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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
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
Clinically Significant
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
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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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NICoE Healing Arts Program
Observed NICoE Mask-making Themes
Patriotism
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NICoE Healing Arts Program
Death/Grief
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NICoE Healing Arts Program
Split self
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NICoE Healing Arts Program
Camouflage/War paint
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NICoE Healing Arts Program
Compartmentalization/Fragmentation
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NICoE Healing Arts Program
Spouse art: Caregiver/Nurturer
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NICoE Healing Arts Program
Montage PaintingsThe NICoE Experience
“The Clarity of Chaos” “Ready or Not”
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NICoE Healing Arts Program
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NICoE Healing Arts Program
“Grasping for Normal”
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NICoE Healing Arts Program
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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Forge
tfulne
ss
Difficu
lty fa
lling
aslee
p
Poor c
once
ntra
tion
Irrita
bility
Poor f
rust
ratio
n to
leran
ce
Heada
ches
Slowed
think
ing
Fatigu
e an
d los
s of
ene
rgy
Feelin
g an
xious
Difficu
lty m
aking
dec
ision
s
Hearin
g Diff
iculty
Sensit
ivity
to L
ight
Sensit
ivity
to n
oise
Feelin
g de
pres
sed
Numbn
ess
or ti
nglin
g
Vision
pro
blem
s
Poor C
oord
inatio
n
Loss
of A
ppet
iteDizz
y
Loss
of B
alanc
e
Nause
a
Chang
e in
tast
e / s
mell
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
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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Forge
tfulne
ss
Irrita
bility
Proor
frus
tratio
n
Feelin
g Anx
ious
Heada
ches
Hearin
g Diff
icultie
s
Feelin
g Dep
ress
ed
Numbn
ess
Vision
Balanc
e
Nause
a0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
PTSD+PTSD-
Av
era
ge
Sc
ore
P <.001 all
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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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Integrative Medicine / High Touch
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