Forsvarsudvalget 2016-17
FOU Alm.del Bilag 23
Offentligt
1693642_0001.png
Pre-released
STO Technical Report
Integrative Medicine Interventions
for Military Personnel
This report has been pre-released, in its original format, to make it immediately
available to the scientific community. Once the report has been edited,
formatted and formally approved, the CSO will publish an
official version under reference STO-TR-HFM-195.
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0002.png
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0003.png
NATO UNCLASSIFIED
NORTH ATLANTIC TREATY
ORGANIZATION
SCIENCE AND TECHNOLOGY
ORGANIZATION
AC/323(HFM-195) TP/429
www.sto.nato.int
STO TECHNICAL REPORT
STO-TR-HFM-195
INTEGRATIVE MEDICINE INTERVENTIONS FOR
MILITARY PERSONNEL
(INTERVENTIONS MÉDECINE INTÉGRATIVE POUR LE
PERSONNEL MILITAIRE)
This report documents the findings of Task Group 195, which investigated the current status of
Complementary and Alternative Medicine (CAM) in NATO countries focusing on the utilization
and acceptability for Military Personnel. Various modalities are described in detail as possible
treatments for conditions such as pain, stress and for improved quality of life and resiliency.
Published xxxx 2016
RTO-RTG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0004.png
NATO UNCLASSIFIED
RTO-RTG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0005.png
NATO UNCLASSIFIED
The NATO Science and Technology Organization
Science & Technology (S&T) in the NATO context is defined as the selective and rigorous generation and application of state-of-
the-art, validated knowledge for defence and security purposes. S&T activities embrace scientific research, technology
development, transition, application and field-testing, experimentation and a range of related scientific activities that include
systems engineering, operational research and analysis, synthesis, integration and validation of knowledge derived through the
scientific method.
In NATO, S&T is addressed using different business models, namely a collaborative business model where NATO provides a
forum where NATO Nations and partner Nations elect to use their national resources to define, conduct and promote cooperative
research and information exchange, and secondly an in-house delivery business model where S&T activities are conducted in a
NATO dedicated executive body, having its own personnel, capabilities and infrastructure.
The mission of the NATO Science & Technology Organization (STO) is to help position the Nations’ and NATO’s S&T
investments as a strategic enabler of the knowledge and technology advantage for the defence and security posture of NATO
Nations and partner Nations, by conducting and promoting S&T activities that augment and leverage the capabilities and
programmes of the Alliance, of the NATO Nations and the partner Nations, in support of NATO’s objectives, and contributing to
NATO’s ability to enable and influence security and defence related capability development and threat mitigation in NATO
Nations and partner Nations, in accordance with NATO policies.
The total spectrum of this collaborative effort is addressed by six Technical Panels who manage a wide range of scientific
research activities, a Group specialising in modelling and simulation, plus a Committee dedicated to supporting the information
management needs of the organization.
• AVT
• HFM
• IST
• NMSG
• SAS
• SCI
• SET
Applied Vehicle Technology Panel
Human Factors and Medicine Panel
Information Systems Technology Panel
NATO Modelling and Simulation Group
System Analysis and Studies Panel
Systems Concepts and Integration Panel
Sensors and Electronics Technology Panel
These Panels and Group are the power-house of the collaborative model and are made up of national representatives as well as
recognised world-class scientists, engineers and information specialists. In addition to providing critical technical oversight, they
also provide a communication link to military users and other NATO bodies.
The scientific and technological work is carried out by Technical Teams, created under one or more of these eight bodies, for
specific research activities which have a defined duration. These research activities can take a variety of forms, including Task
Groups, Workshops, Symposia, Specialists’ Meetings, Lecture Series and Technical Courses.
The content of this publication has been reproduced directly from material supplied by STO or the authors.
Published xxxx 2016
Copyright © STO/NATO 2016
All Rights Reserved
ISBN xxx-xx-xxx-xxxx-x
Single copies of this publication or of a part of it may be made for individual use only by those organisations or individuals in
NATO Nations defined by the limitation notice printed on the front cover. The approval of the STO Information Management
Systems Branch is required for more than one copy to be made or an extract included in another publication. Requests to do so
should be sent to the address on the back cover.
iii
iiiiii
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0006.png
NATO UNCLASSIFIED
Table of Contents
Page
List of Figures
List of Tables
List of Acronyms/Abbreviations
Glossary
Terms of Reference
Acknowledgements
HFM-195 Membership List
X
X
X
X
X
X
X
Executive Summary and Synthèse
Chapter 1 – Integrative Health and Healing as the New Health Care
Paradigm for the Military
Abstract
Keywords
1.1
Introduction
1.2
Operational Definition of Complementary and Alternative Medicine
1.3
Integrative Health and Healing
1.4
Losing the Doctor-Patient Relationship
1.5
The Push for the New Paradigm
1.6
What is Truly “Evidence-Based?
1.7
Integrative Health and Healing in the Federal Healthcare System
1.8
The New Paradigm
1.9
The Future
1.10
References
R.P. Petri, Jr.
ES-1
1-1
1-1
1-1
1-1
1-2
1-3
1-5
1-6
1-6
1-7
1-8
1-11
1-13
Chapter 2 – Historical and Cultural Perspectives of Integrative Medicine
Abstract
Keywords
2.1
Introduction
2.2
Historical Perspectives
2.3
The Periods
2.3.1
Mesopotamia and Egypt: 3100 BC
2.3.2
India: 2500 BC
2.3.3
China: 1600 BC
2.3.4
Greece: 800 BC
2.3.5
Rome: 27 BC
2.3.6
Islamic Golden Age: 622 AD
2.3.7
The Renaissance to the Modern Era
2.3.8 Shamans, Medicine Men and Curanderos
R.P. Petri, Jr., R. Delgado, and K. McDonnell
2-1
2-2
2-2
2-2
2-2
2-3
2-3
2-4
2-5
2-7
2-8
2-9
2-11
2-11
iv
iviv
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0007.png
NATO UNCLASSIFIED
2.4
2.5
2.6
2.7
Discussion
Conclusion
Recommendations
References
2-12
2-13
2-14
2-14
Chapter 3 – Overview of Integrative Medicine Practices and Policies in
NATO Participant Countries
Abstract
Keywords
3.1
Introduction
3.2
Needs and Expectations Regarding CAM
3.3
Complementary and Alternative Medicine Utilization in the
European Union
3.4
Provider Patterns
3.5
Complementary Medicine and Medical Education
3.6
Providers’ Perspective on CAM
3.7
Status of CAM research in the European Union
3.8
Impact of Crossborder Variations
3.9
Regulatory and Legal
Status of CAM in Europe
3.10
Harmonizatin of Regulations for Increased Patient Safety
3.11
Discussion
3.12
Conclusions
3.13
Recommendations
3.14
References
G. Hegyi,
R.P. Petri, Jr., P. Roberti di Sarsina and R. Niemtzow
3-1
3-2
3-2
3-2
3-4
3-4
3-6
3-7
3-8
3-8
3-8
3-8
3-9
3-10
3-11
3-11
3-12
Chapter 4 – Integrative Medicine Experience in the United States Department
of Defense
Abstract
Keywords
4.1
Introduction
4.2
Methods
4.3
Main Outcome Measure
4.4
Results
4.5
Discussion
4.6
Conclusion
4.7
Recommendations
4.8
References
R.P. Petri, Jr. and R. Delgado
4-1
4-1
4-2
4-2
4-3
4-3
4-4
4-7
4-8
4-8
4-9
Chapter 5 – Integrative Health and Healing Practices Specifically for
Service Members: Self-Care Techniques
Abstract
Keywords
5.1
Introduction
5.2
Understanding IM for NATO Forces on the Larger Stage
5.3
IM as a Practice for Self-Care:
The Shift Toward Empowerment
5.4
Role of Specific IM Practices for NATO Forces
5.4.1 Acupuncture and Acupressure
5.4.2 Biofeedback
5.4.3 Energy Practices
5.4.4 Herbal Medicine and Supplementation
R.P. Petri, Jr., J.A.G. Walter and Jon Wright
5-1
5-2
5-2
5-2
5-3
5-3
5-4
5-4
5-6
5-6
5-7
v
vv
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0008.png
NATO UNCLASSIFIED
5.5
5.6
5.7
5.8
5.4.5 Meditative Practices (Mindfulness, Meditation and Imagery)
5.4.5 Movement Practices (Exercise, Running, Yoga,
T’ai Chi
and Martials Arts)
5.4.5 Rituals, Spirituality and Religiosity
Discussion
Conclusions
Recommendations
References
5-8
5-8
5-9
5-10
5-10
5-11
5-11
Chapter 6 – Battlefield Acupuncture in the United States Military: A Pain
Reduction Model for NATO
Abstract
Keywords
6.1
Introduction
6.2
Mechanism of Action
6.3
Technique
6.4
U.S. Air Force Acupuncture
and Alternative Medicine Center
6.5
Discussion
6.6
Conclusions
6.7
Recommendations
6.8
References
R. Niemtzow, J-L. Belard and R. Nogier
6-1
6-1
6-2
6-2
6-4
6-4
6-5
6-5
6-6
6-6
6-6
Chapter 7 – Mindfulness Based Practices as a Resource for Health
and Well Being
Abstract
Keywords
7.1
Introduction
7.2
Definitions of Mindfulness
7.3
Traditional Mindfulness Techniques
7.4
Cognitive, Behavorial and Physiological Effects of Mindfulness
7.5
Measuring Mindfulness
7.6
Efficacy of
Mindfulness Based Interventions
7.7
Mindfulness Based Stress Reduction (MBSR)
7.8
Mindfulness Based Approaches Evaluated in a Military Environment
7.8.1 PROPresence
7.8.2 PROPresence and Watsu
7.8.3 Mindfulness-Based Mind
Fitness Training (MMFT)
7.8.4
Transcendental Meditations (TM) in a Military Environment
7.5.5 Other Mindfulness Based Approaches for Therapeutic Settings
7.9
Minfulness Training: 25-Minutes
of Self-Care
7.10
Discussion
7.11
Conclusions
7.12
Recommendations
7.13
References
F.
