COMPLEMENTARY AND ALTERNATIVE THERAPIES NICOE S APPROACH TO

COMPLEMENTARY AND ALTERNATIVE THERAPIES NICOE’ S APPROACH TO INTEGRATED

Disclaimer The views expressed in this presentation are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government 1

NICo. E Mission and Vision Do. D Institute Vision: To be the nation’s institute for traumatic brain injury and psychological health dedicated to advancing science, enhancing understanding, maximizing health and relieving suffering. Mission: As the Military Health System institute dedicated to understanding complex, combat and mission related comorbid TBI and PH conditions, we deliver interdisciplinary and holistic care, conduct focused research, and export knowledge to benefit service members, their families and society. Ø Research: A Do. D Institute with a unique patient base and the most current technical and clinical resources for initiating innovative pilot studies designed to advance the characterization of the pathophysiology of the co-morbid state, while additionally serving as a “hub” for exchanging information with federal and academic partners Ø Training and Education: A venue for the dissemination of next generation standards of care and resilience to providers as well as service members and families Ø Clinical: A model of holistic, interdisciplinary evaluation and treatment in a family focused, collaborative environment that promotes physical, psychological and spiritual healing of service members (SM) with the complex interaction of TBI and PHI who are not responding to conventional therapy elsewhere in the Military Health System (MHS) 2

Proof of Concept Interdisciplinary Pt. Centered Evaluation and Treatment 4 weeks of intensive diagnostics and treatment planning 3

Major Diagnostic and Rehabilitation Equipment Magneto Encephalography (MEG) Scanner Diffusion Tensor Imaging (DTI) Positron Emission Tomography with Computed Tomography (PET/CT) CAREN (Computer Assisted Rehabilitation Environment) system MRI (3 -T) / Functional MRI Trans-Cranial Doppler Ultrasound 4

DTI Fiber Segmentation Identifies individual WM tracts. Segmented fibers Manual labeling for 18 WM tracts all tracts one end region two end regions Streamline fiber tracking using TRACULA results as seeds. 5

Research at NICo. E MRI Findings CT Routine MRI- GRE New TBI Study- SWI ? Read as Normal Possible Lesion Corpus Callosum Multiple Lesions Detected 6

Medical Imperative: Challenging Co-morbidity PTSD • Flashbacks • Avoidance • Hypervigilance • Nightmares • Re-Experiencing TBI • Cognitive Deficits • Headache • Irritability • Sensitivity to Light or Noise • Insomnia • Nausea & Vomiting • Depression • Vision Problems • Fatigue • Dizziness • Anxiety Polypharmacy Pain/Suffering 7

Demographics and Outcomes D/C Satisfaction Survey – 99% functional improvement Subject Population Demographics Injury related Clinical Findings Rank Branch Age 35. 05 ± 8. 1 Gender 95. 8% male Years of education 13. 71 ± 1. 9 Time in service 13. 41 ± 7. 5 Number of military deployments 2. 4 ± 0. 7 Blast-related m. TBI, prevalence 82. 0% Multiple m. TBI exposures 85. 0% PTSD 68. 0% Headaches 88. 4% Insomnia 54. 5% Memory complaints 51. 0% Attention complaints 47. 5% Dizziness 34. 0% Fatigue 31. 3% Junior Level (E 1 -E 3) 3. 6% Mid Level (E 4 -E 6) 48. 9% Non. Commissioned Officers (E 7 -E 9) 33. 7% Warrant and Commissioned Officers 12. 0% USA 39. 8% USAF 9. 1% USMC 21. 3% USN 28. 8% 8

