Whole Health

Arhin AO, Gallop K, Mann J, Cannon S, Tran K, Wang MC.  Acupuncture as a Treatment Option in Treating Posttraumatic Stress Disorder-Related Tinnitus in War Veterans: A Case Presentation.  J Holist Nurs. 2016

Although close associations between tinnitus and posttraumatic stress disorder (PTSD) among war veterans has been documented, there is limited research that explores evidence-based, efficacious interventions to treat the condition in this particular population. This article presents a case of three war veterans with PTSD symptoms who received a series of acupuncture treatments for tinnitus with positive outcomes. Even though the article presents cases of only three veterans and was based on self-reports, there were very clear trends on how veterans with tinnitus symptoms responded to acupuncture treatments. Information generated from this case presentation is a good starting place in exploring evidence-based approaches in treating tinnitus symptoms in war veterans with PTSD.

Chang BH, Sommers E.  Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder. Am J Addict. 2014 Mar-Apr;23(2):129-36. doi: 10.1111/j.1521-0391.2013.12079.x. Epub 2013 Aug 30.

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) is a major health issue, especially among military veterans. We previously reported the effects of auricular acupuncture and the relaxation response (RR) on reducing craving and anxiety following 10-week interventions among veterans who were in recovery from SUDs. Our current analysis examines effects following each intervention session and RR daily practice.

METHODS

We conducted a three-arm randomized controlled trial on residents of a homeless veteran rehabilitation program. Sixty-Seven enroled participants were randomly assigned to acupuncture (n=23), RR (n=23), or usual care (n=21). Participants in the two intervention groups rated their degree of craving for substance on a scale of 1-10 and anxiety levels on a scale of 1-4 (total score 20-80) before and after each intervention session. Mixed effects regression models were used for analysis.

RESULTS

Craving and anxiety levels decreased significantly following one session of acupuncture (-1.04, p=.0001; -8.83, p<.0001) or RR intervention (-.43, p=.02; -4.64, p=.03). The level of craving continued to drop with additional intervention sessions (regression coefficient b=-.10, p=.01, and b=-.10, p=.02 for acupuncture and RR groups, respectively). Number of daily practice days of RR-eliciting techniques is also associated with reduction in craving ratings (b=-.02, p=.008).

CONCLUSIONS

Findings demonstrate the value of attending regular acupuncture and RR-eliciting intervention sessions, as well as the daily practice of RR-eliciting techniques.

SCIENTIFIC SIGNIFICANCE

Substance addiction is a complex disease and effective treatment remains a challenge. Our study findings add to the scientific evidence of these two non-pharmaceutical approaches for SUD.

Conboy L, Gerke T, Hsu KY, St John M, Goldstein M, Schnyer R.  The Effectiveness of Individualized Acupuncture Protocols in the Treatment of Gulf War Illness: A Pragmatic Randomized Clinical Trial. PLoS One. 2016 Mar 31;11(3):e0149161. doi: 10.1371/journal.pone.0149161. eCollection 2016.

BACKGROUND

Gulf War Illness is a Complex Medical Illness characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain affecting veterans of the first Gulf War. No standard of care treatment exists.

METHODS

This pragmatic Randomized Clinical Trial tested the effects of individualized acupuncture treatments offered in extant acupuncture practices in the community; practitioners had at least 5 years of experience plus additional training provided by the study. Veterans with diagnosed symptoms of Gulf War Illness were randomized to either six months of biweekly acupuncture treatments (group 1, n = 52) or 2 months of waitlist followed by weekly acupuncture treatments (group 2, n = 52). Measurements were taken at baseline, 2, 4 and 6 months. The primary outcome is the SF-36 physical component scale score (SF-36P) and the secondary outcome is the McGill Pain scale.

RESULTS

Of the 104 subjects who underwent randomization, 85 completed the protocol (82%). A clinically and statistically significant average improvement of 9.4 points (p = 0.03) in the SF-36P was observed for group 1 at month 6 compared to group 2, adjusting for baseline pain. The secondary outcome of McGill pain index produced similar results; at 6 months, group 1 was estimated to experience a reduction of approximately 3.6 points (p = 0.04) compared to group 2.

CONCLUSIONS

Individualized acupuncture treatment of sufficient dose appears to offer significant relief of physical disability and pain for veterans with Gulf War Illness. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Gulf War Illness Research Program under Award No. W81XWH-09-2-0064. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.