Zimmermann
7-1
7-1
7-1
7-2
7-2
7-3
7-5
7-5
7-6
7-7
7-7
7-7
7-10
7-11
7-11
7-11
7-12
7-14
7-14
7-14
7-15
Chapter 8 – Spirituality / Religiosity as a Resource to Cope in Soldiers
A Summarizing Report
Abstract
Keywords
8.1
Introduction
8.2
Definitions of Spirituality / Religiosity
A Büssing
8-1
8-1
8-1
8-1
8-2
vi
vivi
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0009.png
NATO UNCLASSIFIED
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.9
8.10
Associations between Spirituality / Religiosity and Health-Related
Variables
Spiritual Needs
Spirituality in the Military Context
Help Seeking from Spiritual Counselors and Clergy
Discussion
Conclusion
Recommendations
Resource
References
8-3
8-4
8-5
8-6
8-7
8-7
8-7
8-8
8-8
Chapter 9 – Tactics to Optimize the Potential (TOPS) and
Cardiobiofeedback (CBF) in Stress Management: The French
Experience
Abstract
Keywords
9.1
Introduction
9.2
Methods
9.2.1 Participants
9.2.2 Measurements
9.2.3 Compliance with the Program
9.2.4 Protocol
9.2.5 Statistical Analyses
9.3
Results
9.3.1 Participants
9.3.2 Main Outcome
9.3.3 Seconday Outcomes
9.3.4 Long-term
Effects
9.4
Discussion
9.4.1 Strengths
9.4.2 Limitations
9.5
Conclusions
9.6
Recommendations
9.7
References
M. Trousselard,
F. Dutheil, M-H. Ferrer, N. Babouraj and F. Canini
9-1
9-1
9-2
9-2
9-2
9-2
9-3
9-3
9-3
9-4
9-5
9-5
9-6
9-6
9-7
9-8
9-9
9-9
9-9
9-10
9-10
Chapter 10 – Healing and the Trauma Spectrum Response
Abstract
Keywords
10.1
Introduction
10.2
Components of wrTSR
10.3
PTSD and Substance Abuse
10.4
PTSD and Pain
10.5
Traumatic Brain Injury and wrTSR
10.6
Failure to Address the wrTSR Adequately
10.7
The Need for Whole-Person wrTSR Strategy
10.8
Complementary and Integrative Medicine Practices
10.8.1 Self-Care
10.8.2 Drugless Treatments
10.9
Conclusions
10.10
Recommendations
10.11
References
W. Jonas, J.A.G. Walter and R.P. Petri, Jr.
10-1
10-1
10-2
10-2
10-3
10-3
10-4
10-4
10-5
10-5
10-5
10-6
10-6
10-7
10-7
10-7
vii
viivii
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0010.png
NATO UNCLASSIFIED
Chapter 11 – Systematic Approaches to Evaluation and Integration of
Eastern and Western Medical Practices
11-1
11-1
11-2
11-2
11-3
11-3
11-7
11-8
11-9
11-12
11-13
11-15
11-15
11-15
Abstract
Keywords
11.1
Introduction
11.2
Western and Eastern
Sciences
11.3
Ayurveda: A Systems Science
11.4
The Systems Biological Approach to Health in Eastern Medicine
11.5
Symptoms as Intermediaries between Western and Asian Diagnosis
11.6
Using Metabolomics Technology to Validate and Understand Symptom Patterns
11.7
Endobiogeny: A Systems Endocrinology Approach
11.8
Modelling Integrative Medicine Perspectives
11.9
Conclusions
11.10
Recommendations
11.11
References
J. van der Greef, H. van Wietmarschen, Y. Schoën, N. Babouraj and M. Trousselard
Chapter 12 – Current and Future Directions for Integrative Health and
Healing: A Summary of the NATO HFM-195 Task Force
Abstract
Keywords
12.1
Introduction
12.2
Cultural Concept of Healthcare Systems: The Need to Understand and Embrace
12.3
Integrative Health and Healing Practices
12.4
Discussion
12.4.1 An Exploratory Task Force
12.4.2 The Need for Collaboration
12.5
Recommendations
12.5.1 Clinical Aspects
12.5.2 Educational Aspects
12.5.3 Research Aspects
12.6
Remaining Questions
12.7
Conclusions
12.8
References
R.P. Petri, Jr.,
F. Zimmermann, M. Trousselard and R. Niemtzow
12-1
12-2
12-2
12-2
12-3
12-6
12-8
12-8
12-9
12-9
12-9
12-9
12-9
12-10
12-10
12-11
Annex A – Summary of the 1
st
NATO Meeting
Theme: Group Kickoff and Organization
21-23 March 2011
Val de Grace, Paris, France
A1
A2
Participation/Programme Committee
Summary of Presentations
A2.1 NATO RTO Orientation
A2.2 Chairman’s Opening Comments, Introduction and Initial Discussion
A2.3 Overview of U.S. Department of Defense CAM Research and Applications
A2.4
Emerging Trends in CAM
A2.5 Integrative/Complementary Medicine in Germany – Spirituality as a Resource
to Cope
A2.6 CAM in Hungary
– CAM in Military Medicine, New Techniques
A2.7 Is Integrative Medicine the New World Practice?
