Complementary and alternative medicine for veterans and military personnel

A growing body of research evidence shows that complementary and alternative medicine (CAM) has health benefits for US military veterans and active duty personnel, according to" Building the Evidence Base for Complementary and Integrative Medicine Use among Veterans and Military Personnel," a special December supplement to Medical Care. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The special issue presents new studies and commentaries on the benefits and increasing use of CAM techniques in the Veterans Health Administration (VHA) and other military health settings. "The papers in this supplement represent promising steps to improve the health of veterans and active military personnel," according to an introductory article by Guest Editors Stephanie L. Taylor, PhD, of Greater Los Angeles VA Healthcare System and A. Rani Elwy, PhD, of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Mass. "They mirror the countless stories we hear from veterans and their providers about the positive effect that CAM is having on their lives."

Studies Show Value of CAM for Improving Health of Military Personnel

The supplement presents 14 original studies reporting on specific CAM therapies and on the current use, perceptions, and acceptance of CAM in veterans and current military personnel. The special issue of Medical Care is sponsored by the VHA's Office of Patient Centered Care and Cultural Transformation.

Complementary and alternative medicine therapies are increasingly available, used, and appreciated by military patients, according to Drs Taylor and Elwy. They cite statistics showing that CAM programs are now offered at nearly 90 percent of VA medical facilities. Use CAM modalities by veterans and active military personnel is as at least as high as in the general population.

Previous systematic reviews have reported benefits of CAM treatments for many of the important problems seen in military populations, including chronic pain, anxiety, posttraumatic stress disorder (PTSD), and depression. Those prior results suggest that CAM therapies are "moderately effective" for these conditions--although these conclusions must be weighed against the weaknesses of the evidence base.

Highlights of the research included in the special issue include:

• Studies reporting benefits of specific types of meditation practices. One study finds that a mindfulness-based intervention reduced depression and improved psychological well-being in veterans with PTSD. A study of mindfulness-based stress reduction for veterans shows reductions in anxiety and depression, as well as suicidal thoughts.
• A report showing beneficial effects of acupuncture for veterans with PTSD. In addition to reduced severity of PTSD symptoms, the study shows improvements in depression, pain, and physical and mental health functioning. Another study finds that most veterans use vitamins and nutritional supplements, often substituting them for prescription drugs.
• Studies showing high rates of use and favorable perceptions found of CAM modalities among veterans of the Gulf War and Operation Enduring Freedom/Operation Iraqi Freedom. Veterans with PTSD are more likely to be accepting of CAM therapies.
• Reports describing the rates and preferred types of CAM mind-body and other modalities among military members and veterans, as well as on health care providers' attitudes toward CAM. While VA providers vary in their knowledge of CAM, many perceive benefits for their patients.

A commentary by Laura P. Krejci, MSW, and colleagues of the VA's Office of Patient Centered Care & Cultural Transformation discusses the role of CAM in meeting the "number one strategic priority" of providing "personalized, proactive, patient-driven health care to veterans." Dr Wayne B. Jonas and colleagues of the Samueli Institute, Alexandria, Va., draw attention to several bodies of research on CAM in the US military. They conclude that current policy and priorities leave "the majority of active duty service members, veterans, and their families to fend for themselves, to pay for or go without the beneficial effects of CAM and integrative medicine practices."

While the studies in the special issue show progress, Drs Taylor and Elwy stress the need for additional rigorous research to better understand CAM's potential for managing important conditions seen in military populations. They conclude, "It is time for more funding to be awarded to CAM ...to improve the capacity of the field to carry out rigorous CAM research, which in turn will benefit veterans and military personnel, as well as the general population."

Study shows integrative medicine relieves pain and anxiety for cancer inpatients

Pain is a common symptom of cancer and side effect of cancer treatment, and treating cancer-related pain is often a challenge for health care providers.

