Are Virtual Complementary and Integrative Therapies as Effective as In-Person Therapies? Examining Patient-Reported Outcomes Among Veterans with Chronic Musculoskeletal Pain

Abstract

Background:

Virtual complementary and integrative health (CIH) therapy availability increased during the COVID-19 pandemic, but little is known about effectiveness. We examined the perceived effectiveness of in-person and virtual CIH therapies for patients with chronic musculoskeletal pain who recently started using CIH therapies.

Methods:

The sample included Veterans (n = 1,091) with chronic musculoskeletal pain, identified in the Veterans Health Administration’s electronic health record based on initiation of CIH therapy use, who responded to VA’s Patient Complementary and Integrative Health Therapy Experience Survey during March, 2021, to August, 2022. Using multivariable models with self-guided virtual (apps or videos) delivery as the reference, we compared patient-reported outcomes (pain, mental health, fatigue, and general well-being) associated with any yoga, Tai Chi/Qigong, or meditation use delivered: (1) only in-person, (2) only virtually with a live provider, (3) only virtually self-guided, (4) virtually self-guided + virtually provider-guided, or (5) hybrid in-person + virtual (self-or provider-guided).

Results:

Under 10% of Veterans reported only in-person use; 54% used only virtual formats and 36% a hybrid of in-person and virtual. Forty-one percent reported improvement in general well-being, 40.6% in mental health, 37.1% in pain, and 22.7% in fatigue. Compared with Veterans using only self-guided virtual CIH therapies, Veterans using only in-person therapies were more likely to report improvement in fatigue (odds ratio [OR]: 1.8, confidence interval [CI]: 1.1–3.1) and general well-being (OR: 1.7, CI: 1.0–2.6).

Conclusions:

Many patients perceived health improvements from CIH therapies, with in-person users reporting more improvement in fatigue and well-being than those using virtual sessions and similar improvements in pain and mental health for in-person and hybrid users.

Introduction

Complementary and integrative health (CIH) therapies such as yoga, acupuncture, Tai Chi, Qigong, and meditation are evidence-based treatments for chronic musculoskeletal pain.¹ As such, they are included in national American College of Physician pain management guidelines² and are a key component to the Veterans Health Administration (VA) Whole Health medical care transformation’s efforts to provide nonpharmacological approaches to health for its patients.³ As a result, the VA has prioritized the implementation of these evidence-based CIH therapies for over a decade, making them available as medical care for little to no cost.

Due to the COVID-19 pandemic, the VA rapidly accelerated the implementation of telehealth, including virtual CIH therapies.^4
–6 As more patients gain access to virtual CIH therapies, it is important to assess their effectiveness. Yet, only a few small studies have done so, and they showed that patients appear to benefit from their use.^7,8 However, no large-scale examination of patient-reported outcomes of virtual CIH therapies exists. Therefore, we aimed to examine the effectiveness of Veterans’ use of virtual CIH therapies relative to their use of in-person CIH therapies. We did so among a large-scale sample of Veterans with chronic musculoskeletal pain who used VA health care.

Methods

ANALYTIC SAMPLE

The sample comprised respondents to the VA Office of Patient Centered Care and Cultural Transformation’s Complementary and Integrative Health Therapy Patient Experience Survey, the nation’s largest longitudinal survey of CIH therapy use to-date.⁹ From March, 2021, to April, 2023, the survey team invited 15,608 Veterans nationally with chronic musculoskeletal pain who were identified as newly starting any of six CIH therapies (acupuncture, therapeutic massage, yoga, Tai Chi/Qigong, meditation/mindfulness, and chiropractic care, which the VA considers allopathic care, not complementary medicine) to complete the survey. We defined “newly starting” CIH therapy use as a new visit or referral with no prior CIH therapy visits in the electronic health record (EHR) for at least 6 months. We defined chronic musculoskeletal pain as having a history of EHR-recorded ICD-10 musculoskeletal pain diagnoses and having at least two 0–10 pain numeric rating scores ≥4. Those pain diagnoses included back pain, neck pain, limb/extremity pain, joint pain, most arthritic disorders (not gout and other crystal arthropathies or neuropathic arthropathy), fibromyalgia, tension-type headache, orofacial pain, ear pain, temporomandibular disorder pain, musculoskeletal chest pain, and general pain (details are provided in our earlier work survey description).⁶

Of the 15,608 Veterans invited, 41% (6,453) met all eligibility criteria and completed the survey online or by phone, with a baseline response rate of 45.6%. Of those, 2,183 reported using yoga, Tai Chi/Qigong, or meditation/mindfulness during the past 4 weeks, therapies that are amenable to virtual CIH therapy delivery formats. We excluded Veterans who used the CIH therapies two or more times per week during the past 6 months (n = 858) because we aimed to examine therapy effectiveness, so we wanted Veterans with limited to no prior CIH therapy use to our study. We also excluded Veterans who had no data on CIH delivery format (n = 234). We analyzed baseline survey data collected between March 23, 2021 and August 31, 2022. This process resulted in an analytic sample of 1,091 respondents. The Greater Los Angeles VA Healthcare System Institutional Review Board determined that this project is a nonresearch quality improvement effort.

