COMPLEMENTARY AND ALTERNATIVE THERAPIES
NICOE’ S APPROACH TO INTEGRATED MEDICINE
Robert Koffman, MD, MPH
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
NICoE Mission and Vision
DoD 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.
 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)
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 NICoE
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 mTBI, prevalence
82.0%
Multiple mTBI 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 (E1-E3)
3.6%
Mid Level (E4-E6)
48.9%
NonCommissioned Officers (E7-E9)
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 NICoE 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
7.0%
• 22 items
• Possible score range: 0-88
• N: 320
10.9% 13.4%
Clinically
Significant
4.7%
6.6%
Clinically
Significant
Clinically
Significant
14.0%
10.6%
12.5%
5.9%
35.8%
18.0%
8.7%
Clinically
Significant
53.1%
Clinically
Significant
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
3.6%
8.5%
20.1%
Clinically
Significant
Clinically
Significant
17.9%
36.1%
25.3%
17.6%
35.8%
Clinically
Significant
Clinically
Significant
HIT: 2.3 point ∆
SWLS: 5 point ∆
NSI: 5 point ∆
Epworth: 3 point ∆
DHI: 18 point ∆
PCLM: 10 point ∆
3.5% 3.5%
Clinically
Significant
14.6%
Clinical
Significance Key*
31.4%
Clinically
Significant
31.3%
47.0%
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.
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/mphp439/complimentary_meds.pdf
10
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
11
Most Commonly Used CAM
Modalities by US Adults (NHIS
2002)
12
12
Military
CAM Use Among ActiveDuty (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
 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
14
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
15
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
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.
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:
Therapeutic touch, Reiki, qigong, electromagnetic
therapy
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:
 relaxation
 Hypnosis
 visual imagery
 Meditation
 Yoga
 Biofeedback
 Tai chi
 Qi gong
 cognitive-behavioral therapies
 group support
 prayer
 spirituality
18
Alternative/
whole medical systems
Examples:
 Traditional Chinese medicine
(TCM)
 Ayurvedic medicine
 Homeopathy
 Naturopathy
19
Biologically-based
Treatments
Examples:
 botanicals
 animal-derived extracts
 Vitamins
 Minerals
 fatty acids
 amino acids
 Proteins
 prebiotics and probiotics
 functional foods.
20
Manipulative and
Body-based Methods
Examples:
 Chiropractic and osteopathic
manipulation,
 Massage therapy
 Tui Na
 Reflexology
 Rolfing
 Alexander technique
 Feldenkrais method
21
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
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Reactive
Disease-driven
Less choice
Parts of a Person
Treatment of symptoms
Fear as Motivator
External Power and
Control
 Aspiritual
 Quantity of Life
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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 NICoE
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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
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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
Problem
Hyperarousal
Avoidance
Re-experiencing
Anxiety
Depression
Bereavement
Guilt
Hopelessness
Low self-compassion
Low self-efficacy
Moral Injury
Sleep problems
Pain
Tobacco use
Increased alcohol use
Misuse of medications
Polypharmacy
Other high-risk behaviors
Attention/Concentration
Memory
Balance
Cardiovascular/metabolic
Deconditioning
Nutrition Exercise Yoga Tai Chi/Qigong Trauma Releasing Exercises Breathing Rec Therapy Laughter and Humor
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CAM Applications
Problem
Nature Animal-assisted therapy Meditation Mindfulness/acceptance therapies Positive psychology Biofeedback
Hyperarousal
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Avoidance
Re-experiencing
Anxiety
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Depression
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Bereavement
Guilt
Hopelessness
Low self-compassion
Low self-efficacy
Moral Injury
Sleep problems
Pain
Tobacco use
Increased alcohol use
Misuse of medications
Polypharmacy
Other high-risk behaviors
Attention/Concentration
Memory
Balance
Cardiovascular/metabolic
Deconditioning
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CAM Applications
Problem
Hyperarousal
Avoidance
Re-experiencing
Anxiety
Depression
Bereavement
Guilt
Hopelessness
Low self-compassion
Low self-efficacy
Moral Injury
Sleep problems
Pain
Tobacco use
Increased alcohol use
Misuse of medications
Polypharmacy
Other high-risk behaviors
Attention/Concentration
Memory
Balance
Cardiovascular/metabolic
Deconditioning
Neurofeedback Autogenic training Guided Imagery Hypnosis Art Therapy Music Therapy Journaling Bibliotherapy
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CAM Applications
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-compassion
Low self-efficacy
Moral Injury
Sleep problems
Pain
Tobacco use
Increased alcohol use
Misuse of medications
Polypharmacy
Other high-risk behaviors
Attention/Concentration
Memory
Balance
Cardiovascular/metabolic
Deconditioning
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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/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]
30
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
31
Medical Acupuncture
32
Conditions Being Treated with
Acupuncture in US Military
Pain/MSK issues
Sinus
PTSD
TBI
Smoking cessation
Tinnitus
Gastrointestinal issues
Preoperative preparation
Xerostomia,
Orthopedic issues
Vomiting
Preoperative preparation
“Mental health issues”
Laryngitis
Neuropathy
Sleep difficulties
Relaxation
Depression
Anxiety
Headaches/migraines Obesity
Substance abuse
Allergies
Vertigo
Infertility,
Fibromyalgia
Pelvic issues
Masticatory/cervical myalgia
Nausea
Paralysis
Anger/irritability.
33
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.
34
Effects of needle stimulation on 18 common acupoints
on fMRI
Huang W, Pach D, Napadow V, Park K, et al. (2012)
35
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
36
37
“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
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)
 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
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
NICoE 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
NICoE Healing Arts Program
Observed NICoE Mask-making Themes
Patriotism
49
NICoE Healing Arts Program
Death/Grief
50
NICoE Healing Arts Program
Split self
51
NICoE Healing Arts Program
Camouflage/War paint
52
NICoE Healing Arts Program
Compartmentalization/Fragmentation
53
NICoE Healing Arts Program
Spouse art: Caregiver/Nurturer
54
NICoE Healing Arts Program
Montage Paintings
The NICoE Experience
“The Clarity of Chaos”
“Ready or Not”
55
NICoE Healing Arts Program
56
NICoE Healing Arts Program
“Grasping for Normal”
57
NICoE 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., McFann, 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
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
0.00
Forgetfulness
Difficulty falling asleep
Irritability
Poor concentration
Proor frustration
Slowed thinking
Feeling Anxious
Fatigue
Headaches
Difficulty making…
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+
PTSD-
1.50
P <.001 all
1.00
0.50
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64
Ten Most Commonly Utilized CAM
Modalities in US (2004)
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65
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)
68
68
DoD/VA PTSD Clinical Practice
CAM Guidelines: Acupuncture
69
69
Ten Most Commonly Utilized CAM
Modalities in US (2004)
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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)
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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 elimination
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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
18.3 17.9 17.6
16.1
Suicide Deaths Per 100,000
13.1
13.9
11.4 11.3
11
10.5
10.3
200120022003200420052006200720082009201020112012
Source: Mortality Surveillance Division, Armed Forces Medical Examiner
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74
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dk
Integrative Medicine /
High Touch
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