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A Systematic Scoping Review of Complementary and Alternative Medicine Mind and Body Practices to Improve the Health of Veterans and Military Personnel

Elwy, A. Rani PhD*,†; Johnston, Jennifer M. PhD; Bormann, Jill E. RN, PhD§,∥; Hull, Amanda PhD; Taylor, Stephanie L. PhD#,**

doi: 10.1097/MLR.0000000000000228
Original Research

Background: Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Yet, the research on mind and body practices has been critiqued as being too limited in evidence and scope to inform clinical treatment.

Objectives: We conducted a systematic scoping review of mind and body practices used with veterans or active duty military personnel to identify gaps in the literature and make recommendations for future primary research.

Research Design: Following systematic literature review methodology, we searched 5 databases using 27 different National Center for Complementary and Alternative Medicine-defined mind and body practices as text words, keywords, and MeSH terms through June 30, 2014. We also conducted handsearches of 4 previous reviews.

Subjects: Active duty military members or veterans 18 years or older participating in mind and body practice interventions globally.

Measures: Data were extracted from studies meeting 5 inclusion criteria. The quality of randomized controlled trials (RCTs) was assessed using an existing checklist.

Results: Of 1819 studies identified, 89 interventions (50 RCTs) published between 1976 and 2014, conducted in 9 countries, using 152 different measures to assess 65 health and well-being outcomes met our inclusion criteria. Most interventions took place in the United States (n=78). Meditation practices (n=25), relaxation techniques including imagery (n=20), spinal manipulation including physical therapy (n=16), and acupuncture (n=11) were the most frequently studied practices. Methodological quality of most RCTs was rated poorly.

Conclusions: Meditation and acupuncture practices are among the most frequently offered and studied mind and body practices. Future research should include yoga as it is currently understudied among veterans and military personnel. A repository of mind and body intervention outcome measures may further future research efforts, as would conducting pragmatic trials and more robust RCTs.

*Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford

Departments of Health Policy and Management

Psychiatry, Boston University School of Medicine, Boston, MA

§Center for Excellence for Stress and Mental Health, VA San Diego Healthcare System

Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA

Integrative Health and Wellness Program, War Related Injuries and Illness Center, Washington DC VA Medical Center, Washington, DC

#Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Medical Center, North Hills

**RAND Corporation, Santa Monica, CA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website, www.lww-medicalcare.com.

Supported by the Department of Veterans Affairs, Health Services Research and Development Service, SDR 13-424.

A portion of this review was presented at the AcademyHealth annual research meeting on June 24, 2013, in Baltimore, MD. The views presented in this paper are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

A.R.E. is also an investigator with the Implementation Research Institute, at the George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative. The remaining authors declare no conflict of interest.

Reprints: A. Rani Elwy, PhD, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Mailstop 152, Bedford, MA 01730. E-mail: rani.elwy@va.gov.

Complementary and alternative medicine (CAM) mind and body practices involve a large and diverse group of techniques that are administered or taught to others by a trained practitioner or teacher, and focus on the interaction between the brain, mind, body, and behavior.1 The most commonly used mind and body practices to improve health and well-being in the United States include deep breathing, meditation, chiropractic and osteopathic manipulation, massage, yoga, progressive relaxation, and guided imagery.2 Evidence suggests that many mind and body practices are beneficial for individuals with a wide range of health care problems, including chronic low back pain,3,4 depression and anxiety,5,6 sleep disorders,7 and cancer.8 People using mind-body practices to address back and neck problems also report significantly better self-reported health, a lower number of comorbidities, and lower health care costs than non-CAM users.9

