Beyond medications final

Select SLIDE MASTER to Insert Briefing Title Here

Apr-9-13 COL Richard P Petri, Jr., MC/ WBAMC IPMC / (915) 742-7407 (DSN 969) / [email protected] FOUO

Military Workshop Beyond Medications: Military Medicine’s Expansion of Pain

Management Treatment Options

National RX Drug Abuse Summit Orlando, Florida

COL RICHARD P. PETRI, Jr., MC William Beaumont Army Medical Center

Interdisciplinary Pain Management Center

4 April 2013

Information Brief Unclassified



Disclosure

Richard Petri has no financial relationships with proprietary entities that produce health care goods or

services.

Picture/clip art is non-copyrighted material taken off the internet



Learning Objectives

1.  Outline strategies to provide community level support to soldiers and their families struggling with prescription pain addiction.

2.  Plan how to establish a support group for spouses and children of military families.

3.  Identify ways to leverage partnerships to impact your community.



Questions

•  What are the current integrative modalities used by the Department of the Army for pain management.

•  Describe the tiered approach to integrative modalities for use in the Department of the Army pain management programs.

•  Name five of the pillars of approach to the wholistic pain management program within the Department of the Army



Goals

Understand the history of, present day usage and impact of Integrative Medicine (IM) in the United States as well as the military

Identify the expansion of IM within the military over the past four years

Identify several IM research projects within the DoD

Understand the importance, now and in the future of IM especially as it relates to the Military





The History of Alternative Medicine

In the beginning…..



2000 BC

“Where is my root?”



1000 AD “That root is heathen,

say this prayer”



1850 AD “That prayer is

superstition, drink this potion”



1900 AD “That potion

is snake oil, swallow this

pill”



1945 AD “That pill is

ineffective, take this antibiotic”



AD 2000

“That antibiotic is artificial, eat this root”



The cycle of herbals


Apr-9-13 COL Richard P Petri, Jr., MC/ WBAMC IPMC / (915) 742-7407 (DSN 969) / [email protected] FOUO Picture/clip art is non-copyrighted material taken off the internet



CAM Definition

NCCAM defines CAM as a group of diverse medical and health care systems, prac6ces, and products that are not generally considered part of conven8onal medicine as prac8ced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals such as physical therapists, psychologists, and registered nurses.

Conven8onal medicine is also known as Western or allopathic medicine.

The boundaries between CAM and conven8onal medicine are not absolute, and specific CAM prac8ces may, over 8me, become widely accepted.

NCCAM Publica8on No. D347. “CAM basics What Is Complementary and Alterna8ve Medicine ? Update April 2010. 15 Jul 2010 <hTp://nccam.nih.gov/health/wha8scam>



CAM Definitions

•  Complementary medicine refers to use of CAM together with conventional medicine

Example- Acupuncture for pain management. Most use of CAM by Americans is complementary

•  Alternative medicine refers to use of CAM in place of conventional medicine

Example-herbals instead of chemotherapy for cancer management

•  Integrative medicine (also called integrated medicine) refers to a practice that combines both conventional and CAM treatments for which there is evidence of safety and effectiveness

Example- Chiropractic Manipulation for low back pain

•  Integrative Health and Healing is similar to Integrative Medicine but replaces the term “medicine” for “Health and Healing”; two concepts representing the goal of the practice of medicine




Terminology

OR

• Scientifically Proven with Evidence Based Research • Unproven Practices

• Conven8onal or Allopathic • Complementary and Alterna8ve Medicine (CAM) or now know as Integra8ve Medicine (IM)




NCCAM Classification of CAM Therapies with Examples and Prevalence of Selected Modalities

•  Natural Products (17.7%)* –  Herbals/Botanicals –  Supplements –  Probiotics

•  Mind-body Medicine –  Meditation (9.4%)* –  Yoga (6.1%)* –  Acupuncture ** (1.4%)* –  Guided Imagery –  Hypnotherapy –  Progressive Relaxation –  Qi Gong –  Tai Chi

•  Manipulative and Body-Based methods –  Osteopathic and Chiropractic Manipulation (8.6%)* –  Massage (8.3%)*

•  Other CAM Practices –  Movement Therapies –  Traditional Healers –  Energy (Magnet, Light, Qi Gong, Reiki, Healing Touch) –  Whole Medical Systems (Ayurvedic, TCM)


• Based on the 2007 Na6onal Health Interview Survey (NHIS)

**Also considered part of Energy , Manipula6ve and Body Based Methods and TCM







CAM in the United States

•  42.1% of patient seek CAM treatments •  72% conceal use from doctors •  83% use in combination with conventional

medicine •  21.2 billions of dollars per year spent per year [1]

•  More visits than to Primary Care (60M) •  “Minor” treatments include weight loss,

performance enhancement, self-care, pediatrics

[1] Eisenberg DM, Davis RB, Ettner SL, Appel S, et al. Trends in alternative medicine use in the United States. Journal of the American Medical Association. 1998;280: 1569-1575

Updated Tindle, H., Davis, R., Phillips, R., Eisenberg, DM, Trends in Use of Complementary and Alternative Medicine by US Adults: 1997-2002. Alternative Therapies in Health and Medicine Jan/Feb 2005 Vol 11 (1), 42-49.