Crawford P, Penzien DB, Coeytaux R. Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population. Med Acupunct. 2017 Aug 1;29(4):229-231. doi: 10.1089/acu.2017.1234. PubMed PMID: 28874924; PubMed Central PMCID: PMC5580367

BACKGROUND

Acupuncture is being offered to patients as part of routine medical care in selected military bases in the United States. There is little published information about the clinical outcomes associated with acupuncture in these clinical settings.

OBJECTIVE

The goal of this research was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center.

MATERIALS AND METHODS

This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O'Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life.

RESULTS

Opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50-3.11 (P < 0.002) for question 1, 4.18-3.46 (P < 0.00001) for question 3, and 2.73-2.43 (P < 0.006) for question 4.

CONCLUSIONS

In this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.

Engel CC, Cordova EH, Benedek DM, Liu X, Gore KL, Goertz C, Freed MC, Crawford C, Jonas WB, Ursano RJ. Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Med Care. 2014 Dec;52(12 Suppl 5):S57-64. doi: 10.1097/MLR.0000000000000237. PubMed PMID: 25397825.

BACKGROUND

Initial posttraumatic stress disorder (PTSD) care is often delayed and many with PTSD go untreated. Acupuncture appears to be a safe, potentially nonstigmatizing treatment that reduces symptoms of anxiety, depression, and chronic pain, but little is known about its effect on PTSD.

METHODS

Fifty-five service members meeting research diagnostic criteria for PTSD were randomized to usual PTSD care (UPC) plus eight 60-minute sessions of acupuncture conducted twice weekly or to UPC alone. Outcomes were assessed at baseline and 4, 8, and 12 weeks postrandomization. The primary study outcomes were difference in PTSD symptom improvement on the PTSD Checklist (PCL) and the Clinician-administered PTSD Scale (CAPS) from baseline to 12-week follow-up between the 2 treatment groups. Secondary outcomes were depression, pain severity, and mental and physical health functioning. Mixed model regression and t test analyses were applied to the data.

RESULTS

Mean improvement in PTSD severity was significantly greater among those receiving acupuncture than in those receiving UPC (PCLΔ=19.8±13.3 vs. 9.7±12.9, P<0.001; CAPSΔ=35.0±20.26 vs. 10.9±20.8, P<0.0001). Acupuncture was also associated with significantly greater improvements in depression, pain, and physical and mental health functioning. Pre-post effect-sizes for these outcomes were large and robust.

CONCLUSIONS

Acupuncture was effective for reducing PTSD symptoms. Limitations included small sample size and inability to parse specific treatment mechanisms. Larger multisite trials with longer follow-up, comparisons to standard PTSD treatments, and assessments of treatment acceptability are needed. Acupuncture is a novel therapeutic option that may help to improve population reach of PTSD treatment.

Fan AY, Miller DW, Bolash B, Bauer M, McDonald J, Faggert S, He H, Li YM, Matecki A, Camardella L, Koppelman MH, Stone JAM, Meade L, Pang J. Acupuncture's Role in Solving the Opioid Epidemic: Evidence, Cost-Effectiveness, and Care Availability for Acupuncture as a Primary, Non-Pharmacologic Method for Pain Relief and Management-White Paper 2017. J Integr Med. 2017 Nov;15(6):411-425. doi: 10.1016/S2095-4964(17)60378-9. PubMed PMID: 29103410.

The United States (U.S.) is facing a national opioid epidemic, and medical systems are in need of non-pharmacologic strategies that can be employed to decrease the public's opioid dependence. Acupuncture has emerged as a powerful, evidence-based, safe, cost-effective, and available treatment modality suitable to meeting this need. Acupuncture has been shown to be effective for the management of numerous types of pain conditions, and mechanisms of action for acupuncture have been described and are understandable from biomedical, physiologic perspectives. Further, acupuncture's cost-effectiveness can dramatically decrease health care expenditures, both from the standpoint of treating acute pain and through avoiding addiction to opioids that requires costly care, destroys quality of life, and can lead to fatal overdose. Numerous federal regulatory agencies have advised or mandated that healthcare systems and providers offer non-pharmacologic treatment options for pain. Acupuncture stands out as the most evidence-based, immediately available choice to fulfill these calls. Acupuncture can safely, easily, and cost-effectively be incorporated into hospital settings as diverse as the emergency department, labor and delivery suites, and neonatal intensive care units to treat a variety of commonly seen pain conditions. Acupuncture is already being successfully and meaningfully utilized by the Veterans Administration and various branches of the U.S. Military, in some studies demonstrably decreasing the volume of opioids prescribed when included in care.

