NICoE's Approach to Integrated Medicine

1. Complementary AND ALTERNATIVE THERAPIES NICoE’ s Approach to Integrated medicine Robert Koffman, MD, MPH

2. 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

3. NICoE Mission and VisionDoD 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 comorbidTBI and PH conditions, we deliver interdisciplinary and holistic care, conduct focused research, and export knowledge to benefit service members, their families and society. Research: A DoD Institutewith 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 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 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)

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

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

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

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

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

9. Demographics and Outcomes D/C Satisfaction Survey – 99% functional improvement

10. Overview of Outcome MeasuresJuly 2011-December 2013 The charts below reflect score changes between admission and discharge across six NICoE outcome measures • Headache Impact Test (HIT-6) • 6 items • Possible score range: 36-78 • N: 322 • Satisfaction With Life Scale (SWLS) • 5 items • Possible score range: 5-35 • N: 316 • Neurobehavioral Symptom Inventory (NSI) • 22 items • Possible score range: 0-88 • N: 320 Clinically Significant Clinically Significant Clinically Significant Clinically Significant Clinically Significant Clinically Significant Clinical Significance Key* HIT: 2.3 point ∆ SWLS: 5 point ∆ NSI: 5 point ∆ Epworth: 3 point ∆DHI: 18 point ∆ PCLM: 10 point ∆ • Epworth Sleepiness Scale • 8 items • Possible score range: 0-24 • N: 318 • Dizziness Handicap Inventory (DHI) • 25 items • Possible score range: 0-100 • N: 83 • PTSD Military Checklist (PCLM) • 17 items • Possible score range: 17-85 • N: 315 Clinically Significant Clinically Significant Clinically Significant Clinically Significant Clinically Significant Clinically Significant • Interpretation of results: • 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.

11. CAM Relevance References: http://library.thinkquest.org/24206/facts-stats.html http://www.cwru.edu/med/epidbio/mphp439/complimentary_meds.pdf • 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

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

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

14. 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

15. CAM Economics • Popular • 6 - 80 % of use world wide • 40% of Americans use (50% of women) • more visits than to primary care (600M) • "minor" - self care, weight loss, pediatrics • 50% of cancer patients; AIDS users • Paid - $10.3B in 1990; $24B in 1997 • Concealed - 72% don't talk about it to doctor • Combined - 83% used conventional treatment

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

17. Traditional HealthCare Costs Today: Unsustainable • 2.7 trillion spent in the current healthcare system • 4.3 trillion by 2023 • 16% of nations GDP • Double the amount of other western nations • US ranked 37th in the world in health outcomes

18. CAM Domains

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

20. Alternative/ whole medical systems Examples: • Traditional Chinese medicine (TCM) • Ayurvedic medicine • Homeopathy • Naturopathy

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

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

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

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

25. Complementary and Alternative Medicine Practices at NICoE • 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 • 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

26. CAM Applications

27. CAM Applications

28. CAM Applications

29. CAM Applications

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

31. VA/DoD PTSD CPG Recommendations on CAM • There is insufficient evidence to recommend as first line treatments for PTSD [l] • 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] • May be considered as adjunctive approaches to address some co-morbid conditions (e.g. acupuncture for pain) [C]

32. Other CAM Modalities reviewed in the PTSD CPG • : • 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 • Meditation Training (e.g., zen) Improves sleep, anxiety, and pain, BUT no RCTs in PTSD • Exercise (mostly aerobic exercise) Rarely conducted in isolation from other interventions • Energy Medicine (e.g., Qi Gung, Reiki, Johrei) Improvement in comorbid conditions, BUT not RCTs in PTSD

33. Medical Acupuncture

34. 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”

35. Pain – How acupuncture works • Pain Gate Theory • Acupuncture may alter how pain signals are perceived in the brain. • Endorphins • Acupuncture causes local damage to tissues causing a release of endorphins. • fMRI Studies • Acupuncture causes changes in the brain in areas responsible for pain perception.

36. Effects of needle stimulation on 18 common acupoints on fMRIHuang W, Pach D, Napadow V, Park K, et al. (2012)

37. Pain and the Brain Pain affects our brain • Age related losses in gray matter = 0.5%/year • Chronic low back pain patients = 5-11% decrease in gray matter compared to controls • Impact of chronic low back pain is an additional 10 years of brain atrophy Our Brain affects pain • Anxiety about pain is a predictor of pain - McCraken 1998 • Depression an important predictor of LBP – Jarvik, Spine, 2005 • Pain is modulated by perception-Different patients tolerate pain differently Journal of Neuroscience, 2004 Nov

39. “Battlefield” Acupuncture • Auricular Acupuncture is utilized largely to deal w/ acute pain management in field/combat environments (COL Niemtzow) • The main points used are: shenmen, point 0, thalamus, omega2, and cingulate gyrus

40. Electro-Acupuncture

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

43. Veterans Caring for Veterans

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

46. 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

47. MEG Pattern of PTSD

48. NICoE Healing Arts Program MASK-MAKING “The Warrior Identity”

49. 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

50. NICoE Healing Arts Program Observed NICoE Mask-making Themes Patriotism