What is the usage of CAM in the Military?

•  35% of US adults use some type of CAM [1]

• Military has a higher percentage of usage than the general public at 81% [2] [4]

•  Herbal use has the highest usage [1],[2]

•  Low back pain is the most common reason patients use CAM [3]

• Military personnel reported using three CAM stress-reduction therapies at 2.5-7 times the rate of civilians. [4]

1 Tindle et al Trends in use of complementary and alterna8ve medicine by US adults: 1997-‐2002 Altern Ther Health Med 2005 Jan-‐Feb; 11(1) 42-‐9 2 McPherson F Schwenka MA, Use of complementary and alterna8ve therapies among ac8ve duty soldiers, military re8rees, and family members at a military hospital Mil Med 2004 May;169(5):354-‐7 3 Sherman, et al, Complementary and alterna8ve medical therapies for chronic low back pain: What treatments are pa8ents willing to try? BMC Complementary and AlternaFve Medicine 2004, 4:9 4 Goertz et al Military Report More Complementary and Alterna8ve Medicine Use Than Civilians J Altern Complement Med 2013 Jan 16 [Epub ahead of print]



0

10000

20000

30000

40000

50000

60000

66-69 70-74 75-79 80-84 85-89 90-94

95-99 00-04

05-09

1 1 7 14 50 162 312 989 2476

3441 6989 8671 9769 11538 15083

21695

34014

44813

6559 7006 8739 9888 12543 17237

22875

37538

53371

Pub

Med

Cita

tions

Und

er "

Alte

rnat

ive,

Com

plem

enta

ry o

r Int

egra

tive

Med

icin

e"

Year Range

Growth of CAM Studies from 1966 to 2009

Integrative

Complementary

Alternative

* Pubmed Citations Under Alternative Medicine ** Pubmed Citations Under "Alternative, Complementary or Integrative Medicine"

Data derived from PubMed http://www.ncbi.nlm.nih.gov/pubmed



4% 5%

7%

13%

13% 20%

23%

15%

Pub Med Cita6ons by Publica6on Type 2009

Evalua8on Studies (887)

LeTers (946)

Case Reports (1,471)

Compara8ve (2,611)

RCT (2,682)

Clinical Trials (4,054)

Reviews (4,657)

Others (2,935)

Other includes 30+ categories

Data derived from PubMed http://www.ncbi.nlm.nih.gov/pubmed



Public’s Concerns With Conventional Medicine

• Medical Health Costs • Safety and Iatrogenic

Complications • Aging and chronic illness • Technology and knowledge

(depersonalization) • Role of science in medicine




Depersonaliza8on Picture/clip art is non-copyrighted material taken off the internet








Unique Aspects of Military and IM

•  Lifestyle of being a Soldier •  The “testosterone” effect •  Demands of the job •  Leads to a culture of health promotion •  Universal health care •  More flexibility toward available services •  Visibility

1 Baldwin CM, Long K, Kroesen K, Brooks AJ, Bell IR, Arch Intern Med. 2002 Aug 12-26;162(15):1697-704 2 McPherson F Schwenka MA, Use of complementary and alternative therapies among active duty soldiers, military retirees, and family members at a military hospital Mil Med 2004 May;169(5):354-7



Psychiatric Drug use among military children on the rise! US Navy Seals blog 2011

Two Army Families deal with PTSD, and Suicide ABC World News 2010

Senators raise concerns with prescription-drug use in military Virginian -Pilot 2008

Army Responds to Rising Suicide Rates www.army.mil 2008

Mild TBI Remains Little Understood and Hard to Diagnose US Medicine 2012










A Return to the Basics




Empower

Energize

Enrich Picture/clip art is non-copyrighted material taken off the internet



April 19, 2011 US aims at its deadliest drug problem: painkillers



Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: 2007. Department of Health and Human Services, et al.[6]

Concern for Abuse







Top concerns among primary care physicians -- related to controlled substance prescribing. From Bhamb B, et al.[5]

Concerns Among PCMs



Poisoning Deaths, 1999 – 2006



Poisoning Deaths, 1999 – 2006



Overview

• One of most frequent reasons for physician care • Over 50 million Americans suffer with chronic pain • Annual cost ~ $100 billion

–  Health care expenses –  Lost income –  Lost Productivity

• Back pain – leading cause of disability for Americans < 45 y/o



1980

1984

2005

2011



Military Relevance



Musculoskeletal Injuries

386, 562 100% Limited motion, ankle

58, 642 15.2%

Tenosynovitis 65, 364 16.9%

Limited flexion of leg

74, 627 19.3%

Degenerative arthritis, spine

77, 420 20.0%

Lumbosacral or cervical strain

110, 509 28.6%

Total MSK disabili8es of veterans who served from 2001 – 2010:



Integrative Medicine in the Military Systems




The Center for Integrative Medicine ~A Department of Defense First~

•  Established Nov 2003 at The Center for Integrative Medicine ~ A Department of Defense First~

•  Began with acupuncture and chiropractic services. Currently offering holistic approach to pain with “Conventional” and “Alternative” modalities

•  New facility constructed Dec 2008 on Ft Bliss- name changed to the Interdisciplinary Pain Management Center (IPMC) in 2012

•  The Center has brought in over $800,000 research dollars and had the first senior Samueli Institute research associate in the DoD (2004)

•  The Center conducted the first Military Chiropractic study for Acute Low Back Pain in the United States with Samueli Institute and Palmer College of Chiropractic. Approved for publication in Spine As a result of the study, Congress mandated a follow up study with $7.2M funding.

