy Anorectal Disorders Long-term efficacy of simple behavioral therapy for daytime wetting in children Consensus statement AIGO/SICCR diagnosis, and treatment of chronic constipation, and obstructed defecation (Part II: Treatment)
1 1
222 135
2008 2007
20.2 11.3
1 1 1 1 2 2 2 3 3 3
135 71 63 49 130 67 53 100 94 66
2007 2009 2006 2010 2012 2010 2013 2011 2011 2010
11.3 7.1 4.8 5.4 18.6 7.4 8.8 12.5 11.8 7.3
4 4 4 4 4
126 80 73 67 65
2013 2000 2013 2010 2012
21.0 4.2 12.2 7.4 9.3
4 4
57 55
2010 2013
6.3 9.2
5 6 6 6
50 143 107 80
2012 2003 2005 2015
7.1 8.9 7.6 20.0
6
65
2005
4.6
6 7 7 7 7
52 337 257 124 115
2017 2008 2005 2007 2015
26.0 30.6 18.4 10.3 28.8
7
105
2015
26.3
7
104
2010
11.6
7 7
95 87
2015 2014
23.8 17.4
7
68
2012
9.7
7 7
61 58
2012 2013
8.7 9.7
8 8 8
536 200 73
2011 2009 2013
67.0 20.0 12.2
8 8 8 8 9
68 65 65 50 82
2011 2014 2009 2012 2000
8.5 13.0 6.5 7.1 4.3
9 10 10 10 10 10
53 261 77 63 59 49
1997 2006 2008 2016 2000 2012
2.4 20.1 7.0 21.0 3.1 7.0
a
refer to Table 5 for topics.
and enhanced susceptibility to false memories from mindfulness,54 and musculoskeletal injuries due to yoga.52 More efforts in this area would allow healthcare professionals and users an informed decision of MBT use. Finally, previous bibliometric analyses have evaluated the research landscape with regards to particular MBT practices or single diseases.
This study provides an overview of major trends for the variety of MBT, and the conditions they are applied. Hence, it provides insight into the changes of research interests, and advancement over a few decades, which is useful for future research, and policy development. This study has some limitations. The restriction of the search strategy to research papers and reviews in the English language might 5
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Table 5 Ten research topics classified by Latent Dirichlet allocation. Rank by the highest volume last five years
Research topics
N
Percent
Topic Topic Topic Topic Topic Topic Topic Topic Topic Topic
Randomized Controlled Studies on MBT efficacy Benefits of MBT in non-clinical populations, and digital delivery of MBT Scale validity, and mechanism of mindfulness Systematic reviews, and meta-analysis on MBT efficacy Conceptual theory of MBT MBT use in chronic conditions MBT impact on psychological well-being Effect of MBT on cognition, imaging, and biomarkers Exercise efficacy of MBT in rehabilitation, and QoL The use of MBT in constipation, incontinence, and sialorrhea
814 444 395 388 313 289 225 180 190 207
23.6% 12.9% 11.5% 11.3% 9.1% 8.4% 6.5% 5.2% 5.5% 6.0%
1 2 3 4 5 6 7 8 9 10
However, a summary is appropriate for an overview of the research direction. 5. Conclusions Mind-body therapy has proven promising in a wide range of medical conditions, not only as a complementary therapy but also been incorporated as an option into health services, especially for chronic diseases. Its rising popularity and recognition of the limitations of allopathy medicine in raising the quality of life demand a concerted effort to provide quality evidence. This global review and content analysis provide a summary of the field. An attempt has been made to highlight key areas which could be further developed for a greater understanding of the subject. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Fig. 2. Changes in research topics development.
compromise the comprehensiveness of the article, such as articles in the local language, which may reflect less globalized/well-known practices. Analyses of keywords may not fully reflect the content of articles.
Declaration of Competing Interest None
Fig. 3. Dendrogram of coincidence of research areas using the WoS classifications. The research landscapes in using mind-body therapies to improve quality of life rooted in the following disciplines: 1) Psychology, and 2) Biomedical Social Sciences as the first chunk in the bottom the dendrogram. This method had a close relationship with other research areas in Behavioral Sciences or clinical (Surgery, and Clinical Neurology), but had not a close connection with Psychiatry, Clinical Psychology, or Family Studies.
6
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Appendix A
Fig. A1. Process of selection.
Appendix B. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ctim.2020.102350.
