4 What is Integrative Health Care? New and growing approach to health care deliveryBroader in focus than conventional careCoordinated health careExplicitly combines conventional and complementary approachesComplementary 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, communityTradition and innovationHealing extends beyond cureTailored toward patient goalsShared responsibility
6 Qualities of Integrative Health Care Holistic, broad scopeScientifically-rigorousValues wisdomMotivationalPatient-centeredPrevention and treatmentInterdisciplinaryHealing environments and relationshipsCross-trained providersIncorporates mind-body skills
7 Who can benefit? Individuals managing chronic illnesses People facing acute health and life eventsIndividuals who want to optimize wellness
9 The WRIISC and Post-Deployment Health Care War Related Illness and Injury Study CenterVA Office of Public Health and Environmental HazardsClinical care, research, education, risk communicationNational referral programOutpatient programs (DC, NJ, CA)Identified need for coordinated treatment approaches
10 Acupuncture Satisfaction Data 2010 total encounters649 individual full body890 group ear acupunctureImprovement in symptoms(n = 103)45% yes, completely51% yes, somewhat3% no improvement<1% too early to tellOverall quality (n = 112)70% excellent20% very good10% good<1% poorWould recommend to other Veterans (n = 130)99% yes<1% no
11 Acupuncture Satisfaction Data Yes, CompletelyYes, SomewhatNoDon’t Have This ProblemBack Pain22%57%13%7%Musculoskeletal Pain25%64%5%6%Headaches28%47%19%Upset Stomach15%26%37%Constipation/Diarrhea8%16%20%55%Trouble Sleeping51%18%Energy Level32%53%11%4%Irritability/Angry Outbursts27%42%Concentration10%DepressionAnxiety61%3%Jumpy/Easily Startled56%Disturbing Memories46%
12 iRest® Yoga Nidra Satisfaction Data 2010 total encounters1,318 sessionsImprovement in symptoms (n = 165)10% yes, completely85% yes, somewhat4% no improvement<1% don’t have symptomsOverall quality (n = 184)66% excellent30% very good1% good2% poorWould recommend to other Veterans (n = 184)100% yes
13 Yoga Nidra Satisfaction Data Yes, CompletelyYes, SomewhatNoDon’t Have This ProblemBack Pain8%64%19%9%Musculoskeletal Pain68%11%13%Headaches10%41%16%33%Upset Stomach4%18%26%51%Constipation/Diarrhea15%62%Trouble Sleeping72%6%Energy Level12%Irritability/Angry Outbursts14%55%Concentration20%Depression52%25%Anxiety66%17%5%Jumpy/Easily Startled22%Disturbing Memories45%
14 Labyrinth Satisfaction Data Would you walk the labyrinth again? (n = 227)99% yes<1% noDescriptions of the labyrinth:Calming, relaxing, serene,awesome, soothing, wonderful,excellent, mellow, balanced,peaceful, meditative, rejuvenating,surprising, inspirational, therapeutic,centering, uplifting, helpful,purposeful, anchoring, euphoric2010 total visits481How was your walk on the Freedom Labyrinth Path? (n = 227)50% excellent42% very good7% fair<1% no value
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 yogaWould you recommend WRIISC yoga to a friend ?(n = 11)100% yesDo you feel better after class than before? (n = 13)100 % yesWould you participate in WRIISC yoga again? (n = 12)
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 InjuriesPI: Louise Mahoney, MS, WRIISC-CAThe Effect of Acupuncture for PTSD-Related InsomniaPI: Michelle Prisco, MSN, ANP-C, WRIISC-DCResults anticipated May-June 2012
18 Integrative Health Care Research at the WRIISC Qigong for Symptom Management and Function in Veterans with Fatiguing IllnessesPI: Anna Rusiewicz, PhD, WRIISC-NJResults anticipated September 2012Acupuncture to Improve the Quality of Life in Veterans with TBI and PTSDPI: Anna Rusiewicz, PhD & Thomas Findley, MD PhD, WRIISC-NJResults anticipated January 2012
19 Integrative Modalities Throughout the VHA System AcupunctureAquatic bodyworkAromatherapyBiofeedbackDeep-breathing exercisesGuided imageryHypnotherapyLabyrinthLaughter yogaMindfulness meditationMassageProgressive relaxation Tai Chi Qigong Reiki Spinal manipulation Structural integration Therapeutic touch Yoga with movement Yoga Nidra
