A Scoping Review on the Efficacy/Effectiveness and Utilization of Complementary and Integrative Health for Pain in the Military Health System

Abstract

Introduction:

This scoping review evaluated the efficacy/effectiveness and utilization of complementary and integrative health (CIH) therapies for pain management within the Military Health System (MHS). Specifically, it aimed to assess evidence-based modalities such as acupuncture, biofeedback, hypnosis, massage therapy, meditation, guided imagery, Tai Chi/Qi Gong, and yoga, which are part of the Veterans Administration’s (VA) Whole Health program. The goal was to determine their effectiveness in military service members and understand their utilization in the MHS, as well as explore CIH research in the MHS to identify gaps.

Methods:

A comprehensive search of PubMed, Embase, and Ovid All EBM Reviews databases was conducted for studies published from January 1, 2014 to March 22, 2024. The search focused on CIH therapies related to pain management in military populations, yielding 433 studies. After screening for eligibility, 53 studies were included for detailed review. Studies included randomized controlled trials, case studies, large database analyses, and retrospective chart reviews. Exclusion criteria eliminated nonpeer-reviewed articles, not pain-related, not related to one of the prespecified CIH modalities (acupuncture, biofeedback, hypnosis, massage therapy, meditation, guided imagery, Tai Chi/Qi Gong, and yoga), and those not specific to the MHS. The review did not address bias due to the heterogeneity of study designs included.

Results:

The review identified significant evidence supporting the use of CIH modalities for pain management. Acupuncture, particularly Battlefield Acupuncture, showed immediate reduction in pain score for both acute and chronic pain. Studies of massage therapy and biofeedback demonstrated efficacy/effectiveness in reducing pain and improving functional outcomes in various musculoskeletal and stress-related disorders. Meditation and yoga were shown to be effective for chronic pain, stress management, and enhancing overall well-being. Utilization data indicated a steady increase in CIH therapy use across military facilities.

Discussion:

CIH therapies, particularly acupuncture, massage therapy, and yoga, appear to be effective nonpharmacologic interventions for pain management in military populations. Their growing utilization reflects the recognition of their benefits in managing chronic pain and improving quality of life among service members. Further research is needed to standardize practices and optimize utilization across the MHS.

Registration of Protocol:

PROSPERO 2024 CRD4202453685, 29 April 2024, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024536853.

Introduction

Acute and chronic pain are endemic in military service members and are a treatment priority within military medicine. Pain has substantial economic, operational, and personal impact within the Department of Defense (DoD).^1
–3 In the DoD Military Health System (MHS), rates of chronic pain (pain lasting at least 3 months) diagnoses quadrupled from 2007 to 2014.⁴ Almost half (44%) of nontreatment seeking, active-duty, postcombat deployed service members report chronic pain.⁵ Compared with their civilian counterparts, pain prevalence is higher in active-duty service members and veterans, and frequently follows combat deployments.^6,7 Musculoskeletal pain incidence is steadily increasing among Operations Enduring Freedom, Iraqi Freedom, and New Dawn veterans.⁸ Pain-related conditions are economically costly and fuel military attrition in times of conflict eroding the fighting force.² Ensuring access to effective nonpharmacological treatments across the MHS could reduce the impact of acute and chronic pain and improve quality of life among service members and veterans. Examining the use of these therapies is critical to identifying gaps in access, as well as informing strategies to expand their availability to the active-duty population.

Complementary and integrative health (CIH) treatment modalities have been recognized as effective pain treatment options and have been implemented as part of the Veterans Health Administration’s (VHA) Whole Health System of care included in Department of VA Directive 1137—Provision of Complementary and Integrative Health (recertified December 2022).⁹ CIH modalities in the VHA include acupuncture, biofeedback, hypnosis, massage therapy, meditation, guided imagery, Tai Chi/Qi Gong, and yoga. The VHA conducted a review of these approaches and determined them to be safe and supported as evidence-based care.⁹ We used the Veterans Administration’s established list of medical CIH therapies to define the scope of our review because it provides a comprehensive and evidence-based framework that has been rigorously evaluated and implemented in a comparable health care system.

While CIH therapies have been extensively studied and implemented in the VHA, differences in population demographics and operational environments between the VHA and MHS warrant focused investigation. For example, the MHS primarily serves actively deployed service members and younger individuals facing combat-related injuries and operational stressors, whereas the VHA largely supports older veterans. These distinctions may result in varying utilization patterns and effectiveness of CIH therapies. Differences in population characteristics, care delivery models, and operational demands necessitate further research to understand CIH implementation in the MHS context.

While the evidence base on the efficacy/effectiveness of CIH therapies for pain is growing, utilization of these modalities in the MHS is less clear. Acupuncture has been explored in military settings as a nonpharmacological approach to pain management, with protocols such as battlefield acupuncture developed for quick deployment in field conditions.¹⁰ Likewise, biofeedback and hypnosis were integrated selectively within military mental health programs for stress and pain management, particularly for managing post-traumatic stress disorder and combat-related chronic pain.^11,12 Emerging research and policy changes have encouraged broader integration, supporting these modalities as viable components of holistic care for active-duty personnel and veterans.^12,13 Despite these developments, a lack of standardized training and credentialing across facilities has often limited consistent application.¹⁴

The goal of this scoping review is to describe CIH efficacy/effectiveness and utilization in the MHS within a framework of evidence-based practices incorporated in the VA’s Whole Health program¹⁵ addressing the following questions: 1) What is the state of the science for each one of these modalities for pain management for military service members; and 2) What is the state of utilization of these modalities in the MHS and what are the gaps?

Materials and Methods

This scoping review examined the efficacy/effectiveness and use of acupuncture, biofeedback, hypnosis, massage therapy, meditation, guided imagery, Tai Chi/Qi Gong, and yoga within the MHS. The review focuses on studies conducted and published between 2014–2024. We used the VA’s list of CIH therapies to define the scope of our review, as it offers a validated, evidence-based framework relevant to comparable health care systems. The research was conducted in accordance with Institutional Review Board requirements under a protocol deemed exempt from full review.

The review was registered with Prospero. The search, title and abstract screening, full-text review, and data extraction steps were performed using Covidence (https://app.covidence.org). We did not include the funding source PRISMA¹⁶ field.

Search strategy

A research librarian performed the literature searches using PubMed, Embase, and Ovid All EBM Reviews (Cochrane) databases. The search strategies are specified below for each database. A combination of subject headings and keywords were utilized to fully represent the concepts of pain, CIH therapies, and various military terms.

The following filters were used for each database search: English language; Date Range: 2014–present; and Document types: journal articles. All searches were performed on March 22, 2024. The specific search terms used for each database were as follows:

PubMed

(“Acupuncture”[mh] OR “Acupuncture Therapy”[mh] OR “Biofeedback, Psychology”[mh] OR “Complementary Therapies”[Mesh] OR “Hypnosis”[mh] OR “Massage”[mh] OR “Meditation”[mh] OR “Qigong”[mh] OR “Tai Ji”[mh] OR “Yoga”[mh] OR alternative-medicine[tiab] OR biofeedback[tiab] OR complementary-medicine[tiab] OR complementary-therap*[tiab] OR integrative-health[tiab] OR massage*[tiab] OR acupuncture[tiab] OR yoga[tiab] OR meditation[tiab] OR hypnosis[tiab] OR guided-imagery[tiab] OR tai-chi[tiab] OR tai-ji[tiab] OR qi-gong[tiab] OR qigong[tiab]) AND (“Pain”[mh] OR “Pain Management”[mh] OR pain[tiab]) AND (“Military Personnel”[mh] OR active-duty[tiab] OR air-force[tiab] OR airmen* [tiab] OR armed-forces[tiab] OR armed-services[tiab] OR army[tiab] OR guardian*[tiab] OR marine-corps*[tiab] OR marines[tiab] OR military[tiab] OR navy[tiab] OR sailor*[tiab] OR servicemember*[tiab] OR service-member*[tiab] OR soldier*[tiab] OR space-force*[tiab]) AND english[lang] AND (2014:3000/12/12[pdat]).

