Integrated Approaches to Health

The health and wellbeing of our service members and their families is a top priority for the Department of Defense. Whether it is CONUS and OCONUS, pre- or post-deployment, service members deserve optimal care from military healthcare professionals. Improved screenings, battlefield treatment, rehabilitation, and mental and behavioral care have a significant impact on the re-integration of America’s troops. IDGA’s @DefenseInsider Chris Archer discusses the latest advances in military medicine with Captain Anita Hickey, Director of the Pain Research and Integrative Pain Medicine, Department of Anesthesiology at the Naval Medical Center San Diego. This interview investigates the use of ‘integrated’ approaches to modern military medical challenges, like the use of acupuncture to treat PTSD in veterans. The interview also touches on current research into the continuum of care for wounded warriors. [eventPDF] @DefenseInsider Chris Archer Start by telling us a little bit more about yourself and your experience in this area. CAPT Anita Hickey I first became interested in the field of integrative medicine as an undergraduate at Northern Arizona University. I enrolled in an honors class called "Mapping Reality", which explored the correlation between Eastern philosophy, Eastern theoriesof health and consciousness and their commonalities with modern theories of quantum physics. The mathematical models of reality underlying the new physics are consistent with the principles of integrative medicine. Integrative medicine looks at human beings and health in a holistic way that is different from the model that we use in our traditional biomedical approach. Our current medical and scientific approaches are based on the views of Sir Isaac Newton, Rene Descartes and Galileo Galilee. Although these theories were developed centuries ago, this model of reality, even today dominates our current medical and scientific approaches. It utilizes the metaphor of the human being and the universe as a machine and proposes that we can better understand the human body by breaking it up into its components or parts. Integrative Medicine views the whole using systems thinking which views the whole as greater than the sum of its parts. When I entered the University of Arizona School of Medicine Dr. Andrew Weil, one our professors who is a renown pioneer of mind-body medicine, introduced us to the concept that, although our current biomedical system has advanced healthcare tremendously in the treatment of acute trauma with surgical and anesthetic advancements, the treatment and prevention of bacterial and viral diseases with antibiotics and vaccines), because our current medical treatments for chronic disease often result in inadequate relief of symptoms or result in intolerable side effects, many patients turn to complementary and alternative therapies to not only address illness but to prevent it in the first place. A landmark study by Dr. David Eisenberg and colleagues published in the Journal of the American Medical Association (JAMA) in 1998 reported that approximately 1/3 of the individual's surveyed in the United States had used complementary and alternative medicine in 1990 and 42.1 percent in 1997, and that visits to complementary and alternative therapists had exceeded those to primary care physicians to the tune of 243 million visits in 1997. After this report, the National Institutes of Health (NIH) and other investigators began increasingly to investigate complementary and alternative therapies in regard to safety and effectiveness, for treatment and prevention of various illnesses. There has been additional research looking at the patient-driven increase in availability of complementary and alternative therapies and their use within our current medical system. A publication by the American Hospital Association found that between 1999 and 2008, there was a greater than 70% increase of complementary and alternative therapies within acute care non-governmental hospitals within the United States...a dramatic increase. Chris Archer Can you explore for us some of these ‘integrated’ approaches that you’ve just mentioned towards healing wounded warriors? How do these differ from traditional methods? Anita Hickey Traditional biomedical therapies, as I mentioned previously, look at or break down the body into individual or separate parts. As such, one specialist will treat the foot, another will treat the nose, another will treat the bones, one will treat the mind, and they look at the body as separate parts which are not really connected. To really understand the difference between our conventional biomedical approach and integrative medicine...it is important to define the terms we are using. Most people think that the term "Integrative Medicine" is synonymous with the terms "complementary" and "alternative medicine". Actually – they are quite different. According to the Consortium of Academic Health Centers for Integrative Medicine, "Integrative" medicine is the practice of medicine that reaffirms the importance of the relationships between the practitioner and the patient, focuses on the whole person is informed by the evidence and make use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing for the patient. Whereas complementary medicine uses additional or adjunctive treatments to supplement traditional biomedical approaches