Mind and Body Approaches for Health Problems in Military Personnel and Veterans: What the Science Says

The available evidence on efficacy of several mind and body practices such as spinal manipulation, acupuncture, massage, and yoga consists of several independent systematic reviews and meta-analyses, and inclusion of recommendations into independent clinical practice guidelines.

• Spinal manipulation. The systematic review supporting the 2007 clinical practice guidelines from the ACP/APS found good evidence that spinal manipulation (as well as cognitive-behavioral therapy, exercise, and interdisciplinary rehabilitation) are all moderately effective for chronic or subacute (>4 weeks' duration) low-back pain. A 2016 Agency for Healthcare Research and Quality review of noninvasive treatments for low-back pain involving 156 studies found that spinal manipulation was as effective as other active interventions (moderate strength of evidence). 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. A 2016 review of 105 U.S.-based randomized controlled trials found that acupuncture had more positive than negative results for low-back pain and thus may help some patients manage pain. A 2016 Agency for Healthcare Research and Quality review of noninvasive treatments for low-back pain involving 156 studies found that acupuncture was an effective therapy compared to placebo (moderate strength of evidence). 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 2016 Agency for Healthcare Research and Quality review of noninvasive treatments for low-back pain involving 156 studies found that massage was an effective therapy compared to placebo (low strength of evidence). 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. A 2017 Cochrane review of 12 trials involving 1,080 participants found that there is 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 was not clinically important. The reviewers concluded that it is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. A 2016 review of 105 U.S.-based randomized controlled trials found that yoga had more positive than negative results for low-back pain and thus may help some patients manage pain. A 2016 Agency for Healthcare Research and Quality review of noninvasive treatments for low-back pain involving 156 studies found that yoga was an effective therapy compared to placebo (low strength of evidence). In a 2011 study, researchers compared yoga (a protocol developed using the principles of viniyoga) with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. The investigators concluded that yoga classes were more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing symptoms due to chronic low-back pain, with benefits lasting at least several months. Conclusions from another 2011 study of 313 adults with chronic or recurring low-back pain suggested that 12 weekly yoga classes resulted in better function than usual medical care.

• 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: 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 a 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.

The available evidence on efficacy of spinal manipulation and acupuncture for neck pain consists of several systematic reviews. The evidence base on efficacy of massage for neck pain is based on a 2013 systematic review that contains several small studies of poor quality.

• 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 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 benefit of these therapies.
• Massage therapy. A 2016 review of four randomized controlled trials found that massage therapy may provide short-term benefits for 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 efficacy of massage for neck pain remains uncertain.

• 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. Understanding the safety of these interventions 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.

The available evidence on efficacy of mind and body practices such as relaxation training, acupuncture, and spinal manipulation for headaches consists of reviews of data from randomized controlled trials, and the evidence base for biofeedback, tai chi, and massage therapy for headaches consists of only a few small, randomized controlled trials.

• 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 efficacy 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.
• Relaxation techniques. 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 can be 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 as 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.

• 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. Examining safety remains an important part of ongoing research.

• A 2015 randomized controlled trial of 51 participants with unilateral lower limb amputation with phantom limb pain and/or phantom limb sensation found that the combined training of progressive muscle relaxation, mental imagery, and phantom exercises twice a week for 4 weeks significantly decreased phantom limb pain and sensation.
• A 2012 review of 19 studies of mind and body interventions for treatment of phantom limb pain in people with amputation concluded that the weight of available data suggests that a mind and body approach to phantom limb pain management is promising and that specific methods may offer either temporary or long-term relief, either alone or in combination with conventional therapies. However, overall, studies were largely exploratory and reflect considerable variability in the application of mind and body intervention, making definitive conclusions inadvisable.
• A 2008 review of pain management interventions for the traumatic amputee concluded that mind and body practices such as acupuncture, biofeedback, hypnosis, and imagery techniques must be studied more rigorously to determine their effectiveness in relieving pain in amputees.

Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.