A2.8 Systems Approach to Integration of Occidental and Eastern Wellness and Healing
A-1
A-1
A-2
A-2
A-2
A-2
A-3
A-3
A-4
A-4
A-4
viii
viiiviii
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0011.png
NATO UNCLASSIFIED
A3
Traditions
A2.9 French Military Effort in Integrative Medicine
Summary of Discussion
A-5
A-6
Annex B – Summary of the 2
nd
NATO Meeting
Theme: Acupuncture and Acute Pain Management
19-21 October 2011
Ordine dei Medici Chirurghi e degli Odontoiatri di Bologna
Bologna, Italy
B1
B2
Participation/Programme Committee
Summary of Presentations
B2.1 Chairman’s Opening Comments, Introduction and Initial Discussion
B2.2 Considerations for Generalizable Use of Acupuncture for Acute Pain Management
in NATO
B2.3 Psychosocial and Spiritual Needs
B2.4 Overview of CAM practices in Italy and the Introduction to CAMbrella
B2.5 Auriolotherapy
B2.6
Protective Environments
B2.7
TOP Intervention and Yogatherapy
B2.8
Yoga in Clinical Studie and Acupuncture in Emergency Medicine
B2.9 Mindfulness Clinical Applications
B2.10 Yamamoto Scalp Acupuncture in Pain
B2.11 Acupuncture in Traditional Korean Medicine
B2.12 Battlefield Acupuncture
Summary of Discussion
B-1
B-1
B-2
B-2
B-2
B-3
B-3
B-3
B-4
B-4
B-4
B-5
B-5
B-5
B-6
B-6
B3
Annex C – Summary of the 3rd NATO Meeting
Theme: Integrative Health Intervention to Improve Resilience
16-18 April 2012
Stefania Palota
Budapest, Hungary
C1
C2
Participation/Programme Committee
Summary of Presentations
C2.1 Chairman’s Opening Comments, Introduction and Initial Discussion
C2.2
Welcome and Overview of Yamamoto Acupuncture and Resilience
C2.3 Tibetan Personlized Medicine
C2.4 Integrative Strategies Involving Neuroprotective Nutrition
C2.5
Resilience Program at Fort Bliss, Texas
C2.6
Yoga Data on Resilience
C2.7
Global Healing Techniques and Initiatives to Maximize Treatment, Resilience
and Human Performance for Military and Veteran Communities
C2.8 Mindfulness Trainings and Watsu as a Rehabilitative Treatment for Deployment
Related Stress
C2.9
TFF Matrix
Summary of Discussion
C-1
C-1
C-2
C-2
C-2
C-2
C-3
C-4
C-4
C-5
C-6
C-6
C-7
C3
ix
ixix
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0012.png
NATO UNCLASSIFIED
Annex D – Summary of the 4th NATO Meeting
D-1
Theme: East West Integration and the Metrics of Integrative Medicine
Interventions
8-10 October 2012
Sino-Dutch Centre for Preventive and Personalized Medicine (DICP-Chinese
Academy of Sciences, University of Leiden and TNO collaboration)
Zeist, The Netherlands
D1
D2
Participation/Programme Committee
Summary of Presentations
D2.1 Chairman’s Opening Comments, Introduction and Initial Discussion
D2.2 Bridging Westeran and Chinese Medicine via Systems Biology
D2.3 Mascots in the Army
D2.4 Acupuncture in NATO
D2.5 Principles of Ayurveda
D2.6 Minfulness and Spiritual Needs
D2.7
Biophotonics as a Diagnostic Tool in Health and Disease
D2.8 Integration of Chinese and Western Medicine – A Key Role for Systems Diagnosis
Related Stress
D2.9
Resilience, Allostasis and Health
– Development of a Systems Modal
D2.10 Documentary:
Escape Fire: The Fight to Rescue American Healthcare
Summary of Discussion
D-1
D-1
D-1
D-2
D-2
D-3
D-3
D-4
D-4
D-4
D-5
D-5
D-6
D3
Annex E – Summary of the 5th NATO Meeting
Theme: Integrative Medicine as a Tool to Enhance Performance
and Wellness
22-24 April 2013
Germany Air Force Facility
Cologne, Germany
E1
E2
Participation/Programme Committee
Summary of Presentations
E2.1
Chairman’s Opening Comments, Introduction and Initial Discussion
E2.2
Usage of Basic Breathing Meditation Technique to Attentuate Perioperative Stress
E2.3 Enhancing Performance and Health: Bio-Neurofeedback
as an Integrative Approach
for Assessement and Training
E2.4 Harnessing the Placebo Effect for Health Promotion and Resilience
E2.5 Efficiency of Tactic to Optimize the Potential (TOPS) and Cardiac Coherence on
Professional Stress
E2.6
Benefits and Neurophysiological Mechanisms of Mindfulness and Training
E2.7 From the Lab to the Therapy Room
–
Process Oriented and Evidence Based
Standard Methods in the Treatment of PTSD
E2.8
Whole Systems Resiliency Assessment-
Health, Resilience and Dynamic Modelling
E2.9 Historical Findings in PTSD
Research
Summary of Discussion
E-1
E-1
E-1
E-1
E-2
E-2
E-3
E-3
E-3
E-4
E-4
E-4
E-5
E3
Annex F – Summary of the 6th NATO Meeting
Theme: The NATO Report Working Group
22-24 April 2013
Radisoon Airport Hotel
El Paso, Texas, USA
F-1
x
xx
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0013.png
NATO UNCLASSIFIED
F1
F2
F3
Participation/Programme Committee
Summary of Presentations
F2.1
Chairman’s Opening Comments, Introduction and Initial Discussion
F2.2
Areas of Interest for NATO Report
F2.3 Executive Summary
F2.4
Recommendations
F2.5
Questions
F2.6 Proposed Quick Wins of the Task Force and Impact on the Military
F2.7 Proposed Long Term Gains of Additional Related Task Forces
F2.8
NATO reports
F2.9
Proposed Medical Acupuncture Journal and NATO Report with Lead Authors
F2.10 Format for Medical Acupuncture
F2.11 Format for NATO report
Summary of Discussion
F-1
F-1
F-1
F-1
F-2
F-2
F-2
F-3
F-3
F-4
F-4
F-5
F-5
F-8
xi
xixi
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0014.png
NATO UNCLASSIFIED
Figure A
Prince Arjuna (left) in discussion with Lord Krishna about struggling with a moral dilemma on the
battlefield in the Kurukshetra War. This is a metaphysical allegory about individuals looking inward to improve
their own well-being. This figure can be interpreted
to represent the Yoga Kormas (or “sheaths”) on the path to self-
enlightenment (equivalent to the five elements in Eastern philosophies). The Kormas include physical (the horse
harness), energy (the horses), mental (the carriage), wisdom (Prince Arjuna), and bliss (Lord Krisna), ending in
“self”. This figure is from the Bhagavad Gita. Excerpted from the presentation by Dr. Natalie Babouraj at the 2
nd
committee meeting in Bologna, Italy, 19-21 October 2011.
xii
xiixii
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0015.png
NATO UNCLASSIFIED
List of Figures
Figure
Figure A
Figure 1-1
Figure 1-2
Figure 1-3
Figure 1-4
Figure 1-5
Figure 1-6
Figure 2-1
Figure 2-2
Figure 2-3
Figure 2-4
Figure 2-5
Prince Arjuna in discussion with Lord Krishna about struggling
with a moral dilemma on the battlefield in the Kurukshetra War
Plant
form: Achillea millefolium
Lemon Sharks
“Super Glue” Plugs Holes in Toddler’s Brain
Berlin, Germany (E): A Ditch, Reminiscent of World War
I Trenches, Runs
Along the Edge of the “Death Strip” in the Rudow District of East Berlin.
Tornado in a glass. 3-D render of swirling storm in a glass of water.
Is it a floor or a balcony?
Thoth, ancient Egyptian god often depicted as an ibis-headed
man.
Based on New Kingdom tomb painting.
The Recording of the Vedas in Ancient India.
Yin Yang Symbol
Hippocrates: Medicine Becomes a
Science
Un missionaire du moyen àge raconte qu’il avait trouvé le point où le ciel
et la Terre se touchent…in L’atmosphére: Métérologie Populaire (1888)
Translated A medieval missionary tells that he has found the point where
heaven
and Earth meet….
Muhammed ibn Zakariya al-Razi,
known as Razis or Rhazes: Persian
Philosopher and Physician
Regional Distribution and Major Expertise of the CAMbrella Project Partners
Regulation of Physiotherapy
within the EU
Change in Integrative Medicine Service Types Available
at Selected U.S. Department of Defense Facilities from 2005 to 2009
Changes in Integrative Medicine Provider Types at Selected
U.S.
Department of Defense Facilities from 2005 to 2009
Changes in Medical Provider Types at Selected U.S. Department of
Defense Facilities from 2005 to 2009
Changes in Integrative Medicine Funding Sources at
Selected U.S.
Page
ix
1-2
1-4
1-5
1-10
1-11
1-12
2-3
2-4
2-6
2-8
2-9
Figure 2-6
Figure 3-1
Figure 3-2
Figure
4-1
Figure 4-2
Figure 4-3
Figure 4-4
2-10
3-3
3-10
4-4
4-5
4-6
4-7
RTO-RTG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0016.png
NATO UNCLASSIFIED
Department of Defense Facilities from 2005 to 2009
Figure 5-1
Figure 6-1
Figure 7-1
Figure
7-2
Figure
7-3
Figure 7-4
Figure
7-5
Figure
7-6
Figure 7-7
Figure
7-8
Figure
7-9
Figure 7-10
Figure
7-11
Figure
7-12
Figure 9-1
Figure 9-2
Figure 9-3
Figure 10-1
Figure 11-1
Location of the Large Intesting 4 (LI4) Acupuncture Point often used
in the treatment of Headaches
Sequence of Needles for
Battlefield Acupuncture (BFA)
Soldier Performing Sitting Meditation
Soldier Performing Walking Meditation
Soldier Performing Body Scan
Mindfulness can be Integrated into Daily Activities
Illustration of a Bistable Image
PROPresence Recruitment Poster
Right
and Left Hemisphere Integration Exercise: Drawing
Right
and Left Hemisphere Integrative Exercise: Writing with both hands
Patient resting in the Arms of the Therapists
Patient enjoying the feeling of weightlessness during the slow and soft
movements in the water.