Overview of Outcome Measures July 2011 -December 2013 The charts below reflect score changes between admission and discharge across six NICo. E outcome measures Headache Impact Test (HIT-6) Satisfaction With Life Scale (SWLS) Neurobehavioral Symptom Inventory (NSI) • 6 items • Possible score range: 36 -78 • N: 322 • 5 items • Possible score range: 5 -35 • N: 316 • 22 items • Possible score range: 0 -88 • N: 320 4. 7% 10. 9% Clinically Significant 6. 6% 13. 4% 7. 0% Clinically Significant 14. 0% Clinically Significant 5. 9% 35. 8% 18. 0% 8. 7% Clinically Significant 10. 6% 12. 5% Clinically Significant 53. 1% Clinically Significant 66. 3% 32. 6% Epworth Sleepiness Scale Dizziness Handicap Inventory (DHI) PTSD Military Checklist (PCLM) • 8 items • Possible score range: 0 -24 • N: 318 • 25 items • Possible score range: 0 -100 • N: 83 3. 6% • 17 items • Possible score range: 17 -85 • N: 315 8. 5% Clinically Significant 20. 1% 3. 6% Clinically Significant 17. 9% 36. 1% 25. 3% 17. 6% 35. 8% Clinically Significant HIT: 2. 3 point ∆ SWLS: 5 point ∆ NSI: 5 point ∆ Epworth: 3 point ∆ DHI: 18 point ∆ PCLM: 10 point ∆ 3. 5% 14. 6% Clinical Significance Key* 31. 4% Clinically Significant 31. 3% Interpretation of results: 47. 0% • • Improvement is determined by any point change greater than 0 signifying a lessening of symptoms. The remained the same category consists of scores that did not change between admission and discharge. Worsening is determined by any point change greater than 0 signifying an increase in symptoms. 9

CAM Relevance • 74 percent of the American population desire a more natural approach to health care • Of the one out of three Americans who say they have used alternative medicine techniques, 84 percent said they would use it again • Traditional Chinese medicine has been chosen by the World Health Organization for worldwide propagation to meet the heath care needs of the twenty-first century. • Most hospitals now offer some form of CAM treatment. A study in the Archives of Internal medicine reported that 43% of U. S. physicians refer patients to CAM providers References: http: //library. thinkquest. org/24206/facts-stats. html http: //www. cwru. edu/med/epidbio/mphp 439/complimentary_meds. pdf 10

Rationale for using CAM Approaches ØPTSD is prevalent among Veterans 10 -16% (Miliken, et al. , 2007) and increasing in the VA (Rosen) Ø 60% of Veterans still meet criteria for PTSD after treatment (Monson, et al. , 2006; Schnurr et al. , 2007) ØNeed to explore new interventions for PTSD 11

Most Commonly Used CAM Modalities by US Adults (NHIS 2002) 12 12

Military CAM Use Among Active. Duty (Smith et al. , 2007) approx 1/3 of the active duty military and 50% of veterans may use a CAM alternative medicine product or practice in any given year 13 13

CAM Economics Ø Popular Ø 6 - 80 % of use world wide Ø 40% of Americans use (50% of women) Ø more visits than to primary care (600 M) Ø "minor" - self care, weight loss, pediatrics Ø 50% of cancer patients; AIDS users Ø Paid - $10. 3 B in 1990; $24 B in 1997 Ø Concealed - 72% don't talk about it to doctor Ø Combined - 83% used conventional treatment 14

CAM Economics Ø Americans spend more out-of-pocket for CAM than for all other health care needs Ø CAM is big business Ø 56% of Americans believe their health plans should cover CAM Ø Many civilian health insurers and HMOs now cover CAM: Blue Cross of Washington and Alaska, Oxford Health, Prudential, Kaiser Permanente 15

Traditional Health. Care Costs Today: Unsustainable Ø 2. 7 trillion spent in the current healthcare system Ø 4. 3 trillion by 2023 Ø 16% of nations GDP ØDouble the amount of other western nations ØUS ranked 37 th in the world in health outcomes 16

CAM Domains NCCAM Domain Definition Example Practices Mind–Body Medicine Mind–body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Biologically Based Practices Biologically-based practices in CAM use substances found in nature, Dietary supplements, herbal products, diet therapy such as herbs, foods, and vitamins. Manipulative and Body-based Practices Manipulative and body-based practices in CAM are based on manipulation and/or movement of one or more parts of the body. Chiropractic/osteopathic manipulation, massage, Feldenkrais Energy Medicine Energy therapies involve the use of energy fields. They are of two types: Therapeutic touch, Reiki, qigong, electromagnetic therapy Meditation, yoga, prayer, mental healing, creative arts therapies (e. g. , dance) Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. Whole Medical Systems Whole medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from, and earlier than, the conventional medical approach used in the United States. Systems developed in Western cultures: Homeopathic medicine, naturopathic medicine Systems developed in non-Western cultures: Traditional Chinese medicine, Ayurveda 17

Mind-body Interventions Examples: Ø relaxation Ø Hypnosis Ø visual imagery Ø Meditation Ø Yoga Ø Biofeedback Ø Tai chi Ø Qi gong Ø cognitive-behavioral therapies Ø group support Ø prayer Ø spirituality 18