A 2011 national survey of Department of Veterans Affairs (VA) medical facilities found that CAM was available in 125 (89%) facilities,10 which is more than twice the percentage of American Hospital Association hospitals reporting CAM availability.11 Of the VA facilities offering CAM treatment, 33 (41%) provided up to 5 types of CAM and 9 (11%) provided up to 20 types. Meditation was the most commonly offered type of CAM mind and body practice (81% of facilities), followed by guided imagery (66%), acupuncture (46%), and yoga (35%).10 Despite this seemingly widespread dissemination of CAM mind and body practices throughout the VA, most literature reviews conducted with veterans or military members in mind conclude that the evidence for CAM efficacy, although suggestive, is not definitive and that future, more rigorous research is needed.12,13

This paper systematically reviews the veterans-based and active duty military personnel-based CAM mind and body practice literature worldwide. To our knowledge, no thorough review of CAM mind and body practice research conducted specifically with veterans and military personnel has been published. As such, the size and nature of the evidence base for CAM mind and body interventions among these 2 related populations is unclear. There are many challenges inherent in conducting systematic reviews of CAM, such as publication biases, improper indexing of CAM journals and articles, difficulty in specifying the intervention ingredients, and patients’ expectation biases.14 Because of these challenges in CAM practices and study designs, conducting a systematic literature review of the effectiveness of all CAM mind and body interventions was not possible. Instead, a systematic scoping literature review was undertaken because a scoping review can determine the size and nature of the evidence base for CAM interventions, help identify gaps in the CAM mind and body practice literature, and make recommendations for future primary research in this area.15

Our scoping review goals were to (1) examine the size and state of CAM mind and body practice research, allowing us to identify gaps in the literature; (2) assess the quality of the subset of randomized controlled trials (RCTs) to determine whether the details presented were adequate enough to interpret results, and whether bias had been introduced into the study design; and (3) qualitatively synthesize the results to inform future primary research in this area.

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METHODS

Search Strategy

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting and reporting items for systematic reviews.16 All 27 items of the PRISMA checklist were included in our data extraction except for a quantitative synthesis of the results because it was not the focus of our effort. All authors served as literature reviewers. One reviewer searched 5 electronic databases: Medline (PubMed), PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ageline and the Cochrane Central Register of Controlled Trials databases using the 27 National Center for Complementary and Alternative Medicine (NCCAM) mind and body practice terms described in Table 1. We devised a unique search strategy based on these 27 practices for each of the 5 electronic databases (Table 2). All articles were filtered for English language, human, and adult populations. In addition, we handsearched the reference sections of 4 comprehensive systematic reviews previously conducted on mind and body practices, identified through the Cochrane Collaboration,17 to determine whether any literature from these reviews.12,13,18,19

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Inclusion Criteria

We selected studies for review if they met the following 5 criteria: (1) the study consisted of a CAM mind and body intervention as defined by the National Center for Complementary and Alternative Medicine, as shown in Table 21; (2) the intervention provided at least 1 pretest and posttest measure and was conducted prospectively in nature with ≥5 participants; (3) participants were either military veterans or military active duty personnel at least 18 years of age or older; (4) the peer-reviewed paper was written in English; and (5) the full text of the article was available for review. If the paper was not available in an electronic format, we purchased it through a university library center.

Abstracts identified by the search strategy were coded for inclusion using a checklist developed from guidelines by the University of York’s Centre for Reviews and Dissemination.15 The reliability of this checklist was tested by 2 of the reviewers on a subset of 25 included abstracts. If the abstracts did not provide enough information, the full text of the article was obtained for review. Any disagreements on the inclusion of abstracts and the checklist were solved through discussion and consensus. One reviewer coded the remaining articles for inclusion (Table 2).

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Data Extraction

All reviewers independently reviewed 5 articles to test a data extraction sheet adapted from a previous yoga scoping review,18 and based on a consensus process, we subsequently revised the sheet. The final data extraction sheet included the following 11 categories: title of publication, first author, year of publication, journal name, country of study, primary mind and body modality, objective of study, population of study, study design, conditions treated, and measures used.