The Penny George Institute for Health and Healing researchers found that integrative medicine therapies can substantially decrease pain and anxiety for hospitalized cancer patients. Their findings are published in the current issue of the Journal of the National Cancer Institute Monographs.

"Following Integrative medicine interventions, such as medical massage, acupuncture, guided imagery or relaxation response intervention, cancer patients experienced a reduction in pain by an average of 47 percent and anxiety by 56 percent," said Jill Johnson, Ph.D., M.P.H., lead author and Senior Scientific Advisor at the Penny George Institute.

"The size of these reductions is clinically important, because theoretically, these therapies can be as effective as medications, which is the next step of our research," said Jeffery Dusek, Ph.D., senior author and Research Director for the Penny George Institute.

The Penny George Institute receives funding from the National Center of Alternative and Complementary Medicine of the National Institutes of Health to study the impact of integrative therapies on pain over many hours as well as over the course of a patient's entire hospital stay.

"The overall goal of this research is to determine how integrative services can be used with or instead of narcotic medications to control pain," Johnson said.

Researchers looked at electronic medical records from admissions at Abbott Northwestern Hospital between July 1, 2009 and December 31, 2012. From more than ten thousand admissions, researchers identified 1,833 in which cancer patients received integrative medicine services.

Patients were asked to report their pain and anxiety before and just after the integrative medicine intervention, which averaged 30 minutes in duration.

Patients being treated for lung, bronchus, and trachea cancers showed the largest percentage decrease in pain (51 percent). Patients with prostate cancer reported the largest percentage decrease in anxiety (64 percent).

Complementary and Alternative Medicine for Posttraumatic Stress Disorder Symptoms

A Systematic Review

1. Helané Wahbeh, ND, MCR1,2⇑
2. Angela Senders, ND1,2
3. Rachel Neuendorf, MS2
4. Julien Cayton, BA1

1. ¹Oregon Health and Science University, Portland, OR, USA
2. ²National College of Natural Medicine, Portland, OR, USA

1. Helané Wahbeh, ND, MCR, Oregon Health and Science University, 3181 SW Sam Jackson Park Road CR120, Portland, OR 97239, USA. Email: wahbehh@ohsu.edu

Abstract

Objectives. To (1) characterize complementary and alternative medicine studies for posttraumatic stress disorder symptoms, (2) evaluate the quality of these studies, and (3) systematically grade the scientific evidence for individual CAM modalities for posttraumatic stress disorder.

Design. Systematic review. Eight data sources were searched. Selection criteria included any study design assessing posttraumatic stress disorder outcomes and any complementary and alternative medicine intervention. The body of evidence for each modality was assessed with the Natural Standard evidence-based, validated grading rationale.

Results and Conclusions. Thirty-three studies (n = 1329) were reviewed. Scientific evidence of benefit for posttraumatic stress disorder was strong for repetitive transcranial magnetic stimulation and good for acupuncture, hypnotherapy, meditation, and visualization. Evidence was unclear or conflicting for biofeedback, relaxation, Emotional Freedom and Thought Field therapies, yoga, and natural products. Considerations for clinical applications and future research recommendations are discussed.

Acupuncture enhances antidepressant effect of Seroxat

Acupuncture is more effective than oral antidepressants in improving depressive symptoms, and produces fewer side effects than tricyclic antidepressants. Despite the continued development of antidepressants and alternative/synergistic therapies, major depressive disorder has not been comprehensively recognized and treatment outcome is often insufficient. An epidemiological study addressing depression showed that poor recognition and treatment are largely linked to the lack of an accurate assessment tool and to patients' economic situation.

Prof. Yong Huang and team from Southern Medical University in China compared the clinical efficacy of acupuncture/electroacupuncture combined with an antidepressant drug, with that of an antidepressant drug alone, using the Symptom Checklist-90. Researchers found that administration of Seroxat alone or in combination with acupuncture/electroacupuncture can produce a significant effect in patients with primary unipolar depression. Furthermore, acupuncture/electroacupuncture has a rapid onset of therapeutic effect and produces a noticeable improvement in obsessive-compulsive, depressive and anxiety symptoms. These findings have been published in the Neural Regeneration Research (Vol. 9, No. 2, 2014).

