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Office of Public Health & Environmental Hazards Integrative Health Care for Veterans War Related Illness and Injury Study Center Washington, DC.

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Presentation on theme: "Office of Public Health & Environmental Hazards Integrative Health Care for Veterans War Related Illness and Injury Study Center Washington, DC."— Presentation transcript:

1 Office of Public Health & Environmental Hazards Integrative Health Care for Veterans War Related Illness and Injury Study Center Washington, DC

2 Welcome Acupuncture Presenter Jeanette Akhter, MD, MAc, Licensed Acupuncturist Integrative Health Care Presenter Kelly McCoy, PsyD Labyrinth Presenter Brenda Jasper, MEd, PA-C National Referral Program Coordinator Yoga Presenter Louise Mahoney, MS

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4 What is Integrative Health Care?  New and growing approach to health care delivery  Broader in focus than conventional care  Coordinated health care  Explicitly combines conventional and complementary approaches  Complementary and alternative medicine (CAM): “A group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” – NCCAM definition

5 Philosophy of Integrative Health Care  Mind, body, spirit, community  Tradition and innovation  Healing extends beyond cure  Tailored toward patient goals  Shared responsibility

6 Qualities of Integrative Health Care  Holistic, broad scope  Scientifically-rigorous  Values wisdom  Motivational  Patient-centered  Prevention and treatment  Interdisciplinary  Healing environments and relationships  Cross-trained providers  Incorporates mind- body skills

7 Who can benefit?  Individuals managing chronic illnesses  People facing acute health and life events  Individuals who want to optimize wellness

8 Integrative Health Care for Veterans

9 The WRIISC and Post- Deployment Health Care  War Related Illness and Injury Study Center  VA Office of Public Health and Environmental Hazards  Clinical care, research, education, risk communication  National referral program  Outpatient programs (DC, NJ, CA)  Identified need for coordinated treatment approaches

10 Acupuncture Satisfaction Data  2010 total encounters  649 individual full body  890 group ear acupuncture  Improvement in symptoms (n = 103)  45% yes, completely  51% yes, somewhat  3% no improvement  <1% too early to tell  Overall quality (n = 112)  70% excellent  20% very good  10% good  <1% poor  Would recommend to other Veterans (n = 130)  99% yes  <1% no

11 Acupuncture Satisfaction Data N = 102Yes, Completely Yes, Somewhat NoDon’t Have This Problem Back Pain 22%57%13%7% Musculoskeletal Pain 25%64%5%6% Headaches 28%47%6%19% Upset Stomach 15%22%26%37% Constipation/Diarrhea 8%16%20%55% Trouble Sleeping 26%51%18%5% Energy Level 32%53%11%4% Irritability/Angry Outbursts 27%42%18%13% Concentration 18%55%18%10% Depression 16%57%18%8% Anxiety 18%61%18%3% Jumpy/Easily Startled 19%56%18%7% Disturbing Memories 18%46%28%8%

12 iRest® Yoga Nidra Satisfaction Data  2010 total encounters  1,318 sessions  Improvement in symptoms (n = 165)  10% yes, completely  85% yes, somewhat  4% no improvement  <1% don’t have symptoms  Overall quality (n = 184)  66% excellent  30% very good  1% good  2% poor  Would recommend to other Veterans (n = 184)  100% yes

13 Yoga Nidra Satisfaction Data N = 164Yes, Completely Yes, Somewhat NoDon’t Have This Problem Back Pain 8%64%19%9% Musculoskeletal Pain 8%68%11%13% Headaches 10%41%16%33% Upset Stomach 4%18%26%51% Constipation/Diarrhea 4%19%15%62% Trouble Sleeping 9%72%13%6% Energy Level 12%72%12%4% Irritability/Angry Outbursts 14%55%16%14% Concentration 10%55%20%15% Depression 12%52%25%11% Anxiety 12%66%17%5% Jumpy/Easily Startled 9%52%22%17% Disturbing Memories 13%45%26%16%

14 Labyrinth Satisfaction Data  2010 total visits  481  How was your walk on the Freedom Labyrinth Path? (n = 227)  50% excellent  42% very good  7% fair  <1% no value  Would you walk the labyrinth again? (n = 227)  99% yes  <1% no  Descriptions of the labyrinth: Calming, relaxing, serene, awesome, soothing, wonderful, excellent, mellow, balanced, peaceful, meditative, rejuvenating, surprising, inspirational, therapeutic, centering, uplifting, helpful, purposeful, anchoring, euphoric