• Tai chi, qi gong, yoga. A 2013 systematic review and meta-analysis of 7 separate trials involving 362 participants found evidence that meditative movement therapies such as tai chi, qi gong, and yoga resulted in modest improvements in sleep disturbances, fatigue, depressed mood, and health-related quality of life at the conclusion of the study treatment period. Evidence of continued improvement in sleep disturbances and health-related quality of life was seen 3 to 6 months later.
• Massage. A 2010 systematic review included data from six small randomized controlled trials and two single-arm studies of a variety of different forms of massage. The investigators reported evidence of modest, short-term benefits of massage on fibromyalgia symptoms. However, the investigators noted that all reviewed studies had methodological problems, and they concluded that additional rigorous research is needed to establish whether massage therapy is a safe and effective intervention for fibromyalgia.
• Acupuncture. A 2013 Cochrane review summarized data from nine trials involving a total of 395 participants evaluating any type of invasive acupuncture for fibromyalgia. The investigators found low-to-moderate evidence that acupuncture, compared with no treatment or standard therapy, improves pain and stiffness in people with fibromyalgia. Consistent with findings in other pain conditions, they found moderate-level evidence that the effect of acupuncture does not differ from that of sham acupuncture in reducing pain or fatigue, or improving sleep or well-being. However, the authors noted that small sample sizes and heterogeneity of treatment and control interventions weaken the level of evidence and its clinical implications. A 2010 systematic review included data from seven randomized controlled trials evaluating acupuncture for fibromyalgia, involving a total of 385 participants. The investigators reported evidence of a small analgesic effect of acupuncture. However, the effect was not clearly distinguishable from bias, and they concluded that acupuncture cannot be recommended for the management of fibromyalgia symptoms.
• Balneotherapy. A 2009 qualitative systematic review found moderate evidence that balneotherapy may provide short-term improvement in pain and health-related quality of life for patients with fibromyalgia. However, because of variations in the individual study designs and small sample sizes, the investigators determined that definite conclusions about the value of balneotherapy cannot be reached based on the current evidence.

• 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.

The available evidence on efficacy of complementary health approaches for PTSD consists of clinical practice guidelines issued by the Department of Veterans Affairs and the Department of Defense as well as several randomized controlled trials.

• Relaxation techniques. Clinical practice guidelines (1.2MB PDF) issued in 2010 by the Department of Veterans Affairs and Department of Defense on the management of post-traumatic stress recommend that relaxation techniques be considered as a component of treatment approaches for acute stress disorder or PTSD in alleviating symptoms associated with physiological hyper-reactivity. The guidelines also state that complementary health approaches that facilitate a relaxation response (e.g., mindfulness, yoga, acupuncture, massage, and others) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques. These guidelines also suggest relaxation techniques may be helpful, as adjunct treatment, for specific symptoms including sleep disturbance; irritability, severe agitation, or anger; pain; and hyper-arousal.
• Meditation. A 2016 study examined the impact of Transcendental meditation on psychotropic medication use among 74 active duty military service members with documented PTSD and anxiety. Researchers found that at 1 month, 83.7 percent of the meditation group stabilized, decreased, or ceased psychotropic medication use compared with 59.4 percent of the control group. A 2014 randomized controlled longitudinal study in 21 veterans examined the effects of a breathing-based meditation intervention, Sudarshan Kriya yoga, on PTSD and found participants in the meditation group had reductions in PTSD scores, anxiety symptoms, and respiration rate, but the control group did not.
• Yoga. For veterans with combat-related PTSD, there have only been a few small pilot studies examining the effects of yoga on PTSD. However, a 2015 review of complementary health approaches for PTSD concluded that “yoga appears to be a very positive approach with significant potential benefits for those suffering from PTSD and a very limited downside.” The review also noted that it is unclear as to the optimal style, frequency, and duration of yoga for PTSD, and that these decisions should be driven by the clinical scenario as well as physical limitations and logistical realities. A 2015 small study of 12 current or former military personnel with PTSD found that yoga reduced PTSD symptoms but did not significantly increase mindfulness and resilience in this population.
• Acupuncture. A 2015 review of complementary health approaches for PTSD in both military and non-military populations concluded that clinicians should consider acupuncture for those suffering with PTSD, particularly in conjunction with more traditional treatments such as psychotherapy and pharmacotherapy.
• Biofeedback. A 2010 exploratory study examining the efficacy of biofeedback for PTSD among active duty service members concluded that the addition of biofeedback did not produce a measurable improvement in PTSD or depression scores.
• Accelerated resolution therapy. A 2013 randomized controlled trial of accelerated resolution therapy (ART) in 57 U.S. service members or veterans with symptoms of combat-related PTSD concluded that ART appears to be a safe and effective treatment for symptoms of combat-related PTSD, including refractory PTSD, and is delivered in significantly less time than other therapies used by the Department of Defense and Department of Veterans Affairs. A 2014 randomized controlled trial conducted in 45 U.S. military personnel/veterans examined accelerated resolution therapy for the treatment of pain secondary to symptoms of combat-related PTSD and concluded that using accelerated resolution therapy for the brief treatment of symptoms of PTSD appears to acutely reduce concomitant pain.

• Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.
• Meditation is generally considered to be safe for healthy people. There have been rare reports that meditation could cause or worsen symptoms in people with certain psychiatric problems like anxiety and depression. People with existing mental health conditions should speak with their health care providers before starting a meditative practice, and make their meditation instructor aware of their condition.
• Yoga is generally low-impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor. Overall, those who practice yoga have a low rate of side effects, and the risk of serious injury from yoga is quite low. However, certain types of stroke as well as pain from nerve damage are among the rare possible side effects of practicing yoga.
• Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of nonsterile needles and improper delivery of treatments.
• Biofeedback generally does not have harmful side effects.
• A 2013 randomized controlled trial of accelerated resolution therapy for symptoms of combat-related PTSD found that adverse treatment-related events were rare and not serious.

The available evidence on the efficacy of relaxation techniques for anxiety consists of a few reviews and meta-analyses and many randomized trials; however, many of these studies have been small and of poor quality.

• Acupuncture. A 2012 systematic review of 52 reviews on the effectiveness of acupuncture research across components of the trauma spectrum response found that acupuncture appears to be effective for treating headaches and may be a promising option for anxiety, sleep disturbances, depression, and chronic pain, although more research is needed.
• Acupuncture and relaxation response. A 2014 randomized controlled trial of 67 military veterans in recovery from substance abuse disorder examined the effects of auricular acupuncture and the relaxation response on reducing craving and anxiety. The study found that craving and anxiety levels decreased significantly following one session of acupuncture or relaxation response, and the level of craving continued to drop with additional sessions.
• Biofeedback. A 2012 study of 41 U.S. soldiers found that using biofeedback while immersed in a stressful video game increases the effectiveness of stress management skills.
• Yoga. A 2012 randomized controlled trial of 70 military personnel who were deployed to Iraq examined the effects of sensory-enhanced yoga on symptoms of combat stress and found that participants in the sensory-enhanced hatha yoga group had a reduction in state and trait anxiety and improvement in several mental health and quality of life factors.
• Relaxation techniques. A 2011 study of 60 military medical personnel that investigated the effectiveness of technology-enhanced relaxation techniques found that learning relaxation skills with a video clip of virtual reality relaxing scenes showed a statistically significant effect on improving the anxiety levels of the treatment group.
• Meditation. A 2011 review of research on the potential of meditation training to improve soldier resilience concluded that Transcendental meditation, mindfulness, and progressive relaxation have the most supporting data and are suitable potential options for improving resilience.

• Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.
• Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of nonsterile needles and improper delivery of treatments.
• Biofeedback generally does not have harmful side effects.
• Yoga is generally low-impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor. Overall, those who practice yoga have a low rate of side effects, and the risk of serious injury from yoga is quite low. However, certain types of stroke as well as pain from nerve damage are among the rare possible side effects of practicing yoga.
• Meditation is generally considered to be safe for healthy people.

The available evidence of relaxation techniques for insomnia in military personnel consists of only a few small studies.

• A 2000 study of 42 military personnel treated in a 6-session, multiple component behavioral group treatment program consisting of sleep restriction, stimulus control, sleep hygiene, relaxation training, and cognitive therapy found improvements in sleep onset latency (53 percent), wake after sleep onset (40 percent), and sleep efficiency (22 percent).
• Findings from a 2013 randomized controlled trial of 40 combat veterans suggest that cognitive-behavioral therapy combined with adjunctive imagery rehearsal therapy may be promising for reducing both insomnia and PTSD symptoms.
• Findings from a 2010 study in which 35 veterans completed a full course (5 sessions) of imagery rehearsal therapy suggest that the therapy may be helpful as a short-term treatment for PTSD symptoms, including insomnia.

• Relaxation techniques are generally considered safe for healthy people. However, occasionally, people report unpleasant experiences such as increased anxiety, intrusive thoughts, or fear of losing control. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma.
• There is very little published data on safety of imagery rehearsal therapy in veterans or military personnel.