Integrative Health Care for Veterans

1. Integrative Health Care for Veterans War Related Illness and Injury Study Center Washington, DC

2. Welcome Acupuncture Presenter Jeanette Akhter, MD, MAc, Licensed Acupuncturist Jeanette.Akhter@va.gov Integrative Health Care Presenter Kelly McCoy, PsyD Kelly.McCoy2@va.gov Labyrinth Presenter Brenda Jasper, MEd, PA-C National Referral Program Coordinator Brenda.Jasper@va.gov Yoga Presenter Louise Mahoney, MSLouise.Mahoney2@va.gov

4. New and growing approach to health care delivery Broader in focus than conventional care Coordinated health care Explicitly combines conventional and complementary approaches Complementary and alternative medicine (CAM): “A group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” – NCCAM definition http://nccam.nih.gov/health/whatiscam/#definingcam What is Integrative Health Care?

5. Mind, body, spirit, community Tradition and innovation Healing extends beyond cure Tailored toward patient goals Shared responsibility Philosophy of Integrative Health Care

6. Holistic, broad scope Scientifically-rigorous Values wisdom Motivational Patient-centered Prevention and treatment Interdisciplinary Healing environments and relationships Cross-trained providers Incorporates mind-body skills Qualities of Integrative Health Care

7. Individuals managing chronic illnesses People facing acute health and life events Individuals who want to optimize wellness Who can benefit?

8. Integrative Health Care for Veterans

9. War Related Illness and Injury Study Center VA Office of Public Health and Environmental Hazards Clinical care, research, education, risk communication National referral program Outpatient programs (DC, NJ, CA) Identified need for coordinated treatment approaches The WRIISC and Post-Deployment Health Care

10. 2010 total encounters 649 individual full body 890 group ear acupuncture Improvement in symptoms (n = 103) 45% yes, completely 51% yes, somewhat 3% no improvement <1% too early to tell Overall quality (n = 112) 70% excellent 20% very good 10% good <1% poor Would recommend to other Veterans (n = 130) 99% yes <1% no Acupuncture Satisfaction Data

11. Acupuncture Satisfaction Data

12. 2010 total encounters 1,318 sessions Improvement in symptoms (n = 165) 10% yes, completely 85% yes, somewhat 4% no improvement <1% don’t have symptoms Overall quality (n = 184) 66% excellent 30% very good 1% good 2% poor Would recommend to other Veterans (n = 184) 100% yes iRest® Yoga NidraSatisfaction Data

13. Yoga Nidra Satisfaction Data

14. 2010 total visits 481 How was your walk on the Freedom Labyrinth Path? (n = 227) 50% excellent 42% very good 7% fair <1% no value Would you walk the labyrinth again? (n = 227) 99% yes <1% no Descriptions of the labyrinth: Calming, relaxing, serene, awesome, soothing, wonderful, excellent, mellow, balanced, peaceful, meditative, rejuvenating, surprising, inspirational, therapeutic, centering, uplifting, helpful, purposeful, anchoring, euphoric Labyrinth Satisfaction Data

15. Chair yoga Mat yoga (mixed gender) Mat yoga (women only) Satisfaction data collected following completion of 12 weekly sessions of either chair or mat yoga Would you recommend WRIISC yoga to a friend ? (n = 11) 100% yes Do you feel better after class than before? (n = 13) 100 % yes Would you participate in WRIISC yoga again? (n = 12) 100% yes Yoga with Movement

16. “It is one thing I look forward to because for that short amount of time I have hope” – Operation Iraqi Freedom Veteran “Best thing in years” – Korean War Veteran “Wonderful for body and soul” – Gulf War I Veteran “Great class, should meet 2x per week” – Vietnam War Veteran” Yoga with Movement Feedback

17. Yoga and Mind/Body Therapies for Treatment of War Related Illness and Injuries PI: Louise Mahoney, MS, WRIISC-CA The Effect of Acupuncture for PTSD-Related Insomnia PI: Michelle Prisco, MSN, ANP-C, WRIISC-DC Results anticipated May-June 2012 Integrative Health Care Research at the WRIISC

18. Qigong for Symptom Management and Function in Veterans with Fatiguing Illnesses PI: Anna Rusiewicz, PhD, WRIISC-NJ Results anticipated September 2012 Acupuncture to Improve the Quality of Life in Veterans with TBI and PTSD PI: Anna Rusiewicz, PhD & Thomas Findley, MD PhD, WRIISC-NJ Results anticipated January 2012 Integrative Health Care Research at the WRIISC

19. Progressive relaxation Tai Chi Qigong Reiki Spinal manipulation Structural integration Tai Chi Therapeutic touch Yoga with movement Yoga Nidra Integrative Modalities Throughout the VHA System Acupuncture Aquatic bodywork Aromatherapy Biofeedback Deep-breathing exercises Guided imagery Hypnotherapy Labyrinth Laughter yoga Mindfulness meditation Massage

20. Salt Lake City, UT VAMC Acupuncture Aquatic bodywork Stress management class: guided imagery, relaxation techniques, biofeedback, qigong, awareness and reframing of thought patterns Medical hypnosis Yoga with movement Herbal/nutritional supplement/drug interaction education Meditation Qigong Tobacco cessation Weight management class: nutrition, exercise, psychotherapy, hypnosis VA Integrative Health Clinic and Program