15 Yoga with Movement  Chair yoga  Mat yoga (mixed gender)  Mat yoga (women only)  Satisfaction data collected following completion of 12 weekly sessions of either chair or mat yoga  Would you recommend WRIISC yoga to a friend ? (n = 11)  100% yes  Do you feel better after class than before? (n = 13)  100 % yes  Would you participate in WRIISC yoga again? (n = 12)  100% yes

16 Yoga with Movement Feedback  “It is one thing I look forward to because for that short amount of time I have hope” – Operation Iraqi Freedom Veteran  “Best thing in years” – Korean War Veteran  “ Wonderful for body and soul” – Gulf War I Veteran  “Great class, should meet 2x per week” – Vietnam War Veteran”

17 Integrative Health Care Research at the WRIISC  Yoga and Mind/Body Therapies for Treatment of War Related Illness and Injuries  PI: Louise Mahoney, MS, WRIISC-CA  The Effect of Acupuncture for PTSD-Related Insomnia  PI: Michelle Prisco, MSN, ANP-C, WRIISC-DC  Results anticipated May-June 2012

18 Integrative Health Care Research at the WRIISC  Qigong for Symptom Management and Function in Veterans with Fatiguing Illnesses  PI: Anna Rusiewicz, PhD, WRIISC-NJ  Results anticipated September 2012  Acupuncture to Improve the Quality of Life in Veterans with TBI and PTSD  PI: Anna Rusiewicz, PhD & Thomas Findley, MD PhD, WRIISC-NJ  Results anticipated January 2012

19 Integrative Modalities Throughout the VHA System Acupuncture Aquatic bodywork Aromatherapy Biofeedback Deep-breathing exercises Guided imagery Hypnotherapy Labyrinth Laughter yoga Mindfulness meditation Massage Progressive relaxation Tai Chi Qigong Reiki Spinal manipulation Structural integration Tai Chi Therapeutic touch Yoga with movement Yoga Nidra

20 VA Integrative Health Clinic and Program  Salt Lake City, UT VAMC  Acupuncture  Aquatic bodywork  Stress management class: guided imagery, relaxation techniques, biofeedback, qigong, awareness and reframing of thought patterns  Medical hypnosis  Yoga with movement  Herbal/nutritional supplement/drug interaction education  Meditation  Qigong  Tobacco cessation  Weight management class: nutrition, exercise, psychotherapy, hypnosis

21 VA Integrative Health Clinic - Research VA Integrative Health Clinic - Research  Chronic nonmalignant pain  Longitudinal outcome research  Chronic nonspinal-related pain group vs. chronic spinal-related pain group  Nonspinal pain group: Improved depression, anxiety, bodily pain, vitality and health transition  Benefits persisted to 24 months  Spinal-related pain group: trend toward improvement in bodily pain Smeeding, S. J. W., Bradshaw, D. H., Kumpfer, K. L., Trevithick, S. & Stoddard, G. J. (2011). Outcome evaluation of the Veterans Affairs Salt Late City Integrative Health Clinic for chronic nonmalignant pain. The Clinical Journal of Pain, 27,

22 VA Integrative Health Clinic - Research VA Integrative Health Clinic - Research  Depression, anxiety, and posttraumatic stress disorder  Longitudinal outcome research  Group comparisons based on levels of anxiety, depression, and PTSD symptoms  Improved depression, anxiety and health-related quality of life in all groups  Greatest improvements seen in the high anxiety, high depression, and PTSD groups Smeeding, S. J. W., Bradshaw, D. H., Kumpfer, K., Trevithick, S., & Stoddard, G. J. (2010). Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. The Journal of Alternative and Complementary Medicine,16,

23 Acupuncture

24  (acupuncture video 1)

25 Acupuncture is Over Three Thousand Years Old Acupuncture’s greatest contribution to the field medicine is its understanding of qi –translated as life force, or energy. Qi helps us maintain health. It provides the power for:  Growth  Development  Movement  Maintaining body temperature  Protection against illness  Overall regulation

26 When our Qi is balanced, our capacity to both heal disease and prevent future illness is maximized. Our health is influenced by the quality, quantity and balance of our Qi. Symptoms of illness, whether mental, emotional or physical, are an indication of an imbalance of Qi. Qi is Our Life Force