Attunement of the Patient in the Beginning Phase of a Watsu Session
Soft Arm Stretches are an essential part of Watsu and Promotes
the Mobilization of the Patient
Study design of the Stress Management Program (SMP)
Study Flow Chart
Outcome measurements after Stress Management Program
Trauma Spectrum Response Components
A representation of levels of system organization, techniques to measure
these levels of organization and the convergence of Chinese and Western
science
Systems biology as a bridge between Chinese and Western medicine
Ayuredic Doshas of
Fire
(P), Water (K) and Wind (V) in balance
Ayuredic Doshas represents out of balance
The 5 Bodies or 5
Koshas
according to Ayurveda
5-5
6-3
7-3
7-3
7-4
7-4
7-6
7-8
7-9
7-9
7-10
7-11
7-11
7-11
9-4
9-5
9-7
10-3
11-2
Figure 11-2
Figures
11-3
Figure
11-4
Figure 11-5
2
22
RTO-TR-HFM-195
11-4
11- 5
11-6
11-6
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0017.png
NATO UNCLASSIFIED
Figure
11-6
Figure
11-7
Figure
11-8
Figure
11- 9
Figure
11-10
Figure
11-11
Figure
11-12
Figure
11-13
Figure
11-14
Figure 12-1
Conceptual positioning of the relationships between health, resilience
and allostasis
Overlapping symptom patterns between Western rheumatic diseases and
Chinese arthritis related syndromes
Systems Biology Approach
Optimal Principal Component Analysis (PCA)
of Cold and Heat Rheumatoid
Arthritis Scores and Loadings of the Variables.
Optimal Principal Component Analysis (PCA) score plot for three groups of
Pre-diabetes Patients
A Simplified Clinical Case Illustrating the Differences in Treatments in
Chronic Low Back Pain using Ayurvedic Specificities
Relationships between the Endocrine Functions
Flowchart of an Endobiogeny Study Conducted in the French military
Prototype Systems Health
Model built in Marvelous
Proposed Matrix for Integrative Health and Healing Treatments
11-6
11-8
11-9
11-10
11-10
11- 11
11-12
11-13
11-14
12-7
3
33
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0018.png
NATO UNCLASSIFIED
List of Tables
Table
Table 3-1
Table 3-2
Table 3-3
Table 7-1
Table 8-1
Table 9-1
Table 9-2
Table 12-1
Prevalence of Complementary and Alternative Medicine in the EU
Top Five Most Commonly Reported Therapies in the EU
Complementary and Alternative Medicine Provider Data
Clinical Applications for Mindfulness Based Interventions
Illustration of the Complex Interplay
of Health, Illness and Recovery
Determinants
Means and Standard-Deviations (SD) at baseline for the full group
and each of the randomized groups
Means and Standard-Deviations (SD) at M12 and M18 (follow-up)
for the full, SPM and control groups
Cultural Aspects of Global Healthcare Systems
Page
3-5
3-5
3-7
7-6
8-8
9-6
9-7
12-4
4
44
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0019.png
NATO UNCLASSIFIED
List of Inserted Boxes
Box
Box 7-1
Example of Mindfulness Practice
Page
7-13
5
55
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0020.png
NATO UNCLASSIFIED
List of Acronyms and Abbreviations
15h30
18h00
4h
ACT
ACT-CIM
AD
ALT
AM
ANOVA
ASP
ATACS
BFA
BUN
CAM
CBF
CCP
CD
CHAMP
CHOL
CI
CIM
CIM
CMS
COL
CSF
CY
d
DA
DBT
DCCS
DCoE
DHA
DO
DoD
DoD/VA
DVD
e.g.
EC
EEA
EEG
EFCAM
EICCAM
EU
EXCEL
6
66
RTO-TR-HFM-195
3:30 pm
6:00 pm
Four hours
Acceptance and Commitment Therapy
Active Self-Care Complementary and Integrative Medicine
Active Duty
Alanine aminotransferase
Anthroposophic Medicine
Analysis of Variance
Acupuncture Semi-Permanent
Acupuncture Training Across Clinical Settings
Battlefield Acupuncture
Blood-urea-nitrogen
Complementary and Alternative Medicine
CardioBioFeedback
Citullinated Protein Antibiotics
Compact Disc
Consortium for Health and Military Performance
Cholesterol
Confidence Interval
Center for Integrative Medicine
Complementary and Integrative Medicine
Centers for Medicare & Medicaid Services
Colonel (US Military)
Comprehensive Soldier Fitness
Calendar Year
Effect size (Cohen’s d statistical test)
Department of the Army
Dialectical Behavior Therapy
Deputy Chief of Clinical Services
The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
Defense Health Agency
Doctor of Osteopathic Medicine
Department of Defense
Department of Defense/Veterans Affairs
Digital Versatile Disc, Digital Video Disc
Exempli gratia, “for example”
European Commission
European Economic Area
Electroencephalography
European Federation for Complementary and Alternative Medicine
European Information Center on Complementary and Alternative Medicine
European Union
Army’s Excellence in Character, Ethics and Leadership
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0021.png
NATO UNCLASSIFIED
FF
FHPR
FMI
fMRI
GAO
GER
GNP
GP
HAIG
HFM
HPO
HRPC
HRV
IED
IgA
IgG
IgM
IH
2
IM
ISAF
JHWH
K
LAc
LBP
LY#
M0
M12
M18
M4
M6
MBCT
MBSR
MCHC
MD
MeSH
MHS
MHS
MMFT
MPH
MRMC
mTBI
MTF
MWR
Firefighter
Force Health and Protection and Readiness
Frieburg Mindfulness Inventory
Functional Magnetic Resonance Imaging
Government Accounting Office
German
Gross National Product
General Practitioner
Healthcare Analysis & Information Group
Human Factors and Medicine
Human Performance Optimization
Human Performance Resource Center
Heart Rate Variability
Improvised
Explosive Device
Immunoglobulins A
Immunoglobin G
Immunoglobin M
Integrative Health and Healing
Integrative Medicine
International Security Assistance Force
Jehwah (Hebrew for God)
Kapha (water)
Licensed Acupuncturist
Low Back Pain
Lymphocyte number
Month 0
Month 12
Month 18
Month 4
Month 6
Mindfulness Based Cognitive Therapy
Mindfulness Based Stress reduction,
Mean Corpusular Hemoglogin Concentration
Medical Doctor
Medical Subject Heading
Military Health System
Military Health System
Mindfulness-Based
Mind Fitness Training
Masters of Public Health
Medical Research and Materiel Command
mild Traumatic Brain Injury
Medical Treatment Facilities
Morale, Welfare and Recreation
7
77
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0022.png
NATO UNCLASSIFIED
N
NATO
NCCAM
NCCIH
NICoE
NIH
NNMC
NNT
NP
OAM
OEF
OIF
OTSG
P
PA
PC1
PCL-M
PEK
PFF
PharmD
PhD
PLT
POMS
PSS
PTSD
QoL
RA
RCT
RDW
REM
RGT
RN
RP
SAS
SD
SD PPM
SM
SMP
SpNQ
SpR
SPSS
STO
TAG
TATRC
TBI
TCM
8
88
RTO-TR-HFM-195
Sample Size
North Atlantic Treaty Organization
National Center for Complementary and Alternative Medicine
National Center for Complementary and Integative Health
National Intrepid Center of Excellence
National Institute of Health
National Naval Medical Center
Number needed to treat
Nurse Practitioner
Office of Alternative Medicine
Operation Enduring Freedom
Operation Iraqi
Freedom
Office of The Surgeon General
Pitta (fire)
Physician Assistant
Principal Component 1
Postraumatic Stress Disorder Checklist-Military Version
Programm Evaluation Komplementärmedizin
Paris Firefighters
Doctor of Pharmacology
Doctor of Philosophy
Platelet count
Profile of Mood States
Perceived Stress Scale
Posttraumatic Stress Disorder
Quality of Life
Rheumatoid Arthritis
Random Controlled Trial
Red Blood Cell Distribution Width
Rapid Eye Movement
Task Group
Registered Nurse
Relapse Prevention
Special Air Service
Standard Deviation
Sino-Dutch Centre for Preventive and Personalized Medicine
Service Member
Stress Management Programs
Spiritual Needs Questionnaire
Spirituality/religiosity
Statistical Package for the Social Sciences
Science and Technology Organization
Technical Advisory Group
Telemedicine and Advanced Technology Center
Traumatic Brain Injury
Traditional Chinese Medicine
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0023.png
NATO UNCLASSIFIED
TFF
TM
TNO
TOP
TR
US
USUHS
V
v
VA
VA
VAS
VHA
WG
WHO
wrTSR
WWII
Total Force Fitness
Transcendental Meditation
The Netherlands Organization for Applied Scientific Research
Techniques d‘ Optimisation du Potential, Techniques That Optimize Potential
Technical Report
United States
Uniformed Services University of the Health Sciences
Vata (wind)
Version
Veterans Affairs
Virginia
Visual Analog Scale
Veterans Health Administration
Working Group
World
Health Organization
War-related, Trauma Spectrum Response
World War Two (II)
9
99
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0024.png
NATO UNCLASSIFIED
GLOSSARY
Active Participation modality
is a treatment modality in which the individual actually engages in the
treatment. It is related to the patient’s active involvement in their own care by participating in both the
care plan and treatment. Examples of active participation modalities include
yoga, meditation,
acupressure and exercise.
