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).
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.
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
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.
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%).
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%).
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.
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).
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).
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.
2. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. CDC National Health Statistics Report #12, 2008.
3. Sherman KJ, Cherkin DC, Wellman RD, et al.. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171:2019–2026.
4. Groessl EJ, Weingart KR, Aschbacher K, et al.. Yoga for veterans with chronic low-back pain. J Altern Complement Med. 2008;14:1123–1129.
5. Kessler RC, Soukup J, Davis RB, et al.. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158:289–294.
6. Hoffman SG, Sawyer AT, Witt AA, et al.. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78:169–183.
7. Ghaly M, Teplitz D. The biologic effects of grounding the human body during sleep as measured by cortisol levels and subjective reporting of sleep, pain, and stress. J Altern Complement Med. 2004;10:767–776.
8. Bränström R, Kvillemo P, Brandberg Y, et al.. Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for cancer patients—a randomized study. Ann Behav Med. 2010;39:151–161.
9. Martin BI, Gerkovich MM, Deye RA, et al.. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care. 2012;50:1029–1036.
10. Ezeji-Okoye SC, Kotar TM, Smeeding SJ, et al.. State of care: complementary and alternative medicine in Veterans Health Administration: 2011 survey results. Fed Pract. 2013;30:14–19.
11. Ananth S. 2010 Complementary and Alternative Medicine Survey of Hospitals. Samueli Institute, Alexandria VA. Available at: http://www.samueliinstitute.org
. Accessed March 14, 2014.
12. Strauss JL, Coeytaux R, McDuffie J, et al.. Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder. VA Evidence Synthesis Report. 2011.Washington, DC: Department of Veterans Affairs.
13. Schlenger WE, Mauch D, Mulvaney-Day N, et al.. Behavioral Health Research Gap Analysis. Final report for the US Army Medical Research and Materiel Command, Contract #W81XWH-10-C-0246, October 2012.
14. Shekelle PG, Morton SC, Suttorp MJ, et al.. Challenges in systematic reviews of complementary and alternative medicine topics. Ann Intern Med. 2005;142:1042–1047.
16. Moher D, Liberati A, Tetzlaff J, et al.. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–269.
17. Lefebvre C, Manheimer E, Glanville JHiggins JPT, Green S. Chapter 6: searching for studies. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.0. 2011.Oxford, England: The Cochrane CollaborationAvailable at: http://www.cochrane-handbook.org
. Accessed March 14, 2014.
18. Elwy AR, Groessl EJ, Eisen SV, et al.. A systematic scoping review of yoga intervention components and intervention quality. Am J Prev Med. 2014;47:220–232.
19. Green BN, Johnson CD, Lisi AL, et al.. Chiropractic practice in military and veterans health care: the state of the literature. J Can Chiropr Assoc. 2009;53:194–204.
20. United States Preventive Services Task Force. Guide to the Clinical Preventive Services: Report of the US Preventive Services Task Force, “Levels of Evidence”. 1989DIANE Publishing;294.
21. Schultz KF, Altman DG, Moher D. CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152:726–732.
22. Mohr DC, Spring B, Freedland KE, et al.. The selection and design of control conditions for randomized controlled trials of psychological interventions. Psychother Psychosoms. 2009;78:275–284.
23. Anderson DJ. Transcendental meditation as an alternative to heroin abuse in servicemen. Am J Psychiatry. 1977;134:1308–1309.
24. Arch JJ, Ayers CR, Baker A, et al.. Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogenous anxiety disorders. Behav Res. 2013;51:185–196.
25. Bhatnagar R, Phelps L, Rietz K, et al.. The effects of mindfulness training on post-traumatic stress disorder symptoms and heart rate variability in combat veterans. J Altern Complement Med. 2013;19:860–861.
26. Bormann JE, Smith TL, Becker S, et al.. Efficacy of frequent mantram repetition on stress, quality of life, and spiritual well-being in veterans: a pilot study. J Holist Nurs. 2005;23:395–414.
27. Bormann JE, Thorp S, Wetherell JL, et al.. A spiritually based group intervention for combat veterans with posttraumatic stress disorder: a feasilibility study. J Holist Nurs. 2008;26:109–116.