27 Qi Imbalance  Qi depletion, obstruction, disorganization  Causes of imbalance  Injury  Illness  Environmental exposure  Poor quality nourishment  Lack of physical exercise

28 Rest and digest Daytime, summer Nighttime, winter Awake and alert YANG/Sympathetic Arousal YIN/Parasympathetic Restoration Inhale Exhale Balance is a constantly changing state. It exists in a dynamic and fluid interplay between our more substantial, dense yin aspect, and our more insubstantial, active yang aspect. Qi Moves with a Rhythm, Inside a Boundary

29 Acupuncture heals below cognition It helps people feel more embodied, more present, more self aware 12 main pathways – connected end to end like garden hoses Acupuncture Helps Restore Balance

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31 How Does Acupuncture Work?  Local effect  Mechanical stimulation of connective tissue  Adenosine release  Increase local blood flow  “Gate” mechanism

32 How does Acupuncture Work?  Increases release and binding of endogenous opioids  Basal forebrain  Limbic system  Brainstem  fMRI studies  Positron emission tomography studies

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35 Goals of Acupuncture  Unique - focused on individual Veteran’s needs  Physical  Mental  Emotional  Spiritual

36 Method  Ask  Listen  Observe  Palpate  Choose specific points  Observe results

37 Washington, DC WRIISC Acupuncture Options  Full body, individual series of treatments  Unique design for the individual’s presentation

38 DC Acupuncture Options  Group Ear Acupuncture  Five points on each ear  Balance of sympathetic/parasympathetic nervous systems as well as emotional balance  Can be used for detoxification  Often affects sleep patterns  Multiple venues at DC WRIISC

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40 Acupuncture Interest at WRIISC-DC  Year 2010  649 full body acupuncture treatments  145 Gulf War Veteran treatments  890 ear acupuncture treatments  103 Gulf War Veteran treatments

41 Acupuncture and Integrative Health Care  Acupuncture can help:  Improve focus and attention, supporting psychotherapy clients to integrate and embody insights  Bring energy to physical injuries, supporting the work of physical therapists  Mitigate side effects of necessary medications  Help some reduce medications – for sleep or pain for example

42 Acupuncture helps the mind find a place to rest, the body release trauma's imprint and the spirit come back home – safe and sound. Acupuncture Helps Veterans Get All The Way Home - Safe and Sound

43 Berman, B. M., Langevin, H. M., Witt, C. M., Dubner, R. (2010). Acupuncture for chronic low back pain. New England Journal of Medicine, 363, Birch, S., Hesselinm, J. K., Jonkman, F. A., & Hekker, T. A. (2004). Clinical Research on Acupuncture: Part I. What have Reviews of the Efficacy and Safety of Acupuncture told us so far? The Journal of Alternative and Complementary Medicine, part%201 Blitzer, L., Atchison-Nevel, D., & Kenny, M. (2004). Using acupuncture to treat major depressive disorder: a pilot investigation. Clinical Acupuncture and Oriental Medicine, 4, Chen HY, Shi Y, Ng CS, Chan SM, Yung KK, Zhang QL. Auricular acupuncture treatment for insomnia: A systematic review. J Altern Complement Med 2007; 13(6): Duncan A, Liechty JM, Miller C, Chinoy G, Ricardi, R. Employee use and perceived benefit of a CAM wellness clinic at a major military hospital: Evaluation of a pilot program. J Altern Complement Med. In Press. Eich, H., Agelink, M.W., Lehmann, E., Lemmer, W., & Klieser, E. (2000). Acupuncture in patients with minor depressive episodes and generalized anxiety disorders: Results of an experimental study. Fortsch Neurol Psychiatrie, 68, or%20depression Acupuncture Research – Selected Bibliography

44 Goertz CM, Niemtzow R, Burns SM, Fritts MJ, Crawford CC, Jonas WB. Auricular acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med 2006; 171(10): Haker, E., Egekvist, H., & Bjerring, P. (2000). Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. J Auton.Nerv.Syst., 79, hy%20subjects Hicks J, Hicks A, Mole P. Five element constitutional acupuncture. Edinburough: Elsevier, Hollifield, M., Sinclair-Lian, N., Warner, T. D., & Hammerschlag, R. (2007). Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial. J Nerv.Ment.Dis., 195, Hui, K. K., Liu, J., Makris, N., Gollub, R. L., Chen, A. J., Moore, C. I. et al. (2000). Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum.Brain Mapp., 9, Acupuncture Research – Selected Bibliography (continued)

