Manipulative and Body-Based Practices: An Overview

Manipulative and body-based practices focus primarily on the structures and systems of the body, including the bones and joints, the soft tissues, and the circulatory and lymphatic systems. Practices include chiropractic and osteopathic manipulation, therapeutic massage, and a variety of other "bodywork" therapies.

Acupuncture

What’s the Bottom Line?

• How much do we know about acupuncture?
  There have been extensive studies conducted on acupuncture, especially for back and neck pain, osteoarthritis/knee pain, and headache. However, researchers are only beginning to understand whether acupuncture can be helpful for various health conditions.
• What do we know about the effectiveness of acupuncture?
  Research suggests that acupuncture can help manage certain pain conditions, but evidence about its value for other health issues is uncertain.
• What do we know about the safety of acupuncture?
  Acupuncture is generally considered safe when performed by an experienced, well-trained practitioner using sterile needles. Improperly performed acupuncture can cause serious side effects.

What Is Acupuncture?

Acupuncture is a technique in which practitioners stimulate specific points on the body—most often by inserting thin needles through the skin. It is one of the practices used in traditional Chinese medicine.

What the Science Says About the Effectiveness of Acupuncture

Results from a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low-back pain, neck pain, and osteoarthritis/knee pain. It also may help reduce the frequency of tension headaches and prevent migraine headaches. Therefore, acupuncture appears to be a reasonable option for people with chronic pain to consider. However, clinical practice guidelines are inconsistent in recommendations about acupuncture.

The effects of acupuncture on the brain and body and how best to measure them are only beginning to be understood. Current evidence suggests that many factors—like expectation and belief—that are unrelated to acupuncture needling may play important roles in the beneficial effects of acupuncture on pain.

What the Science Says About Safety and Side Effects of Acupuncture

• Relatively few complications from using acupuncture have been reported. Still, complications have resulted from use of nonsterile needles and improper delivery of treatments.
• When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, collapsed lungs, and injury to the central nervous system.
• The U.S. Food and Drug Administration (FDA) regulates acupuncture needles as medical devices for use by licensed practitioners and requires that needles be manufactured and labeled according to certain standards. For example, the FDA requires that needles be sterile, nontoxic, and labeled for single use by qualified practitioners only.

More to Consider

• Don’t use acupuncture to postpone seeing a health care provider about a health problem.

• If you decide to visit an acupuncturist, check his or her credentials. Most states require a license, certification, or registration to practice acupuncture; however, education and training standards and requirements for obtaining these vary from state to state. Although a license does not ensure quality of care, it does indicate that the practitioner meets certain standards regarding the knowledge and use of acupuncture. Most states require a diploma from the National Certification Commission for Acupuncture and Oriental Medicine for licensing.

• Some conventional medical practitioners—including physicians and dentists—practice acupuncture. In addition, national acupuncture organizations (which can be found through libraries or by searching the Internet) may provide referrals to acupuncturists. When considering practitioners, ask about their training and experience.

• Ask the practitioner about the estimated number of treatments needed and how much each treatment will cost. Some insurance companies may cover the costs of acupuncture, while others may not. For more information, see NCCIH’s fact sheet Paying for Complementary Health Approaches.
• Help your health care providers give you better coordinated and safe care by telling them about all the health approaches you use. Give them a full picture of what you do to manage your health.

Massage Therapy

Massage therapy encompasses many different techniques. In general, therapists press, rub, and otherwise manipulate the muscles and other soft tissues of the body. They most often use their hands and fingers, but may use their forearms, elbows, or feet.

Learn more on the National Center for Complementary and Integrative Health website.

Reflexology

Reflexology is a practice in which different amounts of pressure are applied to specific points on the feet or hands. These points are believed to match up with certain other parts of the body. Reflexology is claimed to cause relaxation and healing in those parts of the body, but this has not been proven. In a study funded by the National Cancer Institute, women with advanced breast cancer who received reflexology treatments showed improvement in a few symptoms, such as shortness of breath, but not others, such as nausea or pain. In this study, reflexology was safe even for the most fragile patients.

Spinal, Chiropractic and Osteopathic Manipulation

Chiropractic manipulation focuses on the relationship between the body's structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself.

Spinal Manipulation is the application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage, and naturopathy.

Osteopathic manipulation is a type of manipulation practiced by osteopathic physicians. It is combined with physical therapy and instruction in proper posture.