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Quality Assessment

We evaluated the methodological quality of the subset of included RCTs, consider the gold standard of evidence,20 using 7 categories of potential methodological biases from a previously developed checklist from the University of York’s Centre for Reviews and Dissemination15: (1) was the method used to generate random allocation adequate?; (2) was the allocation adequately concealed?; (3) were the groups similar at the outset of the study in terms of prognostic factors, for example, severity of disease?; (4) were the care providers, participants, and outcome assessors blind to treatment allocation?; (5) were there any unexpected imbalances in drop-outs between the groups?; (6) is there any evidence to suggest that the authors measured more outcomes than they reported?; and (7) did the analysis include an intention-to-treat analysis? Many of these quality items would be addressed by adherence to the Consolidated Standards of Reporting Trials (CONSORT) Statement, a 25-item checklist to focus reporting on how the trial was designed, analyzed, and interpreted, and the inclusion of a flow diagram to display the progress of all participants through the trial.21 One reviewer rated each study on these 7 categories with a “yes, adequate description” (high-quality) or “not adequate description” (low-quality) rating. When 1 reviewer had a question about a particular RCT’s methodology, she sought the opinion of other reviewers for discussion and consensus.

We also examined the appropriateness of the RCTs’ control and comparison groups, which is an important consideration because comparison of the intervention and control groups allows researchers to isolate and test the purported “active ingredient” of the intervention, while holding all other factors constant.18 Unlike studies of drug effects where a placebo is relatively straightforward, control condition selection is much more complex for behavioral interventions.18,22

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RESULTS

We identified 1819 articles examining NCCAM mind and body practices used with veteran and military populations. Eighty-nine of these spanning the years between 1976 and 2014 met our inclusion criteria (Fig. 1).4,23–110 Of these, 50 (56%) were RCTs, and the remaining 39 (44%) were prospective, observational studies, with or without control or comparison groups. The online appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/A800) provides detailed information extracted from each of the 89 articles, following the categories of the data extraction sheet.

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Types of Mind and Body Practices Used

Meditation practices (n=25, 28%); relaxation techniques including imagery (n=20, 22%); spinal manipulation including physical therapy (n=16, 18%); and acupuncture (n=11, 12%), were the most frequently studied practices. Meditation practices included mantram meditation (n=4, 4%); mindfulness-based stress reduction (n=7, 8%); transcendental meditation (n=3, 3%); and other forms of meditation and mindfulness (n=11, 12%). Imagery (n=9, 10%); progressive muscle relaxation (n=3, 3%); relaxation response (n=3, 3%); nonspecific relaxation techniques (n=3, 3%); and breathing exercises (n=2, 2%) comprised the relaxation technique category. Spinal manipulation practices consisted of physical therapy (n=12, 13%); spinal manipulation therapy (n=2, 2%); osteopathic manipulation therapy (n=1, 1%); and chiropractic (n=1, 1%). Auricular acupuncture (n=6, 6%) and traditional acupuncture (n=5, 5%) were included in the acupuncture practices. The remainder of the studies examined: massage therapies (n=6, 6%); yoga (n=6, 6%); hypnotherapy (n=3, 3%); healing or therapeutic touch (n=3, 3%); tai chi (n=2, 2%); and structural movement therapy (n=1, 1%).

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Countries Represented

Eight countries are represented in these studies of mind and body practice research with veterans and the military, although the United States (n=78, 88%) was represented most often in the research. Other countries where mind and body practice research took place with veterans and military members included: Israel (n=3, 3%); India (n=2, 2%); Australia (n=1, 1%); Finland (n=1, 1%); Taiwan (n=1, 1%); Thailand (n=1, 1%); and Turkey (n=1, 1%).

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Overview of Outcomes Assessed

Sixty-five different domains of health and well-being were assessed in these 89 mind and body practice interventions (see online appendix, Supplemental Digital Content 1, http://links.lww.com/MLR/A800). Mental health-related outcomes were prominent in this review, with 26 (29%) studies evaluating posttraumatic stress disorder (PTSD) symptoms, 16 (18%) evaluating the impact of mind and body practices on anxiety outcomes, and 13 (15%) examining depression symptoms. Eleven (12%) studies assess specific psychological aspects of PTSD and depression, including psychological nightmares and sleep difficulties. Pain and musculoskeletal outcomes were examined in 27 (30%) of the studies, with pain measured as a primary outcome. Quality of life was assessed in 7 (8%) studies. Because many studies reported on >1 outcome, these numbers exceed 65.