Embase

(“acupuncture”/exp OR “biofeedback”/exp OR ‘alternative medicine’/exp OR ‘hypnosis’/de OR “massage”/exp OR “meditation”/exp OR “Tai Chi”/syn OR (alternative-medicine OR biofeedback OR complementary-medicine OR complementary-therap* OR integrative-health OR massage* OR acupuncture OR yoga OR meditation OR hypnosis OR guided-imagery OR tai-chi OR tai-ji OR qi-gong OR qigong):ab,ti,kw) AND (“pain”/exp OR pain:ab,ti,kw) AND (“military phenomena”/exp OR (active-duty OR air-force OR airmen* OR armed-forces OR armed-services OR army OR guardian* OR marine-corps* OR marines OR military OR navy OR sailor* OR servicemember* OR service-member* OR soldier* OR space-force*):ab,ti,kw) AND [english]/lim AND [2014–2024]/py AND ([article]/lim OR [article in press]/lim OR [review]/lim).

Ovid All EBM Reviews (Cochrane)

(alternative-medicine OR biofeedback OR complementary-medicine OR complementary-therap* OR integrative-health OR massage* OR acupuncture OR yoga OR meditation OR hypnosis OR guided-imagery OR tai-chi OR tai-ji OR qi-gong OR qigong).ab,ti. AND pain.ab,ti. AND (active-duty OR air-force OR airmen* OR armed-forces OR armed-services OR army OR guardian* OR marine-corps* OR marines OR military OR navy OR sailor* OR servicemember* OR service-member* OR soldier* OR space-force*).ab,ti. AND english.lg.

1. limit 1 to yr=“2014–2024”

Inclusion/exclusion criteria

English language studies from any country with all types of study designs were included in the search. Articles from nonpeer-reviewed sources, abstracts from conference proceedings, and other non-scholarly sources were excluded. Articles were considered for final inclusion if they described or studied acupuncture, biofeedback, hypnosis, massage therapy, meditation, guided imagery, Tai Chi/Qi Gong, and yoga for pain management within the U.S. MHS. Although battlefield acupuncture is a specific auricular protocol, it was included under the umbrella of acupuncture for the purpose of this review. Forms of manual therapy were included in the reported studies of massage therapy as they met the initial search criteria, although the focus of this review was to include massage therapy as a distinct treatment modality.

Methods of review

All authors except one who performed the search, participated in abstract and title screening, full-text screening, and data extraction performed in Covidence and were blinded to other reviewers’ decisions. Duplicate studies were removed by Covidence and manually prior to screening. For abstract and title screening, each abstract was reviewed by two reviewers; disagreements were resolved by a third reviewer. Articles determined to meet inclusion criteria from preliminary abstract review were then reviewed by two independent reviewers based on the article full text; reviewers were required to agree on the reason for exclusion for any full-text article excluded. Discrepancies among reviewers were resolved by a third (blinded) reviewer.

Data extraction for articles selected as meeting inclusion criteria based on full-text review was performed by one of the authors for the following elements: General Information: study title, lead author, and publication year; Methodology: study aim, study focus (efficacy/effectiveness, utilization, other), study design, intervention/CIH modality, intervention details and comparator, outcome(s) (pain, post-traumatic stress disorder, traumatic brain injury, other), and outcome measurement frequency; Participants: population description, number of participants, and setting; and Findings and Conclusions. Final data extraction information in Covidence was exported as .csv files and saved as Excel files. Following data extraction, all studies were grouped based on Efficacy/Effectiveness, Utilization, or Other. Within these groups, studies were stratified by CIH modality. Results of the Data Extraction are presented by CIH modality by Efficacy/Effectiveness, Utilization, or Other study focus. Quality scoring was not performed as the articles reviewed were not homogenous and it was not the objective of the review.

Results

Search and screening

The number of studies resulting from each database search, abstract/title screening, and full-text screening are presented in the PRISMA¹⁶ flow chart in Figure 1 and detailed below.

FIG. 1.

Study identification and screening.

Search results

The total number of studies resulting from the databases search was n = 433 (Embase, n = 168; PubMed, n = 160; Ovid/Cochrane, n = 105). Of these studies, 153 references were removed; 145 by Covidence; 8 manually.

Abstract and full-text screening

A total of 280 study abstracts were screened and 180 were excluded, leaving 100 for full-text review. Forty-seven were then excluded for the following reasons: editorial (n = 2), wrong setting (n = 2), wrong outcomes (n = 4), wrong intervention (n = 10), wrong study design (n = 3), conference abstract (n = 4), wrong patient population (n = 11), or clinical trial registration (n = 12). The total number of studies included in the review was n = 53. Average inter-rater reliability for abstract and full-text screening were 0.71 (range 0.52–0.85) and 0.73 (range 0.66–0.81) respectively, demonstrating substantial agreement among reviewers. No results were found for Qi Gong, Tai Chi, and hypnosis.

Data extraction

Results of the data extraction by CIH modality within Efficacy/Effectiveness or Utilization study focus are summarized in Tables 1–2 and reported below.

Table 1.

Efficacy/Effectiveness Studies (n = 36) of (a) Acupuncture, (b) Biofeedback, (c) Guided Meditation, (d) Massage Therapy, (e) Yoga, and (f) General Complementary and Integrative Health/Multiple Modalities^a