Gibson CJ, Grasso J, Li Y, et al. An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain [published online ahead of print, 2020 Feb 25]. Pain Med. 2020;pnaa003. doi:10.1093/pm/pnaa003

OBJECTIVE

Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse.

DESIGN

Single-group quality improvement study.

SETTING

Large VA health care system.

SUBJECTS

Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years).

METHODS

Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters.

RESULTS

After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., "very satisfied" = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01).

CONCLUSIONS

Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Golden RE, Klap R, Carney DV, Yano EM, Hamilton AB, Taylor SL, Kligler B, Whitehead AM, Saechao F, Zaiko Y, Pomernacki A, Frayne SM; WH-PBRN-CIH Writing Group. Promoting learning health system feedback loops: Experience with a VA practice-based research network card study. Healthc (Amst). 2021 Jun;8 Suppl 1:100484. doi: 10.1016/j.hjdsi.2020.100484. Epub 2021 Jun 23. PMID: 34175097.

BACKGROUND

We tested the capacity of the 60-site VA Women’s Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans’ perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement.

METHODS

VA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project’s feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads.

RESULTS

Twenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1,191 women Veterans responded (median 57; range 8-151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted.

CONCLUSIONS

VA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project.

IMPLICATIONS

Card studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices.

Glynn LH, Chen JA, Dawson TC, Gelman H, Zeliadt SB. Bringing chronic-pain care to rural veterans: A telehealth pilot program description. Psychol Serv. 2020 Jan 16.

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Halpin SN et al. J Altern Complement Med. (2014) Determining attitudes toward acupuncture: a focus on older U.S. veterans. Halpin SN et al. J Altern Complement Med. (2014)

OBJECTIVE

To explore whether factors related to attitudes toward acupuncture use in a population of older veterans is similar to previously identified motivators for nonveterans.

METHODS

A sample of veterans was asked to complete a questionnaire, which included questions on sociodemographic traits, history of acupuncture, chronic diseases, and the Health Belief Model (HBM). Data reduction was performed by using principal components analysis to identify major factors among the HBM responses. Linear regression was performed to evaluate variables that may contribute to attitudes toward acupuncture.

RESULTS

There were 402 completed questionnaires. Principal components analysis yielded three significant factors. Linear regression resulted in a model that explained 35% of the variance for positive attitudes toward acupuncture: Age, race, religion, access to acupuncture, self-efficacy for nonpharmacologic treatments, and the presence of one or more physical and mental chronic health condition were significantly related to positive attitudes toward acupuncture.

CONCLUSIONS

Factors related to attitudes toward acupuncture were very similar to factors identified in other literature for nonveterans, with the exception of income and education. The findings suggest that availability of treatment influences attitudes toward acupuncture.

Halpin SN, Huang W, Perkins MM. Physicians' influence on veterans' decision to use acupuncture. Patient Educ Couns. 2014 Nov;97(2):211-5. doi: 10.1016/j.pec.2014.07.021. Epub 2014 Jul 22.

OBJECTIVE

To compare patients' acupuncture use with physician's attitudes toward and history of referral for acupuncture.

METHODS

A questionnaire was administered to patients of the Atlanta Veterans Affairs Medical Center and the physicians whom they identified as most influencing their healthcare decisions. A total of 114 patients were matched with 33 physicians.

RESULTS

Physicians' history of referral was not significantly related to patients' acupuncture use. Physicians' belief that acupuncture would increase patient satisfaction, however, was associated with higher rates of patient acupuncture use (p=0.01). Qualitative analysis of an open-ended question that probed further into physicians' attitudes regarding acupuncture revealed three key themes: lack of knowledge about the treatment; misperceptions regarding availability of acupuncture at VA; and lack of VA providers to meet demand.

