COMPLEMENTARY AND ALTERNATIVE THERAPIES NICOE’ S APPROACH TO INTEGRATED MEDICINE Robert Koffman, MD, MPH

COMPLEMENTARY AND ALTERNATIVE THERAPIES

NICOE’ S APPROACH TO INTEGRATED MEDICINE

Robert Koffman, MD, MPH

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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

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NICoE Mission and VisionDoD Institute

Research: A DoD 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

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)

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.

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Proof of Concept Interdisciplinary Pt-

Centered Evaluation and

Treatment4 weeks of intensive diagnostics and treatment planning

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Major Diagnostic and Rehabilitation

Equipment

MRI (3-T) / Functional MRI

Positron Emission Tomography with Computed Tomography (PET/CT)

Magneto Encephalography (MEG) Scanner

Trans-Cranial Doppler Ultrasound

CAREN (Computer Assisted Rehabilitation Environment) system

Diffusion Tensor Imaging (DTI)

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DTI Fiber Segmentation Identifies individual WM

tracts.

Manual labeling for 18 WM tracts

Segmented fibers

Streamline fiber tracking using TRACULA results as seeds.

all tracts one end region two end regions

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Research at NICoEMRI Findings

CT Routine MRI- GRE New TBI Study- SWI

Read as Normal Possible Lesion Corpus Callosum

Multiple Lesions Detected

?

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Medical Imperative:Challenging Co-

morbidity

TBIPTSD

• Headache

• Sensitivity to Light or Noise

• Nausea & Vomiting

• Vision Problems

• Dizziness

• Cognitive Deficits

• Irritability

• Insomnia

• Depression

• Fatigue

• Anxiety

• Flashbacks

• Avoidance

• Hypervigilance

• Nightmares

• Re-Experiencing

Pain/Suffering

Polypharmacy

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Subject Population

Demographics

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

Injury relatedBlast-related mTBI, prevalence 82.0%

Multiple mTBI exposures 85.0%

Clinical Findings

PTSD 68.0%

Headaches 88.4%

Insomnia 54.5%

Memory complaints 51.0%

Attention complaints 47.5%

Dizziness 34.0%

Fatigue 31.3%

Rank

Junior Level (E1-E3) 3.6%

Mid Level (E4-E6) 48.9%

NonCommissioned Officers (E7-E9) 33.7%

Warrant and Commissioned Officers 12.0%

Branch

USA 39.8%

USAF 9.1%

USMC 21.3%

USN 28.8%

Demographics and OutcomesD/C Satisfaction Survey – 99% functional improvement

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31.4%

47.0%

14.6%

3.5% 3.5%

36.1%

31.3%

25.3%

3.6%3.6%

20.1%

35.8%17.6%

17.9%

8.5%

12.5%

66.3%

5.9%

10.6%

4.7%

35.8%

32.6%

18.0%

6.6%

7.0%13.4%

53.1%

8.7%

14.0%

10.9%

PTSD Military Checklist (PCLM)• 17 items• Possible score range: 17-85• N: 315

Headache Impact Test (HIT-6)• 6 items• Possible score range: 36-78• N: 322

Overview of Outcome Measures

July 2011-December 2013

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.

Neurobehavioral Symptom Inventory (NSI)• 22 items• Possible score range: 0-88• N: 320

Satisfaction With Life Scale (SWLS)• 5 items• Possible score range: 5-35• N: 316

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

The charts below reflect score changes between admission and discharge across six NICoE outcome measures

Clinical Significance Key*

HIT: 2.3 point ∆SWLS: 5 point ∆

NSI: 5 point ∆Epworth: 3 point ∆

DHI: 18 point ∆PCLM: 10 point ∆

Clinically Significant












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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.htmlhttp://www.cwru.edu/med/epidbio/mphp439/complimentary_meds.pdf

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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 interventions for PTSD

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Most Commonly Used CAM Modalities by US Adults (NHIS

2002)

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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 CAMalternative medicine product or practice in any given year

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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

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CAM Economics

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

http://www.knoxvillecollege.edu/images/business.gif

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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

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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.

Meditation, yoga, prayer, mental healing, creative arts therapies (e.g., dance)

Biologically Based Practices

Biologically-based practices in CAM use substances found in nature, such as herbs, foods, and vitamins.

Dietary supplements, herbal products, diet therapy

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:

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.

Therapeutic touch, Reiki, qigong, electromagnetic therapy

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

CAM Domains

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Mind-body Interventions

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

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Alternative/ whole medical systems

Examples: Traditional Chinese medicine

(TCM) Ayurvedic medicine Homeopathy Naturopathy

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Biologically-based Treatments

Examples: botanicals animal-derived extracts Vitamins Minerals fatty acids amino acids Proteins prebiotics and probiotics functional foods.

