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

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.

Meditation/Hypnotherapy/Relaxation. A 2019 European study conducted in 131 children (9 to 18 years of age) with primary headaches investigated the effectiveness of transcendental meditation or hypnotherapy, and compared them with progressive muscle relaxation exercises (active control group). The study found clinically relevant headache reduction (≥ 50%) in 41% and 47% of children at 3 and 9 months respectively, with no significant differences between the groups.

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 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 treated. A type of spinal manipulation that focuses on the neck has been linked to cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.

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. A 2018 pragmatic randomized controlled trial conducted in Europe involving 328 participants with recurrent and persistent low-back pain found that chiropractic maintenance care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific low-back pain, but it resulted in a higher number of treatments.
• 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 2018 review by the Agency for Healthcare Research and Quality (AHRQ) looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment. It found that acupuncture was associated with slightly greater effects on pain and function at 1-6 months when compared to controls, such as sham (fake) acupuncture or usual care. One study also found a greater reduction in pain after more than 12 months.
• 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.
• A 2018 AHRQ systematic review of noninvasive nonpharmacological treatment of chronic pain concluded that exercise, psychological therapies (primarily CBT), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and MDR improved function and/or pain for at least one month.

Safety

• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. A type of spinal manipulation that focuses on the neck has been linked to cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.
• 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: In Depth.
• 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 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.
• A 2018 AHRQ systematic review of noninvasive nonpharmacological treatment of chronic pain concluded that exercise, low-level laser, Alexander Technique, and acupuncture improved function and/or pain rating for at least one month.

Safety

• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. A type of spinal manipulation that focuses on the neck has been linked to cervical artery dissections (CAD). These tears are rare but can lead to a stroke. Any kind of sudden neck movement, such as playing sports, getting whiplash, and violent vomiting or coughing may also increase the risk of tears. The available evidence suggests that the incidence of CAD in people getting spinal manipulation is low, but patients need to be informed of this potential risk.
• 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.
• A 2018 AHRQ systematic review of noninvasive nonpharmacological treatment of chronic pain concluded that for knee osteoarthritis exercise, and ultrasound. For hip osteoarthritis, exercise, manual therapies improved function and/or pain rating for at least one month.

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 2018 meta-analysis of 13 trials involving a total of 1,557 participants with knee osteoarthritis and rheumatoid arthritis found that regular yoga training was helpful in reducing knee arthritic symptoms, promoting physical function, and general wellbeing in arthritic patients. 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