CONCLUSION

These results indicate that physicians' referral patterns are not associated with patients' acupuncture use. However, some evidence shows a link between patients' acupuncture use and physicians' beliefs that the treatment will increase patient satisfaction, showing that physician attitudes may have some influence on patients' acupuncture use.

PRACTICAL IMPLICATIONS

In order to cultivate shared-decision making between patients and their physicians it will be important to address gaps in provider knowledge about acupuncture and its availability.

Halpin SN, Huang WH, Perkins MM. Comparisons between Body Needle Acupuncture, Auricular Acupuncture, and Auricular Magnet Therapy Given to Veterans Suffering from Chronic Pain. 2015

No known research has investigated patients' attitudes toward different acupuncture techniques, including those that require less training to administer and potentially could be made more widely available in order to meet the growing demand for acupuncture. The aim of this study was to determine attitudes toward and expectations regarding three different types of acupuncture. The cohort included all patients (n=114) who received acupuncture treatment at the Atlanta Veterans Affairs Medical Center between May 2012 and May 2014. The patients were mailed questionnaires. Patients who agreed to be contacted by phone also participated in semi-structured telephone interviews. The respondents to the mailed surveys (n=72) varied in their demographics and attitudes toward experiences with different types of acupuncture. Of these, a subset of respondents also completed semi-structured telephone interviews (n=45). Thematic analysis of the data revealed three key themes, including (1) perceived time commitment versus return on investment; (2) anxiety, pain, and fear of needles; and (3) the importance of the patient/clinician relationship. Findings showed that the quality of the patient/clinician relationship was a critical factor that shaped the respondents' attitudes toward the different treatment options and also influenced satisfaction with treatment. Patients who were disinclined toward needles and those who wanted longer-lasting pain relief were more likely to endorse auricular magnet therapy.

Huang W, Johnson TM, Kutner NG, Halpin SN, Weiss P, Griffiths PC, Bliwise DL. Acupuncture for Treatment of Persistent Disturbed Sleep: A Randomized Clinical Trial in VeteransWith Mild Traumatic Brain Injury and Posttraumatic Stress Disorder. J Clin Psychiatry. 2018 Dec

OBJECTIVE

To evaluate real, as compared with sham, acupuncture in improving persistent sleep disturbance in veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD).

METHODS

This sham-controlled randomized clinical trial at a US Department of Veterans Affairs Medical Center (2010-2015) included 60 veterans aged 24-55 years (mean of 40 years) with history of mTBI of at least 3 months and refractory sleep disturbance. Most of these participants (66.7%) carried a concurrent DSM-IV clinical diagnosis of PTSD. For the present study, they were randomized into 2 groups and stratified by PTSD status using the PTSD Checklist-Military Version. Each participant received up to 10 treatment sessions. The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy-assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate.

RESULTS

Mean (SD) preintervention global PSQI score was 14.3 (3.2). Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, P = .04) and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, P = .0016). Effective blinding for active treatment was maintained in the study. PTSD participants presented with more clinically significant sleep difficulties at baseline; acupuncture was effective for both those with and without PTSD.

CONCLUSIONS

Real acupuncture, compared with a sham needling procedure, resulted in a significant improvement in sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD. These results indicate that an alternative-medicine treatment modality like acupuncture can provide clinically significant relief for a particularly recalcitrant problem affecting large segments of the veteran population.

Hull A, Reinhard M, McCarron K, Allen N, Jecmen MC, Akhter J, Duncan A, Soltes K. Acupuncture and meditation for military veterans: first steps of quality management and future program development. Glob Adv Health Med. 2014 Jul;3(4):27-31. doi: 10.7453/gahmj.2013.050.

Veterans of all war eras have a high rate of chronic disease, mental health disorders, and chronic multi-symptom illnesses (CMI).(1-3) Many veterans report symptoms that affect multiple biological systems as opposed to isolated disease states. Standard medical treatments often target isolated disease states such as headaches, insomnia, or back pain and at times may miss the more complex, multisystem dysfunction that has been documented in the veteran population. Research has shown that veterans have complex symptomatology involving physical, cognitive, psychological, and behavioral disturbances, such as difficult to diagnose pain patterns, irritable bowel syndrome, chronic fatigue, anxiety, depression, sleep disturbance, or neurocognitive dysfunction.(2-4) Meditation and acupuncture are each broad-spectrum treatments designed to target multiple biological systems simultaneously, and thus, may be well suited for these complex chronic illnesses. The emerging literature indicates that complementary and integrative medicine (CIM) approaches augment standard medical treatments to enhance positive outcomes for those with chronic disease, mental health disorders, and CMI.(5-12.).