•  The Center provides valuable complementary modalities for difficult medical conditions.

•  Built and sustained on passion, compassion and “out of the box” ideology

Conceptual Plan for an Institute for Integrative Health and Healing. The current WBAMC Interdisciplinary Pain Management Center (IPMC) Campus buildings are on Ft Bliss, Buildings 2485D and 2487



Integrative Medicine Model

The mission of the Integrative Medicine Model is to provide an environment that promotes existing and new medical treatments that may offer safe

and effective approaches to the health and healing care through education, clinical practices and

research. Additionally, the mission is to implement those modalities that meet research standards into the current standards of patient health care through collaborative partnerships

with existing medical practices.



ARMY SURGEON GENERAL ANNOUNCES RECOMMENDATIONS OF PAIN MANAGEMENT TASK FORCE AND RELEASES REPORT

June 23, 2010 •  Lt. Gen. Eric B. Schoomaker, Former Army Surgeon General and Commander, U.S.

Army Medical Command, said that “this report is a pivotal effort to better understand and treat the growing challenges of providing comprehensive pain management for our patients.

•  Recommendations for a MEDCOM comprehensive pain management strategy that was holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain

•  Focus on a holistic, patient-centered approach which employs all modes of therapy--from more conventional means which rely upon the use of drugs, to complementary and alternative modes such as acupuncture, meditation, biofeedback, yoga and others

http://ausar-web01.inetu.net/publications/ausanews/specialreports/2011/06/Pages/AAPMhonorsfiveArmymedicalofficers.aspx



TSG Pain TF Recommendations for CAM for Pain Management

•  Recommendation 4.2.1.1 Adopt a tiered approach for the effective integration of integrative modalities to augment pain management for military and Veteran populations.

•  Recommendation 4.2.1.2 Establish integrative pain medicine capabilities at RPCoE's and DoD sites (Army, Navy, and Air Force) to champion integrative pain care with a focus on the best clinical practices, education, and research.

•  Recommendation 4.2.1.3 Establish baseline data on the clinical integrative practices being used, along with provider and patient perspectives, through a comprehensive DoD survey, utilizing existing survey models (if appropriate).

•  Recommendation 4.2.1.4 Develop an advisory board, with scholarly leaders in various integrative medicine fields, to assist in the development of appropriate programs, ensure proper credentialing of providers, and establish necessary guidelines for outcome measures and uniformed quality of care.

•  Recommendation 4.2.1.5 Establish standardized and appropriate strategic communication plans on integrative health care methods for pain medicine.

•  Recommendation 4.2.1.6 Develop and fund pilot programs across DoD in the delivery of integrative pain.

•  Recommendation 4.2.1.7 Request Health Affairs undertake the evaluation of integrative medicine modalities in Tier I for inclusion as covered TRICARE benefits.



Clinic A Clinic D Clinic B Clinic

C

Typical Stove Piped Approach

Requires a Cultural Shift in Healthcare Delivery The IPMC is that shift



Environmental Optimal Healing Philosophy

Green Spaces Zen Gardens

Labyrinth

Medical Management Primary Care Champions

Clinical Pharmacist Interventional Spine

Procedures

Spiritual Core values Perspective

Identity, Meaning and Purpose

Social Soldier and Family Caregiver Support Groups

Educational Curriculum Social, Family and Task Cohesion

Research DoD Survey of IM

Mindfulness and PTSD Spousal Needs Assessment

Most Research in IM (VA/DoD)

Integrative Modalities Acupuncture

Movement-Yoga Warrior Tai Chi Body Based Manipulation

Medical Massage Biofeedback

Mind-Body/Mindfulness

Functional Restoration

Strength Endurance Flexibility

Culinary Education Healthy Choice Kitchen

Behavioral Substance Abuse Counseling

Coping Skills Mind Wellness



Step Care Model of Treatment

Interdisciplinary Pain Department

IPMC

Tertiary Level Interventions

Advanced Pain Medicine Diagnostics and

Interventions

Secondary Level Interventions Rehabilitation Medicine

Behavioral Medicine

Acute/Primary Care Management PCM Pain Champions

Early Interventions Patient Self Management

Prevention

Goal of restoration with function, risk management

• In processing • Wellness Fusion Campus

• Medical/Post Initiative

Patient Centered

Medical Home

• Outlying Clinics (PCM and Specialty)