45 Kaptchuck TJ. The web that has no weaver: Understanding Chinese medicine, 2 ed. N.Y.: McGraw-Hill, Kim KB, Sok SR. Auricular acupuncture for insomnia: Duration and effects in Korean older adults. J Gerontol Nurs 2007; 33(8): 23-8; quiz Leo, R. J. & Ligot, J. S., Jr. (2007). A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect.Disord., 97, %20depression Napadow, V., Makris, N., Liu, J., Kettner, N. W., Kwong, K. K., & Hui, K. K. (2005). Effects of electroacupuncture versus manual acupuncture on the human brain as measured by fMRI. Hum.Brain Mapp., 24, e Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders--a systematic literature review. Acupunct Med 2007; 25(1-2): Acupuncture Research – Selected Bibliography (continued)

46 Plank S, Goodard J. The effectiveness of acupuncture for chronic daily headache: An outcomes study. Mil Med 2009; 174(12): Sjoling M, Rolleri M, Englund E. Auricular acupuncture versus sham acupuncture in the treatment of women who have insomnia. J Altern Complement Med 2008; 14(1): ave%20insomnia Spence, D. W., Kayumov, L., Chen, A., Lowe, A., Jain, U., Katzman, M. A. et al. (2004). Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. J Neuropsychiatry Clin Neurosci., 16, Spira A. Acupuncture: A useful tool for health care in an operational medicine environment. Mil Med 2008; 173(7): Van Tulder, M. W., Furlan, A. D., & Gagnier, J. J. (2005). Complementary and alternative therapies for low back pain. Best.Pract.Res Clin Rheumatol., 19, Acupuncture Research – Selected Bibliography (continued)

47  (acupuncture video 2)

48 Yoga Nidra

49  (yoga nidra video 1)

50  (yoga nidra video 2)

51 Labyrinth

52  (labyrinth video)

53 Labyrinth – Brief History  > 4,000 year history  Found in many cultures and religious traditions  Now used in health care facilities, schools, and houses of worship worldwide Labyrinth from the Atlantic Bronze Age, Galicia (Spain) Labyrinth carving at a temple in Halebid, India, circa 2500 BC

54 Labyrinth - Research  Walking meditation is shown to reduce anxiety and elicit a 'relaxation response’ associated with:  lower blood pressure and breathing rates  reduced incidents of chronic pain and insomnia  Also associated with many of the benefits seen in sitting meditation and yoga Benson, H., "The relaxation response: therapeutic effect," Science Dec 5;278(5344): PMID:

55 Labyrinths at VA  Veterans, staff, and volunteers can walk a labyrinth at:  Albany VAMC  Canandaigua VAMC  Seattle VAMC  Memphis VAMC  Washington, DC VAMC

56 Labyrinth Resources  Labyrinth Society   Worldwide Labyrinth Locator 

57 Labyrinth - Practice  Not like a maze: no dead ends  Pace is up to you  Opportunity to slow down, relax, relieve stress, reflect, meditate 9/11 Memorial Labyrinth at Boston College

58 Reasons for Walking the Labyrinth  To relax  To express intent  For physical healing  As a pilgrimage  To meditate  To ask a question  For emotional healing  To ease grief  For inspiration  To pray  For ceremony or ritual  Just for fun!

59 Benefits of Walking the Labyrinth  Decreases stress  Helps reconnect physical, emotional, and spiritual wellbeing  Provides opportunity for personal space  Offers strength and hope

60 Stages of Walking the Labyrinth  Releasing  Receiving  Renewal Chartres Cathedral labyrinth in Nature’s First Pattern by Gilchrist, 1996

61 Preparation for Walking  Wait until there is enough room for you  Remove shoes or cover them  Quiet your mouth and body to promote a peaceful ambiance  Breathe deeply, center yourself, and put other things out of your mind  If you wish, invoke the presence of a higher force for guidance  Pause at the entrance to bow or in some way acknowledge the labyrinth

62 Walking the Labyrinth  Walk at your own pace  There may be two-way traffic, cooperate  It is okay to pass others or be passed  Bring awareness to your experience, your body, your thoughts, and your feelings  Pause in the center if you wish to meditate there  Return by the same path you entered or, if you choose, walk directly out  Upon exiting, turn and again acknowledge the labyrinth