VARIABLES

Demographics

We obtained age, gender, race, and ethnicity from the VA EHR and relationship status, education, and income from the survey.

CIH therapy delivery format

For each therapy, the survey asked patients about their use of three delivery formats: (1) in-person only (with a live provider), (2) provider-guided virtual only, and (3) self-guided virtual via app or recording. We created two additional categories to capture use of multiple formats: (4) virtual self-guided + virtual provider-guided and (5) hybrid (in-person + virtual [self- or provider-guided]) therapies.

Global impressions of change

To assess the short-term effectiveness of these CIH therapies, we used the Patient Global Impression of Change scale to assess patient-reported outcomes for pain, fatigue, mental health, and general-well-being.¹⁰ The initiative on methods, measurement, and pain assessment in clinical trials (IMMPACT) recommended this measure for use as a core outcome measure of global pain improvement with treatment.^11,12 Patients responded to the following question, “Since doing [CIH therapy] recently, have you seen changes in your pain?,” and the CIH therapy they electronically reported earlier was populated here. The survey asked the same question for fatigue, mental health, and well-being. The response options included: (1) Much Better; (2) Slightly Better; (3) About the Same; (4) Slightly Worse; and (5) Much Worse. We reverse coded responses so a higher score indicated a better outcome. We also grouped the response options into three categories (Worse, Same, or Better) for descriptive analysis and into two categories (Better vs. Worse/Same) to create a dichotomous variable for logistic regression analysis.

ANALYSES

Among Veterans reporting CIH therapy use in the survey, we descriptively examined (1) the percent using each of the five CIH therapy delivery formats) and (2) patient-reported outcomes (pain, fatigue, mental health, general well-being) of that use. We then combined yoga, meditation/mindfulness, and Tai Chi/Qigong use and calculated the frequencies of patient-reported outcomes from using each delivery format. Finally, we conducted a multivariable logistic regression analysis to examine the association between CIH therapy delivery format and dichotomized patient-reported outcomes. We controlled for past 4-week use of these and other (acupuncture, chiropractic care, and therapeutic massage) CIH therapies, how consistently they used yoga, Tai Chi/Qigong, and meditation/mindfulness (new user/missing vs. once per week), and demographic characteristics.

Results

CIH THERAPY USE AND CHARACTERISTICS OF USERS

As shown in Table 1, the sample of patients was predominantly aged 40–65 years, male, and White. Overall, 90.4% reported using some form of virtual CIH therapy during the COVID pandemic, either on its own or in combination with other formats. As shown in Table 2, patients using yoga frequently reported using a self-guided virtual delivery format (43.4%) as did those using meditation (64.1%). However, patients using Tai Chi/Qigong most frequently used a provider-guided virtual delivery format (37.6%).

Table 1.

Characteristics of Patients Using In-Person and Virtual CIH Therapy Delivery Formats

