A systematic scoping review of complementary and alternative medicine mind and body practices to improve the health of veterans and military personnel

Abstract: 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. 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. 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. 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, depression and anxiety, sleep disorders, and cancer. 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. A 2011 national survey of Department of Veterans Affairs (VA) medical facilities found that CAM was available in 125 (89%) facilities, which is more than twice the percentage of American Hospital Association hospitals reporting CAM availability. 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%). 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. 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. 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. 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.