10. Sewitch MJ, Yaffe M, Maisonneuve J, et al. Use of complementary and alternative medicine by cancer patients at a Montreal Hospital. Integr Cancer Ther. 2011;10(4):305–311. https://doi.org/10.1177/1534735410395136. 11. Gansler T, Kaw C, Crammer C, et al. A population-based study of prevalence of complementary methods use by cancer survivors. Cancer. 2008;113(5):1048–1057. https://doi.org/10.1002/cncr.23659. 12. Kuyken W, Warren FC, Taylor RS, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized TrialsEfficacy of mindfulness-based cognitive TherapyEfficacy of mindfulness-based cognitive therapy. JAMA Psychiatry. 2016;73(6):565–574. https://doi.org/10.1001/jamapsychiatry.2016.0076. 13. Feinstein A, Magalhaes S, Richard J-F, et al. The link between multiple sclerosis and depression. Nat Rev Neurol. 2014;10:507. 14. Huang H, He M, Wang H, et al. A meta-analysis of the benefits of mindfulness-based stress reduction (MBSR) on psychological function among breast cancer (BC) survivors. Breast Cancer. 2016;23(4):568–576. https://doi.org/10.1007/s12282-0150604-0. 15. Cramer H, Lauche R, Klose P, et al. Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer. Cochrane Database Syst Rev. 2017;1(1) https://doi.org/10.1002/14651858. CD010802.pub2 CD010802-CD010802. 16. Maddali Bongi S, Paoletti G, Calà M, et al. Efficacy of rehabilitation with Tai Ji Quan in an Italian cohort of patients with Fibromyalgia Syndrome. Complement Ther Clin Pract. 2016;24:109–115. https://doi.org/10.1016/j.ctcp.2016.05.010. 17. Akyuz G, Kenis-Coskun O. The efficacy of Tai Chi and yoga in rheumatoid arthritis and spondyloarthropathies: A narrative biomedical review. Rheumatol Int. 2018;38(3):321–330. https://doi.org/10.1007/s00296-017-3867-2. 18. Pullen PR, Nagamia SH, Mehta PK, et al. Effects of yoga on inflammation and exercise capacity in patients with chronic heart failure. J Card Fail. 2008;14(5):407–413. https://doi.org/10.1016/j.cardfail.2007.12.007. 19. Kwok JYY, Choi KC, Chan HYL. Effects of mind–Body exercises on the physiological and psychosocial well-being of individuals with Parkinson’s disease: A systematic
References 1. Theadom A, Cropley M, Smith HE, et al. Mind and body therapy for fibromyalgia. Cochrane Database Syst Rev. 2015(4) https://doi.org/10.1002/14651858.CD001980. pub3. 2. Taylor AG, Goehler LE, Galper DI, et al. Top-down and bottom-up mechanisms in mind-body medicine: Development of an integrative framework for psychophysiological research. Explore (NY). 2010;6(1):29–41. https://doi.org/10.1016/j.explore. 2009.10.004. 3. Hölzel BK, Lazar SW, Gard T, et al. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6(6):537–559. https://doi.org/10.1177/1745691611419671. 4. Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–183. https://doi.org/10.1037/a0018555. 5. Wahbeh H, Elsas S-M, Oken BS. Mind-body interventions: Applications in neurology. Neurology. 2008;70(24):2321–2328. https://doi.org/10.1212/01.wnl.0000314667. 16386.5e. 6. Raghavendra RM, Vadiraja HS, Nagarathna R, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast Cancer patients undergoing adjuvant radiotherapy: A randomized controlled trial. Integr Cancer Ther. 2009;8(1):37–46. https://doi.org/10.1177/1534735409331456. 7. Tsang HWH, Cheung L, Lak DCC. Qigong as a psychosocial intervention for depressed elderly with chronic physical illnesses. Int J Geriatr Psychiatry. 2002;17(12):1146–1154. https://doi.org/10.1002/gps.739. 8. Ross C. Integral healthcare: The benefits and challenges of integrating complementary and alternative medicine with a conventional healthcare practice. Integr Med Insights. 2009;4:13–20. https://doi.org/10.4137/IMI.S2239. 9. Bertisch SM, Wee CC, Phillips RS, et al. Alternative mind-body therapies used by adults with medical conditions. J Psychosom Res. 2009;66(6):511–519. https://doi. org/10.1016/j.jpsychores.2008.12.003.
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review and meta-analysis. Complement Ther Med. 2016;29:121–131. https://doi.org/ 10.1016/j.ctim.2016.09.016. Fernros L, Furhoff A-K, Wändell PE. Improving quality of life using compound mindbody therapies: Evaluation of a course intervention with body movement and breath therapy, guided imagery, chakra experiencing and mindfulness meditation. Qual Life Res. 2008;17(3):367–376. https://doi.org/10.1007/s11136-008-9321-x. Carlson LE, Zelinski E, Toivonen K, et al. Mind-body therapies in Cancer: What is the latest evidence? Curr Oncol Rep. 2017;19(10):67. https://doi.org/10.1007/s11912017-0626-1. Carr AJ, Higginson IJ. Are quality of life measures patient centred? BMJ. 2001;322(7298):1357–1360. https://doi.org/10.1136/bmj.322.7298.1357. Post MWM. Definitions of quality of life: What has happened and how to move on. Top Spinal Cord Inj Rehabil. 2014;20(3):167–180. https://doi.org/10.1310/sci2003167. Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: A meta-analysis. Ann Behav Med. 2014;47(3):259–269. https://doi.org/10. 1007/s12160-013-9559-6. Nipp RD, El-Jawahri A, Fishbein JN, et al. The relationship between coping strategies, quality of life, and mood in patients with incurable cancer. Cancer. 2016;122(13):2110–2116. https://doi.org/10.1002/cncr.30025. Alhaddad IA, Hamoui O, Hammoudeh A, et al. Treatment adherence and quality of life in patients on antihypertensive medications in a Middle Eastern population: Adherence. Vasc Health Risk Manag. 2016;12:407–413. https://doi.org/10.2147/ VHRM.S105921. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284–1293. https://doi.org/10.1001/jama.2009. 1384. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: A randomized clinical TrialIntervention to promote physician Well-beingIntervention to promote physician well-being. JAMA Intern Med. 2014;174(4):527–533. https://doi.org/10.1001/jamainternmed.2013. 