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NCCIH Clinical Digest

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Mind and Body Approaches for Chronic Pain:
What the Science Says

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March 2018
Back Pain

   

Clinical Guidelines, Scientific Literature, Info for Patients: 
​​​​​​​Mind and Body Approaches for Chronic Pain

Fibromyalgia

Recent systematic reviews and randomized clinical trials provide encouraging evidence that practices such as tai chi, qi gong, yoga, acupuncture, mindfulness, and biofeedback may help relieve some fibromyalgia symptoms. Current diagnostic criteria are available from the American College of Rheumatology. Treatment often involves an individualized approach that may include both pharmacologic therapies (prescription drugs, analgesics, and NSAIDs) and nonpharmacologic interventions such as exercise, muscle strength training, cognitive-behavioral therapy, movement/body awareness practices, massage, acupuncture, and balneotherapy.

What Does the Research Show?

  • In 2017, the European League Against Rheumatism (EULAR) evaluated non-pharmacologic therapies, including complementary health approaches, and issued revised recommendations for the management of fibromyalgia. The strength of these recommendation is “based on the balance between desirable and undesirable effects (considering values and preferences), confidence in the magnitude of effects, and resource use. A strong recommendation implies that, if presented with the evidence, all or almost all informed persons would make the recommendation for or against the therapy, while a weak recommendation would imply that most people would, although a substantial minority would not.”
    • Based on the evaluation of acupuncture, meditative movement practices (e.g., tai chi, qi gong, and yoga), and mindfulness-based stress reduction, the recommendation for each was weak for use of the therapy.
    • Based on the evaluation of biofeedback, hydrotherapy, and massage therapy, the recommendation for each was weak against use of the therapy.
    • Based on the evaluation of chiropractic, the recommendation was strong against use of the therapy.
  • A 2015 Cochrane review of 61 trials involving 4,234 predominantly female participants with fibromyalgia concluded that the effectiveness of biofeedback, mindfulness, movement therapies, and relaxation techniques remains unclear as the quality of evidence was low or very low.
  • A 2013 Cochrane review of 9 studies involving a total of 395 participants found low-to-moderate evidence that acupuncture improves pain and stiffness in people with fibromyalgia, compared with no treatment and standard therapy. The reviewers also found moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.

Safety

  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients should modify or avoid certain tai chi postures due to acute back pain, knee problems, bone fractures, sprains, and osteoporosis.

 

Headache

Results of research on mind and body practices such as relaxation training, biofeedback, acupuncture, and spinal manipulation for headaches suggest that these approaches may help relieve headaches and may be helpful for migraines.

What Does the Research Show?

  • A 2017 review based on five meta-analyses, seven systematic reviews, and 34 randomized controlled trials on complementary and integrative health approaches for headache concluded that acupuncture, massage, yoga, biofeedback, and meditation have a positive effect on migraine and tension headaches. The review also concluded that spinal manipulation, chiropractic care, and hydrotherapy may also be beneficial for migraine headaches.
  • Biofeedback. The efficacy of biofeedback has been evaluated in numerous studies for tension headaches, with positive results. However, a 2009 systematic review of 11 randomized controlled trials concluded that there is conflicting evidence on the effectiveness of biofeedback compared with placebo to prophylactic drugs or any other treatment. Several studies have shown biofeedback decreased the frequency of migraines. A 2007 meta-analysis of 55 studies found a modest effect for biofeedback interventions and was seen lasting over an average followup phase of 17 months. However, a 2008 review concluded that biofeedback has beneficial clinical effects for migraine but whether those effects are specific or non-specific remains unclear. A 2016 meta-analysis of five studies involving a total of 137 pediatric participants concluded that biofeedback seems to be an effective intervention for pediatric migraine, but more research is needed to increase the reviewers’ confidence in the estimate.
  • Relaxation techniques. A 2017 review found that cognitive behavioral therapy, biofeedback, and relaxation techniques are associated with significant improvements in chronic migraine symptoms. There is limited evidence to support the efficacy of relaxation techniques for tension-type headaches. A 2009 systematic review of eight studies comparing relaxation training to wait list conditions found inconsistent results. Authors of the review concluded that there is no indication, based on current evidence, that relaxation training is better than no treatment or a placebo. A 2008 meta-analysis of 53 studies suggests that relaxation training is less effective than biofeedback. The US Headache Consortium guidelines (link is external) (85KB PDF) for management of migraines include behavioral and physical treatment recommendations based on evidence from 39 controlled trials. The guidelines indicate that relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine and combined with preventive drug therapy to achieve additional clinical improvement for migraine relief.
  • Tai chi. Data are too limited to draw meaningful conclusions about whether tai chi is effective for tension-type headaches. One small clinical trial (n=47) suggested that a 15-week program of tai chi was effective in reducing the impact of tension-type headaches when compared to a wait-list control group.
  • Acupuncture. The combined results from studies evaluating the efficacy of acupuncture for headaches indicate that acupuncture may provide beneficial clinical effects, but whether those effects of acupuncture treatment are specific or non-specific has not been determined, and is under active investigation. A 2012 individual patient data meta-analysis concluded that acupuncture can be a reasonable referral option for chronic pain conditions, including headache.
  • Massage therapy. Limited evidence from two small studies suggests massage therapy is possibly helpful for migraines, but clear conclusions cannot be drawn. A 2011 systematic review of these two studies concluded that massage therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine.
  • Spinal manipulation. Findings from numerous systematic reviews on spinal manipulation for headaches are contradictory. A 2011 review concluded that higher-quality systematic reviews are needed before the benefit of spinal manipulation for headaches can be defined.