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Article: "Acupuncture/electroacupuncture enhances anti-depressant effect of Seroxat: the Symptom Checklist-90 scores " by Junqi Chen1, Weirong Lin2, Shengxu Wang3, Chongqi Wang3, Ganlong Li1, Shanshan Qu3, Yong Huang3, Zhangjin Zhang4, Wei Xiao3 (1 The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong Province, China; 2 The Shenzhen TCM hospital, Shenzhen, Guangdong Province, China; 3 School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; 4 School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China)

Chen JQ, Lin WR, Wang SX, Wang CQ, Li GL, Qu SS, Huang Y, Zhang ZJ, Xiao W. Acupuncture/electroacupuncture enhances anti-depressant effect of Seroxat: the Symptom Checklist-90 scores. Neural Regen Res. 2014;9(2):213-222.

Yoga-based interventions hold promise for smoking cessation

This study provided a review of evidence-based yoga interventions’ impact on smoking cessation. The researchers reviewed articles obtained from MEDLINE (PubMed), EBSCOHOST, PROQUEST, MEDINDIA, CINAHL, Alt HealthWatch, and AMED databases. Inclusion criteria were as follows: (a) study published between 2004 and 2013, (b) study published in English language, (c) study used yoga-based interventions, (d) study involved smokers with varying level of smoking, (e) study used any quantitative design, and (f) study had physiological and/or psychological outcomes. 

A total of 10 studies met the inclusion criteria. Designs were 2 pre–post tests and 8 randomized controlled trials. 

A majority of the interventions were able to enhance quitting smoking rates in the participants under study. 

Adequate Doses of Massage Treatment Necessary for Relief of Neck Pain

Neck pain is a common and debilitating condition, and massage therapy is commonly used to treat it, yet there is little quality research on the optimal dose of therapeutic massage for neck pain. Randomizing 228 patients with chronic neck pain to five different groups receiving various doses of massage for a five-week period, researchers found the benefits of massage treatments for chronic neck pain increase with dose. Specifically, they found that patients who received 30-minute treatments two or three times weekly were not significantly better than a wait-listed control group in terms of achieving a clinically meaningful improvement in neck dysfunction or pain. In contrast, patients who received 60-minute treatments two or three times weekly showed significant improvement in neck dysfunction and pain intensity compared to the control group. Compared with their control counterparts, massage participants were three times more likely to have clinically meaningful improvement in neck function if they received 60 minutes of massage twice a week and five times more likely if they received 60 minutes of massage three times a week. The authors conclude patients who receive massage treatment for chronic neck pain may not be realizing benefits from treatment because they are not receiving an effective treatment dose.

Yoga regulates stress hormones and improves quality of life for women with breast cancer undergoing radiation therapy

For women with breast cancer undergoing radiation therapy, yoga offers unique benefits beyond fighting fatigue, according to research from The University of Texas MD Anderson Cancer Center.

The preliminary findings were first reported in 2011 by Lorenzo Cohen, Ph.D., professor and director of the Integrative Medicine Program at MD Anderson, and are now published in the Journal of Clinical Oncology. This research is part of an ongoing effort to scientifically validate mind-body interventions in cancer patients and was conducted in collaboration with India's largest yoga research institution, Swami Vivekananda Yoga Anusandhana Samsthana in Bangalore, India.

Researchers found that while simple stretching exercises counteracted fatigue, patients who participated in yoga exercises that incorporated controlled breathing, meditation and relaxation techniques into their treatment plan experienced improved ability to engage in their daily activities, better general health and better regulation of cortisol (stress hormone). Women in the yoga group were also better equipped to find meaning in the illness experience, which declined over time for the women in the other two groups.