Chiropractic is a health care profession that focuses on the relationship between the body's structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself.

Key Points

• Most research on chiropractic has focused on spinal manipulation. Spinal manipulation appears to benefit some people with low-back pain and may also be helpful for headaches, neck pain, upper- and lower-extremity joint conditions, and whiplash-associated disorders.
• Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. There have been rare reports of serious complications such as stroke, but whether spinal manipulation actually causes these complications is unclear. Safety remains an important focus of ongoing research.
• Tell all your health care providers about any complementary health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Tai Chi and Qi Gong

Tai chi and qi gong are centuries-old, related mind and body practices. They involve certain postures and gentle movements with mental focus, breathing, and relaxation. In contrast to qi gong, tai chi movements, if practiced quickly, can be a form of combat or self-defense.

• How much do we know about tai chi and qi gong?
  Several clinical trials have evaluated the effects of tai chi and qi gong in people with various health conditions.
• What do we know about the effectiveness of tai chi and qi gong?
  Practicing tai chi may help to improve balance and stability in older people and in those with Parkinson’s disease, reduce back pain and pain from osteoarthritis, and improve quality of life in people with heart disease, cancer, and other chronic illnesses. Tai chi and qi gong may ease fibromyalgia pain and promote general quality of life. Qi gong may reduce chronic neck pain, but study results are mixed. Tai chi also may improve reasoning ability in older people.
• What do we know about the safety of tai chi and qi gong?
  Tai chi and qi gong appear to be safe practices, but it’s a good idea to talk with your health care providers before beginning any exercise program.

What Are Tai Chi and Qi Gong?

Tai chi and qi gong are centuries-old, related mind and body practices. They involve certain postures and gentle movements with mental focus, breathing, and relaxation. The movements can be adapted or practiced while walking, standing, or sitting. In contrast to qi gong, tai chi movements, if practiced quickly, can be a form of combat or self-defense.

What the Science Says About the Effectiveness of Tai Chi and Qi Gong

Research findings suggest that practicing tai chi may improve balance and stability in older people and those with Parkinson’s, reduce pain from knee osteoarthritis, help people cope with fibromyalgia  and back pain,  and promote quality of life and mood in people with heart failure  and cancer. There’s been less research on the effects of qi gong, but some studies suggest it may reduce chronic neck pain (although results are mixed) and pain from fibromyalgia. Qi gong also may help to improve general quality of life.

Both also may offer psychological benefits, such as reducing anxiety. However, differences in how the research on anxiety was conducted make it difficult to draw firm conclusions about this.

Falling and Balance

Exercise programs, including tai chi, may reduce falling and the fear of falling in older people. Tai chi also may be more effective than other forms of exercise for improving balance and stability in people with Parkinson’s disease.

• A 2012 review determined that tai chi, as well as other group- and home-based activity programs (which often include balance and strength-training exercises) effectively reduced falling in older people, and tai chi significantly reduced the risk of falling. But the reviewers also found that tai chi was less effective in older people who were at higher risk of falling.
• Fear of falling can have a serious impact on an older person’s health and life. In a 2014 review, researchers suggested that various types of exercise, including tai chi, may reduce the fear of falling among older people.
• Findings from a 2012 clinical trial with 195 people showed that practicing tai chi improved balance and stability better than resistance training or stretching in people with mild-to-moderate Parkinson’s disease. A 2014 followup analysis showed that people who practiced tai chi were more likely to continue exercising during the 3 months following the study compared with those who participated in resistance training or stretching.

Mental Health and Cognitive Function

While a range of research has suggested that exercise helps reduce depression and anxiety, the role of tai chi and qi gong for these and other mental health problems is less clear. However, there is evidence that tai chi may boost brain function and reasoning ability in older people.

• NCCIH-supported research suggested that practicing tai chi may help reduce stress, anxiety, and depression, and also improve mood and self-esteem. However, in their 2010 review, which included 40 studies with more than 3,800 participants, the researchers noted that they couldn’t develop firm conclusions because of differences in study designs.
• In a 2010 NCCIH-supported review, researchers found that the results from 29 studies with more than 2,500 participants didn’t offer clear evidence about the effectiveness of tai chi and qi gong on such psychological factors as anxiety, depression, stress, mood, and self-esteem. But the researchers noted that most of these studies weren’t looking primarily at psychological distress and didn’t intentionally recruit participants with mental health issues.
• Results from another NCCIH-supported review published in 2014 suggested that practicing tai chi may enhance the ability to reason, plan, remember, and solve problems in older people without evidence of significant cognitive impairment. The data also indicated that tai chi boosted cognitive ability in people who showed signs of mild cognitive impairment to dementia, but to a lesser degree than in those with no signs of cognitive impairment.