Title	Author	Year	Aim	Design	N	Intervention(s)/ comparator	Outcome(s)	Findings and conclusions
a. Acupuncture (n = 15)
Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder¹⁷	Engel et al.	2014	To evaluate the use of a brief course of manual acupuncture for military-related post-traumatic stress disorder (PTSD).	Randomized controlled trial (RCT)	55, active-duty at a military medical clinic	Acupuncture bi-weekly, 60-min sessions for 4 weeks (8 total sessions). Comparator was usual care (guided by existing standards outlined in the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress.	Pain baseline and follow-up; PTSD at baseline, 4, 8, and 12 weeks.	Individuals receiving acupuncture with usual care showed greater improvements in PTSD, depression, and pain severity than those receiving usual care alone. Acupuncture may offer a unique addition to current PTSD treatment that addresses PTSD, pain, depression, loss of function, and health-related quality of life.
Ear Acupuncture for Acute Sore Throat: A Randomized Controlled Trial¹⁸	Moss and Crawford	2015	To evaluate the efficacy of battlefield acupuncture (BFA) in relieving pain from acute sore throat	RCT	56, DOD beneficiaries at an MTF	BFA one time with standard of care vs. standard of care	Pain scores before treatment, 15-min later and after discharge at 6, 24, and 48 h.	Pain scores in the BFA group were significantly lower compared with standard of care only at 15 min, 6 h, and 24 h. Compared with usual treatment, BFA seems to reduce pain and decrease medication use for acute sore throat and may be a valuable treatment option for sore throat pain.
Acupuncture for the Treatment of Sports Injuries in an Austere Environment¹⁹	Bell and Falconi	2016	To review the military’s use of acupuncture to treat injuries (lower back pain, osteoarthritis, traumatic brain injury [TBI]) in a deployed setting and translate to care of sports injuries in an austere environment.	Literature review	Studies on active U.S. military members	Acupuncture	Pain; TBI	There is low to moderate quality evidence that acupuncture is effective for treatment of lower back pain and knee osteoarthritis and weak evidence for acupuncture efficacy for TBI symptoms. Military research demonstrates favorable results on acupuncture use in austere settings to treat acute and chronic pain; acupuncture can be rapidly performed with few side effects.
Physical Therapy Treatment of Chronic Neck Pain²⁰	Guthrie et al.	2016	To report the effects of a PT plan including needling techniques for a patient poorly responsive to previous interventions for neck pain.	Case study	1, active-duty at outpatient military PT clinic	6 weeks of BFA and 8 weeks of dry needling	Pain assessed weekly for 8 weeks	The patient reported a reduction of neck pain from 9/10 to 0–2/10 within five treatment sessions (1 month). BFA and dry needling may serve as an effective intervention for chronic spinal conditions.
A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury²¹	Jonas et al.	2016	To compare Traditional Chinese acupuncture (TCA) to auricular acupuncture (AA) and usual care for TBI-associated headaches and co-morbid symptoms of trauma.	RCT	43, active-duty service members with mild-to-moderate TBI at 3 military medical centers	Acupuncture	Pain, TBI at baseline, each visit, and 6 weeks post-treatment	Headache impact scores significantly decreased from baseline to week 6 in the AA group compared with UC and pain for both TCA and AA group decreased; within-subject differences were not significant. This study supports the use of acupuncture as a part of standard care for treatment of TBI.
Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population²²	Crawford et al.	2017	To assess clinical outcomes among adult patients who received acupuncture treatments at a U.S. Air Force medical center	Retrospective chart review/cohort analysis	172, adult patients who received acupuncture at a U.S. Air Force medical center.	Acupuncture, at least 4 acupuncture treatments (variety of medical acupuncture protocols) within 1 year by their primary care physicians.	Prescriptions for opioids, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (DSAIDS) and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life, 60 days pre- and post- the first acupuncture session and 1 year later.	The number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being. Acupuncture may be associated with clinically significant reductions in medication use and improvements in clinical outcomes.
Successful Treatment of Achilles Tendinopathy with Electroacupuncture: Two Cases²⁵	Hawks	2017	To describe a new technique of acupuncture for the treatment of Achilles tendinopathy and provide 2 illustrative cases.	Case study	1, deployed active-duty military at a MTF	Acupuncture. First patient: 3 sessions over 9 days Second patient: 2 sessions	Pain, functionality	Patient 1 had a pain reduction of 10/10 to 3/10 after the 3 sessions and increased functionality. Patient 2 had a pain reduction from 4/10 to 0/10. This novel technique could be an effective adjunct to traditional therapies in the treatment of Achilles tendinopathy.
Acupuncture for the Treatment of Chronic Pain in the Military Population Factors Associated With Treatment Outcomes⁵⁷	Plunkett et al.	2017	To determine which (if any) characteristics from electronic medical record review from military treatment facilities can predict successful responses to acupuncture.	Database analyses	222, patient data from electronic records of patients who received acupuncture for pain at two selected military treatment facilities	Acupuncture, initial and 12 weeks following initial treatment	Pain, treatment success: 2-point or greater reduction on the numerical rating scale or visual analog scale 12 weeks post-initial treatment	94 (42.3%) who experienced a successful treatment outcome and 128 (57.7%) with an unsuccessful treatment result. Treatment success was strongly correlated with post-treatment pain score and the use of stimulation needles. The combination of baseline pain, number of psychological comorbidities, and use of stimulation needles correctly classified 61% of cases. These factors should be considered when determining which patients to initiate treatment for, and in the design of future randomized trials.
Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial²³	Garner et al.	2018	To assess the feasibility (recruitment, enrollment, randomization, and retention) in patients with chronic pain and insomnia and credibility of auricular acupuncture treatment and to evaluate the effectiveness of auricular acupuncture on pain and insomnia severity compared to usual care.	RCT	45 (n = 22 auricular acupuncture), Military beneficiaries (active-duty, retirees, or family members), U.S. military regional medical treatment facility in Germany	Auricular acupuncture (BFA) for up to 4 days or usual care control group (maintained current level of care).	Pain; insomnia; Brief Pain Inventory and Insomnia Severity Index measured on Days 1, 4, and 8. Feasibility assessed by # of participants recruited and retained in study.	Significant within- and between-group reduction in pain severity and interference scores compared to usual care. Auricular acupuncture reduced pain and insomnia compared to usual care. Retention of participants and credibility of treatment was high.
Modified Battlefield Acupuncture Does Not Reduce Pain or Improve Quality of Life in Patients with Lower Extremity Surgery²⁴	Crawford et al.	2019	To determine if modified BFA (mBFA) plus standard therapy vs. sham acupuncture plus standard of care vs. standard therapy alone causes pain relief, reduces medication use and improves functioning after lower extremity surgery at two Air Force Medical Centers.	RCT	233 (92 females); 81 randomized to Mbfa at two Air Force Medical Centers	Modified Battlefield Acupuncture vs. sham acupuncture applied 30-minutes post-surgery.	Pain; Return to work, pain medication usage, date and hours post-surgery walking without assistance; prior to surgery, at 24 h, 48 h, 1 week, and 1 month post-intervention. Medical records were also reviewed.	This multi-site RCT evaluating mBFA for lower extremity surgery did not show effects for the primary outcomes. Post hoc analyses showed that surgery severity and opioid use likely obscured any effects of acupuncture. Severe Injuries, when treated with mBFA, are still painful and require other pain control modalities.
Frequency-Specific Microcurrent as Adjunctive Therapy for Three Wounded Warriors⁶¹	Sharp et al.	2019	To present 3 cases in which frequency-specific microcurrent was applied concurrently with acupuncture and associated symptom changes.	Case study	3, wounded warriors at military medical center	Frequency-specific microcurrent with acupuncture	Pain; memory problems, mental sluggishness, post-traumatic stress disorder at varying intervals of patient care	Frequency-specific microcurrent was found to be a safe, nonpainful, noninvasive treatment that could be administered concurrently and beneficially with acupuncture. There is an added treatment benefit of symptom reduction following the combination of frequency-specific microcurrent and acupuncture treatment for wounded warriors, to address their pain, PTSD, and other associated conditions. Further research is warranted.
Successful Treatment of Medial Tibial Stress Syndrome with Interosseous Membrane Acupuncture: A Case Series²⁶	Riegleman et al.	2021	To describe an acupuncture technique for the treatment of medial tibial stress syndrome, also known as shin splints.	Case study	2, 1 active-duty patient, 1 unknown duty status patient at a MTF	One, 5 min interosseous membrane acupuncture session	Pain, functionality: Case 1: baseline, immediate post-treatment, 6 months post-treatment Case 2: baseline, immediate post-treatment, 4 weeks post-treatment	Both patients had clinically significant reductions in pain immediately post-treatment and at their follow up appointments, endorsed sustained reduced pain and improvements in functionality. This technique shows promise in becoming the solitary effective intervention in addition to conservative management in the treatment of MTSS.
Battlefield acupuncture appears to be an effective therapy for pain management²⁷	Kim et al.	2022	To evaluate the effectiveness of BFA for pain in a military outpatient clinic.	Prospective observational	69, military beneficiaries eligible for care at an Air Force base	Acupuncture; one session of BFA vs. usual pain care.	Pain; Numerical rating scale of pain at 24 and 48 h following BFA.	The BFA intervention group showed a clinically meaningful decrease in pain immediately following, 24 h after, and 48 h after. BFA may be an effective nonpharmacologic adjunct to pain management with immediate and significant pain relief for patients.
Acupuncture for Plantar Fasciopathy: A Randomized Controlled Trial²⁸	Cagle et al.	2023	To determine if acupuncture plus home exercise reduces pain and improves functioning more than home exercise alone.	RCT	94, DOD beneficiaries at Air Force MTFs	Acupuncture (every 2 weeks for 4 total)/ home exercise program	Pain; foot function at baseline, each visit, and 6 weeks post-treatment	Acupuncture treatment with home exercise reduced pain significantly (by >50%) in patients with plantar fasciopathy throughout the weeks of treatment and at 12 weeks (by 37%) post-treatment follow-up compared with exercise alone.
Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial²⁹	Hawks et al,	2023	To compare the effectiveness of electro-acupuncture plus home prescribed home exercise to exercise alone.	RCT	59, military hospital	Daily home exercise program performed 3 times per day for 12 weeks with or without electroacupuncture at 0, 2, 4, 6, and 12 weeks (5 sessions).	Pre-and post-exercise pain at 0, 2, 4, 6, and 12 weeks; change in functionality	No significant differences between groups; both groups showed improvement in functionality and pain. Electroacupuncture (EA), as an adjunct to home eccentric-exercise therapy, improved short-term pain control of insertional Achilles tendinopathy and may indicate a role for EA treatment.
b. Biofeedback (n = 3)
Lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa³⁰	Baker et al.	2018	1) To reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post-traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine.	case control	25, active-duty, dependents	Biofeedback; Guided Imagery/ Meditation/ Mindfulness; Other: cognitive-behavior therapy. Establishment of neurology subspecialty care, educational pamphlets, didactics	Polypharmacy, improvement in migraines, decrease in appointment frequency over 2 years with a retrospective review.	36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared with the 2 years prior to intervention. 24% had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year. A combined multidisciplinary approach to treatment is likely to be most efficacious in the treatment of chronic post-traumatic headache and post-traumatic headache, especially in the military population given known lifestyle stressors and risk of TBI.
A randomized trial comparing the Tennant Biomodulator to transcutaneous electrical nerve stimulation and traditional Chinese acupuncture for the treatment of chronic pain in military service members³¹	Peacock et al.	2019	To compare the efficacy of the Tennant Biomodulator used on its most basic setting against traditional Chinese acupuncture, and acupuncture-like TENS for the reduction of chronic pain and associated functional disability.	RCT	100, military service members and military Veterans, Army Medical Center Pain Clinic	Biofeedback, biomodulator, Baseline, after 6 weeks of active treatment (weekly Traditional Chinese Acupuncture, Biomodulator, TENS) and 1-month follow-up	Pain, functional disability	All three interventions produced significant reductions in chronic pain and functional disability with 6 weeks.
Semi-Automated Neurofeedback Therapy for Persistent Postconcussive Symptoms in a Military Clinical Setting: A Feasibility Study⁵⁸	Hershaw et al.	2020	To assess the feasibility of live Z-score training (LZT), a variant of neurofeedback, to treat persistent postconcussive symptoms in a military clinical setting.	Single-group, pre–post intervention design	38, military outpatient care	Biofeedback, Live Z-score training (LZT) over maximum 6 weeks for at least 5 session; 10–30 min.	Self-reported survey symptoms, baseline (T1), post treatment (T2), follow up (T3)	Overall, participants reported positive (>2.0) perceptions of the treatment and attributed improvements in memory (57.6% of respondents) and concentration/attention (81.8% of respondents). LZT is a clinically practical treatment that shows promise for improving postconcussive symptoms, was easily administered, and could be readily implemented in military clinical settings.
c. Guided Meditation (n = 4)
Mind Body Medicine in the Care of a U.S. Marine With Chronic Pain: A Case Report³²	Millegan et al.	2014	To follow one Marine’s use of a self-care-based MBM program from entry into the program through 7 months of follow up.	Case study	1, active-duty Marine in military center outpatient care	Guided imagery/ meditation/ mindfulness: 2-h group sessions weekly for 6 consecutive weeks	Pain, Pittsburg Sleep Quality Index, Sheehan Disability Scale, PHQ8, GAD7, WHO Quality of Life preintervention, postintervention, 4-month follow up, 7-month follow up	The patient had mild improvements in most measured categories at the end of the 6-week program and marked improvements at 4 months, maintained 7 months. This study highlights the potential of a MBM program to change a patient’s relationship with chronic pain and for the specific use of a self-care model to deliver MBM to chronic pain patients.
The Emerging Role of Mindfulness Meditation as Effective Self-Management Strategy, Part 2: Clinical Implications for Chronic Pain, Substance Misuse, and Insomnia³³	Khusid et al	2016	Evaluates the efficacy, mechanism, and safety of mindfulness meditation for chronic pain, substance use disorder, tobacco use disorder, and insomnia frequently co-occurring after return from deployment	Systematic review	72 studies, active-duty, veterans, and civilian	Mind-body interventions (MBIs; mindfulness-based stress reduction, mindfulness-oriented recovery enhancement)	Pain, pain intensity, functional status, pain-related psychological consequences, quality of life, cravings and opioid use	MBIs effectively and durably reduce pain intensity, improve functional status, pain-related psychological consequences, quality of life, and help individuals feel more in control and acceptant of chronic pain. MBIs show promising initial results on reduction of cravings and use opioid analgesic, but further research is needed. MBIs are effective in management of chronic pain, improving functional status, and psychological implications of pain. Mindfulness meditation is best utilized as a self-management approach in addition to standard care.
Effectiveness of a Self-Care Toolkit for Surgical Breast Cancer Patients in a Military Treatment Facility³⁴	Stoerkel et al.	2018	To assess whether a self-care toolkit (SCT) provided to breast cancer patients undergoing surgery could mitigate distress and lessen symptoms associated with surgery.	RCT	100, breast cancer surgery patients at 2 Army Medical Centers	Hypnosis; guided imagery/ meditation/ mindfulness; acupressure bands. Self-care kit (an MP3 player with audio-files of guided mind-body techniques) and acupressure anti-nausea wristband compared with treatment as usual.	Pain; anxiety, nausea, sleep, fatigue, global health, and quality of life and inflammatory blood markers at Baseline (T1), immediately before surgery (T2), within 10 h postoperatively (T3), and 2 weeks post-surgery (T4)	There were significant between-group differences in Pain Interference, Fatigue, and Satisfaction with Social Roles from T1 to T4, favoring the self-care toolkit group compared with Treatment as usual and a significant mean change in Defense and Veterans Pain Rating Scale (DVPRS) scores from T2 to T3, with the self-care group having significantly smaller increases in postoperative pain and in postoperative ESR compared with the control group. Using the self-care toolkit in the perioperative period decreased pain perceptions, fatigue, and inflammatory cytokine secretion.
Complementary Approaches for Military Women with Chronic Pelvic Pain (CPP): A Randomized Trial³⁵	Crisp et al.	2023	To determine the effectiveness of noninvasive, self-explanatory mindfulness-based stress reduction (MBSR) or self-paced healthy lifestyle (HL) interventions on CPP in AD women.	Randomized trial, no control group	25, active-duty women aged 21–55-from AF MTF	Guided imagery/ meditation/ mindfulness; other: nutritionist;	Pain; other: depression, circulating cytokine levels; at baseline before beginning either intervention and 6 weeks postintervention	MBSR improved pain and related depression symptoms. Findings support MBSR as an effective and viable behavioral treatment for active-duty women suffering from CPP and provide premise for larger randomized controlled studies.
d. Massage Therapy (n = 2)
Pilot study of the effects of mixed light touch manual therapies on active-duty soldiers with chronic post-traumatic stress disorder and injury to the head³⁶	Davis et al.	2015	Designed to examine the effects of mixed Light Touch Manual Therapies (LTMT) on headache, anxiety and other symptoms suffered by active-duty servicemembers experiencing chronic PTSD.	Cohort (changes to symptoms before and after treatment, no control)	10, active-duty outpatient care at military treatment center	Massage therapy: 2 sessions 1 week apart prior to an intensive outpatient program	Pain interference, anxiety, headache, severity of other PTSD symptoms, before and after each LTMT session and 4–7 after last session	Both headache and anxiety were significantly reduced pre- to post-treatment. Pain Interference was significantly decreased several days after the second session. Massage is helpful in reducing pain interference, headache and anxiety in active-duty patients with chronic PTSD; massage may be a nonpharmacological intervention for these symptoms.
The Benefits of Reflexology for the Chronic Pain Patient in a Military Pain Clinic³⁷	Kern et al.	2018	To determine the feasibility of incorporating the use reflexology for U.S. Army soldiers with chronic pain within in an interdisciplinary pain clinic.	Prospective, nonrandomized, observational study	311, military medical center	Received 25 min of therapy using both feet in addition to their standard of care pain management therapies, which could include acupuncture, chiropractic care, massage, exercise therapy, physical therapy, interventional pain procedures, and prescription medications.	Pain (DVPRS)	Females reported a median pretreatment pain of 5; males reported a median pretreatment pain of 6. Post-treatment, males and females reported a decrease in pain. Reflexology, when used as part of a multidisciplinary treatment plan, has been shown to have high patient tolerability with pain reduction. Further studies are warranted.
e. Yoga (n = 4)
Relax While You Rehabilitate: A Pilot Study Integrating a Novel, Yoga-Based Mindfulness Group Intervention Into a Residential Military Brain Injury Rehabilitation Program³⁸	Combs et al.	2018	Assessed the effectiveness of a group-based, mindfulness intervention in a residential, rehabilitation setting with specific focus on assessing participants self-report of perceived benefit of the intervention on overall health, pain, sleep, mood/anxiety, attention, and self-awareness, as well as implementing modifications needed for successful intervention application among a diverse, clinical military population.	Pilot clinical trial	10 veterans, 9 AD at 5 residential VA rehab sites	Yoga: Weekly, 60-minute Mindfulness and yoga-based group intervention for up to 32 weeks.	Pain, Pittsburg Sleep Quality Index, Sheehan Disability Scale, PHQ8, GAD7, WHO Quality of Life pre-intervention, post-intervention, 4 month follow up, 7 month follow up	The patient had mild improvements in most measured categories at the end of the 6 week program and marked improvements at the 4 month time point. These were maintained at the 7 month follow up time point, however, these findings were confounded by the surgical implantation of a neurostimulator.
Benefits of the Restorative Exercise and Strength Training for Operational Resilience and Excellence Yoga Program for Chronic Low Back Pain in Service Members: A Pilot Randomized Controlled Trial³⁹	Highland et al.	2018	Examine the feasibility and preliminary effectiveness of an individualized yoga program.	RCT	68, Military Hospital	Two individual yoga sessions per week in weeks 1 to 4 and then once-weekly sessions in weeks 5 to 8 compared with control	Pain at baseline, week 4, week 8, 3-month, and 6-month follow-ups	Pilot results have direct implications for future clinical programming and research in the areas of yoga-based interventions for chronic pain in military members and veterans