	CIH THERAPY DELIVERY FORMAT
	SELF-GUIDED VIRTUAL ONLY	PROVIDER-GUIDED VIRTUAL ONLY	PROVIDER-GUIDED VIRTUAL + SELF-GUIDED VIRTUAL	IN-PERSON ONLY	HYBRID (IN-PERSON + VIRTUAL)	TOTAL
N (%)	590 (54.1)	246 (22.5)	91 (8.3)	105 (9.6)	59 (5.4)	1091 (100.0)
CIH (Yoga, Tai Ch/Qigong, Meditation/Mindfulness) Therapy Use Consistency
New user/missing	46.4	59.8	47.3	62.9	33.9	50.4
One time per week	53.6	40.2	52.7	37.1	66.1	49.6
Demographic Characteristics	%	%	%	%		%
Age Group
18 to 39	19.3	11.8	20.9	10.5	15.3	16.7
40 to 65	61.7	60.6	54.9	51.4	57.6	59.7
65 or older	19.0	27.6	24.2	38.1	27.1	23.6
Gender
Male	70.8	70.3	58.2	79.0	66.1	70.2
Female	29.2	29.7	41.8	21.0	33.9	29.8
Race
AIAN	1.2	0.8	1.1	0.0	0.0	0.9
Asian	1.0	0.0	1.1	2.9	0.0	0.9
Black	23.6	29.7	28.6	21.0	39.0	25.9
Multiple Races	1.4	1.6	1.1	1.9	0.0	1.4
NHOPI	0.8	0.8	1.1	1.0	1.7	0.9
Unknown	7.8	7.3	6.6	1.9	1.7	6.7
White	64.2	59.8	60.4	71.4	57.6	63.2
Ethnicity
Non-Hispanic	81.0	85.0	81.3	86.7	94.9	83.2
Hispanic	11.7	10.2	7.7	9.5	1.7	10.3
Unknown	7.3	4.9	11.0	3.8	3.4	6.5
Relationship Status
Married/Relationship/Widowed	69.5	70.7	67.0	70.5	55.9	68.9
Single	15.4	15.4	12.1	15.2	16.9	15.2
Divorced/Separated	15.1	13.8	20.9	14.3	27.1	15.9
Unknown	69.5	70.7	67.0	70.5	55.9	68.9
Education
High school or less	10.7	12.2	5.5	17.1	10.2	11.2
Some college	43.4	42.7	35.2	43.8	49.2	42.9
4-year college or higher	45.9	45.1	59.3	39.0	40.7	45.9
Income
Comfortable	35.3	37.0	31.9	41.9	42.4	36.4
Just enough to make ends meet	43.4	38.2	39.6	38.1	39.0	41.2
Not enough to make ends meet	16.6	18.7	23.1	16.2	13.6	17.4
Prefer not to answer	4.7	6.1	5.5	3.8	5.1	5.0

*p < 0.05.

AIAN, American Indian/Alaska Native; CIH, complementary and integrative health; NHOPI, Native Hawaiian/Other Pacific Islander.

Table 2.

Patients’ Use of Yoga, Tai Chi/Qigong, and Mindfulness/Meditation by Delivery Format

	YOGA (n = 424)	TAI-CHI/QIGONG (n = 263)	MEDITATION/MINDFULNESS (n = 766)
Self-guided virtual only (%)	43.4	20.9	64.1
Provider-guided virtual only (%)	23.4	37.6	14.4
Provider-guided virtual + self-guided virtual (%)	13.9	14.8	10.1
In-person only (%)	11.6	17.5	5.0
Hybrid (in-person + virtual) (%)	7.8	9.1	6.5
Total (%)	100.0	100.0	100.0

CIH THERAPY EFFECTIVENESS

After using yoga, Tai Chi/Qigong, or meditation/mindfulness, patients reported meaningful improvements in all four patient-reported outcomes, with the largest improvements in mental health (40.9%) and general well-being (41.1%) (Table 3). Table 4 shows the results of the multivariable logistic regression analyses. Compared with patients using only self-guided CIH therapies, patients using only in-person CIH therapies reported better fatigue (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.1–3.1) and general well-being (OR: 1.9, 95% CI: 1.0–3.0). No other significant differences in delivery format were found, indicating comparable outcomes for self-guided virtual formats versus other delivery formats.

Table 3.

Frequencies of Patient-Reported Outcomes from Using In-Person and Virtual CIH Therapy Delivery Formats

CIH THERAPY DELIVERY FORMAT
	SELF-GUIDED VIRTUAL ONLY	PROVIDER-GUIDED VIRTUAL ONLY	PROVIDER-GUIDED VIRTUAL + SELF-GUIDED VIRTUAL	IN-PERSON ONLY	HYBRID (IN-PERSON + VIRTUAL)	TOTAL
N (%)	590 (54.1)	246 (22.5)	91 (8.3)	105 (9.6)	59 (5.4)	1091 (100.0)
Pain
Worse	7.5	8.1	3.3	10.5	6.8	7.5
Same	50.5	63.4	68.1	52.4	55.9	55.4
Better	42.0	28.5	28.6	37.1	37.3	37.1
Fatigue
Worse	12.2	10.6	11.0	6.7	13.6	11.3
Same	64.2	71.1	67.0	61.0	69.5	66.0
Better	23.6	18.3	22.0	32.4	16.9	22.7
Mental Health
Worse	7.8	5.3	7.7	4.8	5.1	6.8
Same	49.5	63.4	41.8	53.3	54.2	52.6
Better	42.7	31.3	50.5	41.9	40.7	40.6
General Well-Being
Worse	6.3	4.5	6.6	6.7	3.4	5.8
Same	51.4	60.6	50.5	44.8	59.3	53.2
Better	42.4	35.0	42.9	48.6	37.3	41.1

Table 4.