Safety

  • Relaxation techniques are generally considered safe for healthy people; however, there have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain mental illnesses, or with a history of abuse or trauma.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Tai chi is a relatively safe practice; however, some patients with acute back pain, knee problems, bone fractures, sprains, and osteoporosis may need to modify or avoid certain tai chi postures.
  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were addressed. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke. Safety remains an important part of ongoing research.

 

Low-Back Pain

For patients with chronic low-back pain, recent evidence-based clinical practice guidelines from the American College of Physicians (ACP) gave a strong recommendation based on moderate-quality evidence that clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, or mindfulness-based stress reduction. The guidelines also strongly recommend, based on low-quality evidence, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

What Does the Research Show?

  • Spinal manipulation. 2017 clinical practice guidelines issued by ACP strongly recommended spinal manipulation, based on low-quality evidence, as initial treatment for patients with chronic low-back pain. A systematic review supporting the 2017 clinical practice guidelines evaluated 32 randomized controlled trials involving more than 6,000 participants and found modest, short-term effects on pain. A 2010 Agency for Healthcare Research and Quality (AHRQ) systematic review concluded that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. The researchers did not find consistent differences when they compared spinal manipulation with massage or physical therapy. A 2011 Cochrane review of 26 clinical trials looked at the effectiveness of different treatments, including spinal manipulation, for chronic low-back pain. The authors concluded that spinal manipulation is as effective as other interventions for reducing pain and improving function.
  • Acupuncture. 2017 clinical practice guidelines issued by ACP strongly recommended acupuncture, based on moderate-quality evidence, as initial treatment for patients with chronic low-back pain. A systematic review supporting the 2017 clinical practice guidelines evaluated 32 randomized controlled trials involving 5,931 participants and found that acupuncture was associated with lower pain intensity and better function compared to no acupuncture treatment. A rigorous 2012 patient data meta-analysis found clear evidence that acupuncture is useful in treating chronic back and neck pain, and the investigators concluded that it is therefore a reasonable referral option. While they found evidence of acupuncture-specific effects attributable to needling, suggesting that acupuncture is more than an elaborate placebo, they noted that these effects are relatively modest and that other non-acupuncture-specific factors are major contributors to the clinical benefit. Findings from a 2016 review of evidence suggest that acupuncture can help some patients manage low-back pain.
  • Massage. A 2015 Cochrane review found evidence that massage may provide short-term relief from low-back pain, but the evidence is not of high quality. The long-term effects of massage for low-back pain have not been established.
  • Yoga. 2017 clinical practice guidelines issued by ACP strongly recommended yoga, based on low-quality evidence, as initial treatment for patients with chronic low-back pain. A systematic review supporting the 2017 clinical practice guidelines evaluated 14 randomized controlled trials and found that yoga was associated with lower pain scores, although the effects were small and were not always statistically significant. A 2017 Cochrane review of 12 trials involving 1,080 participants found low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at 3 and 6 months. Yoga may also be slightly more effective for pain at 3 and 6 months, however the effect size did not meet predefined levels of minimum clinical importance.