Alternative/ whole medical systems Examples: Ø Traditional Chinese medicine (TCM) Ø Ayurvedic medicine Ø Homeopathy Ø Naturopathy 19

Biologically-based Treatments Examples: Ø botanicals Ø animal-derived extracts Ø Vitamins Ø Minerals Ø fatty acids Ø amino acids Ø Proteins Ø prebiotics and probiotics Ø functional foods. 20

Manipulative and Body-based Methods Examples: Ø Chiropractic and osteopathic manipulation, Ø Massage therapy Ø Tui Na Ø Reflexology Ø Rolfing Ø Alexander technique Ø Feldenkrais method 21

Energy Therapies Examples: Ø Reiki and Johrei Ø Qi gong Ø Healing touch Ø Therapeutic Touch Ø Intercessory prayer Ø Magnetic Therapy Ø Distant healing Ø Acupuncture 22

Allopathic vs. Holistic Ø Ø Ø Ø Reactive Disease-driven Less choice Parts of a Person Treatment of symptoms Fear as Motivator External Power and Control Ø Aspiritual Ø Quantity of Life Ø Ø Ø Ø Ø Proactive Prevention More Choice Treating the whole Underlying Cause Feeling Good Empowerment Internal Power Spiritual Quality of Life 23

Complementary and Alternative Medicine Practices at NICo. E Ø Ø Ø Ø Nutrition Exercise Yoga Tai Chi/Qigong Trauma Releasing Exercises Rec Therapy Laughter and Humor Animal-Assisted Therapy Meditation Mindfulness/Acceptance Therapies Positive Psychology Biofeedback Neurofeedback Autogenic Training Ø Ø Ø Ø Guided Imagery Hypnosis Art Therapy Music Therapy Journaling Bibliotherapy Other Creative Arts Spirituality Acupuncture Acupressure Emotional Freedom Techniques Cranial Electrical Stimulation Reiki/Healing Touch Other Bodywork 24

CAM Applications 25

CAM Applications 26

CAM Applications 27 27

CAM Applications 28 28

Curing vs. Healing “I would rather know the person who has the disease than know the disease the person has” Hippocrates… c. 400 BC 29

VA/Do. D PTSD CPG Recommendations on CAM Ø There is insufficient evidence to recommend as first line treatments for PTSD [l] Ø CAM approaches that facilitate a relaxation response (e. g. mindfulness, yoga, massage) may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques [l] Ø May be considered as adjunctive approaches to address some co-morbid conditions (e. g. acupuncture for pain) [C] 30

Other CAM Modalities reviewed in the PTSD CPG Ø: Ø Body-Mind Approaches (e. g. , Yoga, & Tai Chi) RCTs show benefits in other areas (e. g. sleep, stress, anxiety, etc. ), BUT no RCTs or comparison trials in PTSD Ø Meditation Training (e. g. , zen) Improves sleep, anxiety, and pain, BUT no RCTs in PTSD Ø Exercise (mostly aerobic exercise) Rarely conducted in isolation from other interventions Ø Energy Medicine (e. g. , Qi Gung, Reiki, Johrei) Improvement in comorbid conditions, BUT not RCTs in PTSD 31

Medical Acupuncture 32

Conditions Being Treated with Acupuncture in US Military Pain/MSK issues Laryngitis Neuropathy Sinus Sleep difficulties Relaxation PTSD Depression Anxiety TBI Headaches/migraines Obesity Smoking cessation Substance abuse Allergies Tinnitus Vertigo Infertility, Gastrointestinal issues Fibromyalgia Preoperative preparation Pelvic issues Xerostomia, Masticatory/cervical myalgia Orthopedic issues Nausea Vomiting Paralysis Preoperative preparation Anger/irritability. “Mental health issues” 33

Pain – How acupuncture works ØPain Gate Theory Ø Acupuncture may alter how pain signals are perceived in the brain. ØEndorphins Ø Acupuncture causes local damage to tissues causing a release of endorphins. Øf. MRI Studies Ø Acupuncture causes changes in the brain in areas responsible for pain perception. 34

Effects of needle stimulation on 18 common acupoints on f. MRI Huang W, Pach D, Napadow V, Park K, et al. (2012) 35