14387. Chandola T, Brunner E, Marmot M. Chronic stress at work and the metabolic syndrome: Prospective study. BMJ. 2006;332(7540):521–525. https://doi.org/10.1136/ bmj.38693.435301.80. Brower V. Mind-body research moves towards the mainstream. EMBO Rep. 2006;7(4):358–361. https://doi.org/10.1038/sj.embor.7400671. Institute of Medicine (US) Committee on the Use of Complementary and Alternative Medicine by the American Public. Complementary and alternative medicine in the United States. Washington (DC): National Academies Press (US); 2005 7 I of C and CMedicineA from: https://www. ncbi. nlm. nih. gov/books/NBK83807/. No Title. Herman PM, Anderson ML, Sherman KJ, et al. Cost-effectiveness of mindfulnessbased stress reduction versus cognitive behavioral therapy or usual care among adults with chronic low back pain. Spine. 2017;42(20):1511–1520. https://doi.org/ 10.1097/BRS.0000000000002344. McGuire C, Gabison J, Kligler B. Facilitators and barriers to the integration of mind–Body medicine into primary care. J Altern Complement Med. 2016;22(6):437–442. https://doi.org/10.1089/acm.2016.0043. Lee C, Group AS-CT for P (PACT) W, Crawford C, et al. Mind–Body therapies for the self-management of chronic pain symptoms. Pain Med. 2014;15(S1):S21–S39. https://doi.org/10.1111/pme.12383. Grossman P, Niemann L, Schmidt S, et al. Mindfulness-based stress reduction and health benefits: A meta-analysis. J Psychosom Res. 2004;57(1):35–43. https://doi. org/10.1016/S0022-3999(03)00573-7. Shin ES, Seo KH, Lee SH, et al. Massage with or without aromatherapy for symptom relief in people with cancer. Cochrane Database Syst Rev. 2016(6) https://doi.org/10. 1002/14651858.CD009873.pub3.
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Global mapping of interventions to improve quality of life using mind-body therapies during 1990–2018
T
Bach Xuan Trana,b,*, Chloe Harijantoc,h, Giang Thu Vud, Roger C.M. Hoe,f,g a
Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, 100000, Viet Nam Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA c Manchester Medical School, University of Manchester, Manchester, M13 9PL, United Kingdom d Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 700000, Viet Nam e Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore f Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, 119077, Singapore g Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 700000, Viet Nam h Institute for Global Health Innovations, Duy Tan University, Da Nang, 50000, Viet Nam b
ARTICLE INFO
ABSTRACT
Keywords: Scientometrics Content analysis Text mining Interventions Mind-body therapy QoL
Objectives: Mind-body therapies (MBT) are a range of practices which improve well-being and have shown promising results in a variety of illness. To inform the application of MBT in health promotion, and intervention designs, we conducted a global review of publication growth and content analysis of studies examining the impacts of MBT on quality of life (QoL) of different patient groups. Design: Data from 1990 to 2018 was collected from the Web of Science (WoS). They were analyzed with descriptive statistics (publication volume by year, citations, and countries). The development of research areas overtime was structured using Latent Dirichlet Allocation, and co-occurrence of keywords of titles, and abstracts. Results: 3906 studies were obtained, with an exponential increase in recent years. Mindfulness, mental health, cancer, surgery, and QoL are common themes in the literature. Research has explored the efficacy, mechanism, and approaches to deliver MBT in both the general population and the patients. Conclusions: MBT has proven promising in a wide range of medical conditions, not only as a complementary therapy but also been incorporated into health services, especially for chronic diseases. By characterizing the trends in research productivity, and topics, we suggest robust adverse reporting, and guidelines for disease specific MBT should be improved. This global mapping of MBT studies also provides insight for future research, policy, and management direction.
1. Introduction Mind-body therapy (MBT) is a broad group of practices which aim to enhance well-being holistically by focusing on the relationship between mental, and physical processes.1 This relationship has been recognized as bidirectional, where both entities influence mental and physical health.2 They may be broadly categorized into focus-based practices, relaxation therapy, and movement therapy. The former includes mindfulness which emphasizes a non-judgmental focus on the present moment, including thoughts, emotions, and bodily sensations.3 This practice supposes to counter maladaptive coping strategies such as avoidance and rumination.4 Breathing, and relaxation exercises are often used in conjunction and affect the parasympathetic system to
reduce stress.5 Yoga and qigong utilize movement to improve the quality of life (QoL).6,7 These practices encourage self-management and promote diversity and comprehensive treatment of illness.8 The 2002 National Health Interview Survey revealed that 16.6 % of Americans use MBT, mostly concurrent with standard therapy in musculoskeletal chronic pain conditions, insomnia, anxiety, and depression.9 Prevalence of MBT is high in cancer survivors, with one study quoting use in over 40 % of participants.10,11 Users tended to be of higher socioeconomic status and education level.9,11 The literature reflects the popularity of MBT across a wide range of illnesses. Meta-analyses have concluded that programs such as mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT) are effective in mitigating symptoms,4 and relapse in
⁎ Corresponding author at: Institute for Preventive Medicine and Public Health, Hanoi Medical University, No. 1 Ton That Tung Street, Dong Da District, Hanoi, 100000, Viet Nam. E-mail address: [email protected] (B.X. Tran).
https://doi.org/10.1016/j.ctim.2020.102350 Received 18 September 2019; Received in revised form 31 January 2020; Accepted 18 February 2020 Available online 19 February 2020 0965-2299/ © 2020 Published by Elsevier Ltd.