21. Chronic nonmalignant pain Longitudinal outcome research Chronic nonspinal-related pain group vs. chronic spinal-related pain group Nonspinal pain group: Improved depression, anxiety, bodily pain, vitality and health transition Benefits persisted to 24 months Spinal-related pain group: trend toward improvement in bodily pain Smeeding, S. J. W., Bradshaw, D. H., Kumpfer, K. L., Trevithick, S. & Stoddard, G. J. (2011). Outcome evaluation of the Veterans Affairs Salt Late City Integrative Health Clinic for chronic nonmalignant pain. The Clinical Journal of Pain, 27, 146-155. VA Integrative Health Clinic - Research

22. Depression, anxiety, and posttraumatic stress disorder Longitudinal outcome research Group comparisons based on levels of anxiety, depression, and PTSD symptoms Improved depression, anxiety and health-related quality of life in all groups Greatest improvements seen in the high anxiety, high depression, and PTSD groups Smeeding, S. J. W., Bradshaw, D. H., Kumpfer, K., Trevithick, S., & Stoddard, G. J. (2010). Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. The Journal of Alternative and Complementary Medicine,16, 823-835. VA Integrative Health Clinic - Research

23. Acupuncture

24. (acupuncture video 1)

25. Acupuncture is Over Three Thousand Years Old Acupuncture’s greatest contribution to the field medicine is its understanding of qi –translated as life force, or energy. Qihelps us maintain health. It provides the power for: Growth Development Movement Maintaining body temperature Protection against illness Overall regulation

26. Qi is Our Life Force When our Qi is balanced, our capacity to both heal disease and prevent future illness is maximized. Our health is influenced by the quality, quantity and balance of our Qi. Symptoms of illness, whether mental, emotional or physical, are an indication of an imbalance of Qi.

27. Qi Imbalance • Qi depletion, obstruction, disorganization • Causes of imbalance • Injury • Illness • Environmental exposure • Poor quality nourishment • Lack of physical exercise

28. Qi Moves with a Rhythm, Inside a Boundary YANG/Sympathetic Arousal Daytime, summer Awake and alert Inhale Exhale Nighttime, winter Rest and digest YIN/Parasympathetic Restoration Balance is a constantly changing state. It exists in a dynamic and fluid interplay between our more substantial, dense yin aspect, and our more insubstantial, active yang aspect.

29. Acupuncture Helps Restore Balance Acupuncture heals below cognition It helps people feel more embodied, more present, more self aware 12 main pathways – connected end to end like garden hoses

31. How Does Acupuncture Work? • Local effect • Mechanical stimulation of connective tissue • Adenosine release • Increase local blood flow • “Gate” mechanism

32. How does Acupuncture Work? • Increases release and binding of endogenous opioids • Basal forebrain • Limbic system • Brainstem • fMRI studies • Positron emission tomography studies

35. Goals of Acupuncture • Unique - focused on individual Veteran’s needs • Physical • Mental • Emotional • Spiritual

36. Method • Ask • Listen • Observe • Palpate • Choose specific points • Observe results

37. Full body, individual series of treatments Unique design for the individual’s presentation Washington, DC WRIISC Acupuncture Options

38. Group Ear Acupuncture Five points on each ear Balance of sympathetic/parasympathetic nervous systems as well as emotional balance Can be used for detoxification Often affects sleep patterns Multiple venues at DC WRIISC DC Acupuncture Options

40. Year 2010 649 full body acupuncture treatments 145 Gulf War Veteran treatments 890 ear acupuncture treatments 103 Gulf War Veteran treatments Acupuncture Interest at WRIISC-DC

41. Acupuncture and Integrative Health Care Acupuncture can help: Improve focus and attention, supporting psychotherapy clients to integrate and embody insights Bring energy to physical injuries, supporting the work of physical therapists Mitigate side effects of necessary medications Help some reduce medications – for sleep or pain for example

42. Acupuncture Helps Veterans Get All The Way Home - Safe and Sound Acupuncture helps the mind find a place to rest, the body release trauma's imprint and the spirit come back home – safe and sound.