The study also assessed, for the first time, yoga benefits in cancer patients by comparing their experience with patients in an active control group who integrated simple, generic stretching exercises into their lives.

"Combining mind and body practices that are part of yoga clearly have tremendous potential to help patients manage the psychosocial and physical difficulties associated with treatment and life after cancer, beyond the benefits of simple stretching," said Cohen.

To conduct the study, 191 women with breast cancer (stage 0-3) were randomized to one of three groups: 1) yoga; 2) simple stretching; or 3) no instruction in yoga or stretching. Participants in the yoga and stretching groups attended sessions specifically tailored to breast cancer patients for one-hour, three days a week throughout their six weeks of radiation treatment.

Participants were asked to report on their quality of life, including levels of fatigue and depression, their daily functioning and a measure assessing ability to find meaning in the illness experience. Saliva samples were collected and electrocardiogram tests were administered at baseline, end of treatment, and at one, three and six months post-treatment.

Women who practiced yoga had the steepest decline in their cortisol levels across the day, indicating that yoga had the ability to help regulate this stress hormone. This is particularly important because higher stress hormone levels throughout the day, known as a blunted circadian cortisol rhythm, have been linked to worse outcomes in breast cancer.

Additionally, after completing radiation treatment, only the women in the yoga and stretching groups reported a reduction in fatigue. At one, three and six months after radiation therapy, women who practiced yoga during the treatment period reported greater benefits to physical functioning and general health. They were more likely to find life meaning from their cancer experience than the other groups.

According to Cohen, research shows that developing a yoga practice also helps patients after completing cancer treatment.

"The transition from active therapy back to everyday life can be very stressful as patients no longer receive the same level of medical care and attention. Teaching patients a mind-body technique like yoga as a coping skill can make the transition less difficult."

Through a grant from the National Cancer Institute, Cohen and his team are now conducting a Phase III clinical trial in women with breast cancer to further determine the mechanisms of yoga that lead to improvement in physical functioning, quality of life and biological outcomes during and after radiation treatment. A secondary aim of the trial, but one of great importance, stressed Cohen, is assessing cost efficiency analysis for the hospital, health care usage costs in general and examining work productivity of patients.

New therapy helps to improve audio and visual perception in stroke patients

 
A stroke can cause permanent damage to important parts of the brain, with the result that many stroke survivors require lifelong care and support. 'It is not uncommon for stroke patients to suffer from an awareness deficit or a reduced response to stimuli on one side of their body. This condition, known as hemispatial neglect, can mean that patients are unable to properly perceive people, images or sounds on that side,' explains Professor Georg Kerkhoff from the Department of Clinical Neuropsychology at Saarland University. 'These phenomena tend to be observed when the right side of the brain is damaged, in which case, the left side of the body is affected.' Another factor that complicates the situation is that patients are often unable to correctly assess their own state of health or even deny that they have a deficit in this area. Experts refer to this aspect of hemispatial neglect as patient unawareness. 'This lack of awareness reduces the chances of therapeutic success and makes treatment more difficult,' says Kerkhoff. 'So far there have only been limited therapeutic options for this group of patients.'

The team of neuropsychologists at Saarbrücken have developed a novel therapeutic approach that has now been tested in two separate studies. In optokinetic stimulation therapy (OKS), patients are shown a cloud of dots on a large screen in which one of the dots is highlighted in a different colour. The dots move horizontally at a constant speed from one side of the screen to the other. Patients must follow the movement of the dots with their eyes. The direction of motion depends on which side of the patient's body is affected. 'If the left side is affected, the dots move from the right side of the screen to the left,' explains Professor Kerkhoff. The dots therefore move from the healthy side of the body to the neglected side. 'This effectively forces the patient to become aware of his neglected side,' says Kerkhoff. Once the dot has reached the edge of the screen, the patient has to move his or her eyes back to the initial fixation point and the exercise begins again.

