From Research to Practice: Samueli Institute's Work on Integrative Medicine in the Military: from an ongoing series by

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From Research to Practice: Samueli Institute's Work on Integrative Medicine in the Military

The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series

Summary: Perhaps the best way to gauge the impact of a healthcare researcher's work is whether medical practice changed. By such a measure, the Samueli Institute's robust military research initiative relative to integrative practices, led by Joan Walter, JD, PA is showing significant success. Pilot projects in auricular acupuncture, for instance, have led to education of Air Force doctors in a novel, 5-point auricular acupuncture protocol. A Yoga Nidra trial is incorporated in a program for soldiers with post-traumatic stress disorder. Here is a look at some Samueli Institute initiatives that are transitioning from research to practice. Will these breakthroughs one day shift civilian care?

The name, Center for Research on Integrative Medicine in the Military, and the associated acronym, CRIMM, each sound like part of James Bond story. What is integrative medicine in this context? Might practices be integrated which could have important civilian applications?

CRIMM is one of 4 key initiatives

CRIMM exists. The center is the leading strategic initiative for one of the most influential organizations involved with integrative practice in the United States. In the last half-decade, CRIMM projects led to over a score of publications. Some 30 projects are completed, presently in progress or planned with collaborating institutions such as Walter Reed Army Medical Center, Malcolm Grow Medical Center, William Beaumont Army Medical Center, Madigan Army Medical Center, U.S. Army Medical Research and Materiel Command, U.S. Air Force, the Uniformed Services University of the Health Sciences (USUHS) and the Veterans Health Administration (VHA).

The research organization behind this work is the Samueli Institute, founded in 2001 by philanthropists Henry and Susan Samueli, and Wayne Jonas, MD. Jonas, the former director of the National Institutes of Health's Office of Alternative Medicine (now NCCAM), has a long association with both Walter Reed and USUHS as well as a lengthy professional and personal interest in integrative practices. He serves as the Institute's president and CEO. Joan Walter, JD, PA, the Institute's vice president for military medical research, leads the military initiative.

While time will tell whether the Samueli Institute's military-based research through CRIMM will translate into civilian uses, the Institute's research is already shifting care in parts of the sprawling U.S. military. States Walter: "We have a number of initiatives that have gone beyond us sitting around and saying 'wouldn't it be nice' if something was part of typical care. These initiatives have either been taken up and are funded through the Department of Defense (DoD) or members of the DoD at some level have said, 'we'd like to develop this with you.'"

"Battlefield acupuncture" - a new 5-point protocol for primary care doctors

A leading area where evidence developed in Samueli Institute pilot projects is now being transformed into practice in military medicine is in the use of auricular acupuncture. The Air Force has particularly shown interest in training its physicians in a limited use of needles.

The initiative began with Samueli Institute working in cooperation with medical acupuncturist Colonel Richard Niemtzow, MD. Niemtzow developed a 5-point auricular therapy through "distilling the literature and applying critical thinking to what he was seeing in his clinical practice" said Walter. Niemtzow and another medical acupuncturist, Colonel Stephen Burns, MD delivered the treatments in the pilot projects.

______________________________

Case Example: Samueli Institute's
Translation of Specially Developed
Auricular Acupuncture from Pilot Projects
to Education of Primary Care Military Physicians

Year	Partner	Project
2004	Malcolm Grow Air Force Medical Center	Auricular Acu in ER for acute pain
2005	Malcolm Grow Air Force Medical Center	Outcome assessments for Acu in AF studies
2006	Bedford VA	Acu for homeless Vets with substance abuse
2006	Walter Reed Army Medical Center	Acu for treatment of trauma survivors
2007	USAF Medical Comment	Requested acu training program & evaluation
2008	Baltimore VA	Acu to improve function, exercise capacity and pain
2008	Malcolm Grow Air Force Medical Center	Acu training program developed
2008	Landstuhl Regional Medical Center (Germany)	Possible expansion of acupuncture training

Source: Materials supplied by Samueli Institute.

______________________________

Following a series of pilot studies, an Air Force leader was "sufficiently impressed," said Walter, to wonder how they could "make the therapy more widely available." The Institute's next contract was to take the therapy and "manualize" it. The Samueli Institute team developed materials for doctors - mainly family practitioners - as well as explanatory materials for patients.

Colonel Richard Niemtzow, MD, PhD, medical acupuncturist
Why the value to the Air Force? Walter notes that acupuncture for pain can limit the need for pain medications that area often used treatments that are often used such as motrin ("Vitamin M" as it is known to soldiers) or even narcotic medications. Adds Walter: "A pilot can't fly while on (these drugs)." Acupuncture was viewed as a treatment that might avoid the side effects of drowsiness and decreased alertness which are common wiht the use of medications. Through the program to educate other physicians in the protocol, in partnership with Anderson Air Force Base, the Institute is assisting the Air Force in evaluating whether the therapy, in hands other than Niemtzow's and Burns, will prove as effective. Interest has also been expressed by leaders of a U.S. base in Germany.