Community Based Medical

Home



Clinical Care is Predicated on the Self

Self actualization

Self awareness

Self responsibility Self discipline

Self care

Self determination

Pillars of Integra6ve Health Model

Clinical Care

Research

Education Community

Patient Provider





Proposed IPMC Organizational Chart



IPMC Programs

• Pain Clinic •  Intensive Outpatient

Program (IOP) • Functional Restoration

Program • acute Intensive Outpatient

Program (aIOP) • Addiction based program

http://wunderkammer.ki.se/assets/uploads/image/asset/331/large_Bobbin_tandutdragning_med_tr_d.jpg



Interdisciplinary Pain Management Center IPMC Process Map 2013



Clinic Process Chronic Pain Management

Follow-Up Clinical Evaluation with Medical Provider

Medium/High complexity case (CHUP)

Referral Review Individual Service Chiefs

Low complexity case

Clinical Evaluation with Medical Provider

PCM Champion

Rehab Therapy Interventional IM

Discharge Return to PCM with treatment plan.

IOP

ECHO consultation prn

Behavioral Health

Multi-disciplinary Pain Management Clinic

Patient with minimal symptoms requiring only one provider

Interventional

Integrative

Behavioral

Pain Champion

Pharmacological

Patient tailored care plans Multi-Disciplinary Weekly Team Meetings

PCM participation/education Nurse Case Management

Functional Restoration

Patient

Patient identified as good candidates for holistic care



Clinic Process Intensive Outpatient Program

Mul6disciplinary Pa6ent Intake Evalua6on (MDPIE)

High risk, at risk pa6ents Developmental Stages

Team Huddle Weekly Multi-D meeting

Patient Completed Question (30 mins)

Patient Interview

with Team

(90 mins)

Individual Assessments BH

(30 mins)

Rehab (30 mins)

MD (30 mins)

Treatment recs. to PCM-Augmentation Team with ECHO

follow-up PRN

Data Analyst to follow

outcomes

Does Not Meet IOP Criteria

Meets IOP Criteria

NCM obtains

command approval

Discharge/ Return to Duty

with recs. for PCM-

Augmentation

ECHO Follow-Up, as needed

Day 1

IOP Team (Individualized Care Plan) Core MD, Rehab, BH, Pharm, NCM, Education Additional IM



Clinic Process Acute Intensive Outpatient Program

Acute Mul6disciplinary Pa6ent Intake Evalua6on (Acute MDPIE)

Pain less than 7 days No history unevaluated trauma (ER or PCM level)

No history of fracture

Patient and Team

Huddle

Begin treatments

in afternoon

Patient presents to clinic, given appointment time for that

morning, paperwork completed (30 mins)

Patient Interview

with Team

(40 mins)

Team Assessment Pain

Champion

Rehab

Chiropractor/DO

Treatment recs. to PCM-Augmentation Team or appropriate

IPMC service

Data Analyst to follow

outcomes

Does Not Meet aIOP

Criteria

Meets aIOP

Criteria

Pa6ent obtains

command approval

Discharge/ Return to Duty

with recs. for PCM-

Augmentation

Long term Goals

Create management team at PCM/Unit levels

Educational Awareness on Pain Management

Day 1 Individualized Care Plan Biweekly treatments

Milieu environment

Nurse Case Management

2 week re-evaluation with pain champion

Continued treatment prn

Team consists of MD, IM providers, Rehab team, Chiropractor/DO

IM Provider

Telephonic/Records F/U over 3-6 mos



WBAMC IPMC Patient Visits

IPMC Pa6ent Visits

FY12 FY13

July Aug Sept FY 12 Total Oct Nov Dec Jan Feb Mar Apr May June Jul Aug Sept Oct FY13 Total

Total Since Jul 12

Acupuncture 36 114 106 256 151 128 176 234 244 933 1189

Anodyne 25 59 87 171 102 22 39 13 13 189 360

Case Management 8

Chiroprac6c 325 415 252 992 626 704 517 769 692 3308 4300

Clinical Pharmacy 0 0 0

Clinical Psychology 0 6 6 12 12

Electrodiagnos6cs (EDx) 2 6 8 21 8 9 13 47 98 106

Interven6onal Medicine 145 133 113 391 75 78 101 125 41 420 811

Massage Therapy 0 0 0

Physical Therapy 0 3 41 43 45 60 192 192

Primary Care 94 128 109 331 114 82 110 93 132 531 862

Research 6 13 11 30 16 15 2 6 2 41 71

Yoga 0 9 65 81 120 65 340 340

Total 631 864 684 2179 1117 1143 1078 1424 1310 0 0 0 0 0 0 0 0 6064 8243





Chiropractic Care in the Military




Synergy between Integrative and Conventional Medicine

Health and Healing

Global Context

Community

Patient Centered

Care

Interdisciplinary Pain

Management Center

Combat Stress Disorder

PTSD Facility

TBI Treatment Facility

NICoE

Patient Centered Medical Home Polypharmacy

Surgery Perioperative

Medicine Primary Care Prescriptions

Behavioral Care

Educational Outreach

Research Endeavors

Clinical Practices



Military IM Research

Slide 65 of



Acupuncture treatment for sinusitis

Research

Survey of Complementary and Alternative Medicine Services within the Department of Defense