Comparing Types of Yoga for Chronic Low Back and Neck Pain in Military Personnel: A Feasibility Randomized Controlled Trial⁴⁰	Groessl et al.	2022	To examine the feasibility and acceptability of delivering 2 types of yoga (hatha and restorative) to a sample of active-duty military personnel with chronic low back pain and chronic neck pain (cLBP/cNP).	RCT	49 (24 hatha, 25 restorative), active-duty military at a military outpatient center	Hatha or restorative yoga in-person yoga instruction 1–2 times weekly for 12 weeks with daily home practice recommended.	Pain and disability, rates of recruitment, intervention attendance, attrition, adverse events, and satisfaction ratings; at baseline, 12 weeks, and 6 months.	There were small to moderate reductions in back-pain related disability, pain severity, and pain interference, and improvements in quality of life, grip strength, and balance. Over 90% of participants agreed or strongly agreed that they enjoyed participation, liked the instructor, and would like to continue yoga. Retention rates were 86% and 80% at 12-week and 6-month assessments, respectively. Intervention attendance was adequate but lower than expected. In general, effects were larger for those who attended at least 50% of intervention classes. Participants with cNP tended to have smaller outcome improvements, but conclusions remain tentative given small sample sizes.
Impact of mindfulness training and yoga on injury and pain-related impairment: a group randomized trial in basic combat training⁴¹	Smith at al.	2023	To examine the impact of mindfulness training and yoga on the physical health of service members in an intense military training environment.	RCT	1584 assigned to platoons and randomized to two conditions (intervention, n = 813; no intervention, n = 813) during 10-week basic combat training	Guided Imagery/ meditation/ mindfulness; yoga; mindfulness was delivered via a 4-week, 8-h intervention developed for military personnel with weekly 2-h sessions the first 4 weeks of BCT; hatha yoga was taught every morning, 6 days a week for a total of 3 h per week.	Pain; health, sleep, mood, stress; week 1 (before mindfulness and yoga training), and weeks 4, 6, and 9 of basic training.	Intervention trainees reported significantly better health and less impact of pain on training, sleep, mood, and stress. Intervention trainees had fewer diagnoses and were 30% less likely to have a first medical encounter at any time during BCT. A combined MT and yoga intervention resulted in better trainee health. The US Army and other organizations requiring resilience under extreme stress should consider implementing MT and yoga to offset risks to employee health.
f. General Complementary and Integrative Health and Multiple Modalities (n = 8)
State of the science review: Advances in pain management in wounded service members over a decade at war⁴²	Clifford et al.	2014	To attempt for the first time to summarize many of the issues and the information collected in 12 years of conflict (2001–2014) surrounding the management of pain in this newly expanded population of injured service members.	Literature or Narrative Review	wounded service members	General CIH; Acupuncture; Massage Therapy; Guided Imagery/ Meditation/ Mindfulness; Yoga	Pain	The Pain Management Task Force of The Army Office of the Surgeon General published a report in May 2010 calling for an increased use of complementary and alternative medicine (CAM) as an adjunct therapy to pharmaceuticals to relieve pain. Current pain management research includes evaluating the efficacy of dual-mechanism therapeutics for polytrauma, targeting glia to reduce tolerance to opioid analgesics, peripheral opioid and nonopioid analgesia, advances in the application of regional anesthesia, a pharmacogenetics approach, and CAM approaches.
Integrative Medicine and the Trauma Spectrum Response⁴³	Jonas et al.	2015	This overview describes the interplay between these comorbidities as part of the war-related trauma spectrum response (wrTSR) as well as suggesting how complementary and integrative medicine (IM) approaches may be used to address many of the challenges involved in treating wrTSRs.	Literature or narrative review	DOD	General CIH	Pain	Complementary and IM modalities include tools that induce permanent healing in a whole person. Better and more holistic approaches are needed for healing the wrTSR. In addition, there needs to be greater emphasis on research and implementation of whole-person healing practices. Finally, it is necessary to recognize the importance of healing as much as curing.
Enhancing the success of functional restoration using complementary and integrative therapies: Protocol and challenges of a comparative effectiveness study in active-duty service members with chronic pain⁴⁴	Flynn et al.	2017	To evaluate the benefit of a multimodal complementary and integrative health (CIH) pain management program when added to standard rehabilitative care (SRC) prior to an intensive functional restoration (FR) program compared to SRC alone, and identify factors that predict improvement in pain impact following treatment completion.	Description of an upcoming study; comparative effectiveness study (randomized)	Active-duty Army	Acupuncture; Biofeedback; Massage Therapy; Yoga: Stage 1: 3 weeks of standard rehab care (SRC) vs. 3 weeks of SRC + CIH), then Stage 2: 3–6 weeks of intensive functional restoration	Pain; pain impact/PASTOR, Canadian Occupational Performance Measure (COPM), baseline, after stage 1, after stage 2, 3 month post, 6 month post	Challenges include technical issues, enrollment, and program delivery. Studying the effectiveness of pain treatments among the military population is critical to physical functioning and the quality of life of active-duty service members suffering from chronic pain. If the study’s findings support the effectiveness of CIH added to SRC prior to FR, it will lend support for expanding access to these therapies at other military sites, to other beneficiaries of the Military Health System such as retirees and family members of military personnel, as well as to civilian populations.
Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration⁴⁶	Meerwijk et al.	2020	To compare active-duty U.S. Army service members with chronic pain who did and did not receive nonpharmacological treatments (NPT) in the MHS and describe the association between receiving NPT in the MHS and adverse outcomes observed after transition to the VHA.	Database Analyses	275,820, active-duty Army service members with chronic pain after OEF/OIF/OND deployment ending between October 1, 2007, and September 30, 2014.	Receipt of any nonpharmacologic treatment in the MHS after deployment: Acupuncture; Biofeedback; Massage Therapy; Other: chiropractic, exercise therapy, cold laser therapy, osteopathic spinal manipulation, electrical stimulation	Health records between end of deployment and VHA enrollment.	Use of NPT in the MHS was inversely associated with adverse outcomes in the VHA: active-duty service members with chronic pain who received NPT in the MHS were at significantly lower risk in the VHA for new-onset alcohol and/or drug use disorder, poisoning with opioids, related narcotics, barbiturates, or sedatives, suicide ideation, and self-inflicted injuries including suicide attempts. NPT provided to active-duty service members with chronic pain may reduce their odds of long-term adverse outcomes. Providing NPT to service members with chronic pain could save lives.
Evaluation of a Functional Restoration Program at Fort Bliss Interdisciplinary Pain Management Clinic⁴⁷	Nguyen et al	2020	To report on first-year Functional Restoration program (FRP) results at an Army Medical Center	Nonrandomized clinical trial	32, Army outpatient	Acupuncture; guided imagery/ meditation/ mindfulness; yoga Structured FRP for 8 h a day over 3 weeks	Pain	Fear-avoidance of physical activities and the fear of movement scores were significantly reduced; the Canadian occupational performance and satisfaction, physical strength and endurance were significantly improved; consistent with other FRP program outcomes is other studies.
Complementary and Integrative Health Approaches to Manage Chronic Pain in US Military Populations: Results From a Systematic Review and Meta-Analysis, 1985–2019⁴⁸	Donahue et al.	2021	To examine the efficacy of complementary and integrative health (CIH) approaches for reducing pain intensity, depressive symptoms, and physical functioning among U.S. military personnel living with chronic pain.	Systematic Review and/ or Meta-Analysis	12 studies; Military personnel; active-duty and veterans	Acupuncture; biofeedback; guided imagery/ meditation/ mindfulness; yoga; other: cognitive behavioral therapy, positive psychology	Pain, pain intensity, Depression, physical functioning	Participants who received CIH interventions reported a greater reduction in pain intensity compared with controls. CIH approaches reduced pain intensity and improved physical functioning, offering a nonpharmacological intervention for chronic pain in military personnel.
Use of Complementary and Integrative Health Therapies Before Intensive Functional Restoration in Active-Duty Service Members with Chronic Pain⁴⁵	Flynn et al.	2022	This study aimed to 1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared with SRC alone, as a precursor to an intensive functional restoration (FR) program; 2) identify factors that predict improvement in pain outcomes after treatment; and 3) determine the proportion of participants who experience a clinically meaningful response.	RCT	210 total (104 in experimental arm and 106 in comparator); active-duty Army, reserve, national guard at a military treatment facility	Acupuncture; biofeedback; yoga; STAGE 1: intervention : 3.5 h/day, 2 days/week of CIH + standard rehabilitative care (SRC) vs. comparator: 2.5 h/day, 2 days/week of SRC; STAGE 2: 22 h/week × 3 weeks or 11 h/week × 6 weeks of a functional restoration program	Pain; NIH PIS (composite score of pain intensity, pain interference w/ usual activities, and functional status) PROMIS measures; Baseline, poststage 1, poststage 2	Participants randomized to CIH therapies reported greater improvement in PIS, initially supporting the hypothesis that adding CIH therapies to usual care would enhance treatment response. However, mean baseline PIS was the strongest confounder and associated factor with treatment response. Another important finding is that both treatment groups improved over time. Military service members with the highest baseline PIS values benefit the most from interdisciplinary pain care. Because of an imbalance in baseline PIS between the study treatment groups, despite randomization, we were unable to determine whether the study specific dose and combination of CIH therapies will enhance outcomes when added to SRC before an intensive FR program.
The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military⁴⁹	Eaton et al.	2022	To examine if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain.	RCT	210, active-duty service members	3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies: twice weekly acupuncture and chiropractic treatment, once-weekly yoga, and once-weekly myofascial release instruction by a massage therapist. Biofeed- back if indicated.	Pain, pre- and post-treatment using the Military Health System’s Pain Assessment Screening Tool and Outcomes Registry.	All psychological factors except for chronic pain acceptance were related to improved pain impact. The addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors. Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in psychological factors.