20 VA Integrative Health Clinic and Program Salt Lake City, UT VAMCAcupunctureAquatic bodyworkStress management class: guided imagery, relaxation techniques, biofeedback, qigong, awareness and reframing of thought patternsMedical hypnosisYoga with movementHerbal/nutritional supplement/drug interaction educationMeditationQigongTobacco cessationWeight management class: nutrition, exercise, psychotherapy, hypnosis
21 VA Integrative Health Clinic - Research Chronic nonmalignant painLongitudinal outcome researchChronic nonspinal-related pain group vs. chronic spinal-related pain groupNonspinal pain group: Improved depression, anxiety, bodily pain, vitality and health transitionBenefits persisted to 24 monthsSpinal-related pain group: trend toward improvement in bodily painSmeeding, 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 Depression, anxiety, and posttraumatic stress disorderLongitudinal outcome researchGroup comparisons based on levels of anxiety, depression, and PTSD symptomsImproved depression, anxiety and health-related quality of life in all groupsGreatest improvements seen in the high anxiety, high depression, and PTSD groupsSmeeding, 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,
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:GrowthDevelopmentMovementMaintaining body temperatureProtection against illnessOverall regulation
26 Qi is Our Life Force When our Qi is balanced, our capacity to both heal diseaseand prevent futureillness is maximized.Our health isinfluenced by thequality, quantityand balance of our Qi.Symptoms of illness, whether mental, emotional or physical, are an indication of an imbalance of Qi.26
27 Qi Imbalance Qi depletion, obstruction, disorganization Causes of imbalanceInjuryIllnessEnvironmental exposurePoor quality nourishmentLack of physical exercise
28 Qi Moves with a Rhythm, Inside a Boundary YANG/Sympathetic ArousalDaytime, summerAwake and alertInhaleExhaleNighttime, winterRest and digestYIN/Parasympathetic RestorationBalance 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.
29 Acupuncture Helps Restore Balance Acupuncture heals below cognitionIt helps people feel more embodied, more present, more self aware12 main pathways – connected end to end like garden hoses29
37 Washington, DC WRIISC Acupuncture Options Full body, individual series of treatmentsUnique design for the individual’s presentation
38 DC Acupuncture Options Group Ear AcupunctureFive points on each earBalance of sympathetic/parasympathetic nervous systems as well as emotional balanceCan be used for detoxificationOften affects sleep patternsMultiple venues at DC WRIISC
40 Acupuncture Interest at WRIISC-DC Year 2010649 full body acupuncture treatments145 Gulf War Veteran treatments890 ear acupuncture treatments103 Gulf War Veteran treatments
41 Acupuncture and Integrative Health Care Acupuncture can help:Improve focus and attention, supporting psychotherapy clients to integrate and embody insightsBring energy to physical injuries, supporting the work of physical therapistsMitigate side effects of necessary medicationsHelp some reduce medications – for sleep or pain for example41
42 Acupuncture Helps Veterans Get All The Way Home - Safe and Sound the mind find a place to rest,the body release trauma's imprint andthe spirit come back home – safe and sound.
43 Acupuncture Research – Selected Bibliography 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, 10.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,
44 Acupuncture Research – Selected Bibliography (continued) 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,Hicks J, Hicks A, Mole P. Five element constitutional acupuncture. Edinburough: Elsevier, 2004.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,
45 Acupuncture Research – Selected Bibliography (continued) Kaptchuck TJ. The web that has no weaver: Understanding Chinese medicine, 2 ed. N.Y.: McGraw-Hill, 2000.Kim KB, Sok SR. Auricular acupuncture for insomnia: Duration and effects in Korean older adults. J Gerontol Nurs 2007; 33(8): 23-8; quiz 30-1.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,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,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): 1-10.