Survey of Complementary and Alternative Medicine Services within the Department of Defense



Results

2

4

6

8

10

12

14

16

18

20

Wal

ter R

eed

AM

C

Mad

igan

AM

C

Bro

oke

AM

C

Wrig

ht-P

atte

rson

M

C

Land

stuh

l AM

C

Nav

al M

edic

al

Cen

ter S

an D

iego

Will

iam

Bea

umon

t A

MC

Wom

ack

AM

C

Nav

al H

ealth

Clin

ic

Gre

at L

akes

Trip

ler A

MC

Nav

al M

edic

al

Cen

ter P

orts

mou

th

Mal

colm

Gro

w M

C

Eis

enho

wer

AM

C

Num

ber o

f CA

M S

ervi

ces

Prov

ided

Facility

Change in the Number of Services Provided by Facility N = 13

(% Change)

2005

2009

-36% -22%

44%

80% 80% 60%

50%

333%

233% 175%

171%

133% Decrease In Existing Services

New Services

Increase in Existing Services



Results

15%

15%

8%

8%

46% 15%

77% 62%

92% 15%

69% 38%

62%

93%

8% 8% 8% 8%

8% 8%

15% 15%

23%

31% 31%

46%

54% 54% 54%

69% 85%

92% 92% 92% 92%

100%

0% 20% 40% 60% 80% 100% 120%

Native

EMDR, NLP, Life Coach

Rife

Sound Therapy

Vibe

Qi Gong

Healing Touch

Herbal

CES

Yoga

Meditation

Relaxation

Imagery

Behavioral Techniques

Spiritual Healing

Biofeedback

Percentage

Type

of S

ervi

ce

Type of CAM Services Available at MTF with CAM 2005-2009

2009

2005



Results

4

1 8

Types of CAM Facilities at MTF with CAM 2005, 2009

Centralized but not CIM

Designated as a CIM

Services available in existing clinic as additional service (Chiropractor, Physical Medicine & Rehab, or Family Practice , Pain or TBI)

MTF with individuals performing CAM modalities as additional services

MTF with designated Center for Integrative Medicine



Results

0%

0%

92%

69%

8%

8%

15%

15%

15%

23%

23%

31%

62%

85%

92%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other

LVN

Native American

Naturopaths

Volunteers

Nurse Practitioner

PharmD

Energy Therapist

Massage Therapist

Physician Assistant

Nurse Anesthetist

Licensed Acupuncturist

RN

PhD

Chiropractor

MD

Percentage

Type

of P

rovi

der

Types of Providers by Percentage at MTF with CAM 2005-2009

2009 2005



Results

1

1

15

20

37

2

3

5

6

9

13

32

2

5

21

89

187

0 20 40 60 80 100 120 140 160 180 200

Other

Na8ve American

Naturopaths

LVN

Volunteers

Physician Assistant

Energy Therapist

Massage Therapist

Nurse Prac88oner

RN

Nurse Anesthe8st

PhD

PharmD

Licensed Acupuncturist

Chiropractor

MD

TOTAL

Number of Providers

Type

of P

rovide

r

Number of Providers at MTF with CAM 2005-‐2009

2009

2005



Results

8%

54% 54%

38%

15%

85%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Congressional OTSG Facility Other (Grants)

Perc

enta

ge o

f Fun

ding

Type of Funding

Source of CAM Funding at MTF with CAM 2005-2009

2005 2009



A Randomized Controlled Trial of Chiropractic Manipulative Therapy and Standard of Care for Active Duty Soldiers with Acute Low Back Pain

Picture/clip art is non-copyrighted material taken off the internet Dr Aaron Harris, WBAMC Chiropractic Service



Methods

Inclusion Criteria

"   Age range 18-35 "   Diagnosis of acute low back pain or

reoccurrence of chronic low back pain of no more than 4 weeks

"   Written informed consent "   Military Active duty status

Exclusion Criteria

"   LBP pain from other than somatic tissues as determined by history, examination.

"   Radicular pain worse than back pain "   Co-morbid pathology or poor health conditions

that may directly impact spinal pain. "   Bone and joint pathology contraindicating

patient for M/MT. "   Other contraindications for M/MT of the lumbar

spine and pelvis (ie, bleeding disorders or anticoagulant therapy)

"   Pregnancy; all female potential participants will undergo pregnancy testing

"   Use of manipulative care for any reason within the past month

"   Unable to follow course of care for four weeks "   Unable to give informed consent for any

reason "   Unable to confirm that they will not be deploy

during the course of the study.