Efficacy/effectiveness (Table 1)

Thirty-six of the 53 articles included in the review (68%) assessed efficacy/effectiveness of CIH modalities; 15 for acupuncture, 3 for biofeedback, 3 for guided meditation, 2 for massage therapy, 4 for yoga, and 8 for general CIH/multi-modality. Hypnosis and Tai Chi/Qi Gong were not assessed for efficacy/effectiveness by the studies under review in our sample.

Acupuncture

The studies reviewed demonstrate diverse applications and effectiveness of acupuncture for pain management in the military context. Engel et al. (2014) found that active-duty military personnel with post-traumatic stress disorder experienced significant improvements in pain severity, symptoms, and depression with acupuncture compared with usual care.¹⁷ Moss and Crawford (2015) reported that battlefield acupuncture significantly reduced sore throat pain in DoD beneficiaries with effects sustained up to 24 h post-treatment.¹⁸ Bell and Falconi (2016) reported acupuncture showed low to moderate effectiveness in managing lower back pain and osteoarthritis in deployed environments, suggesting feasibility in austere settings.¹⁹ Guthrie et al. (2016) demonstrated that a combined battlefield acupuncture and dry needling intervention reduced chronic neck pain significantly.²⁰

Studies on traumatic brain injury and headache management (Jonas et al., 2016) and general pain reduction in military populations (Crawford et al., 2017) supported acupuncture’s role in reducing symptom severity and medication use.^21,22 Garner et al. (2018) confirmed that auricular acupuncture reduced pain and insomnia in military beneficiaries.²³ However, Crawford et al. (2019) observed that modified battlefield acupuncture did not yield significant benefits for pain management postsurgery.²⁴

Case studies by Hawks (2017) and Riegleman et al. (2021) highlighted successful pain reduction and functional improvement with battlefield acupuncture in patients with Achilles tendinopathy and medial tibial stress syndrome, respectively.^25,26 Kim et al. (2022) supported battlefield acupuncture’s effectiveness as an adjunct for immediate pain relief.²⁷ Recent randomized controlled trials found that acupuncture combined with home exercises significantly reduced pain in plantar fasciopathy.^28,29

Biofeedback

Studies on biofeedback interventions demonstrate promising outcomes for managing chronic pain and post-traumatic headache within military populations. Baker et al. (2018) investigated a multidisciplinary approach involving biofeedback, guided imagery, meditation, mindfulness, and cognitive behavior therapy to address medication-refractory post-traumatic headache among active-duty personnel and observed a 36% reduction in headache frequency, a 56% decrease in headache severity, improved quality of life for 60% of participants, polypharmacy rates declined by 24%, and annual appointment frequency for migraines decreased significantly.³⁰ A randomized controlled trial comparing biofeedback, traditional Chinese acupuncture, and transcutaneous electrical nerve stimulation for chronic pain relief in military service members showed that all three interventions resulted in significant reductions in chronic pain and functional disability over 6 weeks.³¹

Guided meditation

Studies on guided meditation and mindfulness-based interventions reveal potential for managing chronic pain and improving mental health among military populations. A case study on an active-duty Marine participating in a mindfulness-based meditation program, which included guided imagery and mindfulness sessions, demonstrated mild improvements in pain, sleep quality, and mental health postintervention, with more substantial improvements observed at 4- and 7-month follow-ups.³² Khusid et al. (2016) conducted a systematic review of 72 studies, encompassing active-duty, veteran, and civilian populations, to evaluate mindfulness-based interventions for chronic pain, substance misuse, and insomnia; their findings indicated that mindfulness-based interventions effectively reduced pain intensity, improved functional status and quality of life, alleviated psychological impacts related to chronic pain, and showed potential for reducing opioid cravings and misuse.³³ Stoerkel et al. (2018) assessed the efficacy of a self-care toolkit containing guided meditation audio files and acupressure bands for breast cancer surgery patients at two Army medical centers and showed that the toolkit group reported lower pain interference, fatigue, and postoperative pain scores, as well as reduced inflammatory responses.³⁴ In a randomized trial, Crisp et al. (2023) evaluated mindfulness-based stress reduction for chronic pelvic pain among active-duty women, with results showing reductions in both pain and depression symptoms.³⁵

Massage therapy

The studies on massage therapy within military populations indicate beneficial effects for pain management and symptom relief. Davis et al. (2015) examined the effects of Light Touch Manual Therapy on active-duty soldiers with chronic post-traumatic stress disorder and head injury, noting significant reductions in headache severity and anxiety immediately after each session with decreased pain interference sustained several days post-treatment.³⁶ Kern et al. (2018) conducted a prospective observational study to assess the feasibility and effectiveness of reflexology for chronic pain management in a military pain clinic and found soldiers receiving 25-min reflexology sessions alongside their standard pain management therapies reported a decrease in pain.³⁷

Yoga

Studies on yoga and mindfulness interventions revealed positive impacts on pain management, mental health, and overall physical resilience among military personnel. Combs et al. (2018) conducted a pilot study integrating a group-based yoga and mindfulness program into military brain injury rehabilitation, finding moderate improvements in health, pain, sleep, and mood at 4 months, with effects sustained at 7 months, although some results were potentially influenced by concurrent neurostimulator treatment.³⁸ Highland et al. (2018) explored the feasibility of an individualized yoga program for chronic low back pain in service members through a randomized controlled trial; participants showed reductions in pain intensity and disability over the 8-week program, with long-term follow-up supporting sustained benefits.³⁹ Groessl et al. (2022) compared hatha and restorative yoga types in active-duty personnel with chronic back and neck pain: both led to moderate reductions in pain-related disability, pain severity, and improvements in quality of life, grip strength, and balance.⁴⁰