Quality of Life

• A 2010 NCCIH-supported research review examined the effects of tai chi and qi gong on the quality of life of adults who were healthy, elderly, were breast cancer or stroke survivors, or had a chronic disease. The analysis suggested that practicing tai chi or qi gong may improve quality of life in healthy and chronically ill people.

What the Science Says About Safety of Tai Chi and Qi Gong

Tai chi and qi gong appear to be safe practices.  One NCCIH-supported review noted that tai chi is unlikely to result in serious injury but it may be associated with minor aches and pains.  Women who are pregnant should talk with their health care providers before beginning tai chi, qi gong, or any other exercise program.

More To Consider

• Learning tai chi or qi gong from a video or book does not ensure that you’re doing the movements correctly or safely.
• If you have a health condition, talk with your health care provider before starting tai chi or qi gong.
• Ask a trusted source (such as your health care provider) to recommend a tai chi or qi gong instructor. Find out about the training and experience of any instructor you’re considering.
• Tell all your health care providers about any complementary or integrative health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Yoga

Yoga is a mind and body practice with historical origins in ancient Indian philosophy. Like other meditative movement practices used for health purposes, various styles of yoga typically combine physical postures, breathing techniques, and meditation or relaxation. This fact sheet provides basic information about yoga, summarizes scientific research on effectiveness and safety, and suggests sources for additional information.

Key Facts

• Recent studies in people with chronic low-back pain suggest that a carefully adapted set of yoga poses may help reduce pain and improve function (the ability to walk and move). Studies also suggest that practicing yoga (as well as other forms of regular exercise) might have other health benefits such as reducing heart rate and blood pressure, and may also help relieve anxiety and depression. Other research suggests yoga is not helpful for asthma, and studies looking at yoga and arthritis have had mixed results.
• People with high blood pressure, glaucoma, or sciatica, and women who are pregnant should modify or avoid some yoga poses.
• Ask a trusted source (such as a health care provider or local hospital) to recommend a yoga practitioner. Contact professional organizations for the names of practitioners who have completed an acceptable training program.
• Tell all your health care providers about any complementary health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

About Yoga

Yoga in its full form combines physical postures, breathing exercises, meditation, and a distinct philosophy. There are numerous styles of yoga. Hatha yoga, commonly practiced in the United States and Europe, emphasizes postures, breathing exercises, and meditation. Hatha yoga styles include Ananda, Anusara, Ashtanga, Bikram, Iyengar, Kripalu, Kundalini, Viniyoga, and others.

Side Effects and Risks

• Yoga is generally low-impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor.
• Overall, those who practice yoga have a low rate of side effects, and the risk of serious injury from yoga is quite low. However, certain types of stroke as well as pain from nerve damage are among the rare possible side effects of practicing yoga.
• Women who are pregnant and people with certain medical conditions, such as high blood pressure, glaucoma (a condition in which fluid pressure within the eye slowly increases and may damage the eye’s optic nerve), and sciatica (pain, weakness, numbing, or tingling that may extend from the lower back to the calf, foot, or even the toes), should modify or avoid some yoga poses.

What the Science Says About Yoga

Current research suggests that a carefully adapted set of yoga poses may reduce low-back pain and improve function. Other studies also suggest that practicing yoga (as well as other forms of regular exercise) might improve quality of life; reduce stress; lower heart rate and blood pressure; help relieve anxiety, depression, and insomnia; and improve overall physical fitness, strength, and flexibility. But some research suggests yoga may not improve asthma, and studies looking at yoga and arthritis have had mixed results.

• One NCCIH-funded study of 90 people with chronic low-back pain found that participants who practiced Iyengar yoga had significantly less disability, pain, and depression after 6 months.
• In a 2011 study, also funded by NCCIH, researchers compared yoga with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. The results showed that both yoga and stretching were more effective than a self-care book for improving function and reducing symptoms due to chronic low-back pain.
• Conclusions from another 2011 study of 313 adults with chronic or recurring low-back pain suggested that 12 weekly yoga classes resulted in better function than usual medical care.

However, studies show that certain health conditions may not benefit from yoga.