Multivariable Logistic Regression Results of Patient-Reported Outcomes from Using In-Person and Virtual CIH Therapy Delivery Formats (n = 1,091)

	PAIN	FATIGUE	MENTAL HEALTH	GENERAL WELL-BEING
	OR [95% CI]	OR [95% CI]	OR [95% CI]	OR [95% CI]
CIH Therapy Delivery Format
Self-guided virtual only (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Provider-guided virtual only	0.9 [0.6–1.4]	1.0 [0.7–1.6]	1.0 [0.7–1.4]	1.2 [0.8–1.7]
Provider-guided virtual + Self-guided virtual	0.7 [0.4–1.2]	0.9 [0.5–1.6]	1.5 [0.9–2.5]	1.1 [0.7–1.9]
In-person only	1.1 [0.7–1.8]	1.8* [1.1–3.1]	1.5 [0.9–2.4]	1.9* [1.1–3.0]
Hybrid (In-person + virtual)	1.1 [0.6–2.0]	0.6 [0.3–1.3]	1.0 [0.6–1.8]	0.8 [0.5–1.5]
Yoga Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Yes	1.4* [1.0–2.0]	1.6* [1.1–2.3]	1.1 [0.8–1.5]	1.4* [1.0–1.9]
Tai Chi/Qigong Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 a [1.0–1.0]	1.0 [1.0–1.0]
Yes	0.9 [0.6–1.4]	1.2 [0.8–1.9]	0.8 [0.6–1.2]	0.9 [0.6–1.2]
Mindfulness/Meditation Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Yes	1.2 [0.8–1.8]	1.3 [0.9–2.0]	1.9* [1.3–2.7]	1.4 [1.0–2.0]
Acupuncture Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Yes	1.7* [1.1–2.4]	1.1 [0.7–1.7]	1.4 [1.0–2.1]	1.4 [0.9–2.0]
Chiropractic Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Yes	3.0* [2.2–4.0]	1.8* [1.3–2.4]	1.3 [0.9–1.7]	1.6* [1.2–2.2]
Therapeutic Massage Use
No (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Yes	2.4* [1.7–3.4]	2.2* [1.5–3.1]	1.3 [0.9–1.8]	1.6* [1.2–2.3]
CIH Use Consistency
New user/missing (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
1×/week	1.5* [1.1–2.0]	1.6* [1.2–2.2]	1.6* [1.2–2.1]	1.6* [1.2–2.1]
Age
18 to 39	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
40 to 65	1.5* [1.0–2.3]	0.9 [0.6–1.4]	0.9 [0.6–1.3]	0.7* [0.5–1.0]
65 or older	1.4 [0.9–2.2]	1.0 [0.6–1.6]	1.0 [0.6–1.5]	0.7 [0.5–1.1]
Gender
Male (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Female	0.8 [0.6–1.2]	1.0 [0.7–1.4]	1.0 [0.8–1.4]	1.0 [0.7–1.4]
Race
AIAN	0.5 [0.1–2.2]	0.3 [0.0–2.6]	0.8 [0.2–3.1]	1.4 [0.4–5.4]
Asian	0.6 [0.1–2.4]	1.6 [0.4–6.1]	1.8 [0.5–6.7]	2.4 [0.6–9.6]
Black	0.6* [0.4–0.9]	0.7 [0.5–1.1]	0.8 [0.5–1.0]	0.8 [0.6–1.1]
Multi	1.2 [0.4–3.7]	0.4 [0.1–1.7]	1.1 [0.4–3.3]	0.5 [0.2–1.7]
NHOPI	0.9 [0.2–3.7]	1.9 [0.5–7.5]	0.9 [0.2–3.5]	1.9 [0.5–7.3]
Unknown	0.7 [0.4–1.3]	0.7 [0.3–1.4]	0.8 [0.4–1.4]	0.8 [0.5–1.5]
White (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Ethnicity
Non-Hispanic (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Hispanic	0.9 [0.5–1.3]	0.9 [0.6–1.5]	0.9 [0.6–1.3]	1.1 [0.7–1.7]
Unknown	0.8 [0.4–1.5]	1.0 [0.5–2.0]	0.7 [0.4–1.3]	0.7 [0.4–1.3]
Relationship Status
Single/Separated/Divorced/Widowed (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Partnered	1.1 [0.8–1.5]	0.9 [0.7–1.3]	1.0 [0.8–1.4]	0.8 [0.6–1.1]
Education
High school or less (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Some college	1.4 [0.9–2.3]	1.1 [0.7–1.8]	1.2 [0.8–1.9]	1.3 [0.8–2.0]
4-year college or higher	1.3 [0.8–2.0]	0.9 [0.5–1.5]	1.4 [0.9–2.3]	1.3 [0.8–2.0]
Income
Comfortable	1.3 [0.9–2.0]	1.4 [0.9–2.3]	1.2 [0.8–1.7]	1.6* [1.1–2.4]
Just enough to make ends meet	1.2 [0.8–1.9]	1.3 [0.8–2.1]	1.1 [0.8–1.6]	1.5 [1.0–2.1]
Not enough to make ends meet (Reference)	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]	1.0 [1.0–1.0]
Prefer not to answer	1.4 [0.7–2.8]	1.9 [0.9–4.0]	1.4 [0.7–2.7]	1.3 [0.7–2.6]

*p < 0.05.