Smith et al. (2023) conducted a large-scale group randomized controlled trial with 1584 military trainees to assess the combined impact of mindfulness training and yoga on injury resilience during basic combat training, trainees in the intervention group reported better health, less pain-related impairment, and improved sleep, mood, and stress levels compared with controls.⁴¹

General CIH/multi-modality

Studies on general CIH or multi-modality approaches for pain management in military populations report positive impacts, in the form of reduced pain scores and improved subjective quality of life. Clifford et al. (2014) reviewed pain management advancements over a decade, highlighting the Army Surgeon General’s recommendation to increase CIH as an adjunct to pharmaceutical treatments, with promising potential for managing chronic pain in wounded service members.⁴² Similarly, Jonas et al. (2015) discussed how CIH approaches, including whole-person healing, are essential for addressing the war-related trauma spectrum response.⁴³

Flynn et al. (2017, 2022) described protocols for evaluating CIH modalities such as acupuncture, biofeedback, massage therapy, and yoga in pain management programs.^44,45 These studies noted logistical challenges in implementing CIH but showed that service members receiving CIH combined with standard rehabilitative care reported greater pain reduction and functional improvement, particularly for those with high baseline pain levels.^44,45

Meerwijk et al. (2019) analyzed the health records of service members with chronic pain, finding that those who received nonpharmacological treatments had significantly lower risk of adverse outcomes, such as substance use disorders and suicidal ideation, upon transitioning to the VHA.⁴⁶ Nguyen et al. (2020) further supported the benefits of structured CIH programs, reporting improvements in physical strength, endurance, and reduced fear of movement among Army personnel in a functional restoration program.⁴⁷

Donahue et al. (2021) conducted a systematic review and meta-analysis, confirming the effectiveness of CIH in reducing pain intensity and improving physical functioning in military populations.⁴⁸ Eaton et al. (2022) examined the role of psychological factors in pain management outcomes, finding that while psychological aspects related to pain improved, CIH therapies did not directly impact chronic pain outcomes through changes in psychological mediators.⁴⁹

Utilization (Table 2)

Eight of the 53 articles included in the review (15%) assessed utilization of CIH modalities: 3 for acupuncture), 1 for massage therapy, and 4 for general CIH/multi-modality. Yoga, hypnosis, and Tai Chi/Qi Gong were not assessed for utilization by the studies under review in our sample.

Table 2.

Utilization Studies (n = 8) of (a) Acupuncture, (b) Massage Therapy, and (c) General Complementary and Integrative Health/Multiple Modalities

Title	Author	Year	Aim	Design	N	Intervention(s)/ comparator	Outcome(s)	Findings and conclusions
a. Acupuncture (n = 3)
Battlefield Acupuncture in the U.S. Military: a Pain-Reduction Model for NATO^10,50	Niemtzow et al.	2015	To describe the history and use of battlefield acupuncture	Literature or narrative review	Military personnel	Battlefield acupuncture	Pain	BFA may be used as a primary treatment or as an adjunct to various pain modalities now practiced in NATO medical communities. It is therefore recommended that a BFA program similar to the program in the U.S. DoD and VA health systems be implemented at several NATO bases.
Use of Acupuncture in the United States Military Health care System in 2014.⁵⁹	Madsen et al.	2018	To describe the use of acupuncture in the Military Health System including recipient demographics, types of providers and facilities, and diagnoses for which patients were referred	Database Analyses	15,761 patient records	Acupuncture utilization, TRICARE Prime-eligible beneficiaries over 18 who received acupuncture at least once in fiscal year 2014 in Military treatment facilities outpatient care	Pain; all patient diagnoses	Overall, findings of this study were consistent with physician-provided efforts to control pain, and top diagnoses were similar between active- and nonactive-duty beneficiaries.
Trends in Use of Acupuncture During Pregnancy for the Military Health System, 2006–2016⁵²	Madsen et al.	2019	To describe trends in the use of acupuncture in pregant patients within the military health system from 2006 to 2016.	Database Analyses	329, Pregnant women who were active-duty, dependent, activated NG/reserves in the MHS	Acupuncture; Patients who had a CPT coded for acupuncture with an associated CPT code for pregnancy diagnosis in the same clinical encounter.	Number of acupuncture visits per patient, clinics associated with acupuncture visits, major diagnostic categories for acupuncture visits	Number of acupuncture visits per patient, clinics associated with acupuncture visits, major diagnostic categories for acupuncture visits
b. Massage Therapy (n = 1)
The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain⁵³	Rhon et al.	2018	To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only manual therapy (MT) vs. MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.	Database Analyses	1876 (1162 MT+opioids, 714 MT only), active-duty, dependents, retired in military treatment facility/outpatient care	Manuel Therapy (MT) 1) those who only received MT (MT-only) and 2) those who received MT and opioids (MT + opioids) during the 12-month period following the index date.	costs and opioid utilization	MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation.
c. General Complementary and Integrative Health and Multiple Modalities (n = 4)
Use of Complementary Health Approaches at Military Treatment Facilities, Active Component, U.S. Armed Forces, 2010–2015⁵⁴	Williams et al.	2016	To describe trends in the use of chiropractic/osteopathic manipulation, acupuncture, and biofeedback by active service members from 2010 through 2015.	Database Analyses	240 military installations records of health care encounters from U.S. military medical facilities, Active-duty U.S. Army, Navy, Air Force, or Marine Corps	Acupuncture, chiropractic/osteopathic manipulation, and biofeedback.	Acupuncture, chiropractic/osteopathic manipulation, and biofeedback utilization between January 1, 2010, through December 31, 2015	During the 6-year surveillance period, 14.9% (n = 358,394) of active component service members had at least one health care encounter of either chiropractic/osteopathic manipulation, acupuncture, or biofeedback. The most frequent medical condition for which chiropractic/osteopathic manipulation and acupuncture were used was other and unspecified disorders of the back. Chiropractic/osteopathic manipulation, acupuncture, and biofeedback are used frequently among active component U.S. service members. The uses of these CAM approaches have increased since 2010.
Use of Integrative Medicine in the United States Military Health System⁵⁵	Madsen et al.	2017	To summarize the available literature to describe the integrative medicine (IM) therapies being used in the Military Health System (MHS), including the conditions for which they are sought and the evidence base for their use.	Narrative Review	Military Health System Patients	General CIH; Acupuncture; Biofeedback; Hypnosis; Massage Therapy; Guided Imagery/ Meditation/ Mindfulness; Yoga; Chiropractic, Cognitive Behavioral, Light Therapy, Naturopathic Medicine, Nutrition, Spiritual Healing	Pain; PTSD; TBI	Three themes: 1. The principles of IM are well-suited to address the multi-factorial issues underlying the polytrauma triad. 2. Much of the push for IM comes from service members; 3. Research continues to illustrate new mechanisms of action for some modalities, building the research evidence base. There are a wide range of IM options available within the MHS. Given the patient-driven demand for these modalities, their potential for addressing chronic disease in an effective and coordinated way, and a new focus on promoting access to these therapies, it is likely that the scope of IM in the MHS will continue expanding.
Do nonpharmacological services offset opioids in pain treatment for soldiers?⁶⁰	Hodgkin et al	2021	To examine the relationships between nonpharmacological treatment (NPT) utilization and opioid prescriptions and doses and whether these relationships vary according to the type of NPT service received.	Database Analyses	138071, outpatient Army	Acupuncture; Biofeedback; Massage Therapy	Opioid use: 23-month analysis of filled prescriptions and CIH use	Utilization of any NPT service in the past 3 months was positively associated with filling an opioid prescription in the given month, regardless of whether the patient was initially prescribed opioids (percentage point difference [PP] = 2.87, p < 0.01) or not (PP = 0.83, p < 0.01). However, for those not initially prescribed opioids, use of any NPT service in the past 3 months was negatively associated with mean daily opioid dose in the given month (morphine milligram equivalent dose = âˆ’0.4017, p < 0.01). For those initially prescribed opioids, NPT was not associated with opioid dose. NPT only reduced the prescription opioid daily dose for some patients, whereas the probability of receiving an opioid prescription was positively associated with NPT. Future research should assess whether recent system-level policies and program changes influence referral and opioid prescribing patterns.
The Relationship Between Capacity and Utilization of Nonpharmacologic Therapies in the U.S. Military Health System⁵⁶	Bolton et al.	2022	To measure professional capacity to deliver nonpharmacologic therapies (NPT) at Military Treatment Facilities (MTF) and test the associations between professional capacity measures and measures of NPT utilization at MTFs.	Database Analyses	863,855, Army active-duty and activated National Guard and Reserve returning from deployment to Iraq or Afghanistan, Military Health System data from MTFs from October 1, 2009-September 30, 2017.	Acupuncture; Biofeedback; Hypnosis; Massage Therapy; therapeutic exercise, chiropractic/ spinal manipulation, transcranial electrical nerve stimulation (TENS)	Utilization of NPT (# users, occupation full-time equivalents)	The number of FTEs per 100,000 patients at MTFs increased for chiropractors, physical therapists, and behavioral health providers. Use of therapeutic exercise, chiropractic care, massage and acupuncture increased over the study period. Increasing patterns of NPT utilization was linked to growing professional capacity following policy changes to improve access to NPTs; however, these increases were small in comparison with the high prevalence of pain in military service members.