• A 2011 systematic review of clinical studies suggests that there is no sound evidence that yoga improves asthma.
• A 2011 review of the literature reports that few published studies have looked at yoga and arthritis, and of those that have, results are inconclusive. The two main types of arthritis—osteoarthritis and rheumatoid arthritis—are different conditions, and the effects of yoga may not be the same for each. In addition, the reviewers suggested that even if a study showed that yoga helped osteoarthritic finger joints, it may not help osteoarthritic knee joints.

If You Are Considering Practicing Yoga

• Do not use yoga to replace conventional medical care or to postpone seeing a health care provider about pain or any other medical condition.
• If you have a medical condition, talk to your health care provider before starting yoga.
• Ask a trusted source (such as your health care provider or a nearby hospital) to recommend a yoga practitioner. Find out about the training and experience of any practitioner you are considering. To learn more, see Selecting a Complementary Medicine Practitioner.
• Everyone’s body is different, and yoga postures should be modified based on individual abilities. Carefully selecting an instructor who is experienced with and attentive to your needs is an important step toward helping you practice yoga safely. Ask about the physical demands of the type of yoga in which you are interested and inform your yoga instructor about any medical issues you have.
• Carefully think about the type of yoga you are interested in. For example, hot yoga (such as Bikram yoga) may involve standing and moving in humid environments with temperatures as high as 105°F. Because such settings may be physically stressful, people who practice hot yoga should take certain precautions. These include drinking water before, during, and after a hot yoga practice and wearing suitable clothing. People with conditions that may be affected by excessive heat, such as heart disease, lung disease, and a prior history of heatstroke may want to avoid this form of yoga. Women who are pregnant may want to check with their health care providers before starting hot yoga.
• Tell all your health care providers about any complementary health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Key References

Accupuncture:

• Berman BM, Langevin HM, Witt CM, et al. Acupuncture for chronic low back pain. New England Journal of Medicine. 2010;363(5):454–461.
• Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine. 2009;169(9):858–866.
• Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147(7):478–491.
• Cummings M. Modellvorhaben Akupunktur—a summary of the ART, ARC and GERAC trials. Acupuncture in Medicine. 2009;27(1):26–30.
• Furlan A, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for Back Pain II. Evidence Report/Technology Assessment No. 194. Rockville, MD: Agency for Healthcare Research and Quality. 2010. AHRQ Publication No. 10(11)–E007.
• Hinman RS, McCrory P, Pirotta M, et al. Acupuncture for chronic knee pain. A randomized clinical trial. JAMA. 2014;312(13):1313–1322.
• Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2009;(1):CD001218. Accessed at www.thecochranelibrary.com on July 2, 2014.
• Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews. 2009;(1):CD007587. Accessed at www.thecochranelibrary.com on July 2, 2014.
• Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews. 2010;(1):CD001977. Accessed at www.thecochranelibrary.com on July 2, 2014.
• Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Archives of Internal Medicine. 2012;172(19):1444–1453.
• Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9):955–956.
• Witt CM, Jena S, Brinkhaus B, et al. Acupuncture for patients with chronic neck pain. Pain. 2006;125(1–2):98–106.
• Yuan J, Purepong N, Kerr DP, et al. Effectiveness of acupuncture for low back pain: a systematic review. Spine. 2008;33(23):E887–E900.

Chiropractic:

• Agency for Health Care Policy and Research. Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research; 1997. AHCPR publication no. 98–N002.
• Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. CDC National Health Statistics Report #12. 2008.
• Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3):1–33.
• Cassidy JD, Boyle E, Côté P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Journal of Manipulative and Physiological Therapeutics. 2009;32(2 Suppl):S201–S208. (Republished from Spine. 2008;33(4 Suppl):S176–S183.)
• Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002;27(3):291–296.
• The Council on Chiropractic Education. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status January, 2007. The Council on Chiropractic Education Web site. Accessed at www.cce-usa.org/Publications.html (link is external) on November 23, 2009.
• Dagenais S, Haldeman S. Chiropractic. Primary Care. 2002;29(2):419–437.
• Eisenberg DM, Cohen MH, Hrbek A, et al. Credentialing complementary and alternative medical providers. Annals of Internal Medicine. 2002;137(12):965–973.
• Ernst E. Chiropractic: a critical evaluation. Journal of Pain and Symptom Management. 2008;35(5):544–562.
• Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine. 2009; 34(11):E405–E413.
• Kanodia AK, Legedza AT, Davis RB, et al. Perceived benefit of complementary and alternative medicine (CAM) for back pain: a national survey. Journal of the American Board of Family Medicine. 2010;23(3):354–362.
• Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Archives of Internal Medicine. 1998;158(20):2215–2224.
• Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Annals of Internal Medicine. 2002;136(3):216–227.
• Nahin RL, Barnes PM, Stussman BJ, et al. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. CDC National Health Statistics Report #18. 2009.
• Theil HW, Bolton JE, Docherty S, et al. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine. 2007;32(21):2375–2378.