Study Logarithm



Results Logarithm

122 Excluded 80 Ineligible 42 Declined

Enrolled Patients (n = 91)

Assessed for Eligibility (n = 213)

Standard Care SC (n = 46) Attended at least 1 visit with medical provider: 46

Standard Care + Spinal Manipulation SC + M/MT (n = 45)

Attended at least 1 visit with medical provider: 45 Treated by chiropractor at least twice: 45 (Median: 7 visits)

Week 2: 28 Week 4: 29

Analyzed: 32

Week 2: 39 Week 4: 40

Analyzed: 41



Characteristics Standard Care (%) n=46

Standard care + MM/T (%)

n=45

Total (%) n=91

Age Mean 26.2 25.1 25.7

Gender Male 84.8 86.7 85.7 Female 15.2 13.3 14.3

Marital Status Married 50 42.2 46.2

Divorced/Separated 8.7 4.4 6.6 Widowed --- --- --- Never been married 26.1 51.1 38.5

Race American Indian or Alaska Native

6.5 4.4 5.5

Asian 2.2 --- 1.1 Native Hawaiian or Other Pacific Islander

2.2 --- 1.1

Black or African American

21.7 22.2 22

White 52.2 73.3 62.6

Ethnicity Hispanic 17.4 15.6 16.5 Not Hispanic 78.3 82.2 80.2

Results- Demographic Characteristics All participants



Results- Demographic Characteristics Completed

Characteristics Standard Care (%) n=30

Standard care + MM/T (%)

n=39

Total (%) n=69

Age Mean 26.2 25.1 25.7

Gender Male 84.8 86.7 85.7 Female 15.2 13.3 14.3

Marital Status Married 50 40 45.1

Divorced/Separated 6.5 2.2 4.4 Widowed --- --- --- Never been married 23.9 46.7 35.2

Race American Indian or Alaska Native

6.5 2.2 4.4

Asian 2.2 --- 1.1 Native Hawaiian or Other Pacific Islander

2.2 --- 1.1

Black or African American

21.7 22.2 22

White 50 71.1 60.4

Ethnicity Hispanic 17.4 15.6 16.5 Not Hispanic 78.3 82.2 80.2



Results

0

2

4

6

8

Baseline 2 Weeks 4 Weeks

Mea

n N

RS

Numerical Pain Rating Scale

Standard care

Standard Care + MM\T

0

2

4

6

8

10

12

14

Baseline 2 Weeks 4 Weeks M

ean

RM

Q

Roland-Morris Disability

Standard care

Standard Care + MM\T

Measure Week Mean difference* 95% CI* p

NRS (0-10) 2 2.1 1.1, 3.1 <0.001 4 1.2 0.1, 2.2 0.03

RMQ (0-24) 2 4 1.8, 6.1 <0.001 4 4.1 1.3, 6.8 0.004



3.4

24.1

37.9

17.2 13.8

3.4 2.5

7.5

17.5

32.5

37.5

2.5

0

5

10

15

20

25

30

35

40

45

50

Much worse

A liTle worse

About the same

A liTle beTer

Moderately beTer

Much beTer

Completely gone

Percen

t

Category

Back Pain at 4 Weeks Compared to Baseline

Standard care

Standard care + MM/T

Results



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3.4% 0.0%

24.1%

2.5%

37.9%

7.5%

17.2%

17.5%

13.8%

32.5%

3.4%

37.5%

0.0% 2.5%

Back Pain at 4 Weeks Compared to 1st Visit

Completely Gone

Much Better

Moderately Better

A Little Better

About the Same

A Little Worse

Much Worse

SC SC + M/MT

Results

Above “a little better”

90%

Above “a little better”

34.4%



Ft Bliss and WBAMC Initiatives

Research •  Survey of Complementary and

Alternative Medicine Services within the Department of Defense

•  Needs Assessment Among Military Spouses of Active Duty Personnel

•  Relaxation Response (RR) Training for PTSD Prevention in Soldiers a.k.a. “SPIRIT SMART” (Stemming PTSD, Increasing Resilience and Impeding Trauma in Service Members: Assessing Relaxation Response Training)

Clinical •  Ft Bliss Wellness Fusion Campus •  Interdisciplinary Pain Management

Center (IPMC)

Collaborations •  NATO Task Force •  OTSG Pain Task Force •  Samueli Institute



Col. Emmet Schaill, Wellness Fusion Campus project head, and Doug Briggs, director of human performance here, cut the ribbon outside Campus Headquarters, Bldg. 2438 on Cassidy Road May 25 symbolizing the opening of the now fully operational Wellness Fusion Campus. Photo by Marcie C. Wright, Monitor Staff.

http://fbmonitor.com/2011/06/01/bliss-wellness-fusion-campus-now-up-and-running-complex-encompasses-five-pillars-of-strength/



Fort Bliss Wellness Fusion Campus

Vision   Enhance the health and wellness of the Fort Bliss Community by improving the balance,

health, self-confidence Soldiers, Families and Army Civilians whose resilience and total fitness enables them to excel in an era of high operational tempo and persistent conflict.

Mission   The Fort Bliss Comprehensive Fitness Initiative provides a holistic, multidisciplinary,

multimodal fitness campus for Soldiers, Families and Army Civilians in order to optimize performance and build resilience through assessment, education, prevention and treatment. The campus provides a centralized location for comprehensive fitness, well-being, and assessment by assisting in the establishment and attainment of individualized and measurable goals.