63 After Leaving the Labyrinth  Continue to be aware of your labyrinth experience, even into the next day  Take a moment to sit quietly and reflect on your walk  You may wish to journal or draw to express your experience  Thank yourself for the gift you have given yourself  Walk the labyrinth again, as many times as you wish  Use a finger labyrinth to relax anywhere

64 Life is walking a labyrinth, I cannot always know which way I will turn, or even see far ahead, but there are no tricks. It is not a maze, no chance of getting lost, trust in the path that has been laid for me or in the path that I have chosen. Walk it in trust, stop when a break is necessary, and know that the center is always there. - Elizabeth H. Wiggins

65 Yoga for Veterans

66 If you can breathe….. you can do yoga

67 What is Yoga?  Developed from ancient East Indian religious practice  Word derived from Sanskrit root “yuj” meaning to bind  Generally conceptualized as union of mind, body, and spirit  Philosophy outlined in the Yoga Sutras attributed to Patanjali in the 2 nd century BCE  Goal of practicing yoga is to end suffering

68 8 Limbs of Yoga 1.Yama – moral commandments 2.Niyama – discipline 3.Āsana – postures (what most call “Yoga” in the United States – also termed “Hatha” yoga) 4.Pranayama – control or expansion of breath 5.Pratyahara – freedom from domination of the senses and external objects 6.Dharana – concentration 7.Dhyana – meditation 8.Samadhi – super-consciousness

69 Physical Practice of Yoga (Asana)  Most yoga we practiced today in US based on teachings of Krishnamacharya (November 18, 1888 – November 3, 1989)  Developed active form of yoga (Ashtanga)  Also practitioner of Ayurvedic medicine  Father of T.K.V. Desikachar  Teacher of Iyengar (Iyengar - introduced use of props – philosteach people at any level)  T.K.V Desikachar  Yoga practice is adapted to fit the individual and particular situation of each student – a therapeutic approach – called it Viniyoga initially  Mentor of Richard Miller, developer of iRest

70 Western Yoga  Most Yoga postures practiced today in the west developed around the turn of the 20 th century  Influenced by British Physical culture – gymnastics – brought to Indian palaces during colonization

71 Do we need Research on Yoga and Veterans?  PubMed search of “Yoga”  >1500 published articles  PubMed search of “Yoga” and “Veteran”  19 published articles – only 2 used Veterans as subjects  The effectiveness of Yoga to help reduce chronic low back pain (Groessl, 2008)  Yoga as physical fitness in a Veteran nursing home ( Hamilton-Word V, 1982 )

72 Evidence for Yoga as Therapy StudyTargetPopulationSample Size Results Groessl et al, 2008 Low back pain Veterans33Significantly less: Pain, Depression, Fatigue Sherman et al, 2005 Chronic low back pain Civilian Adults 101Both exercise and yoga reduced pain, yoga superior in medication use reduction Da Silva et al, 2007 FibromyalgiaCivilian females 33RY & RYT improve FIQ scores & reduce VAS scores – RY continued to provide benefit after study Vera et al, 2009 Sleep and HPA axis Healthy yoga practioners & controls 26Long term yoga practice improves SSQ, increase in cortosol Pal et al, 2009 Autonomic funcition Healthy volunteers 60Practice of slow breathing for 3 months improves autonomic function, fast breathing does not

73 Reviews Literature Review TargetResults Yang, (review of 32 articles Chronic diseases Weight loss, lower BP, lower blood glucose, lower cholesterol Kirkwood et al, (2005) review of 8 studies AnxietyPositive but inconclusive results Chou & Huffman, (2007) Chronic low back pain Small advantage of yoga over exercise in some but benefits of yoga last longer than benefits of yoga

74 Summary of Benefits  Reduced back pain  Lowered stress  Increased functional ability  Improved sleep  Increased cardiovascular health  Lower cholesterol  Decrease general pain such as experienced in fibromyalgia  Improved autonomic function

75 Possible Mechanisms of Action  ?  Improve structural/postural alignment  Improve muscle tone and flexibility  Enhance function and regulation of autonomic nervous system and re-setting of chronic pain response  Modulation of hormones

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77 WRIISC-CA Yoga  January, 2010 – Program start  Mat classes – meet once/week  Mixed gender mat class  Women only mat class  July 2010, Chair yoga class added  62 referrals to WRIISC yoga through CPRS consult  38 have attended at least once