In order to check how efficient this new method is, the research team ran a study with 50 subjects in which they compared OKS with visual exploration training (VET), which is currently the most commonly used therapeutic procedure for patients with neglect. 'Up until now, patients using VET therapy have only been shown rigid patterns, but patients are generally better able to perceive motion,' explains Kerkhoff. The use of visual motion stimuli activates areas of the stroke patient's brain that are involved in eye movements and that facilitate attention towards the neglected side. 'After five OKS sessions, the subjects had measurably improved perception of sounds and images on the neglected side,' says Professor Kerkhoff. 'And the effect was sustained at follow-up.' In contrast, there was no improvement in symptoms using VET.

In a further study, the research team was able to show that OKS not only trains the senses, but also makes patients better able to deal with day-to-day problems such as locating objects and helps to improve their spatial orientation. After undergoing OKS therapy, patients were also better able to assess their own state of health and were no longer in denial about their functional impairments.

'OKS has been shown to be a very effective method of treatment,' says Kerkhoff, summarizing the results of the two studies. 'OKS speeds up recovery and can be deployed early on in stroke rehabilitation programmes, particularly in the case of patients with a severe lack of awareness.'

Details of the studies have recently been published in the following papers:

Kerkhoff et al, Smooth pursuit eye movement training. Neurorehabilitation & Neural Repair, 2013, DOI: 10.1177/1545968313491012

Kerkhoff et al, Smooth pursuit „bedside" training. Neurorehabilitation & Neural Repair, 2014, DOI: 10.1177/1545968313517757

Acupuncture holds promise for treating inflammatory disease

When acupuncture first became popular in the western hemisphere it had its doubters. It still does. But over time, through detailed observation, scientists have produced real evidence that ancient Chinese practitioners of the medical arts were onto something.

Now new research documents a direct connection between the use of acupuncture and physical processes that could alleviate sepsis, a condition that often develops in hospital intensive care units, springs from infection and inflammation, and takes an estimated 250,000 lives in the United States every year.

"Sepsis is the major cause of death in the hospital," says Luis Ulloa, an immunologist at Rutgers New Jersey Medical School who led the study, which has been published by the journal Nature Medicine. "But in many cases patients don't die because of the infection. They die because of the inflammatory disorder they develop after the infection. So we hoped to study how to control the inflammatory disorder."

The researchers already knew that stimulation of one of the body's major nerves, the vagus nerve, triggers processes in the body that reduce inflammation, so they set out to see whether a form of acupuncture that sends a small electric current through that and other nerves could reduce inflammation and organ injury in septic mice. Ulloa explains that increasing the current magnifies the effect of needle placement, and notes that electrification is already FDA-approved for treating pain in human patients.

When the electroacupuncture was applied to mice with sepsis, molecules called cytokines that help limit inflammation were stimulated as predicted, and half of those mice survived for at least a week. There was zero survival among mice that did not receive acupuncture.

Ulloa and his team then probed further, to figure out exactly why the acupuncture treatments had succeeded. And they made a discovery that, on its face, was very disappointing. They found that when they removed adrenal glands – which produce hormones in the body – the electroacpuncture stopped working. That discovery, on its face, presented a big roadblock to use of acupuncture for sepsis in humans, because most human cases of sepsis include sharply reduced adrenal function. In theory, electroacupuncture might still help a minority of patients whose adrenal glands work well, but not many others.

So the researchers dug even deeper – to find the specific anatomical changes that occurred when electroacupuncture was performed with functioning adrenal glands. Those changes included increased levels of dopamine, a substance that has important functions within the immune system. But they found that adding dopamine by itself did not curb the inflammation. They then substituted a drug called fenoldopam that mimics some of dopamine's most positive effects, and even without acupuncture they succeeded in reducing sepsis-related deaths by 40 percent.

Ulloa considers the results a double triumph.

On the one hand, he says, this research shows physical evidence of acupuncture's value beyond any that has been demonstrated before. His results show potential benefits, he adds, not just for sepsis, but treating other inflammatory diseases such as rheumatoid arthritis, osteoarthritis and Crohn's disease.