Values   We aspire to equip members of the Fort Bliss Community with the capacity to access and

utilize the resources that make up the five pillars of comprehensive fitness; physical, emotional, social, spiritual, and family that sustain their well-being, and their capacity to individually and collectively cope with stress and adversity.

Target Population   Service Members, Families, DA Civilians, Retirees



Evaluation Communicate results and measures via CHPC

ACS (Family) ACEP (Emotional/Physical) CBHS (Emotional) MWR (Family, Social, Physical) Chaplains (Spiritual) MFLCs (Emotional, Family) FAP (Family) USO (Social) CDC (Family) ASAP (Physical) COSC (Emotional)

Teach Intro to Resiliency (RSA for Spouses/FMs)

Deliver Comprehensive Screening/ assessment modules along the 5 Pillars of CSF

Train Soldiers to be fit along the 5 pillars of CSF

Market Center as the premier source of CSF for Soldiers and Families

Provide a recreational and social center for Soldiers and Families

Provide a venue to help Commanders provide assistance to Soldiers in need

Outcomes MEDIUM

TERM LONG TERM

Soldiers and Family members have access to a centralized location capable of providing Comprehensive Fitness and assessment /treatment as required.

An oasis like atmosphere to draw Soldiers and families to the environment

Improved Soldier and Family life

Improved Leader engagement in the lives of their Soldiers

SHORT TERM

Change in attitude toward help and health seeking behavior

Soldier and Family confidence in their ability to navigate resources available on the installation

Facilitate help and health seeking behavior

Visitors to center are knowledgeable of goal setting principles and complete goals book

Activities

Evidence of

Delivery

Drivers

250 individuals visit the center/week

At least one module is offered for each of the five pillars of CSF/week

All visitors are identified as either command or self referrals in a central database

85 % Satisfaction score for modules offered at Center

All Soldiers referred by Commanders are seen at the center

Quarterly article published in The Monitor highlighting activities at the Center

Create feedback mechanism that provides leaders assessment of their Soldiers and Family members

Soldiers and Family members utilize the center more for health seeking versus help seeking behaviors

Commander’s Intent: To provide a Centralized approach to Comprehensive Fitness for our Soldiers and Family members



• Health Related Fitness: Physical training required to reduce the risk of disease or injury .

• Performance Related Fitness: Physical training required to achieve physical goal .

PHYSICAL

• Psychological fitness: Integration and optimization of mental, emotional and behavioral abilities and capacities to optimize performance and strengthen resilience of war fighters and family .

EMOTIONAL

• Social Cohesion: Group of members liking each other and task cohesion to sharing a common goal . Access and use of common facilities and activities participation will fulfill the needs of the individual.

SOCIAL

• Family Fitness: Immediate military family ability to use physical, psychological, social and spiritual resources to prepare for, adapt to, and grow from military lifestyle demands .

FAMILY

•  Spiritual Fitness: A set of components, all pertaining to spirituality, Spiritual beliefs, Spiritual Values, Spiritual Practices and Self-Awareness .

SPIRITUAL

• Program Fitness: Continuous program evaluations with appropriate redirection as indicated. Research on program metrics and outcomes.

PROGRAM EVALUATION AND

RESEARCH

Comprehensive Fitness Core Dimensions and Operational Definitions



(Left to Right) Rollin M. Gallagher, editor, Pain Medicine Journal, American Academy of Pain Medicine, presents AAPM Presidential Commendations to Lt. Gen. Eric B. Schoomaker, commanding general of the U.S. Army Medical Command and the Army’s surgeon general; Brig. Gen. Richard W. Thomas, assistant surgeon general for force protection; Col. Kevin Galloway, chief of staff for the Army’s Pain Management Task Force; and Col. Chester C. Buckenmaier, chief, Army Regional Anesthesia and Pain Management Initiative, Walter Reed Army Medical Center, during the March 26 AAPM conference.

http://ausar-web01.inetu.net/publications/ausanews/specialreports/2011/06/Pages/AAPMhonorsfiveArmymedicalofficers.aspx

Department of The Army OTSG Pain Initiative



OTSG Pain Management Task Force •  Developed 109 recommendations that lead to a

comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach, utilizes state of the art/science modalities and technologies, and provides optimal quality of life for Soldiers and other patients with acute and chronic pain.

•  The recommendations rely heavily on an education and communication plan that crosses DoD and VHA .

•  Emphasis on the synchronization of existing Service and MHS initiatives (e.g. Patient Centered Medical Home, Comprehensive Soldier Fitness).