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depression.12 Other psychological benefits are ameliorating anxiety and stress. This effect has also been observed in patients with mental health comorbidities in conditions like multiple sclerosis,13 and cancer.14,15 In addition, MBT alleviates physical symptoms such as chronic musculoskeletal pain 1,16,17 and improves physical function in the rehabilitation of heart failure, 18 and neurological conditions.5 In a cohort of patients with Parkinson’s disease, posture instability, and motor symptoms were improved.19 Additionally, QoL has been consistently measured and enhanced by MBT.20,21 QoL is defined as the disparity between the individual perception of reality, and expectation.22 It is a multi-dimensional subjective measure of a person’s biopsychosocial state. QoL helps focus therapy on the patient and identify issues pertaining on the individual and their health. This activity is crucial in patients with chronic conditions, to understand the compound impact of the illness psychologically, functionally, and socially.23 Since it aims to represent general well-being, it is thought to be more sensitive than other validated scales of function. Consequently, it can be used as an outcome measure of treatment effectiveness and service quality. The advantages of QoL measure also include its patient-centered nature that reflects the perception, and performance of individuals in their life with specific contexts and values, thus, it could inform interventions to improve the ability of patients to cope, concordance, and improve health outcomes in a more comprehensive approach.24–26 Similarly, MBT has been shown to enhance well-being in non-clinical populations. Krasner et al27 demonstrated improvements in emotional stability, burnout, and empathy in physicians. Numerous other studies reflect this impact on well-being, and job performance in healthcare staff.28 The Whitehall studies found that workers under high levels of stress were considerably more inclined to ill-health.29 By improving QoL, MBT may have a role in preventing morbidity. MBT has received a surge in interest over recent years. This accompanies a greater understanding of the relationship between health, and an individual’s psychology, emotions, and socioeconomic environment, and follows from the widespread incorporation of lifestyle improvements in the management of many chronic diseases.30 A concomitant disappointment in conventional medicine, and increase attention to wellness has fueled consumer, and patient interests, along with investment by the US government, and private institutions.30,31 Furthermore, better technology has allowed for breakthroughs in exploring the physiological responses to MBT.30 Evidence also suggest the cost-effectiveness of MBT to the economy, and healthcare system, compared to usual lone care.32 However, systemic factors have impeded integration of MBT into conventional medicine. Often, insurance cover is inadequate for psychosocial therapies, and are separately categorized, and managed which inconveniences all parties involved.8 Time pressures on services may also compromise MBT use, since less emphasis might be placed on the well-being of patients.33 Other barriers include bias toward MBT, which may stem from a traditional distinction between mind and body. As research into the influence MBT has on physiology develops, such a situation may improve.2 More research, and quality evidence may raise physician confidence to promote, and include MBT in clinical practice. Previous studies have been limited in part by the heterogeneous group of practices covered. Several interventions are considered MBT, of which subtypes exist within a practice.21 For instance, variants of yoga emphasize movement, whereas others have a higher element of meditation or relaxation. The lack of standardization extends to duration, and delivery of therapy.21 This limits the volume of studies for a particular therapy and requires caution when practices are analyzed under an umbrella heading. Further, studies often have small sample sizes. A lack of information regarding effect sizes, dropout rates, blinding, and randomization are common methodology deficiencies.34,35 A lack in reporting adverse events, and data on the longterm effects of MBT need to be addressed.15,36 This paper aims to delineate trends of global studies using MBT to improve QoL. It will highlight gaps in the research, and future direction to better inform
research focus, and policy. 2. Materials and methods 2.1. Search tools, and search strategy The Web of Science was used as a search engine for collecting data. Web of Science was chosen because of its advantages compared with Scopus or PubMed because it 1) allows extracting a large number of papers, 2) provides cited references since 1900, and 3) covers high impact scientific journals worldwide.37,38 The WoS was produced by the Institute for Scientific Information and is managed by Clarivate Analytics.39 We decided to choose until 2018 because the year of 2019 has not ended yet. Thus, the data of half-year 2019 may not reflect fully the trend this year. Papers of our choice were research articles and research reviews in English. The search strategy was described as follow (see Appendix Fig. A1): - Step 1: an online literature search was conducted using “topic” (title, abstract, keywords, and topic) in WoS with the following terms: “Quality of life”, and “well-being” (See Supplementary Table S1) - Step 2: among papers extracted in the first step, we used the terms “Intervention” or “Trial” to filter all papers using STATA - Step 3: from the dataset in step 2, we filtered papers mentioning “Mind-body therapy” in titles and/or abstracts using STATA. The keywords related to Mind-body therapy were formed by discussing among specialists. The data was downloaded separately by two researchers. Disagreements between the two researchers were solved by discussing with a senior researcher. 