Pain and the Brain Pain affects our brain Our Brain affects pain Ø Age related losses in gray matter = 0. 5%/year Ø Chronic low back pain patients = 5 -11% decrease in gray matter compared to controls Ø Impact of chronic low back pain is an additional 10 years of brain atrophy Ø Anxiety about pain is a predictor of pain - Mc. Craken 1998 Ø Depression an important predictor of LBP – Jarvik, Spine, 2005 Ø Pain is modulated by perception-Different patients tolerate pain differently Journal of Neuroscience, 2004 Nov 36

37

“Battlefield” Acupuncture Ø Auricular Acupuncture is utilized largely to deal w/ acute pain management in field/combat environments (COL Niemtzow) Ø The main points used are: shenmen, point 0, thalamus, omega 2, and cingulate gyrus 38

Electro-Acupuncture 39

Curing vs. Healing “I would rather know the person who has the disease than know the disease the person has” Hippocrates… c. 400 BC 40

Veterans Caring for Veterans 42

Clinical Observations of Warrior Canine Interactions Animal assisted therapy has been shown to reduce anxiety ratings in psychiatric patients. (Barker & Dawson, 1998) Ø Improves emotional regulation and patience Ø Improves family dynamics, parenting skills Ø Re-establishes a sense of purpose Ø Reduces social isolation Ø Helps reintegrate into the community Ø Builds relationship skills/trust/confidence Ø Relaxes hyper vigilant survival state Ø Improves sleep patterns and reduces need for pain Rx 43

44

SM’s Work in Healing Arts You allowed me to open up to you and communicate a burden I have carried for so long… here is one more haiku: Bitter no more Dream of hope, freedom at last Change is forever 45

MEG Pattern of PTSD 46 46

NICo. E Healing Arts Program MASK-MAKING “The Warrior Identity” 47

SM’s Work in Healing Arts You allowed me to open up to you and communicate a burden I have carried for so long… here is one more haiku: Bitter no more Dream of hope, freedom at last Change is forever 48

NICo. E Healing Arts Program Observed NICo. E Mask-making Themes Patriotism 49

NICo. E Healing Arts Program Death/Grief 50

NICo. E Healing Arts Program Split self 51

NICo. E Healing Arts Program Camouflage/War paint 52

NICo. E Healing Arts Program Compartmentalization/Fragmentation 53

NICo. E Healing Arts Program Spouse art: Caregiver/Nurturer 54

NICo. E Healing Arts Program Montage Paintings The NICo. E Experience “The Clarity of Chaos” “Ready or Not” 55

NICo. E Healing Arts Program 56

NICo. E Healing Arts Program “Grasping for Normal” 57

NICo. E Healing Arts Program Bitter no more Dream of hope, freedom at last Change is forever 58

Questions 59

PREVALENCE • 2007 - adults in the US spent 33. 9 billion dollars out of pocket on visits to CAM practitioners and on CAM products, classes, and materials • 2002, 62% of adults used some form of CAM therapy during the past 12 months including prayer • 36% of adults used some form of CAM therapy during the past 12 months excluding prayer Barnes, P. , Powell-Griner, E. , Mc. Fann, K. and Nahin, R. (2002) Complementary and Alternative Medicine Use among adults: United States 2004. Seminars in Integrative Medicine, 2 (2) 54 -71. POC: Name Email Phone 60

Acupuncture: Systematic Review The effectiveness of acupuncture research across components of the trauma spectrum response (TSR): a systematic review of reviews Based on the results of 1, 480 citations leading to 52 systematic reviews/meta-analyses, acupuncture appears to be effective for treating headaches … and seems to be a promising treatment option for anxiety, sleep disturbances, depression and chronic pain – Lee, et al, 2012 61

NIH NCCAM Whole Medical Systems: Complete system of theory and practice. • Western Cultures: Homeopathic/ Naturopathic • Non-Western: Traditional Chinese Medicine, Ayurveda Mind-Body Medicine: Designed to have the mind affect bodily function & symptoms (CB Therapy, meditation, prayer, art & dance) Biologically Based Practices: Substances found in nature (herbs, foods & vitamins) Manipulative Body Based Practices: Movement of body and limbs (chiropractic, shiatsu/Acupressure, massage, osteopathic) Energy Therapies: 1) Biofield - Affect energy fields around and in body like qigong and Reiki. 2) Bioelectromagnetic-Based - Use of electromagnetic fields like magnet fields 62