46 Acupuncture Research – Selected Bibliography (continued) 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):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,
53 Labyrinth – Brief History > 4,000 year historyFound in many cultures and religious traditionsNow used in health care facilities, schools, and houses of worship worldwideLabyrinth carving at a temple in Halebid, India, circa 2500 BCLabyrinth from the Atlantic Bronze Age, Galicia (Spain)
54 Labyrinth - ResearchWalking meditation is shown to reduce anxiety and elicit a 'relaxation response’ associated with:lower blood pressure and breathing ratesreduced incidents of chronic pain and insomniaAlso associated with many of the benefits seen in sitting meditation and yogaBenson, H., "The relaxation response: therapeutic effect," Science Dec 5;278(5344): PMID:
55 Labyrinths at VAVeterans, staff, and volunteers can walk a labyrinth at:Albany VAMCCanandaigua VAMCSeattle VAMCMemphis VAMCWashington, DC VAMC
57 Labyrinth - Practice Not like a maze: no dead ends Pace is up to you Opportunity to slow down, relax, relieve stress, reflect, meditatePath winds in a circular pattern towards a midpoint, one way in and the same way out.9/11 Memorial Labyrinth at Boston College
58 Reasons for Walking the Labyrinth To relaxTo express intentFor physical healingAs a pilgrimageTo meditateTo ask a questionFor emotional healingTo ease griefFor inspirationTo prayFor ceremony or ritualJust for fun!
59 Benefits of Walking the Labyrinth Decreases stressHelps reconnect physical, emotional, and spiritual wellbeingProvides opportunity for personal spaceOffers strength and hope
60 Stages of Walking the Labyrinth ReleasingReceivingRenewalChartres Cathedral labyrinth in Nature’s First Pattern by Gilchrist, 1996
61 Preparation for Walking Wait until there is enough room for youRemove shoes or cover themQuiet your mouth and body to promote a peaceful ambianceBreathe deeply, center yourself, and put other things out of your mindIf you wish, invoke the presence of a higher force for guidancePause 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, cooperateIt is okay to pass others or be passedBring awareness to your experience, your body, your thoughts, and your feelingsPause in the center if you wish to meditate thereReturn by the same path you entered or, if you choose, walk directly outUpon exiting, turn and again acknowledge the labyrinth
63 After Leaving the Labyrinth Continue to be aware of your labyrinth experience, even into the next dayTake a moment to sit quietly and reflect on your walkYou may wish to journal or draw to express your experienceThank yourself for the gift you have given yourselfWalk the labyrinth again, as many times as you wishUse 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 meor 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
66 If you can breathe….. you can do yoga From a 1982 paper in Geriatric Nursing about beginning a yoga program in a Veterans nursing home.
67 What is Yoga? Developed from ancient East Indian religious practice Word derived from Sanskrit root “yuj” meaning to bindGenerally conceptualized as union of mind, body, and spiritPhilosophy outlined in the Yoga Sutras attributed to Patanjali in the 2nd century BCEGoal of practicing yoga is to end suffering
68 8 Limbs of Yoga Yama – moral commandments Niyama – discipline Āsana – postures (what most call “Yoga” in the United States – also termed “Hatha” yoga)Pranayama – control or expansion of breathPratyahara – freedom from domination of the senses and external objectsDharana – concentrationDhyana – meditationSamadhi – 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 medicineFather of T.K.V. DesikacharTeacher of Iyengar (Iyengar - introduced use of props – philosteach people at any level)T.K.V DesikacharYoga practice is adapted to fit the individual and particular situation of each student – a therapeutic approach – called it Viniyoga initiallyMentor of Richard Miller, developer of iRestKrishnamacharya taught at his school in Mysore - his pupils were primarily active young boys, he drew on many disciplines—including yoga, gymnastics, and Indian wrestling—to develop dynamically-performed asana sequences aimed at building physical fitness. This vinyasa style uses the movements of Surya Namaskar (Sun Salutation) to lead into each asana and then out again. Each movement is coordinated with prescribed breathing and drishti, "gaze points" that focus the eyes and instill meditative concentration. Eventually, Krishnamacharya standardized the pose sequences into three series consisting of primary, intermediate, and advanced asanas. Students were grouped in order of experience and ability, memorizing and mastering each sequence before advancing to the next.Though Krishnamacharya developed this manner of performing yoga during the 1930s, it remained virtually unknown in the West for almost 40 years.Hatha yoga is the sanctuary for those suffering any kind of pain
70 Western YogaMost Yoga postures practiced today in the west developed around the turn of the 20th centuryInfluenced 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 articlesPubMed search of “Yoga” and “Veteran”19 published articles – only 2 used Veterans as subjectsThe 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)Answer is YES!