2.2. Data exclusion and analysis The data needed for analysis were the title of papers, publication year, the journals title, authors’ keywords, the number of citations, subject areas, and abstracts. After downloading, we excluded papers which were: 1) not article, or review; 2) not in English; 3) anonymous author. The final dataset was transferred to a data file to be further analyzed using STATA. The downloading, and extracting steps were followed by descriptive statistical analysis, in which we used STATA to describe some fundamental characteristics of publications, including years of publication, the number of papers per country/per year, total citations up to 2018, mean citation rate per year, total usage in the last six months/5 years, and mean use rate the last six months/5 years. A network graph showing the co-occurrence network of terms was established by VOSviewer. Latent Dirichlet Allocation was used for classifying papers into similar topics.40–44 Among the most cited papers within each topic, two researchers carefully reviewed the title, and abstracts to label for each topic manually. Besides, we provided the indexes, the total number, and proportion of publications by each topic, and the changes in research interests by ranking these topics based on the total number of publications in the past five years. The analytical techniques applied for each type of data is showed in Table 1: 3. Results Table 2 provides some information about the selected publications. There were 3906 papers mentioned mind-body therapies as a method to improve the quality of life of patients. The first paper was published in 1991, and then the number of studies increased gradually. Although the year 2018 had the highest published work, the highest citation was in 2011. The download times were highest in 2015 and reduced from that year, which shows that the recent interests of readers, was significantly higher within the past five years. 2
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Table 1 Analytical methods and results. Type of data
Unit of analysis
Analytical methods
Presentations of results
Terms, Countries Abstracts WoS classification of research areas
Words Papers WoS research areas
Frequency of co-occurrence Latent Dirichlet Allocation Frequency of co-occurrence
Map of keywords clusters Ten classifications of research topics Dendrogram of research disciplines (WoS classification)
Table 2 General characteristics of publications. Year published
2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1993 1991
Total number of papers
Total citations
597 564 488 452 361 289 260 197 136 118 101 86 60 45 36 21 29 13 19 12 7 5 2 4 3 1
528 2,088 3,268 6,139 7,004 6,954 8,821 8,913 6,733 5,766 7,800 6,259 2,905 2,661 3,630 4,483 2,031 691 1,060 1,039 504 152 15 197 205 30
Table 3 Number of papers by countries as study settings (total 658).
Mean cite rate per year
Total usage last 6 month
Total usage last 5 years
Mean use rate last 6 month
Mean use rate last 5 year
0.9 1.9 2.2 3.4 3.9 4.0 4.8 5.7 5.5 4.9 7.0 6.1 3.7 4.2 6.7 13.3 4.1 3.0 2.9 4.3 3.4 1.4 0.3 2.1 2.6 1.1
3,560 1,976 1,304 1,204 1,050 458 544 494 327 211 262 164 61 35 98 188 27 5 9 8 6 3 0 2 1 0
5,457 9,266 11,538 14,437 13,260 9,557 9,261 7,337 4,536 2,895 3,846 2,649 962 829 1,749 1,874 478 149 175 186 55 22 5 38 23 11
6.0 3.5 2.7 2.7 2.9 1.6 2.1 2.5 2.4 1.8 2.6 1.9 1.0 0.8 2.7 9.0 0.9 0.4 0.5 0.7 0.9 0.6 0.0 0.5 0.3 0.0
1.8 3.3 4.7 6.4 7.3 6.6 7.1 7.4 6.7 4.9 7.6 6.2 3.2 3.7 9.7 17.8 3.3 2.3 1.8 3.1 1.6 0.9 0.5 1.9 1.5 2.2
Rank
Country settings
Frequency
%
Rank
Country settings
Frequency
%
1
United States Australia India Oman Ireland China United Kingdom Canada Iran Hong Kong (China) Brazil New Zealand Taiwan (China)
104
15.8 %
31
Belgium
3
0.5%
75 45 35 34 33 30
11.4% 6.8% 5.3% 5.2% 5.0% 4.6%
32 33 34 35 36 37
France Uganda Colombia Cuba Estonia Iceland
3 3 2 2 2 2
0.5% 0.5% 0.3% 0.3% 0.3% 0.3%
28 26 20
4.3% 4.0% 3.0%
38 39 40
Jordan Myanmar Norway
2 2 2
0.3% 0.3% 0.3%
17 16
2.6% 2.4%
41 42
Poland Argentina
2 1
0.3% 0.2%
16
2.4%
43
1
0.2%
14 12 12 11 10
2.1% 1.8% 1.8% 1.7% 1.5%
44 45 46 47 48
Central African Republic Chad Chile Croatia Georgia Ghana
1 1 1 1 1
0.2% 0.2% 0.2% 0.2% 0.2%
9 8 7 7 7 6 6 5 5 5
1.4% 1.2% 1.1% 1.1% 1.1% 0.9% 0.9% 0.8% 0.8% 0.8%
49 50 51 52 53 54 55 56 57 58
Greece Guinea Haiti Hungary Jersey Kenya Niger Nigeria Peru Portugal
1 1 1 1 1 1 1 1 1 1
0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%
4
0.6%
59
1
0.2%
4
0.6%
60
Puerto Rico Slovenia
1
0.2%
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
29
Sweden Japan Turkey Netherlands South Africa Thailand Iraq Germany Malaysia Singapore Israel Spain Italy Switzerland Wallis and Futuna Afghanistan
30
Austria
19 20 21 22 23 24 25 26 27 28
*Total usage: Total number of downloads; ** Mean use rate: Total number of downloads/Total number of papers.