78 WRIISC-CA Yoga (cont’d)  Mixed gender mat class  20 referrals, 18 have attended at least once 4 have completed post 12 week assessments  Women only mat class  24 referrals, 9 have attended at least once, 3 have completed at least 12 weeks  Chair yoga  15 referral, 13 have attended at least one session 6 have completed at least 12 week

79 Barriers to Attendance?  Location not convenient  No transportation  No childcare  Conflicts with work schedule  Class held during high traffic commute time  Not psychiatrically or medically stable

80 Pilot Results, n=13  Feasibility – Will Veterans participate in yoga?  Yes, if it is convenient and consistent  SF-12 – Health and Well-Being  Increase in energy – most significant  Trend toward improvement in most others areas except depression  McGill Pain Short Form  Decrease in pain intensity

81 Results (cont’d)  PTSD Checklist (PCL-M)  Small trend downward  Flanders Fatigue Scale  Small trend upward  Yoga Satisfaction Questionnaire

82 Yoga Satisfaction – n=12  Yoga class quality: 5 item scale from poor to excellent:  All answered either “Excellent” or “Very Good”  Do you feel better after class than you did before?  All answered “Yes”  Would you participate in WRIISC yoga again?  All answered “Yes”  Would you recommend WRIISC yoga to a friend?  All answered “Yes”  Have your symptoms improved?  3 answered “Yes, completely”  6 answered “Yes, somewhat”

83 Veteran Comments “It is one thing I look forward to because for that short amount of time I have hope” – Female Operation Iraqi Freedom Veteran “Best thing in years” – Male Korean War Veteran “Wonderful for body and soul” – Female Gulf War I Veteran “Great class, should meet 2x per week” – Male Vietnam War Veteran”

84 Other Benefits  Provides opportunity for Veterans to bond with other Veterans in a positive space  Relief from social isolation cause by the illness  Sense of belonging to a group  Lets Veterans know that the VA cares about them

85 Namaste

86 Application of Integrative Health Care

87 Factors to Consider  Does this approach fit with treatment goals?  Risks and benefits  Contraindications, modifications  Research findings  Level B evidence base or higher  Veteran’s self-report  Provider qualifications  Coordination among care providers  Expense and availability

88 Integrative Health in the VA System of Care  VA Office of Patient Centered Care and Cultural Transformation  Post-Deployment Integrated Care Initiative (PDICI)  Planetree  Polytrauma Service, Recreational Therapy  James A. Haley VA Chronic Pain Rehabilitation Program  Training standards & occupational codes

89 Resources  National Center for Complementary and Alternative Medicine at the National Institutes of Health  White House Commission on Complementary and Alternative Medicine Policy  Consortium of Academic Health Centers for Integrative Medicine

90 VA Resources  VA Listservs  Acupuncture Listserv, Integrative Health Care Listserv  VA employees may Dr. Elizabeth Hakas to join  Integrative health care in the VHAHCS: sept/slides/2010_09_15_SmeedingSJW_Developing-an-Integrative.ppt sept/slides/2010_09_15_SmeedingSJW_Developing-an-Integrative.ppt  Washington, DC WRIISC:  Palo Alto, CA WRIISC:  East Orange, NJ WRIISC:  Planetree:

91 Free for Veterans  Acupuncturists Without Borders Military Stress Recovery Clinics  List of clinics nationwide that offer free acupuncture for Veterans  Yoga for Vets  List of yoga studios nationwide that offer at least 4 free yoga classes for Veterans  Labyrinth Society  Worldwide Labyrinth Locator

92 Thank you  Veterans  Bonnie Benetato, Jeanette Akhter, Cory Jecmen, Kathryn Berndtson, Alyssa Adams, Thomas Nassif, Michelle Prisco, Antoinette Lomax, Adrian Johnson, Jacqueline Cherry, Mary Lewis, Becca Handel, Susan Santos, Ron Teichman, Louise Mahoney, Florence Chau, Rita Torres, Melissa Blatt, Anna Rusiewicz, Connie Singleton, Leslie Hurd, Stephen Ezeji- Okoye, Sandra Smeeding, An-Fu Hsiao, Stephen Hunt, Matthew Reinhard, Gudrun Lange, Wes Ashford, Michael Peterson, VA Office of Public Health and Environmental Hazards


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