72 Evidence for Yoga as Therapy StudyTargetPopulationSample SizeResultsGroessl et al, 2008Low back painVeterans33Significantly less: Pain, Depression, FatigueSherman et al, 2005Chronic low back painCivilian Adults101Both exercise and yoga reduced pain, yoga superior in medication use reductionDa Silva et al, 2007FibromyalgiaCivilian femalesRY & RYT improve FIQ scores & reduce VAS scores – RY continued to provide benefit after studyVera et al, 2009Sleep and HPA axisHealthy yoga practioners & controls26Long term yoga practice improves SSQ, increase in cortosolPal et al, 2009Autonomic funcitionHealthy volunteers60Practice of slow breathing for 3 months improves autonomic function, fast breathing does notIncluding only sample articles that may be of value for gulf war illnesses – those addressing chronic pain, Groessl – mean age = 55 – study significant because most non-Veteran studies are 60-70% women, this was 80% malePre post design – baseline and 10 week follow-upPranayama – slow controlled breathing can increase parasympathetic activity – they used alternate nostril breathing.Indian J Med Res. 2004 Aug;120(2):Effect of short-term practice of breathing exercises on autonomic functions in normal human volunteers.Pal GK, Velkumary S, Madanmohan.J Altern Complement Med. 2009 Mar;15(3):293-5.FMS – Randomized, no control groupRelaxing yoga (RY) vs. Relaxing Yoga plus TuNa massage (ryt)8 weeks, 1/week, 50 minutesAdapted Gharotes method of postures + 7 minutes diaphramatic breathing, 15 minutes guided relaxation
73 Reviews Literature Review Target Results Yang, (review of 32 articles Chronic diseasesWeight loss, lower BP, lower blood glucose, lower cholesterolKirkwood et al, (2005) review of 8 studiesAnxietyPositive but inconclusive resultsChou & Huffman, (2007)Chronic low back painSmall advantage of yoga over exercise in some but benefits of yoga last longer than benefits of yogaOf the 32 articles reviewed, 12 described experimentalstudies, 18 described quasi-experimental studies and twodescribed observational studies. Only 2 of the 12 trueexperimental studies (17,18) described the randomizationmethod. Even though risk factors for chronic healthconditions were used as keywords in the search strategy,many of the studies used healthy adult samples; only half ofthe 32 studies actually focused on subjects with diabetes(19–23), hypertension (10,11,18,24–27), or cardiovasculardisease (28–31). Seven of the studies were conducted in theUS; the others, in India and other countries.