Table 3 shows the number of papers by the locations of study settings mentioned in the abstracts. In total, there were 658 times the bibliography included country settings, of those, the number of studies set up in the United States of America accounted for 15.8 %. Half of the countries in the list were developed countries. In the top ten countries, five Asian countries/ regions with the highest proportions of involvements as study settings, they were China (mainland, Hong Kong, and Taiwan), Oman, Iran, and India. By analyzing the content of abstracts, and titles, we scrutinized the terms to characterize the scope of studies, and co-occurrence of terms. Fig. 1 describes the co-occurrence of the most common terms. Four major clusters emerged from 286 most common keywords with co-occurrence of at least 800 times. The four major clusters are: Cluster 1 (red) refers to the application of mindfulness in mental health treatment (depression). Cluster 2 (blue) focuses on applying this therapy for cancer patients. Cluster 3 (yellow) points out that mind-body therapies were used for QoL improvement to the patient with gastroenterology or surgery. Cluster 4 (green) illustrates the kind of mind-body therapies applied to improve QoL, including Tai Chi, or Qigong. Table 4 shows the most cited papers among those each paper has been assigned to a topic referring to Table 5. The papers mentioned mindfulness ranked first in the total citation of six topics (topic 1, topic 2, topic 3, topic 5, topic 7, and topic 8), that shows the concern of scientific researchers to this method due to the benefits it could bring to health.
Using Latent Dirichlet Allocation of texts in the abstracts, we constructed research topics into ten major groups (Table 5). Topics with the highest volumes of publications include “Randomised Controlled Studies on MBT efficacy”, and “Benefits of MBT in non-clinical populations, and digital delivery of MBT”. Rehabilitation of chronic conditions (e.g., COPD, CVD) using MBT (Topic 9), and biofeedback therapy (topic 10) has gained traction in publications. Meanwhile, the interest in topic 1, and 2 have been decreasing in recent years. This change could indicate the increased understanding of the psychological, and physical impact of various MBT in clinical, and non-clinical populations (Fig. 2). Fig. 3 presents the hierarchical clustering of research disciplines in using mind-body therapies to improve quality of life. The horizontal axis of the dendrogram illustrates the dissimilarity between clusters while the vertical axis shows the research disciplines. It can be seen that the research landscapes in using mind-body therapies to improve quality of life rooted in the following disciplines: 1) Psychology, and 2) Biomedical Social Sciences as the first chunk in the bottom the dendrogram. This method had a close relationship with other research areas in Behavioral Sciences or clinical (Surgery, and Clinical 3
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Fig. 1. Co-occurrence of most frequent terms in the titles and abstracts. Note: the strength of the links between items were automatically calculated by VOSviewer using the fractionalization method. The size of a term is determined based on the weight of the item. Cluster 1 (red) refers to the application of mindfulness in depression. Cluster 2 (blue) focuses on applying this therapy for cancer patients. Cluster 3 (yellow) points out that mind-body therapies were used for QoL improvement to the patient with gastroenterology or surgery. Cluster 4 (green) illustrates the kind of mind-body therapies applied to improve QoL, including Tai Chi, or Qigong. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
Neurology). However, this method had not a close connection with Psychiatry, Clinical Psychology, or Family Studies.