Safety

  • Many reviews have concluded that spinal manipulation for low-back pain is relatively safe when performed by a trained and licensed practitioner. The most common minor side effects include feeling tired and temporary soreness. There have been a few reports of cauda equina syndrome (CES), a significant narrowing of the lower part of the spinal canal in which nerves become pinched and may cause pain, weakness, loss of feeling in one or both legs, and bowel or bladder problems, following spinal manipulation. However, the vast majority of cases of CES are not associated with previous spinal manipulation, and in the few cases that are, it is unclear whether this is a complication of manipulation or an underlying disease condition which is causing back pain.
  • In people whose pain is caused by a herniated disc, manipulation of the low back appears to have a very low chance of worsening the herniation. For risks associated with spinal manipulation affecting the upper (cervical) spine, see the NCCIH fact sheet Chiropractic: An Introduction.
  • Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles. Reports of serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Massage therapy appears to have few risks when performed by a trained practitioner. However, massage therapists should take some precautions with certain health conditions. In some cases, pregnant women should avoid massage therapy.  People with conditions such as bleeding disorders, thrombocytopenia and those taking anticoagulant medications should avoid forceful and deep tissue massage. Massage should not be done in any potentially weak area of the skin, such as wounds.
  • Overall, clinical trial data suggest yoga as taught and practiced in these research studies under the guidance of skilled teacher has a low rate of minor side effects. However, injuries from yoga, some of them serious, have been reported in the popular press. People with health conditions should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.

Neck Pain

Available evidence indicates that acupuncture for neck pain may provide better pain relief compared to no treatment. There is some evidence that spinal manipulation may help relieve neck pain, but much of the research on has been of low quality.

What Does the Research Show?

  • Manual therapies. Reviews of research on manual therapies (primarily manipulation or mobilization) and acupuncture for chronic neck pain have found mixed evidence regarding potential benefits and have emphasized the need for additional research. A 2015 Cochrane review of 51 randomized controlled trials involving a total of 2,920 participants concluded that there is some evidence to support the use of thoracic manipulation versus control for neck pain, function, and quality of life; however, results for cervical manipulation and mobilization are few and diverse. The reviewers noted that these findings suggest that manipulation and mobilization present similar results for each outcome at immediate-, short-, and intermediate-term followup. Multiple cervical manipulation sessions may provide better relief of pain and improvement in function than certain medications at immediate-, intermediate-, and long-term followup. Because there is risk of rare but serious adverse events for manipulation, more rigorous research is needed on mobilization, and comparing mobilization and manipulation versus other treatment options. A 2007 review noted that clinical guidelines often endorse the use of manual therapies for neck pain, although there is no overall consensus on the status of these therapies.
  • Massage therapy. A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits from neck pain. However, a 2013 Cochrane review (link is external) of 15 trials on massage therapy for neck pain showed “very low level evidence” that certain massage techniques may have been effective in reducing pain and improving function. Authors of the review concluded that no recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.

Safety

  • Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. Although there have been rare reports of serious complications such as stroke, a large 2009 study did not find a relationship between spinal manipulation and vertebrobasilar artery stroke, which involves the arteries that supply blood to the back of the brain. Safety remains an important part of ongoing research.
  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.

 

Osteoarthritis

Clinical practice guidelines issued by the American College of Rheumatology recommend aerobic exercise and/or strength training, weight loss (if overweight), and a number of pharmacologic and non-pharmacologic modalities for treating osteoarthritis (OA) of the knee, hip, or hand. The guidelines conditionally recommend tai chi, along with other non-drug approaches such as self-management programs and walking aids, for managing knee OA. Acupuncture is also conditionally recommended for those who have chronic moderate-to-severe knee pain and are candidates for total knee replacement but can’t or won’t undergo the procedure.

What Does the Research Show?

  • Acupuncture.  A 2016 meta-analysis of 10 randomized controlled trials concluded that acupuncture can improve short and long-term physical function, but it appears to provide only short-term pain relief in patients with chronic knee pain due to arthritis. A 2012 meta-analysis concluded that acupuncture can be helpful and a reasonable referral option for OA pain. The authors of the meta-analysis also noted that significant differences between true (actual) and sham acupuncture indicate that acupuncture is more than a placebo; however, these differences are relatively modest. Findings suggest that factors other than the specific effects of needling contribute to the therapeutic effects of acupuncture. In a 2008 systematic review of 10 randomized controlled trials of acupuncture for OA of the knee in 1,456 patients, the authors concluded that these studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with OA of the knee. A 2010 systematic review of 16 trials of 3,498 patients examined the effects of acupuncture for OA in peripheral joints and found that although acupuncture, when compared to a sham treatment, showed statistically significant, short-term improvements in OA pain, the benefits were small and not clinically relevant. In contrast, acupuncture, when compared to a waiting list control, showed statistically significant and clinically relevant benefits in people with peripheral joint OA.
  • Massage therapy. A 2017 systematic review of seven randomized controlled trials involving 352 participants with arthritis found low- to moderate-quality evidence that massage therapy is superior to nonactive therapies in reducing pain and improving functional outcomes. A 2013 review of two randomized controlled trials found positive short-term (less than 6 months) effects in the form of reduced pain and improved self-reported physical functioning. Results of a 2006 randomized controlled trial of 68 adults with OA of the knee who received standard Swedish massage over 8 weeks demonstrated statistically significant improvements in pain and physical function.
  • Tai chi. A 2016 randomized, 52-week, single blind comparative effectiveness study involving 204 participants, found that tai chi produced beneficial effects similar to those of a standard course of physical therapy in the treatment of knee osteoarthritis. A 2013 meta-analysis of 7 randomized controlled trials involving 348 participants found that a 12-week course of tai chi provides benefits of improvement in arthritic symptoms and physical function in patients with OA; however, any long-term benefits of tai chi on OA symptoms has not yet been investigated. A 2013 systematic review and meta-analysis of 5 randomized controlled trials involving 252 participants found moderate evidence for short-term improvement of pain, physical function, and stiffness in patients with OA of the knee who practiced tai chi. A 2009 prospective, single-blind, randomized controlled trial of 40 participants found that tai chi demonstrated significantly greater improvement in pain and physical function, as well as improvement in depression, self-efficacy, and quality of life.