Jonas WB, Bellanti DM, Paat CF, Boyd CC, Duncan A, Price A, Zhang W, French LM, Chae H. A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury. Med Acupunct. 2016 Jun 1;28(3):113-130.

BACKGROUND

Headaches are prevalent among Service members with traumatic brain injury (TBI); 80% report chronic or recurrent headache. Evidence for nonpharmacologic treatments, such as acupuncture, are needed.

OBJECTIVE

The aim of this research was to determine if two types of acupuncture (auricular acupuncture [AA] and traditional Chinese acupuncture [TCA]) were feasible and more effective than usual care (UC) alone for TBI-related headache.

MATERIALS AND METHODS

Design: This was a three-armed, parallel, randomized exploratory study. Setting: The research took place at three military treatment facilities in the Washington, DC, metropolitan area. Patients: The subjects were previously deployed Service members (18-69 years old) with mild-to-moderate TBI and headaches. Intervention: The interventions explored were UC alone or with the addition of AA or TCA. Outcome Measures: The primary outcome was the Headache Impact Test (HIT). Secondary outcomes were the Numerical Rating Scale (NRS), Pittsburgh Sleep Quality Index, Post-Traumatic Stress Checklist, Symptom Checklist-90-R, Medical Outcome Study Quality of Life (QoL), Beck Depression Inventory, State-Trait Anxiety Inventory, the Automated Neuropsychological Assessment Metrics, and expectancy of outcome and acupuncture efficacy.

RESULTS

Mean HIT scores decreased in the AA and TCA groups but increased slightly in the UC-only group from baseline to week 6 [AA, -10.2% (-6.4 points); TCA, -4.6% (-2.9 points); UC, +0.8% (+0.6 points)]. Both acupuncture groups had sizable decreases in NRS (Pain Best), compared to UC (TCA versus UC: P = 0.0008, d = 1.70; AA versus UC: P = 0.0127, d = 1.6). No statistically significant results were found for any other secondary outcome measures.

CONCLUSIONS

Both AA and TCA improved headache-related QoL more than UC did in Service members with TBI.

Madsen C, Patel A, Vaughan M, Koehlmoos T.  Use of Acupuncture in the United States Military Healthcare System. Med Acupunct. 2018 Feb 1;30(1):33-38. doi: 10.1089/acu.2017.1260.

OBJECTIVES

The Military Healthcare System (MHS) shows increasing interest in acupuncture as an alternative to opioids for pain control. However, specific factors associated with this procedure in the MHS are not well-described in literature. This study examines usage within the MHS to determine patterns among the diagnoses, provider types, and facilities associated with acupuncture.

MATERIALS AND METHODS

Acupuncture-treated patients were identified from TRICARE claims data in the MHS Data Repository as having at least one acupuncture treatment in fiscal year (FY) 2014. Bivariate analysis was performed to determine demographics, diagnoses, and number of visits, for both active-duty and nonactive-duty personnel. Descriptive statistics were used to show associated provider and facility types.

RESULTS

A total of 15,761 people received acupuncture in the MHS in FY 2014. Use of acupuncture was greater for Army service, white race, and senior enlisted rank overall, and for males ages 26-35 among active-duty and females ages 46-64 among nonactive-duty beneficiaries. A cumulative 76% of diagnoses were for musculoskeletal or nerve and system issues. Approximately 60% of patients received acupuncture from physicians, 16% from physical therapists or chiropractors, and 9.7% from physician extenders. Specific acupuncture techniques (traditional, auricular, etc.) could not be determined from the data set.

CONCLUSIONS

The most common diagnoses associated with acupuncture are consistent with pain management. However, full analysis is hampered by inconsistent coding and lack of granularity regarding specific techniques. Given the popularity of acupuncture in the MHS, further research is necessary to explore the full scope of this intervention.

Olson JL. Licensed Acupuncturists Join the Veterans Health Administration. Med Acupunct. 2018 Oct 1;30(5):248-251. doi: 10.1089/acu.2018.1298. Epub 2018 Oct 15.