28. Brauer AP, Horlick L, Nelson E, et al.. Relaxation therapy for essential hypertension: a Veterans Administration outpatient study. J Behav Med. 1979;2:21–29.
29. Carlson KJ, Silva SG, Langley J, et al.. Mindful-veteran: the implementation of a brief stress reduction course. Complement Ther Clin Pract. 2013;19:89–96.
30. Carmody TP, Duncan C, Simon JA, et al.. Hypnosis for smoking cessation: a randomized trial. Nicot Tob Res. 2008;10:811–818.
31. Chang BH, Hendricks A, Zhao Y, et al.. A relaxation response randomized trial on patients with chronic heart failure. J Cardiopulm Rehabil. 2005;25:149–157.
32. Collinge W, Kahn J, Soltysik R. Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: a pilot study. Mil Med. 2012;177:1477–1485.
33. Cook JM, Harb GC, Gehrman PR, et al.. Imagery rehearsal for posttraumatic nightmares: a randomized controlled trial. J Traum Stress. 2010;23:553–563.
34. Dolbow DR, Gorgey AS, Ketchum JM, et al.. Exercise adherence during home-based functional electrical stimulation cycling by individuals with spinal cord injury. Am J Phys Med Rehabil. 2012;91:922–930.
35. Finkelstein J, Lapshin O, Castro H, et al.. Home-based physical telerehabilitation in patients with multiple sclerosis: a pilot study. J Rehabil Res Dev. 2008;45:1361–1373.
36. Forbes D, Phelps A, McHugh T. Treatment of combat-related nightmares using imagery rehearsal: a pilot study. J Trauma Stress. 2001;14:433–442.
37. Harris JI, Erbes CR, Engdahl BE, et al.. The effectiveness of a trauma focused spiritually integrated intervention for veterans exposed to trauma. J Clin Psychol. 2011;67:425–438.
38. Kearney DJ, Malte CA, McManus C, et al.. Loving-kindness meditation for posttraumatic stress disorder: a pilot study. J Trauma Stress. 2013;26:426–434.
39. Kearney DJ, McDermott K, Malte C, et al.. Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. J Clin Psychol. 2012;68:101–116.
40. Kearney DJ, McDermott K, Malte C, et al.. Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study. J Clin Psychol. 2013;69:14–27.
41. Kearney DJ, McDermott K, Martinez M, et al.. Association of participation in a mindfulness programme with bowel symptoms, gastrointestinal symptom-specific anxiety and quality of life. Aliment Pharmacol Ther. 2011;34:363–373.
42. King AP, Erickson TM, Giardino ND, et al.. A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress Anxiety. 2013;30:638–645.
43. Kozak L, Vig E, Simons C, et al.. A feasibility study of caregiver-provider massage as supportive care for Veterans with cancer. J Support Oncol. 2013;11:133–143.
44. Long ME, Hammons ME, Davis JL, et al.. Imagery rescripting and exposure group treatment of posttraumatic nightmares in Veterans with PTSD. J Anxiety Disord. 2011;25:531–535.
45. Lu M, Wagner A, Van Male L, et al.. Imagery rehearsal therapy for posttraumatic nightmares in US veterans. J Trauma Stress. 2009;22:236–239.
46. Nakamura Y, Lipschitz DL, Landward R, et al.. Two sessions of sleep-focused mind-body bridging improve self-reported symptoms of sleep and PTSD in veterans: a pilot randomized controlled trial. J Psychosom Res. 2011;70:335–345.
47. Nappi CM, Drummond SP, Thorp SR, et al.. Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans. Behav Ther. 2010;41:237–244.
48. Otto KC, Quinn C, Sung YF. Auricular acupuncture as an adjunctive treatment for cocaine addiction. A pilot study. Am J Addict. 1998;7:164–170.
49. Price CJ, McBride B, Hyerle L, et al.. Mindful awareness in body-oriented therapy for female veterans with post-traumatic stress disorder taking prescription analgesics for chronic pain: a feasibility study. Altern Ther Health Med. 2007;13:32–40.
50. Rosenthal JZ, Grosswald S, Ross R, et al.. Effects of transcendental meditation in veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress disorder: a pilot study. Mil Med. 2011;176:626–630.
51. Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. 2013;178:854–860.
52. Swanson LM, Favorite TK, Horin E, et al.. A combined group treatment for nightmares and insomnia in combat veterans: a pilot study. J Trauma Stress. 2009;22:639–642.
53. Taylor MK, Stanfill KE, Padilla GA, et al.. Effect of psychological skills training during military survival school: a randomized controlled field study. Mil Med. 2011;176:1362–1368.
54. Wang KL, Hermann C. Pilot study to test the effectiveness of Healing Touch on agitation in people with dementia. Geriatr Nurs. 2006;27:34–40.
55. Watson CG, Tuorila JR, Vickers KS, et al.. The efficacies o f three relaxation regimens in the treatment of PTSD in Vietnam War veterans. J Clin Psychol. 1997;53:917–923.
56. Dettori JR, Bullock SH, Sutlive TG, et al.. The effects of spinal flexion and extension exercises and their associated postures in patients with acute low back pain. Spine. 1995;20:2303–2312.
57. Goertz CM, Niemtzow R, Burns SM, et al.. Auricular acupuncture in the treatment of acute pain syndromes: a pilot study. Mil Med. 2006;171:1010–1014.
58. Helmhout PH, Harts CC, Viechtbauer W, et al.. Isolated lumbar extensor strengthening versus regular physical therapy in an army working population with nonacute low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89:1675–1685.
59. Jha AP, Stanley EA, Kiyonaga A, et al.. Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion. 2010;10:54–64.
60. Kumnerddee W. Effectiveness of comparison between Thai traditional massage and Chinese acupuncture for myofascial back pain in Thai military personnel: a preliminary report. J Med Assoc Thai. 2009;92suppl 1S117–S1123.
61. Peretz B, Katz J, Zilburg I, et al.. Treating dental phobic patients in the Israeli Defense Force. Int Dent J. 1996;46:108–112.
62. Stetz MC, Kaloi-Chen JY, Turner DD, et al.. The effectiveness of technology-enhanced relaxation techniques for military medical warriors. Mil Med. 2011;176:1065–1070.
63. Stoller CC, Greuel JH, Cimini LS, et al.. Effects of sensory-enhanced yoga on symptoms of combat stress in deployed military personnel. Am J Occup Ther. 2012;66:59–68.
64. Suni JH, Taanila H, Mattila VM, et al.. Neuromuscular exercise and counseling decrease absenteeism due to low back pain in young conscripts: a randomized, population-based primary prevention study. Spine. 2013;38:375–384.
65. Sutlive TG, Mabry LM, Easterling EJ, et al.. Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in military beneficiary population. Mil Med. 2009;174:750–756.
66. Telles S, Bhardwaj AK, Kumar S, et al.. Performance in a substitution task and state anxiety following yoga in army recruits. Psychol Rep. 2012;110:963–997.
67. Winters MV, Blake CG, Trost JS, et al.. Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84:800–807.
68. Chang B-H, Sommers E. Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder. Am J Addict. 2014;23:129–136.
69. Abramowitz EG, Lichtenberg P. A new hypnotic technique for treating combat-related posttraumatic stress disorder: a prospective open study. Int J Clin Exp Hypnosis. 2010;58:316–328.
70. Arena JG, Bruno GM, Hannah SL, et al.. A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache. Headache. 1995;35:411–419.
71. Bormann JE, Thorp SR, Wetherell JL, et al.. Meditation-based mantram intervention for veterans with posttraumatic stress disorder: a randomized trial. Psych Trauma. 2013;5:259–267.
72. Brooks JS, Scarano T. Transcendental meditation in the treatment of post-Vietnam adjustment. J Counsel Devel. 1985;64:212–215.
73. Carson MA, Hathaway A, Tuohey JP, et al.. The effect of relaxation technique on coronary risk factors. Behav Med. 1988;14:71–77.
74. Carson MA. The impact of relaxation technique on the lipid profile. Nurs Res. 1996;45:271–276.
75. Chang B-H, Sommers E, Herz L. Acupuncture and relaxation response for substance use disorder recovery. J Subs Use. 2010;15:390–401.