•  Recommendations are divided into four areas:

–  Provide Tools and Infrastructure that Support and Encourage Practice and Research Advancements in Pain Management

–  Build a Full Spectrum of Best Practices for the Continuum of Acute and Chronic Pain, Based on a Foundation of Best Available Evidence

–  Focus on the Warrior and Family - Sustaining the Force

–  Synchronize a Culture of Pain Awareness, Education, and Proactive Intervention



Hierarchy of IM Implementation

Modality Passive Active

Acupuncture Clinic based Acupuncture Self directed acupressure

Yoga / Yoga Nidra Facility based yoga classes Self directed with video, exercising

Non-allopathic Chiropractic Care Clinic based manipulations Self-correcting exercises

Therapeutic Medical Massage Clinic based treatments Partner or self treatment

Biofeedback Clinic based biofeedback techniques

Self directed biofeedback with video, heart rate variability monitors, meditative

practices Mind-body Therapies

(Meditation, Mindfulness) Facility based classes Self directed

The tiered structure represents a hierarchy of implementation based on current accepted literature supporting efficacy, safety, and widespread use or acceptability. Additionally, licensing and credentialing concerns were taken into consideration in the development of the recommendations. Within the tiers, active and passive treatments are identified to allow for an understanding of how passive treatments can become active

treatments to avoid the pitfalls of passive patient participation.

Tier 1 Modalities



Hierarchy of IM Implementation

Modality Passive Active

Movement therapy (Qi Gong, Tai Chi, Marital Arts) Facility based classes Self directed with video, exercising

Art Therapy Facility based classes Self expression through journaling, art,

dance, etc.

Music Therapy Facility based classes Self directed with iPods, etc.

Aroma Therapy Facility based treatment Self directed

Cold Laser Facility based treatments N/A

Monochromatic Near Infrared Energy (MIRE) Treatments Clinic based treatments

Self directed with MIRE personal equipment

Cranial Electrical Stimulation Clinic based treatments Self directed with CES personal

equipment

Tier 2 Modalities

Tier 2 modalities were not implemented in the initial phase of the IPMC roll out.

While scientific evidence exists regarding some CAM therapies, for most, there are key questions that have yet to be answered through well-designed scientific studies – questions, such as whether these therapies are safe and whether they work for the purposes for which they are used.



acute Intensive Outpatient Program Data (Jul to Present)

Slide 92

Demographics

N = 43

Gender M 98% F 2 % Ave Age 31.9 Age Range 20-61

Number of Visits 275 PCM 18% Chiropractic 54% Acupuncture 25% Interventional 3%

Ave # Visit/patient 6.4 Ave # of week seen 4.0

Presenting Conditions Cervical 20% Thoracic 7% LBP 51% Myofascial 25% Shoulder 13% Hip 15% Shin 9% Scoliosis 19%

5.6 2.7 0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Pre Treatment Pain Level

Pain

Lev

el N

RS

0-10

aIOP Pre and Post Pain Levels

Post Treatment Pain Level



Research Initiative

Needs Assessment Among Military Spouses of Active Duty Personnel



Needs Assessment Among Military Spouses of Active Duty Personnel



Research Initiative

Relaxation Response (RR) Training for PTSD Prevention in Soldiers a.k.a. “SPIRIT SMART” (Stemming PTSD, Increasing Resilience and Impeding Trauma in Service Members:

Assessing Relaxation Response Training)

One armed man in yoga pose http://photos.com



Relaxation Response (RR) Training for PTSD Prevention in Soldiers a.k.a. “SPIRIT SMART” (Stemming PTSD, Increasing Resilience and Impeding Trauma in Service Members: Assessing Relaxation Response Training)



Initiatives and Partnerships

NATO Task Force on Integrative Medicine RTG195




U.S. Army Telemedicine and Advanced Technology Center



National Intrepid Center of Excellence (NICoE)












Combat Initiatives


COL Richard Niemtzow placing auricular acupuncture needles for the battlefield acupuncture protocol



Slide 104 of

• “The Voodoo of it all” -overcoming the Stigma of Integrative Medicine and belief that CAM is pseudo-science

• “Balancing the budget”- obtaining support for non-core treatments in an environment of shrinking funding for core services

• “The tyranny of the blank page”-moving forward when there is so much to do and other stuff to do

• “A new direction”-selling the concept when leadership changes

• “Competing for Soldier’s Time”-allowing soldiers time to heal

• “Rowing in the same direction” –developing coordination of efforts in patient care, research and education

After thoughts



The Paradigm Shift





“Cure sometimes

Heal often

Comfort always”

“The natural healing force within each of us is the greatest force in getting well”





















Questions

1.  What are the current integrative modalities used by the Department of the Army for pain management.

a)  Acupuncture b)  Chiropractic Manipulation c)  Massage Therapy d)  Mind-body techniques/meditation e)  Yoga/Movement

2.  Describe the tiered approach to integrative modalities for use in the Department of the Army pain management programs.

a)  Tiers 1 and 2 b)  The tiered structure represents a hierarchy of implementation based on current accepted

literature supporting efficacy, safety and widespread use or acceptability. Tier 1 and Tier 2

3.  Name five of the pillars of approach to the wholistic pain management program within the Department of the Army

a)  Integrative Modalities b)  Functional Restoration c)  Medical Management d)  Behavioral Management e)  Social Support and Network f)  Spirituality g)  Research h)  Environmental



Slide 118 of

Beyond medications final

Health & Medicine

slide master

mc wbamc ipmc

pillcol richard p petri

internetcol richard

rootcol richard p petri

prayercol richard p

armycol richard p petri

militarycol richard