NSI: Admission vs Discharge 3. 50 3. 00 * * * 2. 50 * * 2. 00 1. 50 1. 00 Admission Discharge 0. 50 * Cohen’s D > 0. 6 0. 00 D iff ic Fo rg et ul f ty fa uln es l lin Po s g or as c le on ep ce Po nt or ra fr tio us n tra Irrit ab tio ilit n y to le ra nc H ea e Fa Sl da tig o c ue w ed hes a nd th lo in ki ss ng o D f iff F e ic ee ne ul lin rg ty g m y a ak nx in io g de us H ea c rin isio ns g Se D ns iff ic iti ul ty Se vity to ns L iti ig vi ht ty Fe to el i no n N is um g d e e pr bn es es se s or d ti Vi ng si o lin Po n p g r ob or C le m oo s rd Lo ss inat i o f A on pp et ite Lo D ss iz o f B zy al C an ha ce ng N e au in ta se st a e / s m el l P< 0. 01 All Items Percentage of “Clinically” Significant Change (>= 2 pts change) Irritability Poor frustration tolerance Difficulty Forgetfulne falling ss asleep Percentage (>= 2) 32. 8% 32. 5% 28. 9% 26. 7% 25. 9% 25. 2% Cohen's D 0. 82 0. 71 0. 66 0. 76 0. 55 0. 63 Feeling anxious Poor Slowed concentratio thinking n Hearing difficulty Difficulty making decisions Loss of appetite Fatigue 23. 6% 23. 2% 22. 8% 19. 5% 19. 0% 0. 51 0. 53 0. 49 0. 43 630. 46

Forgetfulness Difficulty falling asle. . . Irritability Poor concentration Proor frustration Slowed thinking Feeling Anxious Fatigue Headaches Difficulty making dec. . . Hearing Difficulties Sensitivity to Light Feeling Depressed Sensitive to Noise Numbness Poor Coordination Vision Loss of appetite Balance Dizzy Nausea Change in Taste Average Score Ave NSI Scores: PTSD+ vs PTSD- 3. 50 3. 00 2. 50 2. 00 PTSD+ PTSDP <. 001 all 1. 50 1. 00 0. 50 0. 00 64 64

Ten Most Commonly Utilized CAM Modalities in US (2004) 65 65

Physiology of Acupuncture ØNeurotransmitters stimulated by acupuncture stimulation: Ø Serotonin, Norepinephrine, Substance P, -aminobuteric acid, (GABA), Dopamine, Acrenocorticotropic hormone, (ACTH), -endorphin, Enkephalin, Dynorphin Ø Acupuncture analgesia blocked by naloxone and by procaine injection Ø Antagonism of serotonin or norepinephrine receptor sites or depletion of serotonin precursors blocks high frequency acupuncture analgesia 66

National Acupuncture Detoxification Assoc. Ø NADA Protocol originally developed for addiction, now utilized for variety of conditions Ø Five points: Shen Men Sympathetic, Kidney, Liver, Lung Ø Adjunctive application widely supported (Bergdahl et al, 2012) Ø Used by 500 addiction programs in US (SAMHSA, 2000) 67

Most Commonly Used CAM Modalities by US Adults (NHIS 2002) 68 68

Do. D/VA PTSD Clinical Practice CAM Guidelines: Acupuncture 69 69

Ten Most Commonly Utilized CAM Modalities in US (2004) 70 70

Battlefield Acupuncture (Auricular Pain Control) 71 71

Activation of the Parasympathetic System (PNS) Vagus nerve: main pathway of PNS Vagus nerve is bidirectional Breathing activates afferent pathways that stimulate vagus n. Voluntary change in pattern of breath can alter the activity of vagus n. and induce specific emotions (Philippot P & Blairy S. 2003) 72

Relaxation Response (Benson 2011) Repetitive Prayer Yoga Tai Chi Progressive Muscle Relaxation Meditation Qigong Guided Imagery Breathing Exercises Results: Prominent low frequency heart rate oscillation Decreased oxygen utilization Decreased carbon dioxide elimination 73 73

Suicide Rate for Active Duty Trends in the Military • T The suicide rate for Active Duty Service members in the U. S. rose from 2001 to 2009. While rates remained essentially level in 2010 and 2011, they rose again in 2012. Preliminary data indicates they declined in 2013 21. 8 16. 1 Suicide Deaths Per 100, 000 13. 1 18. 3 17. 9 17. 6 13. 9 11. 4 11. 3 10. 5 11 200120022003200420052006200720082009201020112012 Source: Mortality Surveillance Division, Armed Forces Medical Examiner 74 74

Sdk unv; l vknd k Integrative Medicine / High Touch 75

76