Yoga Nidra as part of a program for traumatized soldiers

Walter notes that the uptake of acupuncture follows a typical process in which evidence is first gathered through from multiple studies and, if deemed effective, is slowly incorporated into practice. Then she adds: "Sometimes with the military what makes a treatment attractive is something that will meet a need that is calling out for a new approach."

The uptake of Yoga Nidra for post-traumatic stress disorder (PTSD) is a case in point. Samueli Institute worked with military and clinician researchers and Richard Miller, PhD, a leading Yoga therapist and a co-founder of the International Association of Yoga Therapists. Working with Miller, the Institute developed an 8-week pilot which utilized a manual and a series of CDs to support home practice. Clarifies Walter: "[Miller] Westernized it and took pains to standardize it so that high quality research was possible."

Richard Miller, PhD - Collaborator on Yoga Nidra project
For a variety of reasons related to the scheduling of the classes and the length of the program, only 7 soldiers completed the original Yoga Nidra pilot. The limited sample results showed "a trend toward reduction of PTSD symptoms," notes Walter, along with "help in dealing with anxiety in the soldiers return home." Yet while hardly earth-shaking or conclusive, Yoga Nidra seemed to have no downside. It's potential value, said Walter, "was appreciated by key military personnel."

The outcome is significant. A Yoga Nidra module is now included in a 3-week "Specialized care program." This multifaceted program is provided to troop returning from combat at Walter Reed Army Medical Center's Deployment Health Clinical Center.

Other projects

The Samueli Institute's work with the military has also branched in a number of additional directions, some of which are also moving toward practice.

Dietary Supplements Through 2007 and into 2008 the Institute worked closely with the US Army Institution of Environmental Medicine and with the Institute of Medicine on issues related to dietary supplement use in the military. In 2008, Samueli Institute is partnering with Rand Corporation on clarifying management strategies for the military around dietary supplements.

Chiropractic Two feasibility studies on manual/manipulative therapy for lower back pain have been engaged.

"Reset"-resiliency The concept with "reset" is an analogy to a computer, Walter explains. Additionally, the military already has a reset program for the care and maintenance of heavy equipment when it comes out of hte field. All equipment is refurbished and reconstituted, because it is understood that it has sustained major wear and tear. Similarly, soldiers may return from combat having been exposed to extreme conditions and may be, effectively, overloaded. A two stage initiative is being redeveloped to provide both pre-deployment and post-deployment "reset and skills training program."

Walter reflects on the "reset" program: "We know that troops have been exposed to things that will trigger a stress reaction, depending on the soldier's resiliency. The question of course is: Shouldn't we think about every soldier needing skills and strategies to deal with this effectively?"

An Elephant in the Room

The stated purpose of the Samueli Institute's CRIMM initiative is "support our troops through research, education and advocacy related to Complementary and Integrative Medicine." The core areas of identified interest are pain and chronic disease symptoms, stress and post traumatic stress disorder and a third, "human performance optimization."

Walters notes that "the ethics of the (latter) is the elephant in the room" for the CRIMM initiative. Is it aligned with medical values and the Hippocratic Oath to participate in making an individual a better warrior? And on the other hand, do we not owe a duty to our soldiers to provide them with the best tools and approaches to keep them functioning and healthy amidst the challenges they face? A recent Samueli Institute meeting which I had the privilege to attend included a lively discussion on this topic.

Steps toward Translation into Civilian Practice

Clearly, the focal areas of the Samueli Institute's agenda have civilian applications. Walter notes that the Air Force sponsors of the acupuncture trials, for instance, recently approved Samueli Institute to submit an abstract of the findings for the American Public Health Association's annual meeting. Walter explains: "We think there could be a tremendous value in a public health setting." She imagines an individual coming into a community clinic with a complaint which could respond to the "quick acupuncture technique" the Institute has been researching.

Walter reflects: "In every contract with the military, we are asked to describe the military relevance as well as the public relevance. Might it be useful in the work environment? For care-givers? For traders on the stock exchange?"

Given the emerging upheavals in the U.S. medical system, and the economy's present challenges to Wall Street's warrior, the use of therapies approved in battle conditions may be more appropriate than any of us would like to admit.

Comment: Thinking about the Samueli Institute's CRIMM initiative has me reflecting on some of the anti-war origins of the "alternative medicine" movement back in early 1970s. The era prompted many who viewed the West as the aggressor in a war, who heard propaganda in the U.S. which often demonized the Vietnamese and Chinese, to explore the somewhat romanticized, peaceful gifts of the East: Buddhism, meditation, the mind-body connection, acupuncture and Oriental medicine. These they brought home, and in time, through work, research and profession building, laid down the building blocks of the integrative health movement. And here we are seeing that success now being translated into changes in military medical practices. For the movement, comfort in living with paradox is likely a sign of maturity. Walter is correct in observing that the elephant remains in the room.

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