76. Chen K-M, Lin J-N, Lin H-S, et al.. The effects of a simplified Tai Chi exercise program (STEP) on the physical health of older adults living in long-term care facilities: a single group design with multiple time points. Int J Nurs Stud. 2008;45:501–507.
77. Groessl EJ, Weingart KR, Johnson N, et al.. The benefits of yoga for women veterans with chronic low back pain. J Altern Complement Med. 2012;18:832–838.
78. Jain S, McMahon GF, Hasen P, et al.. Healing touch with guided imagery for PTSD in returning active duty military: a randomized controlled trial. Mil Med. 2012;177:1015–1021.
79. Mularski RA, Munjas BA, Lorenz KA, et al.. Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease. J Altern Compl Med. 2009;15:1083–1090.
80. Niles BL, Klunk-Gillis J, Ryngala DJ, et al.. Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychol Trauma. 2012;4:538–547.
81. Niles BL, Vujanovic AA, Silberbogen AK, et al.. Changes in mindfulness following a mindfulness telehealth intervention. Mindfulness. 2013;4:301–310.
82. Qutubuddin AA, Cifu DX, Armistead-Jehle P, et al.. A comparison of computerized dynamic posturography therapy to standard balance physical therapy in individuals with Parkinson’s disease: a pilot study. NeuroRehabilitation. 2007;22:261–265.
83. Ramel W, Goldin PR, Carmona PE, et al.. The effects of mindfulness meditation on cognitive processes and affect in patients with past depression. Cog Ther Res. 2004;28:433–455.
84. Redwine LS, Tsuang M, Rusiewicz A, et al.. A pilot study exploring the effects of a 12-week tai chi intervention on somatic symptoms of depression in patients with heart failure. J Altern Complement Med. 2012;18:744–748.
85. Sanford JA, Griffiths PC, Richardson P, et al.. The effects of in-home rehabilitation on task self-efficacy in mobility-impaired adults: a randomized clinical trial. J Am Geriatr Soc. 2006;54:1641–1648.
86. Sherman RA. Home use of tape recorded relaxation exercises as initial treatment for stress related disorders. Mil Med. 1982;147:1062–1066.
87. Stone RA, DeLeo J. Psychotherapeutic control of hypertension. New Engl J Med. 1976;294:80–84.
88. Cronin C, Conboy L. Using the NADA protocol to treat combat stress-induced insomnia: a pilot study. J Chinese Med. 2013;103:50–56.
89. da Cunha IT, Lim PA, Qureshy H, et al.. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulatory. Arch Phys Med Rehab. 2002;83:1258–1265.
90. Deyle GD, Henderson NE, Matekel RL, et al.. Effectiveness of manual physical therapy and exercise osteoarthritis. Ann Intern Med. 2000;132:173–181.
91. Fritz DJ, Carney RM, Steinmeyer B, et al.. The efficacy of auriculotherapy for smoking cessation: a randomized, placebo-controlled trial. J Am Board Fam Med. 2013;26:61–70.
92. Goertz CM, Long CR, Hondras MA, et al.. Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. Spine. 2013;38:627–634.
93. Mitchinson AR, Kim HM, Rosenberg JM, et al.. Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial. Arch Surg. 2007;142:1158–1167.
94. Nield MA, Soo Hoo GW, Roper JM, et al.. Efficacy of pursed-lips breathing: a breathing pattern retaining strategy for dyspnea reducation. J Cardiopulm Rehab Prev. 2007;27:237–244.
95. Prisco MK, Jecmen MC, Bloeser KJ, et al.. Group auricular acupuncture for PTSD related-insomnia in veterans. Medical Acupuncture. 2013;25:407–422.
96. Sullivan DH, Wall PT, Bariola JP, et al.. Progressive resistance muscle strength training of hosptilized frail elderly. Am J Phys Med Rehab. 2001;80:503–507.
97. Tok F, Aydemir K, Peker F, et al.. The effects of electrical stimulation combined with continuous passive motion versus isometric exercise on symptoms, functional capacity, quality of life and balance in knee osteoarthritis: randomized clinical trial. Rheum Int. 2011;31:177–181.
98. Wardell DW, Rintala DH, Duan Z, et al.. A pilot study of healing touch and progressive relaxation for chronic neuropathy. J Holist Nurs. 2006;24:231–240.