This article introduces changes occurring in the Veterans Health Administration (VHA) with respect to the delivery of acupuncture. The VHA has published a new occupation code and job qualification standard allowing licensed acupuncturists to practice at the VHA medical centers. This policy shift comes at a time of great need for complementary and integrative health (CIH) options for veterans as identified by the advancing research, policies, and legislation that support CIH. The VHA initiatives include fostering an understanding of the distinct profession of licensed acupuncturists, developing an appreciation of the emerging evidence for acupuncture, and creating the cultural shift to support a wider view of CIH services. Historically, acupuncture was provided in the VHA mostly by physician-acupuncturists and chiropractic acupuncturists. The publication of a qualification standard for licensed acupuncturists allows the VHA to increase its provider base and create cost savings for the delivery of acupuncture. This move requires overcoming barriers to the integration of licensed acupuncturists into the VHA system. The goal is to increase the utilization of acupuncture among veterans.

Olson J, Kligler B. Society for Acupuncture Research Turning Point: Acupuncture in the Veterans Health Administration. J Altern Complement Med. 2021 Jul;27(7):527-530. doi: 10.1089/acm.2021.0194. PMID: 34255536.

As the U.S. health care system struggles to deliver patient-centered quality care, the VHA is focused on implementing a model of care that changes the conversation from “what is the matter with you” to “what matters to you.” The Whole Health (WH) System is designed to orient care delivery around a Veteran's health goals utilizing complementary and integrative health (CIH) approaches in addition to standard biomedical care. The VHA was the first major health care system to offer acupuncture access as part of standard medical benefits. Over the past 5 years of implementation and re-evaluation, a number of lessons have been learned that may be of benefit for other private and government health care systems in the coming years.

Peacock KS, Stoerkel E, Libretto S, et al. A randomized trial comparing the Tennant Biomodulator to transcutaneous electrical nerve stimulation and traditional Chinese acupuncture for the treatment of chronic pain in military service members. Mil Med Res. 2019;6(1):37. Published 2019 Dec 2. doi:10.1186/s40779-019-0227-4

The present investigation tested the efficacy of the Tennant Biomodulator, a novel pain management intervention that uses biofeedback-modulated electrical stimulation, to reduce chronic pain and its psychosocial sequelae in a sample of current and former military service members. The Tennant Biomodulator used on its most basic setting was compared to two commonly used, non-pharmacological pain treatments—traditional Chinese acupuncture and transcutaneous electrical nerve stimulation (TENS)—in a comparative efficacy, randomized, open-label trial.

METHODS

Participants included 100 active duty and retired service men and women with chronic pain undergoing treatment at the Brooke Army Medical Center in Texas, USA, randomly assigned to receive six, weekly sessions of either Tennant Biomodulator treatment, traditional Chinese acupuncture, or TENS, in addition to usual care. Recruitment was conducted between May 2010 to September 2013. Outcome measures were collected at intake, before and after each treatment session, and at a 1-month follow-up. Intent-to-treat analyses were used throughout, with mixed models used to investigate main effects of group, time, and group × time interactions with consideration given to quadratic effects. Outcomes measured included ratings of chronic pain, pain-related functional disability, and symptoms of post-traumatic stress disorder (PTSD) and depression.

RESULTS

On average, regardless of their treatment group, participants exhibited a 16% reduction in pain measured by the Brooke Army Medical Center's Clinic Pain Log [F(1, 335) = 55.7, P <  0.0001] and an 11% reduction in pain-related disability measured by the Million Visual Analog Scale [MVAS: F(1, 84) = 28.3, P <  0.0001] from baseline to the end of treatment, but no one treatment performed better than the other, and the reductions in pain and pain-related disability were largely lost by 1-month follow-up. Symptoms of PTSD and depression did not change significantly as a function of time or group.

CONCLUSIONS

Findings build on previous work suggesting that traditional Chinese acupuncture and TENS can reduce pain and its functional sequelae without risks associated with pharmacological pain management. The Tennant Biomodulator used on its most basic setting performs as well as these other interventions. Based on the present findings, large, randomized controlled trials on the Tennant Biomodulator are indicated. Future work should test this device using its full range of settings for pain-related psychological health.