Acupressure
is the application of pressure in sites used for acupuncture with therapeutic intent.
Acupuncture
is an ancient Chinese healing technique with roots in Traditional Chinese Medicine (TCM)
in which the stimulation of specific points along meridian channels in the body is achieved by piercing the
skin with needles in order to enhance the flow of energy, cure diseases, relieve pain and stress and regulate
the body.
Acupuncture Training Across Clinical Settings (ATACS)
refers to the teaching of the Battlefield
Acupuncture in Medical Facilities of the Department of Defense and the Veterans Administration.
The
program has trained physicians, nurses, Special Forces and other ancillary healthcare clinicians.
Acute pain
is “normal pain” that occurs as a result of injury or disease. It typical lasts no more than 3-6
months, is self-limiting and responsive to appropriate therapies. Acute pain ends when the inciting harm
is ended and the healing response to the harm is complete.
Aiguille semi-permanent (ASP)
refers to a semi-permanent needles used in this technique that are
sterilized and pre-packaged in a plastic injector. The 2 mm-long needles may be gold, titanium or
stainless steel. They “fall” out of external area of the ear in about 3-4
days.
Algorithm
is a procedure or formula for solving a problem. It is a self-contained step-by-step set of
operations (decisions) to be performed. Algorithm is derived from the name of the Persian mathematician,
Mohammed ibn-Musa al Khwarizmi (780-850 AD). An algorithm is typically structurally inflexible but
can have random inputs. Algorithms are often associated with mathematical processes but recently are
being used in medical practices to determine treatment plans.
Allopathic
is the medical practice related to conventional or orthodox medical practice.
Allostasis
is the process of achieving stability, or homeostasis, through physiological or behavioral
change.
Allostatic load
is "the wear and tear on the body" which grows over time when the individual is exposed
to repeated or chronic stress. It represents the physiological consequences of chronic exposure to
fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress.
McEwen and Stellar coined the term in 1993.
Anthroposophic medicine
(Anthropos = human being: Sophia = wisdom) is a form of complementary
medicine developed by Rudolf Steiner that views the entire human being. The anthroposophical approach
to medicine adds spiritual insight to diagnosis and healing. Applied by conventionally trained medical
doctors who combine orthodox medical treatment with complementary practice, this modern holistic
paradigm combines European homeopathics, plant medicines, natural remedies and elements of allopathic
10
1010
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0025.png
NATO UNCLASSIFIED
principles. Inspired by Rudolf Steiner (1861-1925), anthroposophic medicine takes into account that
human beings, nature and the cosmos are interrelated. Many other therapeutic disciplines that have
developed within the approach include homeopathic and herbal remedies, homecare, nursing, artistic
therapy, music therapy, hydrotherapy, curative eurythmy (movement), and massage.
Aromatherapy
is a treatment modality of using plant materials and aromatic plant oils for the purpose of
altering an individual’s mood, cognitive, psychological or physical well-being. The use of essential oils
for therapeutic, spiritual, hygienic and ritualistic purposes dates back to ancient civilizations of the
Chinese, Indians, Egyptians, Greeks and Romans.
Antihomotoxicology (Complex homeopathy)
Classical homoeopathy works with single remedies which
are only partly truly single-constituent remedies, (e.g., sulphur, mercury, arsenic, etc.), or which are
otherwise botanical extractions containing a highly complex mixture of numerous constituents.
Repertories (lists of symptoms produced by drugs) facilitate the selection of the most appropriate remedy
in homoeopathy. Anti-homotoxic medicine usually pursues an indication-oriented approach. The anti-
homotoxic remedies predominantly represent mixtures of substances of low to middle potencies. Through
practical application in homoeopathy it became obvious that the use of concentrated or poisonous tinctures
could damage the patient and that, therefore, they could only be used in homoeopathic dilutions, i.e.,
potencies. This practice was scientifically supported by Rudolf Arndt (psychiatrist, 1835-1900)
and Hugo
Schulz (pharmacologist, 1853-1932) through a quantitative differentiation of the medicinal effect on bio-
systems and still applies as the Arndt-Schulz Principle. It states; 1) weak stimuli stimulate the life
functions (retroaction of homoeopathic preparations), 2) moderately strong stimuli accelerate them, 3)
strong stimuli act as inhibitors and 4) the strongest stimuli suspend the life functions. Since several
tissue-incompatible substances are usually involved during the development of a disease, the simultaneous
use of several potentised ”antitoxins“, as present in the anti-homotoxic
preparations, is justified. Against
the background of the conflicting medicinal and therapeutic concepts promulgated in humoral pathology,
cellular pathology, molecular pathology, and related fields including modern cybernetics, the German
physician Dr. Hans-Heinrich Reckeweg formulated Homotoxicology in 1952. This conception
was
developed from homoeopathy for the purpose of providing a holistic perspective on the synthesis of
medical science.
Ayurvedic medicine
(also called Ayurveda) is one of the world’s oldest medical systems. Ayurveda is
based on the concepts of longevity and the nourishment of life. It originated in India and has evolved over
thousands of years. In the United States and Europe, Ayurvedic medicine is considered a complementary
health approach. Many products and practices used in Ayurvedic medicine are also used on their own as
complementary approaches—for example, herbs, massage, and specialized diets.
Battlefield Acupuncture (BFA)
is an ear acupuncture technique consisting of placing five ASP (Semi-
permanent) needles in the ear in a specific sequence starting with the Cingulate Gyrus, Thalamus, Omega
2, Shen Men and Point Zero to reduce acute and chronic pain. (See each specific point for description).
Benson, Herbert:
An American Cardiologist who has been a pioneer in Mind Body Medicine,
and one of
the first Western physicians to bring spirituality and healing into medicine. Throughout his 40+-year
career, Dr. Benson has worked to build awareness of Mind Body Medicine, to validate it through research,
and to bridge the gap between Western
and Eastern medical practices. Dr. Benson is the Director Emeritus
of the Benson-Henry
Institute (BHI), and Mind Body Medicine Professor of Medicine, Harvard Medical
School.
Biofeedback
is a training technique that enables a patient to gain some element of voluntary control over
autonomic body functions; based on the principle that a desired response is learned when received
information such as a recorded increase in skin temperature (feedback) indicates that a specific thought
complex or action has produced the desired physiologic response.
11
1111
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0026.png
NATO UNCLASSIFIED
Buddhism
is a religious or philosophical system that encompasses a variety of traditions, beliefs and
spiritual practices largely based on the teachings attributed to Gautama Buddha (563 – 400 BC estimated)
or widely known
as Buddha or the “awakened one”.