No results were found for Qi Gong, Tai Chi, and hypnosis.

Acupuncture

The studies on acupuncture use in the military setting highlighted its applications for pain management and other health conditions. Niemtzow et al. (2015) reviewed the history and application of battlefield acupuncture within the U.S. military, suggesting that battlefield acupuncture be expanded to the North Atlantic Treaty Organization (NATO) medical communities as a primary or adjunct pain management modality, recommending its broader integration in MHSs worldwide.⁵⁰

Madsen et al. (2018) analyzed 15,761 patient records from the MHS to examine acupuncture utilization trends among TRICARE Prime-eligible beneficiaries and indicated that acupuncture was primarily used for pain management, with similar top diagnoses across active-duty and nonactive-duty groups.⁵¹ In a separate study, Madsen et al. (2019) explored acupuncture use in pregnant patients within the MHS from 2006 to 2016, finding a growing trend in acupuncture visits among pregnant women, with the majority of sessions related to pain and pregnancy-associated conditions.⁵²

Massage therapy

Rhon et al. (2018) examined health care utilization outcomes over a 1-year period for patients with back or shoulder pain treated with manual therapy alone compared with those treated with both manual therapy and opioids within a military treatment facility setting, including 1876 active-duty, dependent, and retired military personnel, with 714 receiving only manual therapy and 1162 receiving a combination of manual therapy and opioids.⁵³

General CIH/multi-modality

The studies on CIH modalities within military settings revealed significant trends in usage, capacity, and the impact of nonpharmacological therapies on pain management and opioid use. Williams et al. (2016) examined 6 years of data across military treatment facilities and found a steady increase in the use of chiropractic/osteopathic manipulation, acupuncture, and biofeedback, particularly for managing back pain with nearly 15% of active-duty service members using these therapies during the surveillance period.⁵⁴ Madsen et al. (2017) conducted a narrative review summarizing the range of integrative medicine options within the MHS, including acupuncture, biofeedback, and massage therapy noting three key themes: the alignment of integrated medicine approaches with managing multifaceted conditions such as post-traumatic stress disorder and traumatic brain injury, a patient-driven demand for integrative medicine therapies, and increasing research supporting the effectiveness of these therapies.⁵⁵

Bolton et al. (2022) assessed the capacity and utilization of nonpharmacological therapies across MTFs, finding increased full-time equivalent positions for chiropractors, physical therapists, and behavioral health providers and linking the rise in nonpharmacological therapies usage to policy changes that improved access.⁵⁶

Nine of the 53 articles resulting from the search (17%) assessed something other than efficacy/effectiveness or utilization of CIH modalities and thus were not included in the summary of results.

Discussion

This scoping review demonstrates that there is a significant focus on evaluating the efficacy/effectiveness of CIH therapies within the MHS, with 68% of studies concentrating on effectiveness, particularly in acupuncture, yoga, and multimodal CIH approaches. Among these, acupuncture emerges as a predominant intervention for pain relief across both acute and chronic conditions. The research underscores battlefield acupuncture’s immediate efficacy in acute pain settings and suggests sustained benefits for managing chronic pain in military populations, consistent with the findings by Niemtzow et al. (2007) on battlefield acupuncture’s rapid application and pain-relieving effects in austere environments.¹⁰

Yoga and mindfulness-based interventions appear effective for chronic pain, stress management, and enhancing physical resilience. Studies have shown these interventions provide long-term pain reduction and quality-of-life benefits. However, other CIH modalities such as hypnosis and Tai Chi/Qi Gong require further investigation prior to drawing a conclusion on their effectiveness.

Utilization studies show a steady increase in CIH use, yet disparities persist across military settings. Research highlights increasing adoption of acupuncture for diverse patient groups, including those with pregnancy-related symptoms (Madsen et al., 2019),⁵² and indicates the potential for massage therapy to serve as a nonpharmacologic first-line treatment for musculoskeletal pain. Despite this growth, there remains a paucity of utilization studies on hypnosis, Tai Chi/Qi Gong, and yoga within the MHS. Understanding CIH utilization in the MHS provides valuable insights not only for improving care within the military but also for informing broader health care systems. The unique structure of the MHS, which integrates health care delivery with readiness and operational demands, offers a model for studying the scalability and implementation of CIH therapies in other large, complex health care systems.

Lastly, research focused on broader CIH adoption and educational support in MHS emphasizes the need for structural reforms to integrate CIH into standard military health care. Studies from the VA Health Services Research and Development (HSR&D) evidence maps support the potential benefits of these therapies but highlight the importance of addressing challenges in training and availability.¹⁰ Despite evidence supporting the efficacy/effectiveness of CIH therapies such as acupuncture for pain management, their integration into military health care faces significant barriers. TRICARE does not cover these therapies in the purchased care system, limiting access to military treatment facilities, where availability varies widely by location. This inconsistency highlights the need for policy alignment to ensure equitable access to these effective, nonpharmacologic pain management options across the MHS.

This review has several limitations that should be considered when interpreting the findings. First, the reliance on published literature may not fully capture the breadth of CIH therapies implemented within the MHS, particularly at smaller or less-researched facilities. Second, variability in the availability and reporting of CIH therapies across military treatment facilities introduces potential gaps in understanding utilization trends and barriers. Third, this review used the VHA’s list of CIH therapies to guide the scope of analysis, which may not fully align with practices specific to the MHS.

Conclusion

This review highlights that some CIH therapies, particularly acupuncture, yoga, and massage therapy, have been demonstrated to appear to be effective nonpharmacologic options for pain management among military personnel. These findings align with evidence from the VHA, where CIH therapies have demonstrated efficacy/effectiveness in managing chronic pain and improving patient outcomes. However, unique aspects of the MHS population, such as the prevalence of combat-related injuries, acute operational stress, and younger demographics, may influence the patterns of utilization and effectiveness observed. For example, while acupuncture has been widely adopted in the VHA for chronic pain, its implementation in the MHS has focused more on protocols such as battlefield acupuncture for pain relief in operational environments.

As CIH utilization grows within the MHS, these findings support further efforts to standardize CIH practices, enhance access, and provide structural support for implementing these therapies across the MHS. Expanding research on underutilized CIH modalities and ensuring training for health care providers are essential to fully leverage the potential of CIH in improving the health and resilience of service members and veterans.

Registration of protocol

PROSPERO 2024 CRD4202453685, 29 April 2024, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024536853

Footnotes

Authors’ Contributions

A.K.C.: Conceptualization (supporting); title, abstract and full text review (supporting); writing—review (supporting). E.T.: Conceptualization (supporting); title, abstract and full text review (supporting); data extraction (supporting); writing—review and editing (supporting). A.G.B.: Conceptualization (supporting); title, abstract and full text review (supporting); data extraction (supporting); writing—review (supporting); K.M.E.: Conceptualization (supporting); title, abstract and full text review (supporting); writing—review and editing (supporting); T.J.P.: Conceptualization (supporting); title, abstract and full text review (supporting); writing—review and editing (supporting); R.J.A.: Methodology (lead); Search (lead); writing—review and editing (supporting). T.L.R.: Conceptualization (lead); writing—original draft (lead); title, abstract and full text review (lead); data extraction (lead).

Disclaimer

The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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