and alternative medicine is that which seeks to replace conventional biomedical approaches. According to Dr. Weil, while Integrative medicine may include ideas and practices which are beyond the scope of conventional biomedical approaches, it does not reject conventional therapies, and it does not accept alternative therapies uncritically. The goal of integrative medicine is to bring together biomedicine, the complexity of human beings, the intrinsic nature of healing and the rich diversity of therapeutic systems by utilizing the best of conventional medicine and evidence-based complementary and alternative medicine to achieve humanistic patient-centered care while expounding wellness, prevention and healing of all aspects of self practitioners who approach patient care holistically, and yes there is a difference between just using integrative care and using a holistic approach; those who use a holistic approach focus on healing in addition to management of disease and utilize the influences of mind, body, culture and spiritual belief and lifestyle to empower the patient and to enhance the healing process. So, if you were to look at the two side by side in terms of the characteristics of our current biomedical approaches and holistic or integrative approaches; on the one side, our current approach is reactive while integrative medicine is proactive. Our current approach is disease driven whereas an integrative approach focuses on prevention. In our current model, we have less choice for the patient. It’s basically a passive system where we tell the patient what’s available. In the integrative approach, we make the patient a partner in their healthcare and therefore they have more choices available to them. In our current system, as I previously discussed, we treat parts of the patient whereas in the integrative approach, we treat the whole patient. Instead of just treating symptoms, we look for the underlying cause. Instead of using fear as a motivator, (i.e., "we’ve got to rule out cancer, we’ve got to rule out this, we’ve got to rule out that"), we focus on feeling whole and well, (i.e., "how can we make you feel better?' How can we make you feel whole? What things can we do to help you feel good? What are your goals?" So we empower the patient. We – instead of having the power be external to the patient in terms of the system, the doctor, the surgeon, etc., the medication, we empower the patient. We give them internal power. We utilize their own spiritual qualities and instead of just looking at quantity of life, we look to achieve quality of life. Chris Archer That’s very well said. Thank you for that. Now, what is the current focus of your research on pain management and integrative pain medicine? What is the focus at the moment? And what is it teaching us? Anita Hickey Well, in terms of – I would like to address – current research in general since review of this research is part of what I do. This year, both in February and in June, I was invited to be a part of two task forces; one, with the National Center for Complementary and Alternative Medicine (NCCAM) – the branch of the National Institute of Health which studies complementary and alternative medicine, as they met with the DoD and in June with the VA and DOD representatives. In February, we met to discuss, gaps, barriers and opportunities for acupuncture research within the DoD. Since we are training multiple physicians and practitioners to treat patients with acupuncture, how can we study the results we’re deriving from acupuncture and how can we best apply this modality for the benefit of our Wounded Warriors, our retirees and their families. We discussed the fact that there have been great advances in our understanding of how acupuncture works since the initial NIH consensus conference in that was held in 1997. Now we have a tremendous amount of research which has been performed and instead of mostly anecdotal evidence, we have evidence from many large prospective randomized trials, many advanced imaging studies which look at what happens to the brain when we treat a patient with acupuncture. For example, Dr. Z.H. Cho, a renowned physicist who was at the forefront in the development of advanced imaging technologies, in review of advanced imaging studies of acupuncture by a cross discipline multi-centered, international team, summarized the evidence reviewed by proposing that acupuncture effect is produced via the hypothalamic pituitary axis resulting in modulation, regulation and homeostasis of the autonomic nervous system, which balances hormonal regulation and the neuroimmune systems as well as effecting anti- pain and limbic system responses. An additional study that was published in 2009 by a team of researchers from Massachusetts General Hospital, reported that, based on advance imaging studies, a salient mechanism of acupuncture analgesia is to focus attention to and accentuate bodily awareness. This contributes to an enhanced topdown modulation of painful input to the central nervous system-the central pain networks. They concluded that acupuncture may function as a somatosensory guidedmind-body therapy. So that – in fact, these advanced imaging studies together with heart rate variability studies, (heart rate variability is a very important tool which is used to look at the balance of the autonomic nervous system...a balance between our fight or flight system and