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Manipulative and Body-based Methods

Examples: Chiropractic and

osteopathic manipulation, Massage therapy Tui Na Reflexology Rolfing Alexander technique Feldenkrais method

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Energy Therapies

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

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Allopathic vs. Holistic

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

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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

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CAM Applications

Problem Nutrition Exercise Yoga Tai Chi/Qigong Trauma Releasing Exercises Breathing Rec Therapy Laughter and Humor

Hyperarousal Avoidance Re-experiencing Anxiety Depression BereavementGuiltHopelessness Low self-compassion Low self-effi cacy Moral InjurySleep problems Pain Tobacco use Increased alcohol use Misuse of medicationsPolypharmacy Other high-risk behaviors Attention/ConcentrationMemory Balance Cardiovascular/metabolic Deconditioning

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CAM Applications

Problem Nature Animal-assisted therapy Meditation Mindfulness/acceptance therapies Positive psychology Biofeedback

Hyperarousal Avoidance Re-experiencing Anxiety Depression Bereavement Guilt Hopelessness Low self-compassion Low self-effi cacy Moral Injury Sleep problems Pain Tobacco useIncreased alcohol use Misuse of medications Polypharmacy Other high-risk behaviors Attention/Concentration MemoryBalanceCardiovascular/metabolicDeconditioning

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CAM Applications

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Problem Neurofeedback Autogenic training Guided Imagery Hypnosis Art Therapy Music Therapy Journaling Bibliotherapy

Hyperarousal Avoidance Re-experiencing Anxiety Depression Bereavement Guilt Hopelessness Low self-compassionLow self-effi cacy Moral Injury Sleep problems Pain Tobacco use Increased alcohol use Misuse of medicationsPolypharmacy Other high-risk behaviors *Attention/Concentration MemoryBalanceCardiovascular/metabolic Deconditioning

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CAM Applications

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Problem Other Creative Arts Spiritiuality Acupuncture Acupressure EFT Cranial Electrical Stimulation Massage Reiki/Healing Touch Other Bodywork

Hyperarousal Avoidance Re-experiencing Anxiety Depression Bereavement Guilt Hopelessness Low self-compassionLow self-effi cacy Moral Injury Sleep problems Pain Tobacco use Increased alcohol use Misuse of medications Polypharmacy Other high-risk behaviorsAttention/ConcentrationMemory BalanceCardiovascular/metabolicDeconditioning

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Curing vs. Healing

“I would rather know the person who has the disease than know the disease the person has”

Hippocrates… c. 400 BC

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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]

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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

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Medical Acupuncture

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Conditions Being Treated with Acupuncture in US Military

Pain/MSK issues Laryngitis NeuropathySinus Sleep difficulties RelaxationPTSD Depression AnxietyTBI Headaches/migraines ObesitySmoking cessation Substance abuse AllergiesTinnitus 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”

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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.

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

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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

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“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

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Electro-Acupuncture

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Curing vs. Healing

“I would rather know the person who has the disease than know the disease the person has”

Hippocrates… c. 400 BC

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Veterans Caring

for Veterans

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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

Clinical Observations of Warrior Canine Interactions

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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

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MEG Pattern of PTSD

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NICoE Healing Arts Program

MASK-MAKING

“The Warrior Identity”

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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

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Observed NICoE Mask-making Themes

Patriotism

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Death/Grief

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Split self

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Camouflage/War paint

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Compartmentalization/Fragmentation

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Spouse art: Caregiver/Nurturer

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Montage PaintingsThe NICoE Experience

“The Clarity of Chaos” “Ready or Not”

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“Grasping for Normal”

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Bitter no more

Dream of hope, freedom at last

Change is forever

Questions60

61POC: Name

EmailPhone

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., McFann, K. and Nahin, R. (2002) Complementary and Alternative Medicine Use among adults: United States 2004. Seminars in Integrative Medicine, 2 (2) 54-71.

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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

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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

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NSI: Admission vs Discharge

Admission

Discharge

Percentage of “Clinically” Significant Change (>= 2 pts change)

IrritabilityPoor

frustration tolerance

Difficulty falling asleep

Forgetfulness

Feeling anxious

Poor concentration

Slowed thinking

Hearing difficulty

Difficulty making

decisions

Loss of appetite

Fatigue

Percentage (>= 2)

32.8% 32.5% 28.9% 26.7% 25.9% 25.2% 23.6% 23.2% 22.8% 19.5% 19.0%

Cohen's D 0.82 0.71 0.66 0.76 0.55 0.63 0.51 0.53 0.49 0.43 0.46

***

**

*Cohen’s D > 0.6

P< 0.01 All Items

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Ave NSI Scores: PTSD+ vs PTSD-

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Ten Most Commonly Utilized CAM Modalities

in US (2004)

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Physiology of Acupuncture

Neurotransmitters stimulated by acupuncture stimulation: Serotonin, Norepinephrine, Substance P, -aminobuteric acid,

(GABA), Dopamine, Acrenocorticotropic hormone,(ACTH), -endorphin, Enkephalin, Dynorphin

Acupuncture analgesia blocked by naloxone and by procaine injection

Antagonism of serotonin or norepinephrine receptor sites or depletion of serotonin precursors blocks high frequency acupuncture analgesia

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National Acupuncture Detoxification Assoc. NADA Protocol originally

developed for addiction, now utilized for variety of conditions

Five points: Shen Men Sympathetic, Kidney, Liver, Lung

Adjunctive application widely supported (Bergdahl et al, 2012)

Used by 500 addiction programs in US (SAMHSA, 2000)

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Most Commonly Used CAM Modalities by US

Adults (NHIS 2002)

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DoD/VA PTSD Clinical Practice CAM Guidelines:

Acupuncture

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Ten Most Commonly Utilized CAM Modalities

in US (2004)

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Battlefield Acupuncture (Auricular Pain Control)

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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)

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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 elimination74

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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

75Source: Mortality Surveillance Division, Armed Forces Medical Examiner

200120022003200420052006200720082009201020112012

10.310.5 11 11.411.313.113.9

16.1

18.317.917.6

21.8

Suicide Deaths Per 100,000 Peo-ple

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Sdkunv;lvkndk

Integrative Medicine / High Touch

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Documents

COMPLEMENTARY AND ALTERNATIVE THERAPIES NICOE’ S APPROACH TO INTEGRATED MEDICINE Robert Koffman, MD, MPH