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Overview of Measures Used to Evaluate Outcomes

A total of 152 assessments to measure health outcomes and well-being were used in these studies. Common, structured measures included the Impact of Events Scale,111 the Clinician Administered Posttraumatic Stress Disorder Scale,112 variations of the Posttraumatic Stress Disorder Checklist,113 Beck’s Depression and Anxiety Inventories,114,115 the Insomnia Severity Index,116 the Pittsburgh Sleep Quality Index,117 the Addiction Severity Index,118 the SF-36,119 and the Symptom Checklist (SCL-90).120 The Ellison Well-being Scale assessed spiritual well-being121 and the 5 Facet Mindfulness Questionnaire evaluated mindfulness.122 Other measures involved in these studies are listed in the online appendix (Supplemental Digital Content 1, http://links.lww.com/MLR/A800).

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Quality Assessment of the RCTs

Table 3 provides details on each of the 7 quality assessment questions used to examine RCTs. All 50 RCTs provided information that allowed the reviewers to determine if the groups of participants had similar prognostic factors at the study outset. In 19 (38%) RCTs, information was included to be able to determine that the random generation to group assignments was adequate and that this allocation was adequately concealed. In 15 (30%) articles, authors stated that the assessors were blind to treatment allocation. Overall, most articles did not refute these potential biases in the methodological design, and as such, most RCTs were rated as consisting of poor methodological quality.

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Control and Comparison Groups in the RCTs

Treatment as usual (TAU) was the most common control or comparison group used in the 50 RCTs, with 14 (28%) employing a TAU control group. Five (10%) of the physical therapy RCTs used standard physical therapy as a comparison group, and 1 mind and body practice intervention used biofeedback, a different form of CAM, as a comparison group. Six RCTs used a combination of mind and body practices in their intervention, such as acupuncture and relaxation response together (n=2, 2%), or massage and acupuncture (n=1, 1%), hypnosis and breathing practices (n=1, 1%), progressive muscle relaxation and controlled breathing (n=1, 1%). Waitlist control or delayed treatment was used as a control group in 4 (8%) studies. As some RCTs involved >1 mind and body practice in the intervention, these numbers do not add up to 50 (Table 4).

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DISCUSSION

This systematic scoping review represents, to our knowledge, the first comprehensive overview of all CAM mind and body practice interventions specifically undertaken with veteran or active duty military personnel worldwide. We conducted this review to (1) better understand the size and state of published literature on CAM mind and body practice interventions among these 2 populations using systematic literature review methodology; (2) assess the quality of RCTs to determine whether adequate details were presented to interpret results and minimize bias; and (3) qualitatively synthesize the results to inform future research.

Eighty-nine studies met our inclusion criteria. From these we learned that meditation, acupuncture, spinal manipulation, and relaxation techniques have been the most often studied in these populations. Mind and body practices have been tested in these populations using RCTs and uncontrolled prospective designs and nonrandomized controlled studies. Moreover, 152 measures were used to assess 65 health and well-being outcomes among veterans and military personnel. The evidence from this scoping review indicated that many measures from these 89 studies addressed pain, PTSD, anxiety, and depression as primary outcomes. In some studies, specific symptoms of PTSD which often impact a person’s level of functioning, such as sleep difficulties and nightmares, were also assessed. Quality of life measures were included in a small number of studies.