Bureaucracy
is a system of government in which most of the important decisions are made by state
officials rather than by elected representative.
CAMbrella
is an acronym word from CAM and Umbrella words. It represents the
European research
network for complementary and alternative medicine (CAM) that conducted a research program into the
situation of CAM in Europe between 2010 and 2012.
Chinese medicine
See TCM
Chronic pain
Ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more
than 3 to 6 months, and which adversely affects the individual’s well-being. A simpler definition for
chronic or persistent pain is pain that continues when it should not.
Cingulate gyrus
is an auricular acupuncture point situated in the intra-tragal
notch on the cartilaginous ring of the ear. The cingulate gyrus is an anatomical
point representing the cingulate gyrus of the brain. The cingulate gyrus is a part
of the cingulate cortex, which is situated within the cerebral cortex. The cingulate
cortex is part of the limbic cortex; the system related to emotions, learning and
memory.
Complementary and Alternative Medicine (CAM)
is a group of diverse medical and healthcare
practices that are not generally
considered to be part of “conventional medicine” or that which is not
taught in Western medical schools. Complementary refers to those modalities to augment. Alternative
refers to those modalities used instead of.
Complementary and Integrative medicine (CIM)
is the revised terminology of Complementary and
Alternative Medicine (CAM) to include those practices that are “integrative”. Integrative medicine is
characterized by its focus on restoring optimal health and well-being through the use of a wide array of
evidence-based modalities and approaches.
Cold
is the Chinese concept that Cold in the body causes clinical manifestations similar to those of cold in
the natural environment, e.g., low temperature, deceleration of activity, and congealing. Diseases caused
by cold evil result from severe or sudden exposure to cold, e.g., catching cold, excessive consumption of
cold fluids, or exposure to frost. They bear the following features 1) a generalized or local signs of cold,
such as aversion to cold, desire for warmth, pronounced lack of warmth in the extremities, and cold and
pain in the lower abdomen, 2) cold, thin, clear excreta, 3) tendency to develop qi stagnation and blood
stasis, characterized by severe pain and 4) contracture and hypertonicity of the sinews.
Nigel Wiseman,
Feng Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications,
Brookline, Massachusetts, USA.
Comprehensive Pain Management Campaign Plan (CPMCP)
is the standardized DoD and VHA
Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families.
Coping
is described as the active and conscious strategies to deal with problems / stressor (i.e., illness,
distress etc.). These can be either problem or emotion focused to solve the problems, avoid or minimize
the stressor, or to adapt to circumstances.
12
1212
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0027.png
NATO UNCLASSIFIED
Culture
is a way of life of a group of people to include customs, behaviors, beliefs, values, morals, laws
and symbols that are accepted and passed from one generation to the next. Culture is a dynamic process
that changes as the society changes.
Curanderismo
describes a broad healing tradition of Latin America. The word is derived from the
Spanish verb
curar,
which means, “to heal”. There are seven pillars of Curanderismo, which represent the
blending of the ancient civilizations with the native populations.
Curandero
is a traditional Native healer, found in the United States and Mexico. Curandero is Spanish
for “healer.”
Cure
is often described as the absence of disease or illness; however, cure also represents an improved
quality of life, which supports the process of healing, even in the presence of continued disease or illness.
Dampness
In the conceptual meaning of Chinese medicine, Dampness in the body is qualitatively
analogous and causally related to dampness in the natural environment. It is associated with damp weather
or damp climates and with stagnant water in places where ground drainage is poor. To some extent, it is
seasonal in nature, tending to occur when the weather is wet or damp. Dampness has a number of
characteristics: a. it is clammy, viscous and lingering. Dampness diseases are persistent and difficult to
cure; b. Dampness tends to stagnate and the patient may complain of physical fatigue, heavy, cumbersome
limbs, and heavy-headedness, aching joints and inhibited bending and stretching.
Nigel Wiseman, Feng
Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications, Brookline,
Massachusetts, USA.
Descartes, René (1596 – 1650)
was a French philosopher, mathematician and scientist. He is known as
the father of modern western philosophy. Descartes is best known for his concept of the mind and body
separation,
including the superiority of the former (“Cogito ergo sum” translated as “I think, therefore I
am.”)
Deficiency
refers to emptiness or weakness of vital substances of the body.
Doctor-patient relationship
simply put is the relationship between the
patient and doctor. However, the
doctor-patient relationship is central to the practice of healthcare and forms one of the foundations of
contemporary medical ethics. Studies show that the doctor-patient relationship can be as importance to
the overall medical outcome as any treatment. It is based on trust, confidence, rapport, communication,
respect, shared values and perspectives about quality of life, disease, illness and health.
Drugless Treatments
is a group of modalities that encompass non-drug approaches often used by
integrative medicine professionals to complement conventional treatment and facilitate healing.
Acupuncture, Reiki, manipulation as well as Integrative Medicine team approaches are examples of
drugless treatments.
Dynamic system
In mathematics, a dynamical system is a set of relationships among two or more
measurable quantities, in which a fixed rule describes how the quantities evolve over time in response to
their own values.
Eastern Medicine
is a collective group of medical practices typically based on the eastern or ancient
practices. Eastern practices are based on the inductive method (observations of nature with few statements
on the laws or theories of nature). The Eastern approach typically considers health as balanced
states
versus disease as unbalanced states. It adapts to the environment. Examples include Traditional Chinese
Medicine, Ayurveda and homeopathy. The division of “Eastern” and “Western” is an artificially
constructed paradigm (see chapter 12).
13
1313
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0028.png
NATO UNCLASSIFIED
Efficacy
is the ability to produce a desired or intended result. It is the capacity for beneficial changes or
therapeutic effect of a given intervention. Efficacy measures how well a treatment works in structured
clinical trials or laboratory studies.
Effectiveness
is the degree to which something is successful in producing a desired result. Effectiveness
relates to how well a treatment works in the clinical practice of medicine.
Energy Medicine (therapy, healing)
is a sub-practice of “alternative medicine”
that manipulates the
energies (often subtle energies) of the human body to create a positive influence. Examples include Reiki,
Therapeutic Touch, Alpha-stimulation and spiritual healing. Acupuncture can be considered a form of
energy medicine since acupuncture is based on the movement of energy (Qi).
Energetics
is a therapeutic approach that is based on the energy changes involved in the chemical
reactions within living tissue.
Evidence-Based Practice
is the term applied to those practices that have accepted, well designed and
conducted research based evidence to support the effectiveness or efficacy of the practice. It is based on
the terminology of evidence-based
medicine. EBP is an approach that is intended to optimize medical
decision-making in the determination of appropriate treatment plans. The term was introduced in 1992.
Exercise
is any bodily activity that enhances or maintains physical fitness and overall health and wellness.
Exercise benefits the immune, cardiovascular and musculoskeletal systems as well as provides stress
reduction, improved mood, self-esteem and mental health.
Guided imagery
is the use of words and music to evoke positive imaginary scenarios in a subject, with a
view to bringing about some beneficial effect.
Hatha yoga
is a type of yoga consisting of physical exercises and breathing control.
Healing
is the process of restoration of health form an unbalanced, disease, injured or damaged individual.
Healing comes from the old English to “restore to sound health” of Germanic origin, which is related to
the Dutch,
heelen
and German
heilen,
which mean “whole”.
Healing touch
is a therapy involving hands-on contact with the patient, combined with other spiritual
links made between patient and practitioner, that helps to restore and balance energy that has been
depleted due to stress, illness, injury, grief, medical conditions, surgery or medical treatments such as
chemotherapy and radiation.
Health
is one of the most difficult terms to define in medicine because it is based on a multitude of factors
such as individual perspectives, prescribed or expected outcomes
and situations. The World Health
Organization (WHO-
1948) defines health as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity. The Ottawa Charter for Health Promotion (1986)
describes health as
“a resource for everyday life, not the object of living. Health is a positive concept
emphasizing social and personal resources, as well as physical capacities.” The art of medicine is to
understand and to support the patient’s definition of health based on their perspectives and goals.
Health Care System
is the organization of people, institutions and resources that deliver healthcare
services to meet the health needs of target populations. There are four basic types of health care systems.