Safety

  • There are few complications associated with acupuncture, but adverse effects such as minor bruising or bleeding can occur; infections can result from the use of nonsterile needles or poor technique from an inexperienced practitioner.
  • Massage therapy appears to have few risks if it is used appropriately and provided by a trained massage professional.
  • Tai chi is considered to be a safe practice.

 

Rheumatoid Arthritis

Results from clinical trials suggest that some mind and body practices—such as relaxation, mindfulness meditation, tai chi, and yoga—may be beneficial additions to conventional treatment plans, but some studies indicate that these practices may do more to improve other aspects of patients’ health than to relieve pain.

What Does the Research Show?

  • Acupuncture. Acupuncture has been studied for a variety of pain conditions, but very little acupuncture research has focused on RA. A 2017 review identified several studies that have indicated a positive role for acupuncture in the treatment of rheumatoid arthritis, but others have failed to show positive outcomes. A 2010 Cochrane review of two studies—one on acupuncture and the other on electroacupuncture for RA—concluded that acupuncture has no effect on ESR, CRP, pain, patient’s global assessment, number of swollen joints, number of tender joints, general health, disease activity, and reduction of analgesics. Although findings from the study on electroacupuncture showed that electro-acupuncture may reduce symptomatic knee pain, the review noted that the poor quality of the trial, including the small sample size, preclude its recommendation.
  • Mindfulness, biofeedback, and relaxation training. A 2017 review of three randomized controlled trials found that although there is increasing evidence linking the practice of mindfulness techniques to improved immune function, there haven’t been enough large, high-quality studies to determine long-term effects in rheumatic disease. A 2010 systematic review of 31 studies in 2,021 patients looked at the benefits of mind and body practices such as mindfulness meditation, biofeedback, and relaxation training on the physical and psychological symptoms associated with RA. There was some evidence that these techniques may be helpful, but overall, the research results have been mixed.
  • Tai chi. A few small studies have been conducted on tai chi for RA. A 2007 systematic review concluded that tai chi has not been shown to be effective for joint pain, swelling, and tenderness, although improvements in mood, quality of life, and overall physical function have been reported. A small 2010 study of 15 participants found that tai chi improved lower-limb muscle function post-treatment and at the 12-week followup; however, there was no evidence that it reduced disease activity or pain.
  • Yoga. A 2017 review of two studies found some beneficial effect on pain, but due to the high risk of bias in both studies, the reviewers gave a weak recommendation for yoga in rheumatoid arthritis. Yoga incorporates several elements of exercise that may be beneficial for arthritis, including activities that may help improve strength and flexibility. A 2013 systematic review of 8 randomized controlled trials involving a total of 559 participants found very low evidence on the effects of yoga on pain associated with RA. 

Safety

  • Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
  • Some people have reported soreness, but most studies have found that tai chi is relatively safe for people with RA.
  • People with RA who have limited mobility or spinal problems should perform yoga exercises with caution. People with RA may need assistance in modifying some yoga postures to minimize joint stress and may need to use props to help with balance.

References

Fibromyalgia

 

Headaches

 

Low-Back Pain

 

Neck Pain

 

Osteoarthritis

 

Rheumatoid Arthritis

NCCIH Clinical Digest is a service of the National Center for Complementary and Integrative Health, NIH, DHHS. NCCIH Clinical Digest, a monthly e-newsletter, offers evidence-based information on complementary health approaches, including scientific literature searches, summaries of NCCIH-funded research, fact sheets for patients, and more.

The National Center for Complementary and Integrative Health is dedicated to exploring complementary health products and practices in the context of rigorous science, training complementary health researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCIH's Clearinghouse toll-free at 1-888-644-6226, or visit the NCCIH Web site at nccih.nih.gov. NCCIH is 1 of 27 institutes and centers at the National Institutes of Health, the Federal focal point for medical research in the United States.

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This page last modified March 21, 2018