Meditation:

• Barrett B, Hayney MS, Muller D, et al. Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial. Annals of Family Medicine. 2012;10:337–346.
• Brewer JA, Mallik S, Babuscio TA, et al. Mindfulness training for smoking cessation: results from a randomized controlled trial. Drug and Alcohol Dependence. 2011;119(1–2):72–80.
• Brook RD, Appel RJ, Rubenfire M, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association. Hypertension. 2013;61(6):1360–1383.
• Carim-Todd L, Mitchell SH, Oken BS. Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug and Alcohol Dependence. 2013;132(3):399–410.
• Chen KW, Berger CC, Manheimer E, et al. Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety. 2012;29(7):545–562.
• Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240–1249.
• Cramer H, Haller H, Lauche R, et al. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complementary and Alternative Medicine. 2012;12(162):1–8.
• Dakwar E and Levin FR. The emerging role of meditation in addressing psychiatric illness, with a focus on substance use disorders. Harvard Review of Psychiatry. 2009;17(4):254–267.
• Desbordes G, Negi LT, Pace TW, et al. Effects of mindful-attention and compassion meditation training on amygdala response to emotional stimuli in an ordinary, non-meditative state. Frontiers in Human Neuroscience. 2012;6:1–15
• Fang CY, Reibel DK, Longacre ML, et al. Enhanced psychosocial well-being following participation in a mindfulness-based stress reduction program is associated with increased natural killer cell activity. Journal of Complementary and Alternative Medicine. 2010;16(5):531–538.
• Gaylord SA, Palsson OS, Garland EL, et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. American Journal of Gastroenterology. 2011;106(9):1678–1688.
• Goldstein CM, Josephson R, Xie S, et al. Current perspectives on the use of meditation to reduce blood pressure. International Journal of Hypertension. 2012;2012:578397.
• Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Internal Medicine. 2014;174(3):357–368.
• Greeson JM, Webber DM, Smoski MJ, et al. Changes in spirituality partly explain health-related quality of life outcomes after Mindfulness-Based Stress Reduction. Journal of Behavioral Medicine. 2011;34(6):508–518.
• Jedel S, Hoffman A, Merriman P, et al. A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis. Digestion. 2014;89:142–155.
• Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013;26;8(8):e71834.
• Luders E. Exploring age-related brain degeneration in meditation practitioners. Annals of the New York Academy of Sciences. 2013;1307:82–88.
• Luders E, Kurth F, Mayer EA, et al. The unique brain anatomy of meditation practitioners: alterations in cortical gyrification. Frontiers in Human Neuroscience. 2012;6:1–9.
• Nidich SI, Rainforth MV, Haaga DAF, et al. A randomized controlled trial on effects of the transcendental meditation program on blood pressure, psychological distress, and coping in young adults. American Journal of Hypertension. 2009;22(12):1326–1331.
• Morgan N, Irwin MR, Chung M, et al. The effects of mind-body therapies on the immune system: meta-analysis. PLOS One. 2014;9(7):1–14.
• Ong JC, Manber R, Segal Z, et al. A randomized controlled trial of mindfulness meditation for chronic insomnia. Sleep. 2014;37(9):1553–1563.
• Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Medicine. 2013;14:230–242.
• Rosenkranz M, Davidson RJ, MacCoon D, et al. A comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic inflammation. Brain, Behavior, and Immunity. 2013;27(1):174–184.
• Rubia K. The neurobiology of meditation and its clinical effectiveness in psychiatric disorders. Biological Psychology. 2009;82(1):1–11.
• Tang Y-Y, Tang R, Posner MI. Brief meditation training induces smoking reduction. Proceedings of the National Academy of Sciences. 2013;110(34):13971–13975.
• Westbrook C, Creswell JD, Tabibnia G, et al. Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience. 2013;8(1):73–84.
• Zeidan F, Adler-Neal AL, Wells RE, et al. Mindfulness-meditation-based pain relief is not mediated by endogenous opioids. Journal of Neuroscience. 2016;36(11):3391–3397.