74 Summary of Benefits Reduced back pain Lowered stress Increased functional abilityImproved sleepIncreased cardiovascular healthLower cholesterolDecrease general pain such as experienced in fibromyalgiaImproved autonomic function
75 Possible Mechanisms of Action ?Improve structural/postural alignmentImprove muscle tone and flexibilityEnhance function and regulation of autonomic nervous system and re-setting of chronic pain responseModulation of hormones
77 WRIISC-CA Yoga January, 2010 – Program start Mat classes – meet once/weekMixed gender mat classWomen only mat classJuly 2010, Chair yoga class added62 referrals to WRIISC yoga through CPRS consult38 have attended at least once
78 WRIISC-CA Yoga (cont’d) Mixed gender mat class20 referrals, 18 have attended at least once 4 have completed post 12 week assessmentsWomen only mat class24 referrals, 9 have attended at least once, 3 have completed at least 12 weeksChair yoga15 referral, 13 have attended at least one session 6 have completed at least 12 weekMany students have completed 40
79 Barriers to Attendance? Location not convenientNo transportationNo childcareConflicts with work scheduleClass held during high traffic commute timeNot psychiatrically or medically stablePalo Alto is a an expensive place to live and there are not many Veterans living nearby. Those with transportation have a long commute, heavy trafficOften clinicians are looking for anything that will help their patients and they refer Veterans that are not appropriate for “this” class at “this” time. Everyone can do yoga – but not every yoga class is appropriate for an individual.Estimated median household income in 2009: $118,989 (it was $90,377 in 2000) Palo Alto: $118,989 California: $58,931Estimated per capita income in 2009: $66,125 Estimated median house or condo value in 2009: $916,644 (it was $776,000 in 2000) Palo Alto: $916,644 California: $384,200Mean prices in 2009: All housing units: $922,616; Detached houses: $983,880; Townhouses or other attached units: $651,117; In 2-unit structures: $562,122; In 3-to-4-unit structures: $486,340; In 5-or-more-unit structures: $502,094; Mobile homes: $184,523; Occupied boats, RVs, vans, etc.: $14,304 Median gross rent in 2009: $1,675.
80 Pilot Results, n=13 Feasibility – Will Veterans participate in yoga? Yes, if it is convenient and consistentSF-12 – Health and Well-BeingIncrease in energy – most significantTrend toward improvement in most others areas except depressionMcGill Pain Short FormDecrease in pain intensityYes.if it fits with their schedulenot too far and/or not at high traffic timesThe most consistent attended has been in the chair yoga class which is attached to an ongoing MOVE program group and meets right before their weekly group.
82 Yoga Satisfaction – n=12Yoga 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?Would you recommend WRIISC yoga to a friend?Have your symptoms improved?3 answered “Yes, completely”6 answered “Yes, somewhat”Reports from13 Veterans at 12 weeks
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 BenefitsProvides opportunity for Veterans to bond with other Veterans in a positive spaceRelief from social isolation cause by the illnessSense of belonging to a groupLets Veterans know that the VA cares about themThese are my observations.In the women’s group, 2 Veterans who did not know each other worked on the Veteran’s book project together and have received a lot of support from this endeavor. They have developed a friendship and are in contact outside of class.One Veteran said “this is the only thing I have at the VA now”
87 Factors to Consider Does this approach fit with treatment goals? Risks and benefitsContraindications, modificationsResearch findingsLevel B evidence base or higherVeteran’s self-reportProvider qualificationsCoordination among care providersExpense and availability
88 Integrative Health in the VA System of Care VA Office of Patient Centered Care and Cultural TransformationPost-Deployment Integrated Care Initiative (PDICI)PlanetreePolytrauma Service, Recreational TherapyJames A. Haley VA Chronic Pain Rehabilitation ProgramTraining standards & occupational codes
89 ResourcesNational Center for Complementary and Alternative Medicine at the National Institutes of HealthWhite House Commission on Complementary and Alternative Medicine PolicyConsortium of Academic Health Centers for Integrative Medicine
90 VA Resources VA Listservs Acupuncture Listserv, Integrative Health Care ListservVA employees may Dr. Elizabeth Hakas to joinIntegrative health care in the VHAHCS:Washington, DC WRIISC:Palo Alto, CA WRIISC:East Orange, NJ WRIISC:Planetree:
91 Free for VeteransAcupuncturists Without Borders Military Stress Recovery ClinicsList of clinics nationwide that offer free acupuncture for VeteransYoga for VetsList of yoga studios nationwide that offer at least 4 free yoga classes for VeteransLabyrinth SocietyWorldwide Labyrinth Locator
92 Thank youVeteransBonnie 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