These
include 1) government controlled and paid through tax payments (Beveridge, English), 2) insurance
based, but inclusive of all and non-profitable (Bismarck, German), 3) private sector delivered but funded
through government-run
insurance program (National Health
Insurance Model, Canadian) 4) out-of pocket
14
1414
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0029.png
NATO UNCLASSIFIED
or market driven. Countries can have variations and combinations of all models such as the USA where
government controlled is provided for Veterans and citizens over 65 whereas employer provided insurance
is provided for most Americans. Some of the very wealthy and poor will opt/forced to have out-of-pocket
healthcare.
Heart rate variability (HRV)
is the physiological phenomenon of variation in the time interval between
heartbeats. It is measured by the variation in the beat-to-beat interval.
Heat
is the opposite of the Chinese medical concept of Cold. It can five rise to symptoms as fever, fear of
heat, desire for coolness, thirst, red face, red eyes, reddish urine, red tongue with yellow tongue coating
and a rapid pulse.
Nigel Wiseman, Feng Ye; A Practical Dictionary of Chinese Medicine, first edition,
1998; Paradigm Publications, Brookline, Massachusetts, USA.
Herbal medicine
is the discipline of medicine that deals with herbs (plant or plant part) used for its scent,
flavor, or therapeutic properties. Herbal medicines are one type of dietary supplement. They are sold as
tablets, capsules, powders, teas, extracts, and fresh or dried plants. People use herbal medicines to try to
maintain or improve their health.
Hermetic Books
is a collection of heterogeneous body of works attributed to the philosopher Hermes
Trismegistus. The books are mostly philosophical, theosophical, astrological, magical or alchemical in
nature.
Hermes Trismegistus may be a representation
of the syncretic (the combining of different and
often contradictory beliefs while blending various schools of thought) combination of the Greek god
Hermes with the Egyptian god Thoth.
Hippocrates (460 – 370 BC)
was a Greek Physician of Classical Greece and considered to be the father of
Western Medicine. The Hippocrates School of Medicine was revolutionary because it established
medicine as a discipline distinct from other fields with which it had been traditionally associated. This
established
medicine as a profession. Hippocrates was attributed with the
Hippocrates Oath,
an oath often
taken by physicians to uphold ethical standards.
Holistic
is the characteristic of being whole, complete, interconnected, indivisible, ordered. In medicine
the concept is used to address the entire individual and context rather than focusing only on a part or
diagnosis. In biology, the concept according to which the sum of a phenomenon or system cannot be
measured, reduced, observed at the level below that of the entire system.
Homeopathy
The alternative medical system of homeopathy was developed in Germany at the end of the
18th century. Supporters of homeopathy point to two unconventional theories: “like cures like”—the
notion that a disease can be cured by a substance that produces similar symptoms in healthy people; and
“law of minimum dose”—the
notion that the
lower
the dose of the medication, the
greater
its
effectiveness. Many homeopathic remedies are so diluted that no molecules of the
original substance
remain. Homeopathic remedies are derived from substances that come from plants,
minerals, or animals, such as red onion, arnica (mountain
herb),
crushed whole bees, white arsenic, poison
ivy, belladonna (deadly nightshade), and stinging nettle.
Homeopathic remedies are often formulated as
sugar pellets to be placed under the tongue; they may also be in other forms, such as ointments, gels,
drops, creams, and tablets. Treatments are “individualized” or tailored to each person—it
is not
uncommon for different people with the same condition to receive different treatments.
Homeostasis
Homeostasis is the property of a system in which variables are regulated so that internal
conditions remain stable and relatively constant.
Humoral/drain-off therapy (Purgation therapy):
the ancient Greek theory of the four body humors
(blood, yellow bile, black bile, and phlegm) that determined health and disease. The humors were
15
1515
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0030.png
NATO UNCLASSIFIED
associated with the four elements (air, fire, earth, and water), which in turn were paired with one of the
qualities (hot, cold, dry, and moist). A proper and evenly balanced mixture of the humors characterized
health of body and mind; an imperfect balance resulted in disease. Temperament of body or mind also was
supposed to be determined, for example, sanguine (blood), choleric (yellow bile), melancholic (black
bile), or phlegmatic (phlegm). In Ayurvedic medicine, cleansing the body of toxins by taking laxatives.
Synonym:
virechana.
Integrative Health and Healing (IH2)
is a system of medical practice that places a shared responsibility
for health and healing onto the system i.e. patient, provider, delivery and outcomes. The core principles of
IH2 are patient centered, (w)holistic care, as well as empowerment and responsibility. IH2 combines all
healthcare practices and disciplines, to include self-care, which are informed by scientific evidence,
clinical best practices and shaped by goals and expectations. The emphasis of IH2 is on quality of life, not
necessarily cures as a measure of success.
Integrative Medicine (IM)
is the medical practice that combines conventional Western medicine with
complementary and alternative treatments, all in the effort to treat the whole person. Proponents prefer the
term "complementary"
rather than “alternative” to emphasize that such treatments are used with
mainstream medicine, not as replacements or alternatives. There are many definitions of IM. A
comprehensive definition as defined by Duke University states; Integrative
medicine is characterized by the
following 1) The patient and practitioner are partners in the healing process, 2) All factors that influence
health, wellness and disease are taken into consideration, including body, mind, spirit and community, 3)
Providers use all healing sciences to facilitate the body’s innate healing response, 4) Effective interventions
that are natural and less invasive are used whenever possible, 5) Good medicine is based in good science. It is
inquiry driven and open to new paradigms, 6) Alongside the concept of treatment, the broader concepts of
health promotion and the prevention of illness are paramount and 7) The care is personalized to best address
the individual’s unique conditions, needs and circumstances. Practitioners of integrative medicine exemplify
its principles and commit themselves to self-exploration and self-development.”
Joint Incentive Fund
(JIF) was established under Section 721 of the FY 2003 National Defense
Authorization Act to provide seed money and incentives for innovative DoD/VA joint sharing initiatives
to recapture purchased care, improve quality and drive cost savings at facilities, regional and national
levels. The minimum annual contributions to the fund by DoD/VA are $15 million each, for a total of $30
million per year. JIF is only designated for use by the Veterans Health Administration (VHA) and
Defense Health Agency (DHA) entities
for direct medial sharing initiatives or for services or systems that
facilitate DoD/VA interoperability. JIF should not be used to hire military personnel, for major
construction and/or major IT systems.
Funds should also not be used for sustainment purposes. JIF
initiatives should be executed to completion (and funding should be spent) within two years.
Kinesiology
is the science dealing with the interrelationship of the physiological processes and anatomy
of the human body with respect to movement, also known as
human kinetics,
is the scientific study of
human movement. Kinesiology addresses physiological, mechanical, and psychological mechanisms.
Applications of kinesiology to human health include biomechanics and orthopedics; strength and
conditioning; sport psychology methods of rehabilitation, such as physical and occupational therapy; and
sport and exercise. Individuals who have earned degrees in kinesiology can work in research, the fitness
industry, clinical settings, and in industrial environments. Studies of human and animal motion include
measures from motion tracking systems, electrophysiology of muscle and brain activity, various methods
for monitoring physiological function, and other behavioral and cognitive research techniques.
Kinesiology as described above should not be confused with applied kinesiology a controversial medical
diagnostic method. The word comes from the Greek κί�½ησις
kinesis,
"movement" (itself from κι�½εῖ�½
kinein,
"to move"), and -λογία
- logia,"study".
Kneipp therapy (GER)
is a form of hydrotherapy (water therapy) that was created by the Bavarian priest
16
1616
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0031.png
NATO UNCLASSIFIED
Sebastian Kneipp (1821-1897). Today, it still represents a holistic approach in the field of naturopathic
healing and contemporary preventative medicine and is widely practiced in spas and wellness resorts
throughout Europe. It is commonly also known as “Kneipping” or “Kneipp Cure”. The principle of a
Kneipp Therapy is based on hot and cold showers, rinses, baths, and compresses. The interplay of hot and
cold water on the skin, widens the arteries, stimulates blood flow and the metabolic system and
strengthens the immune system.
Licensed Acupuncturist (LAc)
is a provider of acupuncture whose educational focus is in Acupuncture
and Oriental Medicine and has obtained a 3-4 year master’s level degree or diploma and is licensed in one
or more jurisdictions.