We also determined that the subset of 50 RCTs included in this review was largely rated as having poor methodological quality. Researchers might consider the long timeline from 1976 to 2014 when these RCTs were conducted as a reason for this low quality, imagining that RCTs conducted in the earlier years might lack methodological rigor. However, 3 of the 50 RCTs were conducted in the 1970s,24,29,88 2 took place in the 1980s,73,74 and 5 RCTs were undertaken in the 1990s.49,57,71,75,104 Forty of the RCTs have taken place since the year 2000. The overall low-quality rating of the RCTs in this study appears to be not related to time, but instead to the issue that conducting rigorous research in this relatively new mind and body practice intervention field is challenging.

A national VA survey found that meditation, imagery, acupuncture, and yoga were among the most frequently delivered CAM mind-body practices to veterans.10 Our scoping review determined that meditation, imagery (part of relaxation techniques), and acupuncture are among the mind and body practices most often studied in veteran and military populations. However, yoga intervention research is lacking among these populations. Although RCTs remain the gold standard of evidence,20 RCTs assessed in this review were generally rated as consisting of low methodological quality. Our scoping review indicated that TAU was the most often used control or comparison group in these 89 studies. To attain the status of either an adjunctive or stand-alone treatment to improve Veteran and military personnel health, mind and body practices need to be tested against current, active evidence-based treatments, such as prolonged exposure123 or cognitive processing therapy for PTSD,124 or cognitive behavioral therapy for depression.125 Only 1 study in our review used cognitive behavioral therapy as a comparison group, and no studies involved prolonged exposure or cognitive processing therapy as a comparison treatment for mind and body practice interventions addressing PTSD.

Given these issues, we suggest the following 5 recommendations for future research involving mind and body practices to improve the health of veterans and active duty military personnel in the United States and in other countries:

Future research should focus on CAM mind and body practices most often delivered, yet understudied, such as yoga, and more robust research should be planned for interventions involving spinal manipulation therapies, relaxation techniques, and acupuncture.

Future RCTs with these populations should follow the CONSORT statement to increase the quality of the study and enhance the likelihood in which the evidence collected will be free of bias.21 Adherence to the CONSORT Statement would allow readers to identify the potential methodological biases, as well as methodological strengths, of each CAM mind and body practice RCT.

Given the methodological constraints of conducting RCTs of CAM mind and body practices, other study designs which are as rigorous but allow for personal preferences and more transparency in methods should be considered for future CAM mind and body practice studies with veterans and active duty military personnel. Hybrid research designs in which effectiveness and implementation efforts are simultaneously measured would provide information about real-world implications of the mind and body practice interventions and will facilitate translation of CAM practices into VA and military health care.126 Pragmatic trials, which are designed to test interventions in the full spectrum of everyday clinical settings to maximize applicability and generalizability,127 would also allow for assessment of CAM mind and body practices under real-world conditions and will enhance the transparency of data collection and policy-making efforts.128

Researchers examining mind and body practices should increase the use of evidence-based treatments as comparison or control groups in their research.

Measures used to examine common health conditions in these populations such as pain, PTSD, depression, anxiety and sleep disorders, should be made accessible in a publicly available repository. This would allow for wider access to relevant information by VA and military researchers interested in pursuing CAM mind and body intervention research. Using common measures would also facilitate future meta-analyses of mind and body practices, thereby adding to the evidence base of these interventions.

This review has some limitations. We were only able to include articles in the English language because of limited resources for translation purposes. It is also possible that our search strategies did not identify all possible articles for inclusion in the review. However, to address this, we undertook a handsearch of 4 comprehensive systematic reviews involving many different forms of CAM, to determine whether any CAM mind and body practice interventions involving veterans or military personnel were potentially missed in our search strategy.

Despite these limitations, this systematic scoping review provides a comprehensive overview of the state of current CAM mind and body practice intervention research to improve the health and functioning of veterans and active duty military personnel. Our 5 recommendations will enable researchers to design more robust and meaningful mind and body practice interventions with these populations which will increase the evidence base for these currently understudied practices, and ensure that methodological biases are limited in these designs.

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Keywords:

complementary and alternative medicine (CAM); veterans; military; systematic review; methods

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