Redd D, Kuang J, Zeng-Treitler Q.  Differences in nationwide cohorts of acupuncture users identified using structured and free text medical records. AMIA Annu Symp Proc. 2014 Nov 14;2014:1002-9. eCollection 2014.

Integrative medicine including complementary and alternative medicine (CAM) has become more available through mainstream health providers. Acupuncture is one of the most widely used CAM therapies, though its efficacy for treating various conditions requires further investigation. To assist with such investigations, we set out to identify acupuncture patient cohorts using a nationwide clinical data repository. Acupuncture patients were identified using both structured data and unstructured free text notes: 44,960 acupuncture patients were identified using structured data consisting of CPT codes;. Using unstructured free text clinical notes, we trained a support vector classifier with 86% accuracy and was able to identify an additional 101,628 acupuncture patients not identified through structured data (a 226% increase). In addition, characteristics of the patients identified through structured and unstructured data were compared, which show differences in geographic locations and medical service usage patterns. Patients identified with structured data displayed a consistently higher use of the Veterans Health Administration (VHA) medical system.

Reddy KP, Drake D, Kligler B. Acupuncture and Whole Health in the Veterans Administration. Med Acupunct. 2018 Oct 1;30(5):225-227. doi: 10.1089/acu.2018.29096.rdk. Epub 2018 Oct 15. PubMed PMID: 30393506; PubMed Central PMCID: PMC6206594.

Empowering and engaging patients is our goal. Our current healthcare system, however, is a disease-based model in which patients are the passive recipients of advice, prescriptions, and interventions for chronic disorders. Clinical teams often feel they have little choice in managing these chronic conditions, including pain and mental health conditions, and often turn to medications rather than engaging patients in the lifestyle and behavioral modifications that would improve long-term outcomes more significantly.

Sharp SJ, Huynh MT, Filart R.  Frequency-Specific Microcurrent as Adjunctive Therapy for Three Wounded Warriors. Med Acupunct. 2019 Jun 1;31(3):189-192. doi: 10.1089/acu.2019.1366. Epub 2019 Jun 17.

BACKGROUND

Acupuncture is frequently offered for wounded warriors as a component of an integrated approach to pain and associated symptoms, with increasing availability at military treatment facilities and Veterans Administration hospitals. While medications can be effective for many patients, acupuncture and microcurrent therapies address the growing need to offer nonopiate, nonpharmaceutical therapeutics in integrative pain management. Frequency-specific microcurrent (FSM) is a newer, adjustable, microcurrent, electrical stimulation modality with applications for pain and other associated symptoms. Using low amperage, electrical current delivered transcutaneously affects and repairs tissues at the cellular level. Additionally, concomitant treatment with acupuncture is possible, which is particularly helpful when space and time limit the frequency with which acupuncture treatments can be provided.

CASES

For 3 wounded warriors, FSM was combined with acupuncture treatments, resulting in more-rapid reduction of their pain and associated symptoms; including memory problems, mental sluggishness, and post-traumatic stress disorder.

RESULTS

FSM was found to be a safe, nonpainful, noninvasive treatment that could be administered concurrently and beneficially with acupuncture.

CONCLUSIONS

While additional, more-rigorous studies are needed, this case series demonstrates the potential that FSM has within an integrated pain treatment program for wounded warriors.

Sodders MD, Martin AM, Coker J, Hammond FM, Hoffman JM. Acupuncture use for pain after traumatic brain injury: a NIDILRR Traumatic Brain Injury Model Systems cohort study. Brain Inj. 2023 May 12;37(6):494-502. doi: 10.1080/02699052.2023.2187088.

BACKGROUND

Pain after traumatic brain injury (TBI) is common and can become chronic. Acupuncture is an increasingly popular non-pharmacologic option in the United States and is commonly used for pain.

OBJECTIVE

We explored demographics, injury characteristics, and pain characteristics of individuals who reported using acupuncture for chronic pain after TBI.

METHODS

We analyzed a subset of data collected as part of the Pain After Traumatic Brain Injury collaborative study and identified individuals reporting a history of acupuncture as part of management for chronic pain after TBI. We characterized and compared basic demographic data, pain treatment engagements, pain severity, pain interference, functional independence, and pain locations using descriptive and inferential statistics.