considerable work has been done to elucidate the mechanism of MBT. Conceptually, attention and emotional regulation are thought to mediate mindfulness.48 Another aspect investigated is the neurophysiological basis of MBT. Hölzel et al. reported an increase in brain grey matter in areas for considering perspectives, and emotional regulation in participants of MBSR.49 Other parameters include electroencephalogram (EEG), cortisol levels, and immune function.50,51 However, the mechanisms remain poorly understood. Consolidation of this subfield would accelerate the integration of MBT into conventional medicine by promoting understanding, and acceptance by the public, and healthcare professionals. Furthermore, it is essential for directed use, research, and policy advancement, where therapy technique and clinical end-points are better defined and tailored to individual illness.2 LDA analysis has revealed research into the use of MBT as rehabilitation for chronic conditions (Table 5). While publications of these themes remain low, they have burgeoned in recent years (Fig. 2). There may be an increased exploration into the physical benefits of MBT, and their expanding role in medicine. This study has several implications. First, it highlights the substantial research focus on mindfulness and comparative lack of other MBT practices. This is concerning since meta-analyses, and systematic reviews have consistently identified a lack of strength in trials. MBT has full origins,5 and some may be more acceptable in certain cultures. For example, Tsang et al. noted a preference of ‘Chinese’ activities among the elderly community in Hong Kong.7 Hence, more work is required in these areas to capitalize on the potential benefits and provide evidencebased care across cultures. This suggestion is in lieu of a barrier to integrating MBT into conventional medicine – physician-perceived lack of evidence. Second, the adverse effects of MBT are not well represented in the literature. A meta-analysis noted more than two-thirds of trials included did not evaluate the safety profile of yoga52 while a mere 2 of 19 studies reported side effects of aromatherapy, and massage therapy in a systematic review.36 One reason may be the lack of established methods for determining adverse events of MBT.53 Some negative effects of MBT reported include relaxation-induced anxiety,53 psychotic symptoms,
4. Discussion This study has investigated the research landscape for MBT, and their impact on QoL in terms of the distribution of the publications, the terms co-occurrence, and LDA topic modeling. The increase of publications, and readership of peer-reviewed literature, particularly in the last five years, has demonstrated the growing academic, and public interest in the field. This phenomenon might be explained by the promising results of MBT in enhancing QoL in both clinical, and nonclinical populations. Publications have predominantly been spearheaded by the USA, and Australia, and have seen the significant contribution from India, Oman, China, UK, and Canada. Fig. 3 shows the interdisciplinary nature of the research. While previous bibliometric analyses have focused on single MBT practices, this is the first study to encompass the variety of therapies, in attempt to inform future research, and policy on this vast, and complex area. Analysis of keywords and abstracts highlighted mindfulness as the primary MBT extensively studied. Researchers have investigated the effectiveness of mindfulness in a multitude of illnesses, mainly mental health,4,45 chronic pain,1,17 cancer,46 and gastrointestinal conditions,47 as reflected by Fig. 1. The focus on chronic conditions may indicate inadequate management by conventional medicine in these conditions, perceived efficacy,9 and the nature of MBT as a long-term commitment. As highlighted in the introduction, measures include the psychological, physical, and social function and QoL. The volume of papers in this area could be due to the existence of structured programs such as MBSR, and MBCT, allowing for studies to be replicated and improved. It indicates the need for standardization of research in other MBT practices (components, duration, frequency, outcome measures). It might also indicate the heterogeneity of practices considered as mindfulness, including religious meditation, acceptance-based interventions, self-compassion mindfulness, and mindfulness as a trait. Some of the most highly cited articles and LDA analysis shows that 4
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Table 4 Most cited papers. Title
Topica
Total citation
Publication year
Cite rate
Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study Randomized trial of a meditation-based stress reduction program, and cognitive behavior therapy in generalized social anxiety disorder A randomised comparative trial of yoga, and relaxation to reduce stress, and anxiety Yoga for chronic low back pain in a predominantly minority population: a pilot randomized controlled trial Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia Mindfulness-Based Stress Reduction for Failed Back Surgery Syndrome: A Randomized Controlled Trial A mindfulness course decreases burnout, and improves well-being among healthcare providers Mindfulness-Based Stress Reduction (MBSR) for Primary School Teachers Teaching mindfulness in medical school: where are we now, and where are we going? Emotional intelligence mediates the relationship between mindfulness, and subjective well-being Mindfulness, self-compassion, and happiness in non-meditators: A theoretical, and empirical examination A mindfulness model of affect regulation, and depressive symptoms: Positive emotions, mood regulation expectancies, and self-acceptance as regulatory mechanisms A Systematic Review, and Meta-analysis of Yoga for Low Back Pain Mind-body therapies for the treatment of fibromyalgia. A systematic review A systematic review, and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome Cognitive behavioural therapy for tinnitus The Effects of Yoga on Physical Functioning, and Health Related Quality of Life in Older Adults: A Systematic Review, and Meta-Analysis Exercise therapy for schizophrenia Efficacy, and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review, and meta-analysis of randomized controlled trials Mindfulness, and Acceptance Models in Sport Psychology: A Decade of Basic, and Applied Scientific Advancements Migraine prevalence, and treatment patterns: The global Migraine, and Zolmitriptan Evaluation survey Integrative oncology: Complementary therapies for pain, anxiety, and mood disturbance Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society