99. Abramowitz EG, Barak Y, Ben-Avi I, et al.. Hypnotherapy in the treatment of chronic combat-related PTSD patients suffering from insomnia: a randomized, Zolpidem-controlled clinical trial. J Clin Exp Hypnosis. 2008;56:270–280.
100. Bormann JE, Gifford AL, Shively M, et al.. Effects of spiritual mantram repetition on HIV outcomes: a randomized controlled trial. J Behav Med. 2006;29:359–376.
101. Cruser dA, Maurer D, Hensel K, et al.. A randomized, controlled trial of osteopathic manipulative treatment for acute low back pain in active duty military personnel. J Man Manipul Ther. 2012;20:5–15.
102. Fann AV, Spencer HJ, Hammaker AF, et al.. The impact of structural therapy on functioning and pain in chronic pain patients: a pilot study. J Back Musculoskelet Rehab. 2007;20:1–9.
103. Gagne D, Toye RC. The effects of therapeutic touch and relaxation therapy in reducing anxiety. Arch Psychiatr Nurs. 1994;8:184–189.
104. Harb GC, Cook J, Gehrman P, et al.. Post-traumatic stress disorder nightmares and sleep disturbances in Iraq War veterans: a feasible and promising treatment combination. J Agress Maltreat Trauma. 2009;8:516–531.
105. Koppenhaver SL, Fritz JM, Hebert JJ, et al.. Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. J Orthopaedic Sport Phys Ther. 2011;41:389–399.
106. Lathia AT, Jung SM, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med. 2009;15:613–618.
107. McPherson F, McGraw L. Treating generalized anxiety disorder using complementary and alternative medicine. Altern Ther Health Med. 2013;19:45–50.
108. Richards KC. Effect of a back massage and relaxation intervention on sleep in critically ill patients. Am J Crit Care. 1998;7:288–299.
109. Salim M. Role of acupuncture in post-operative pain. Alt Ther Clin Pract. 1996;3:75–79.
110. Weiner DK, Moore CG, Morone NE, et al.. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clin Ther. 2013;35:1704–1720.
111. Horowitz M, Wilner M, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom Med. 1979;41:209–218.
112. Blake DD, Weathers FW, Nagy LM, et al.. The Clinician-Administered PTSD Scale—IV. 1990.Boston: National Center for PTSD-Behavioral Science Division.
113. Weathers FW, Huska JA, Keane TM. The PTSD Checklist-military version (PCL-M). 1991.Boston, MA: National Center for PTSD.
114. Beck AT, Steer RA, Garbin MGJ. Psychometric properties of the Beck Depression Inventory. Twenty-five years of evaluation. Clin Psychol Rev. 1988;8:77–100.
115. Beck AT, Epstein N, Brown G, et al.. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893–897.
116. Morin CM. Insomnia: Psychological Assessment and Management. 1993.New York: Guilford Press.
117. Buyse DJ, Reynolds CF, Monk TH, et al.. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213.
118. Rosen CS, Henson BR, Finney JW, et al.. Consistency of self-administered and interview-based Addiction Severity Index composite scores. Addiction. 2000;95:419–425.
119. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30:473–483.
120. Derogatis LR, Savitz KLMaruish ME. The SCL-90-R and the Brief Symptom Inventory (BSI) in primary care. Handbook of Psychological Assessment in Primary Care Settings, Volume 236. 2000.Mahwah, NJ: Lawrence Erlbaum Associates;297–334.
121. Ellison R, Paloutzian C. Manual for the Spiritual Well-Being Scale. 1991.Nyack, NY: Life Advance Inc..
122. Baer RA, Smith GT, Hopkins J, et al.. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13:27–45.
123. Foa E, Hembree E, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide. 2007.New York, NY: Oxford University Press.
124. Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748–756.
125. Fava GA, Rafanelli C, Grandi S, et al.. Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings. Arch Gen Psychiatry. 1998;55:816–820.
126. Curran GM, Bauer M, Mittman B, et al.. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50:217–226.
127. Patsopoulus NA. A pragmatic view on pragmatic trials. Dialogues Clin Neurosci. 2011;13:217–224.
128. Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Pub Health. 2003;93:1261–1267.