On the other hand, by also establishing that a drug reduced sepsis deaths in mice, he has provided an innovative roadmap toward developing potential drugs for people. That roadmap may be crucial, because no FDA-approved drug to treat sepsis now exists.

"I don't even know whether in the future the best solution for sepsis will be electroacupuncture or some medicine that will mimic electroacupuncture," Ulloa concludes. The bottom line, he says, is that this research has opened the door to both.

Complementary Medicine Widely Used to Treat Children With Autism, Developmental Delay

In a study of the range of treatments being employed for young children with autism and other developmental delays, UC Davis MIND Institute researchers have found that families often use complementary and alternative medicine (CAM) treatments and that the most frequent users of both conventional and complementary approaches are those with higher levels of parental education and income.

There is no Food and Drug Administration-approved medical treatment for the core symptoms of autism spectrum disorder, a lifelong neurodevelopmental condition whose hallmarks are deficits in social relatedness, repetitive thoughts and behaviors and, often, intellectual disability.

In the search for treatments to help their children, families may turn to unconventional approaches such as mind-body medicine (e.g. meditation or prayer), homeopathic remedies, probiotics, alternative diets or more invasive therapies such as vitamin B-12 injections, intravenous immunoglobulin or chelation therapy -- some of which carry significant risks.

The research is published online in the Journal of Behavioral and Developmental Pediatrics. It was led by Robin Hansen, director of the Center for Excellence in Developmental Disabilities at the MIND Institute and chief of the Division of Developmental Behavioral Pediatrics in the UC Davis School of Medicine.

"In our Northern California study population, it does not appear that families use complementary and alternative treatments due to the lack of availability of conventional services, as has been suggested by other research," Hansen said. "Rather, they use the treatments in addition to conventional approaches."

The cause or causes of most neurodevelopmental disorders are not known, and the conditions have no cure. Many children suffer from a wide array of associated symptoms that may not be directly associated with their condition and that make their daily lives and those of their families stressful. Such symptoms include irritability, hyperactivity, gastrointestinal problems and sleep disorders.

The study included nearly 600 diverse children between 2 and 5 years with autism and developmental delay who were enrolled in the Childhood Autism Risk from Genetics and the Environment (CHARGE) study. Of the participants, 453 were diagnosed with autism and 125 were diagnosed with developmental delay.

CAM use was more common among children with autism than children diagnosed with other types of developmental delay, 40 percent versus 30 percent respectively. Nearly 7 percent of children with autism were on the gluten-free/casein-free diet, particularly children with frequent gastrointestinal problems.

"We were pleased to find that most families utilizing CAM therapies were choosing ones that were low risk," said Kathleen Angkustsiri, assistant professor of developmental and behavioral pediatrics and a study co-author.

However, a small but statistically significant number -- about 4 percent -- were found to use alternative treatments classified by the study as potentially unsafe, invasive or unproven, such as antifungal medications, chelation therapy and vitamin B-12 injections.

"Our study suggests that pediatricians and other providers need to ask about CAM use in the context of providing care for children with autism and other developmental disorders, and take a more active role in helping families make decisions about treatment options based on available information related to potential benefits and risks," said Roger Scott Akins, lead author and a former postdoctoral fellow at the MIND Institute, who now is chairman of the Division of Neurodevelopmental Pediatrics at Naval Medical Center Portsmouth, Va.

Irva Hertz-Picciotto, professor of public health sciences and principal investigator for the CHARGE study, said the research supports the emergent need for identifying validated treatments for neurodevelopmental conditions.

"These findings emphasize the enormous and urgent need for effective treatments and for rigorous research that can identify them and verify their effectiveness and safety," Hertz-Picciotto said. "Of course it is reasonable for parents to keep searching for ways to help their children, when there are few effective treatments and none that can help every child."