AIAN, American Indian/Alaska Native; NHOPI, Native Hawaiian/Other Pacific Islander.

Discussion

This is the first large-scale study of patient-reported outcomes from different delivery CIH therapy formats. Our analysis of a sample of Veterans with chronic musculoskeletal pain showed that virtual CIH therapies were equally effective for patient-reported pain and mental health outcomes compared with in-person CIH therapies, whereas in-person therapies are more effective for fatigue and general-well-being. Our findings support the ongoing allocation of resources to ensure availability of virtual CIH therapies for patients with chronic musculoskeletal pain.

It is possible that Veterans who engaged in self-guided virtual CIH therapies are highly motivated to improve their pain, resulting in similar patient-reported outcomes relative to guided, in-person care. Veterans’ willingness to use virtual CIH therapies as a therapeutic option for chronic musculoskeletal pain is promising, as they often experience access barriers to in-person care.¹³ Self-guided virtual CIH therapies in particular can be convenient, adaptable to users’ needs and preferences, and might promote feelings of self-efficacy, factors that could explain positive patient-reported outcomes for pain and mental health in our study.^9,14

Although self-guided telehealth and multiple delivery formats showed similar outcomes for pain and mental health relative to in-person CIH therapy delivery, in-person CIH therapy users reported better outcomes for the secondary outcomes of fatigue and general well-being. This may relate to differences in treatment approaches, patient preferences, or symptom presentation for these outcomes. Although more work is needed to understand Veteran preferences for in-person versus virtual CIH therapies, and how these preferences relate to patient-reported outcomes, findings from this study indicate that self-guided virtual CIH therapies might be a viable alternative to in-person care for management of pain-related outcomes.

Limitations

This study had a few limitations. Given all outcomes were self-reported, they may be subject to recall bias over the 4-week period. We used cross-sectional data, so longer-term outcomes are unknown. Our results could be biased if those opting to take virtual classes did so, for example, because they were too fatigued from COVID-19 or some other condition. Also, because we conducted this survey during the COVID pandemic, it is unclear how much Veteran patients would use virtual CIH therapies if there was no pandemic. However, the primary focus of the paper, the effectiveness of virtual CIH therapies, remains less affected by COVID, other than to strengthen the power to detect effects, give the surge in use of virtual therapies at the time. This analysis did not account for survey respondent’ use of non-CIH pain management strategies, nor did it account for the possibility that some had depression or anxiety (conditions which are relatively comorbid with musculoskeletal pain).

Conclusions

As VA expands CIH therapy delivery, Veterans are using virtual CIH therapies in addition to more traditional practitioner-delivered CIH therapies such as acupuncture, therapeutic massage, and chiropractic care. VA’s experience demonstrates that patients benefit from using virtual CIH therapies for pain management. The availability of virtual therapies has transformed how CIH therapies are being delivered and health care systems now have many options for providing chronic pain care beyond the clinic walls.

Footnotes

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the United States Department of Veterans Affairs or the United States government.

Authorship Contribution Statement

T.P.H.: Writing—original draft (lead); formal analysis (lead); methodology (equal); software (equal). S.B.Z.: Methodology (equal); writing—review and editing (supporting); conceptualization (supporting); supervision (supporting). A.T.K.: Project Administration (equal). B.D.L.: Project administration (equal). J.T.: Data curation (equal); software (equal). A.R.: Data curation (equal); software (equal). A.R.E.: Writing—review and editing (supporting). C.D.-M.: Writing—review and editing (supporting). S.L.T.: Funding acquisition (lead); writing—review and editing (supporting); supervision—(lead); conceptualization (lead); and methodology (equal).

Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

This evaluation was conducted by the Veterans Health Administration’s (VHA) Complementary and Integrative Health Evaluation Center (CIHEC) as part of a quality improvement evaluation initiated requested and funded by the VHA’s Office of Patient Centered Care and Cultural Transformation, and by the VHA Quality Enhancement Research Initiative (QUERI) program [PEC 16-354].

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