Guidelines for trials of behavioral treatments for recurrent headache, first edition: American Headache Society Behavioral Clinical Trials Workgroup Clinical Practice Guidelines on the Evidence-Based Use of Integrative Therapies During, and After Breast Cancer Treatment Mindfulness-Based Cognitive Therapy to Prevent Relapse in Recurrent Depression Impact of Mindfulness-Based Stress Reduction (MBSR) on sleep, mood, stress, and fatigue symptoms in cancer outpatients An open trial of an acceptance-based behavior therapy for generalized anxiety disorder Effectiveness, and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial Systematic review, and meta-analysis of transdiagnostic psychological treatments for anxiety, and depressive disorders in adulthood The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health, and quality of life: A randomized controlled study Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD Mindfulness-Based Stress Reduction Compared with Cognitive Behavioral Therapy for the Treatment of Insomnia Comorbid with Cancer: A Randomized, Partially Blinded, Noninferiority Trial Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms, and symptom clusters Mindfulness-Based Cognitive Therapy for Nonremitted Patients with Bipolar Disorder Qigong Improves Quality of Life in Women Undergoing Radiotherapy for Breast Cancer Results of a Randomized Controlled Trial Mindfulness practice leads to increases in regional brain gray matter density The underlying anatomical correlates of long-term meditation: Larger hippocampal, and frontal volumes of gray matter Mindfulness meditation, well-being, and heart rate variability: A preliminary investigation into the impact of intensive Vipassana meditation The neural substrates of mindfulness: An fMRI investigation Rapid changes in histone deacetylases, and inflammatory gene expression in expert meditators Meditation (Vipassana), and the P3a event-related brain potential Improvement in physiological, and psychological parameters after 6 months of yoga practice Respiratory muscle endurance training in chronic obstructive pulmonary disease - Impact on exercise capacity, dyspnea, and quality of life Exercise training in COPD patients: the basic questions Functional anorectal disorders Dyssynergic defecation, and biofeedback therapy Anorectal Disorders Long-term efficacy of simple behavioral therapy for daytime wetting in children Consensus statement AIGO/SICCR diagnosis, and treatment of chronic constipation, and obstructed defecation (Part II: Treatment)
1 1
222 135
2008 2007
20.2 11.3
1 1 1 1 2 2 2 3 3 3
135 71 63 49 130 67 53 100 94 66
2007 2009 2006 2010 2012 2010 2013 2011 2011 2010
11.3 7.1 4.8 5.4 18.6 7.4 8.8 12.5 11.8 7.3
4 4 4 4 4
126 80 73 67 65
2013 2000 2013 2010 2012
21.0 4.2 12.2 7.4 9.3
4 4
57 55
2010 2013
6.3 9.2
5 6 6 6
50 143 107 80
2012 2003 2005 2015
7.1 8.9 7.6 20.0
6
65
2005
4.6
6 7 7 7 7
52 337 257 124 115
2017 2008 2005 2007 2015
26.0 30.6 18.4 10.3 28.8
7
105
2015
26.3
7
104
2010
11.6
7 7
95 87
2015 2014
23.8 17.4
7
68
2012
9.7
7 7
61 58
2012 2013
8.7 9.7
8 8 8
536 200 73
2011 2009 2013
67.0 20.0 12.2
8 8 8 8 9
68 65 65 50 82
2011 2014 2009 2012 2000
8.5 13.0 6.5 7.1 4.3
9 10 10 10 10 10
53 261 77 63 59 49
1997 2006 2008 2016 2000 2012
2.4 20.1 7.0 21.0 3.1 7.0
a
refer to Table 5 for topics.
and enhanced susceptibility to false memories from mindfulness,54 and musculoskeletal injuries due to yoga.52 More efforts in this area would allow healthcare professionals and users an informed decision of MBT use. Finally, previous bibliometric analyses have evaluated the research landscape with regards to particular MBT practices or single diseases.
This study provides an overview of major trends for the variety of MBT, and the conditions they are applied. Hence, it provides insight into the changes of research interests, and advancement over a few decades, which is useful for future research, and policy development. This study has some limitations. The restriction of the search strategy to research papers and reviews in the English language might 5
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Table 5 Ten research topics classified by Latent Dirichlet allocation. Rank by the highest volume last five years
Research topics
N
Percent
Topic Topic Topic Topic Topic Topic Topic Topic Topic Topic
Randomized Controlled Studies on MBT efficacy Benefits of MBT in non-clinical populations, and digital delivery of MBT Scale validity, and mechanism of mindfulness Systematic reviews, and meta-analysis on MBT efficacy Conceptual theory of MBT MBT use in chronic conditions MBT impact on psychological well-being Effect of MBT on cognition, imaging, and biomarkers Exercise efficacy of MBT in rehabilitation, and QoL The use of MBT in constipation, incontinence, and sialorrhea
814 444 395 388 313 289 225 180 190 207
23.6% 12.9% 11.5% 11.3% 9.1% 8.4% 6.5% 5.2% 5.5% 6.0%
1 2 3 4 5 6 7 8 9 10
However, a summary is appropriate for an overview of the research direction. 5. Conclusions Mind-body therapy has proven promising in a wide range of medical conditions, not only as a complementary therapy but also been incorporated as an option into health services, especially for chronic diseases. Its rising popularity and recognition of the limitations of allopathy medicine in raising the quality of life demand a concerted effort to provide quality evidence. This global review and content analysis provide a summary of the field. An attempt has been made to highlight key areas which could be further developed for a greater understanding of the subject. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Fig. 2. Changes in research topics development.
compromise the comprehensiveness of the article, such as articles in the local language, which may reflect less globalized/well-known practices. Analyses of keywords may not fully reflect the content of articles.
Declaration of Competing Interest None
Fig. 3. Dendrogram of coincidence of research areas using the WoS classifications. The research landscapes in using mind-body therapies to improve quality of life rooted in the following disciplines: 1) Psychology, and 2) Biomedical Social Sciences as the first chunk in the bottom the dendrogram. This method had a close relationship with other research areas in Behavioral Sciences or clinical (Surgery, and Clinical Neurology), but had not a close connection with Psychiatry, Clinical Psychology, or Family Studies.
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Appendix A
Fig. A1. Process of selection.
Appendix B. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ctim.2020.102350.
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