the system which governs rest and restoration-one helps us to avoid danger; and the other helps us to restore our system back to a state of balance. These must work together in order for us to have optimal health and to be able to – with great flexibility, respond to stressors in our environment. So, heart rate variability is one of the markers of a dynamic homeostasis or balance of our autonomic nervous system which coordinates with our immune system, our endocrine system, our musculoskeletal system, and is therefore a very profound marker of health and homeostasis. So the advanced imaging studies of acupuncture together with heart rate variability studies demonstrate that acupuncture brings about this balance of the autonomic nervous system which is connected in our body with all these other systems by multiple feedback loops and networks. Acupuncture has also been shown to increase connectivity between the brain resting state networks or self-referral networks and other brain regions. It results in greater connection between body sensations or – and areas of the brain associated with encoding and retrieval of memories specifically emotional memories and areas of the brain involved in antinociception or relief of pain. In this way, it is believed by researchers that acupuncture can erode centrally driven chronic pain memories, both physical memories and emotional memories. So this is very powerful research that supports utilizing acupuncture, as adjunctive therapy to treat patients who have a combination, for example, of depression or PTSD and pain. These same mechanisms may also apply to the research that we are doing and the theory behind using the Stellate Ganglion Block to treat PTSD. The procedure has recently been referred to "the Chicago Block" because it was first utilized in Chicago by Dr. Eugene Lipov for the treatment of PTSD. This injection of local anesthetic, we believe, blocks sympathetic input to the brain and perhaps decreases the hyperarousal associated with PTSD by decreasing the persistent elevation of sympathetic activity of the cardio vasculature system associated with PTSD as well. Blocking excess central and peripheral sympathetic activity may have profound effects on, helping to bring about homeostasis or balance of the autonomic nervous system in someone who has not been able to regulate this themselves following severe physical and or emotional trauma. Because the autonomic nervous system interacts with the endocrine system and the immune system and the neuromuscular system, regulating the sympathetic and parasympathetic nervous system could potentially have very profound effects on the individual as a whole. So I think you can see why I became so interested in the "Stellate Ganglion Block for PTSD" research in the first place because I was able to see that the theory of how it might work correlated with the findings they’ve already demonstrated in both heart rate variability studies and endocrine studies as well as advanced imaging studies on acupuncture and other mind-body approaches which have already been more thoroughly investigated. Chris Archer Do you think the "Chicago Block" you just mentioned may become the best treatment for those suffering PTSD? Anita Hickey At this point, the published studies are case reports or case series. And as you may know, this level of evidence is considered to be "anecdotal"' a very low type of evidence within our current biomedical system. We have been funded by the Bureau of Medicine and are in the process of conducting the first placebo-controlled prospective study of the stellate ganglion block for PTSD, and this will be considered a pilot study and certainly larger studies and multicenter studies will be needed and will hopefully be funded to further investigate this very promising therapy. We're currently in the process of applying for funds to conduct such a study within the military in the near future. Hopefully, this will give us more answers in terms of questions such as "Is there a significant placebo effect?", "On which patients will this procedure be effective?" We need to find out, first of all, is it effective when looked at prospectively because currently, it’s only been looked at retrospectively. And the outcome data has been examined, utilizing tools which are not considered the gold standard of either diagnosing or looking at treatment effect for PTSD. The PTSD Check List (PCL) and PCL-Military are self-administered questionnaires which have been utilized in the studies published to date. The gold standard for diagnosing and assessing treatment effect is currently the clinician-assisted PTSD scale or "CAPS". Our current study is using this as the primary outcome measure. I’m collaborating with Dr. Robert Mclay, who is the head of mental health research here at Naval Medical Center San Diego. He has vast clinical and research experience in using the gold standard assessments for PTSD. It is a great advantage to have him as a collaborator and partner in this study. I know from talking with Dr. Eugene Lipov that he is very excited that we are going forward and testing the block in this way because his goal is to have this therapy available in larger scale for patients with PTSD, if it is indeed shown to be effective as he has found it to be in his initial case series.

Integrated Approaches to Health

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