43. Acupuncture Research – Selected Bibliography Berman, B. M., Langevin, H. M., Witt, C. M., Dubner, R. (2010). Acupuncture for chronic low back pain. New England Journal of Medicine, 363, 454-461. http://www.ncbi.nlm.nih.gov/pubmed/20818865 Birch, S., Hesselinm, J. K., Jonkman, F. A., & Hekker, T. A. (2004). Clinical Research on Acupuncture: Part I. What have Reviews of the Efficacy and Safety of Acupuncture told us so far? The Journal of Alternative and Complementary Medicine, 10. http://www.ncbi.nlm.nih.gov/pubmed?term=birch%202004%20clinical%20research%20on%20acupuncture%20part%201 Blitzer, L., Atchison-Nevel, D., & Kenny, M. (2004). Using acupuncture to treat major depressive disorder: a pilot investigation. Clinical Acupuncture and Oriental Medicine, 4, 144-147. Chen HY, Shi Y, Ng CS, Chan SM, Yung KK, Zhang QL. Auricular acupuncture treatment for insomnia: A systematic review. J Altern Complement Med 2007; 13(6): 669-76. http://www.ncbi.nlm.nih.gov/pubmed/17718650 Duncan A, Liechty JM, Miller C, Chinoy G, Ricardi, R. Employee use and perceived benefit of a CAM wellness clinic at a major military hospital: Evaluation of a pilot program. J Altern Complement Med. In Press. Eich, H., Agelink, M.W., Lehmann, E., Lemmer, W., & Klieser, E. (2000). Acupuncture in patients with minor depressive episodes and generalized anxiety disorders: Results of an experimental study. FortschNeurolPsychiatrie, 68, 137-144. http://www.ncbi.nlm.nih.gov/pubmed?term=eich%202000%20acupuncture%20in%20patients%20with%20minor%20depression

44. Acupuncture Research – Selected Bibliography (continued) Goertz CM, Niemtzow R, Burns SM, Fritts MJ, Crawford CC, Jonas WB. Auricular acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med 2006; 171(10): 1010-4. http://www.ncbi.nlm.nih.gov/pubmed/17076456 Haker, E., Egekvist, H., & Bjerring, P. (2000). Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. J Auton.Nerv.Syst., 79, 52-59. http://www.ncbi.nlm.nih.gov/pubmed?term=2000%20haker%20effect%20of%20acupuncture%20on%20healthy%20subjects Hicks J, Hicks A, Mole P. Five element constitutional acupuncture. Edinburough: Elsevier, 2004. http://www.worldcat.org/title/five-element-constitutional-acupuncture/oclc/56011386&referer=brief_results Hollifield, M., Sinclair-Lian, N., Warner, T. D., & Hammerschlag, R. (2007). Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial. J Nerv.Ment.Dis., 195, 504-513. http://www.ncbi.nlm.nih.gov/pubmed?term=hollifield%20acupuncture%20for%20posttraumatic%20stress Hui, K. K., Liu, J., Makris, N., Gollub, R. L., Chen, A. J., Moore, C. I. et al. (2000). Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum.Brain Mapp., 9, 13-25. http://www.ncbi.nlm.nih.gov/pubmed/10643726

45. Acupuncture Research – Selected Bibliography (continued) Kaptchuck TJ. The web that has no weaver: Understanding Chinese medicine, 2 ed. N.Y.: McGraw-Hill, 2000. Kim KB, Sok SR. Auricular acupuncture for insomnia: Duration and effects in Korean older adults. J GerontolNurs 2007; 33(8): 23-8; quiz 30-1. http://www.ncbi.nlm.nih.gov/pubmed/17718375 Leo, R. J. & Ligot, J. S., Jr. (2007). A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect.Disord., 97, 13-22. http://www.ncbi.nlm.nih.gov/pubmed?term=leo%202007%20acupuncture%20in%20the%20treatment%20of%20depression Napadow, V., Makris, N., Liu, J., Kettner, N. W., Kwong, K. K., & Hui, K. K. (2005). Effects of electroacupuncture versus manual acupuncture on the human brain as measured by fMRI. Hum.BrainMapp., 24, 193-205. http://www.ncbi.nlm.nih.gov/pubmed?term=2005%20electroacupuncture%20versus%20manual%20acupuncture Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders--a systematic literature review. Acupunct Med 2007; 25(1-2): 1-10. http://www.ncbi.nlm.nih.gov/pubmed?term=2007%20pilkington%20acupuncture%20for%20anxiety

46. Acupuncture Research – Selected Bibliography (continued) Plank S, Goodard J. The effectiveness of acupuncture for chronic daily headache: An outcomes study. Mil Med 2009; 174(12): 1276-81. http://www.ncbi.nlm.nih.gov/pubmed/20055068 Sjoling M, Rolleri M, Englund E. Auricular acupuncture versus sham acupuncture in the treatment of women who have insomnia. J Altern Complement Med 2008; 14(1): 39-46. http://www.ncbi.nlm.nih.gov/pubmed?term=2008%20sjoling%20acupuncture%20in%20women%20who%20have%20insomnia Spence, D. W., Kayumov, L., Chen, A., Lowe, A., Jain, U., Katzman, M. A. et al. (2004). Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. J Neuropsychiatry ClinNeurosci., 16, 19-28. http://www.ncbi.nlm.nih.gov/pubmed?term=2004%20spence%20acupuncture Spira A. Acupuncture: A useful tool for health care in an operational medicine environment. Mil Med 2008; 173(7): 629-34. http://www.ncbi.nlm.nih.gov/pubmed?term=2008%20spira%20acupuncture Van Tulder, M. W., Furlan, A. D., & Gagnier, J. J. (2005). Complementary and alternative therapies for low back pain. Best.Pract.ResClinRheumatol., 19, 639-654. http://www.ncbi.nlm.nih.gov/pubmed/15949781

47. (acupuncture video 2)

48. Yoga Nidra

49. (yoga nidra video 1)

50. (yoga nidra video 2)