Yoga:

• Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. CDC National Health Statistics Report #12. 2008.
• Birdee GS, Legedza AT, Saper RB, et al. Characteristics of yoga users: results of a national survey. Journal of General Internal Medicine. 2008; 23(10):1653–1658.
• Bower JE, Woolery A, Sternlieb B, et al. Yoga for cancer patients and survivors. Cancer Control. 2005;12(3):165–171.
• Bureau of Labor Statistics. U.S. Department of Labor. Occupational Outlook Handbook, 2010–11 Edition: Fitness Workers. Bureau of Labor Statistics Web site. Accessed at http://www.bls.gov/ooh/personal-care-and-service/fitness-trainers-and-instructors.htm on January 24, 2012.
• Kiecolt-Glaser JK, Christian L, Preston H, et al. Stress, inflammation, and yoga practice. Psychosomatic Medicine. 2010;72(2):113–121.
• Lipton L. Using yoga to treat disease: an evidence-based review. JAAPA. 2008;21(2):34–36, 38, 41.
• Oken BS, Zajdel D, Kishiyama S, et al. Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life. Alternative Therapies in Health and Medicine. 2006;12(1):40–47.
• Raub, JA. Psychophysiologic effects of hatha yoga on musculoskeletal and cardiopulmonary function: a literature review. The Journal of Alternative and Complementary Medicine. 2002;8(6):797–812.
• Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. Journal of Alternative and Complementary Medicine. 2010;16(1):3–12.
• Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Archives of Internal Medicine. 2011;171(22):2019–2026.
• Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back pain: a randomized trial. Annals of Internal Medicine. 2011;155(9):569–578.
• Uebelacker LA, Epstein-Lubow G, Gaudiano BA, et al. Hatha yoga for depression: a critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research. Journal of Psychiatric Practice. 2010; 16(1):22–33.
• Williams K, Abildso C, Steinberg L, et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine. 2009;34(19):2066–2076.
• Wren AA, Wright MA, Carson JW, et al. Yoga for persistent pain: new findings and directions for an ancient practice. Pain. 2011;152(3):477–480.

Acknowledgments

Accupuncture: NCCIH thanks the following people for their technical expertise and review of this publication: Lixing Lao, Ph.D., University of Maryland School of Medicine; Karen Sherman, Ph.D., M.P.H., Group Health Research Institute, Seattle; Maria E. Suarez-Almazor, M.D., Ph.D., The University of Texas M.D. Anderson Cancer Center; and Kristin Huntley, Ph.D., Partap Khalsa, D.C., Ph.D., and John (Jack) Killen, Jr., M.D., NCCIH.

Chiropractic: NCCIH thanks the following individuals for their technical expertise and review of this publication: Gert Bronfort, D.C., Ph.D., Northwestern Health Sciences University; Joel Pickar, D.C., Ph.D., Palmer Center for Chiropractic Research; William Meeker, D.C., M.P.H., Palmer College-West; and Partap Khalsa, D.C., Ph.D., NCCIH.

Meditation: NCCIH thanks the following individuals for their technical expertise and review of the 2014 edition of this publication: Richard J. Davidson, Ph.D., Vilas Professor, Psychology and Psychiatry, University of Wisconsin-Madison; Jeffrey M. Greeson, Ph.D., M.S., Assistant Professor, Psychiatry and Behavioral Sciences, Duke University Medical Center; Helané Wahbe, N.D., Assistant Professor, Neurology, Oregon Health & Science University; and John Glowa, Ph.D., and John (Jack) Killen, Jr., M.D., NCCIH. Thank you to David Shurtleff, Ph.D., NCCIH, for his review of the current edition of this publication.

Yoga: NCCIH thanks the following people for their technical expertise and review of this publication: Janice K. Kiecolt-Glaser, Ph.D., Department of Psychiatry and Institute for Behavioral Medicine Research, Ohio State University College of Medicine; Barry S. Oken, M.D., Departments of Neurology, Behavioral Neuroscience, and Physiology & Pharmacology, Oregon Health & Science University; Karen J. Sherman, Ph.D., M.P.H., Group Health Research Institute; John R. Glowa, Ph.D., and John (Jack) Killen, Jr., M.D., NCCIH.