RESULTS

Our sample included 1,064 individuals. Acupuncture use (n = 208) was lower proportionally among females, Blacks/African Americans, Asians, less educated, and nonmilitary service members. Insurance type varied between acupuncture and non-acupuncture users. Functional and pain outcomes were similar, but acupuncture users reported a higher number of pain sites.

DISCUSSION

Acupuncture is one treatment utilized by individuals with TBI and chronic pain. Further investigation would be helpful to understand the barriers and facilitators of acupuncture use to inform clinical trials to examine the potential benefit of acupuncture on pain outcomes after TBI.

Wheeler, M.S., Glass, C.R., Arnkoff, D.B. et al. The Effect of Mindfulness and Acup on Psychological Health in Veterans: an Exploratory Study. Mindfulness (2018) 9: 564. https://doi.org/10.1007/s12671-017-0798-7

iRest Yoga Nidra® is a guided mindfulness approach that encourages relaxation, focused attention, experience of joy, observation of opposite feelings and emotions, non-judgment, and integration of these principles into daily life. iRest was developed for the military population, but the research on its effectiveness is in its infancy. This exploratory study examined the effectiveness of iRest in combination with acupuncture compared to acupuncture alone in improving psychological health in Veterans. The combined treatment yielded significant psychological benefit in depression, psychological symptom severity, depression or tension due to pain, and emotional interference with life activities, while the acupuncture-only treatment did not. Although both conditions showed significant decreases in perceived stress, the effect size for the treatment group was medium to large compared to a small effect size for those receiving acupuncture only. The combined treatment condition, iRest plus acupuncture, also demonstrated clinically meaningful change, with significant decreases in the number of Veterans meeting criteria for mild, moderate, and severe depression. Finally, the combined treatment was equally beneficial independent of factors such as age, gender, or race. Given the pervasiveness of psychological distress and depression in the Veteran population and the efficiency with which these group treatments can be provided, these findings lend preliminary support for the extension of complementary and integrative health offerings including iRest and acupuncture into more Veterans Administration hospitals across the country to improve military mental health. Indeed, the encouraging results of this exploratory study underscore the importance of expanded research on iRest and acupuncture for the treatment of psychological health.

Zeliadt SB, Coggeshall S, Thomas E, Gelman H, Taylor SL. The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health [published online ahead of print, 2020 Jun 10]. Clin Trials. 2020;1740774520928399. doi:10.1177/1740774520928399

Electronic health record data can be used in multiple ways to facilitate real-world pragmatic studies. Electronic health record data can provide detailed information about utilization of treatment options to help identify appropriate comparison groups, access historical clinical characteristics of participants, and facilitate measuring longitudinal outcomes for the treatments being studied. An additional novel use of electronic health record data is to assess and understand referral pathways and other business practices that encourage or discourage patients from using different types of care. We describe an ongoing study utilizing access to real-time electronic health record data about changing patterns of complementary and integrative health services to demonstrate how electronic health record data can provide the foundation for a pragmatic study when randomization is not feasible. Conducting explanatory trials of the value of emerging therapies within a healthcare system poses ethical and pragmatic challenges, such as withholding access to specific services that are becoming widely available to patients. We describe how prospective examination of real-time electronic health record data can be used to construct and understand business practices as potential surrogates for direct randomization through an instrumental variables analytic approach. In this context, an example of a business practice is the internal hiring of acupuncturists who also provide yoga or Tai Chi classes and can offer these classes without additional cost compared to community acupuncturists. Here, the business practice of hiring internal acupuncturists is likely to encourage much higher rates of combined complementary and integrative health use compared to community referrals. We highlight the tradeoff in efficiency of this pragmatic approach and describe use of simulations to estimate the potential sample sizes needed for a variety of instrument strengths. While real-time monitoring of business practices from electronic health records provides insights into the validity of key independence assumptions associated with the instrumental variable approaches, we note that there may be some residual confounding by indication or selection bias and describe how alternative sources of electronic health record data can be used to assess the robustness of instrumental variable assumptions to address these challenges. Finally, we also highlight that while some clinical outcomes can be obtained directly from the electronic health record, such as longitudinal opioid utilization and pain intensity levels for the study of the value of complementary and integrative health, it is often critical to supplement clinical electronic health record–based measures with patientreported outcomes. The experience of this example in evaluating complementary and integrative health demonstrates the use of electronic health record data in several novel ways that may be of use for designing future pragmatic trials.