Manual therapies (Chiropractic, Osteopathy)
contains two main basic systems chiropraxia and
osteopathy) according to it’s main effect of body. It places emphasis on the musculoskeletal system, hence
the name—osteo refers to bone and path refers to disease. Osteopaths also believe strongly in the healing
power of the body and do their best to facilitate that strength. During this century, the disciplines of
osteopathy and allopathic medicine have been converging. Osteopathy shares many of the same goals as
traditional medicine, but places greater emphasis on the relationship between the organs and the
musculoskeletal system as well as on treating the whole individual rather than just the disease.
Martial Arts
are a group of systems and traditions of combat practices, which are practices for self-
defense, competition, physical health and fitness, entertainment as well as physical and spiritual
development. It refers to a combat system of Europe from the early 1550 although it is often associated
with fighting arts of eastern Asia. The term “Martial Arts” is derived
from the Latin and means “arts of
Mars”. Mars was the Roman god of war.
Medical Acupuncturist
is a provider of acupuncture who is trained and licensed in Western medicine
with additional training (300+ hours) and certification specifically in the area of Acupuncture as a
specialty practice.
Meditation
is similar to mindfulness the term “meditation” has different meanings depending on the
context. Generally speaking meditation can be understood as an exercise or a practice in which the
attention is focused inwards. Through meditation a state of consciousness is cultivated that is beyond the
mind and that allows insight into the true nature of reality.
Mesopotamia
is believed to be the oldest civilization. It is the geographical area, which are present-day
Kuwait, Syria and Iraq. Mesopotamia is derived from the Greek to mean the “land between rivers”. Thus,
Mesopotamia was the name for the area between the Tigris and Euphrates river systems.
Metabolomics
is the scientific study of chemical processes involving metabolites. Specifically,
metabolomics is the "systematic study of the unique chemical fingerprints that specific cellular processes
leave behind", the study of their small-molecule metabolite profiles.
Nigel Wiseman, Feng Ye; A Practical
Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications, Brookline, Massachusetts,
USA.
The metabolome represents the collection of all metabolites in a biological cell, tissue, organ or
organism, which are the end products of cellular processes.
National Center for Complementary and
Integrative Health, USA.
mRNA gene expression data and proteomic analyses reveal the set of gene
products being produced in the cell, data that represents one aspect of cellular function. Conversely,
metabolic profiling can give an instantaneous snapshot of the physiology of that cell. One of the
challenges of systems biology and functional genomics is to integrate proteomic, transciptomics, and
metabolomic information to provide a better understanding of cellular biology.
A
meta-study
(or analysis) is one that summarizes the results of data collected in numerous studies with
the same methodological approach (e.g., mindfulness training) but in different contexts (e.g., cancer,
17
1717
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0032.png
NATO UNCLASSIFIED
therapy, drug-abuse prevention, etc.).
Mindfulness
can be defined in many different ways, based on contextual perspectives. In some cases,
mindfulness is referred to as a method or a spiritual practice. Other people use the term to characterize a
mental state or as a personality trait (focusing on the long-term effects). In common terms, mindfulness is
associated with a nonjudgmental observation of thoughts, emotions and bodily sensations that can arise in
a given moment.
Mindfulness based stress reduction
(MBSR) is one of the most popular and well-evaluated mindfulness
training concepts available in the western world. MBSR is an 8-week mindfulness-training program,
which is based upon Buddhist meditation techniques such as sitting meditation, walking meditation, the
body scan and some Hatha Yoga exercises.
Mysticism
is the belief that union with or absorption into the Deity or absolute, or the spiritual
apprehension of knowledge inaccessible to the intellect, may be attained through contemplation and self-
surrender. Mysticism is a group of distinctive practices, discourses, texts, institutions, traditions and
experiences aimed at human transformation.
National Center for Complementary and Integrative (NCCIH)
is the U.S. Federal Government’s lead
agency for scientific research on the diverse medical and health care systems, practices and products that
are not generally considered part of conventional medicine. The NCCIH was established in 1991 as the
Office of Alternative Medicine (OAM). In 1998, the OAM was renamed the National Center for
Complementary and Alternative Medicine and established as a National Institute (NIH) Center. In 2001,
NCCAM and the National Library of Medicine launched
CAM on PubMed,
a comprehensive Internet
source of research-based
information. It 2014, NCCAM was renamed the NCCIH to more accurately
reflect the Center’s commitment to studying promising health approaches already in use by the American
Public.
National Institutes of Health (NIH)
is the U.S. Federal Government Agency in medical research. NIH is
part of the U.S. Department of Health and Human Services. The NIH is composed of 27 different
Institutes and Centers. The roots of the NIH trace back to 1887 as a one-room
laboratory created within
the Marine Hospital Service (MHS), which was the predecessor agency to the U.S. Public Health Service
(PHS).
Naturopathy (GER: “Naturheilverfahren”):
a drugless system of healing by the use of physical
methods, such as light, air, or water. Naturopathy—also called naturopathic medicine—is a medical
system that has evolved from a combination of traditional practices and health care approaches popular in
Europe during the 19th
century. People visit naturopathic practitioners for various health-related purposes,
including primary care, overall well-being, and treatment of illnesses. Naturopathic physicians, traditional
naturopaths, and other health care providers are examples of providers who offer naturopathic services.
Naturopathic
practitioners use many different treatment approaches. Examples include: Dietary and
lifestyle changes, Stress
reduction, Herbs and other dietary supplements, Homeopathy,
Manipulative
therapies, Exercise
therapy, Practitioner-guided detoxification, Psychotherapy
and counseling. Some practitioners use other methods as well or, if appropriate, may refer patients to
conventional health care providers.
Neural therapy (Huneke):
Neural therapy has been described as a form of holistic medicine for treating
illness and chronic pain with local anesthetic medicaments but with non-curing dosage. The idea
underlying the therapy is that "interference fields" (Störfelder) at certain sites of the body are responsible
for a type of electric energy that causes illness. The fields can be disrupted by injection, allowing the body
to heal. The practice originated in 1925 when Ferdinand Huneke, a German surgeon, used a newly
launched pain drug that contained procaine (a local anesthetic) on his sister who had severe intractable
18
1818
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0033.png
NATO UNCLASSIFIED
migraines Instead of using it intramuscularly as recommended he injected it intravenously and the
migraine attack stopped immediately. He and his brother
Walter subsequently used Novocaine in a similar
way to treat a variety of ailments. In 1940, Ferdinand Huneke injected the painful shoulder of a woman
who also had an osteomyelitis in her leg, which (before antibiotics) threatened her with amputation. The
shoulder pain improved somewhat but the leg wound became itchy. On injecting the leg wound the
shoulder pain vanished immediately – a reaction he called the "phenomenon of seconds"
(Sekundenphänomen). Neural therapy used frequently in Mid-European
countries
(Germany, Switzerland,
Austria, Hungary).
Non-Allopathic
is consider those practices also known as complementary and alternative, i.e. those that
are not generally considered part of conventional medicine.
North Atlantic Treaty Organization (NATO)
is an international alliance of 28 countries with the
mission to safeguard the freedom and security of its members through political and military means.
NATO was officially formed on 4 April 1949 with the signing of the
Washington Treaty
in response to the
threat
posed by the Soviet Union as well as the prevention of European nationalist militarism through a
North American presence in Europe. Further, NATO was formed to encourage European political
integration. Currently, NATO membership is open to “any other
European State in a position to further
the principles of the NATO treaty and to contribute to the security of the North Atlantic area.
Off-label
is the practice of prescribing a medication/pharmaceutical drug for an illness or disease other
than the
approved indication of the medication i.e. Federal Drug Administration (FDA) label. The
Archives of Internal Medicine
reported that 73% of off-label use has little or no scientific support. (2006)
Omega 2 auricular acupuncture point
is situated on the outer rim of the pinna.
Omega 2 point is a functional point rather than an anatomical point since there is
no corresponding brain structure. Omega 2 reflects the inner feeling and
perception of the person as related to the surrounding personal space. It
represents the connection of the self to the world as well as how one perceives the
world.
Orthomolecular therapy
is a form of alternative medicine aimed at maintaining health through
nutritional supplementation and based on the idea that there is an optimum nutritional environment in the
body and that diseases reflect deficiencies in this environment. Treatment for disease, according to this
view, is an attempt to correct, "imbalances or deficiencies based on individual biochemistry" by use of
supposedly "natural" substances such as vitamins, minerals, amino acids, trace elements and fatty acids.
The notions behind orthomolecular medicine are not supported by sound medical evidence and the therapy
is not effective even the accuracy of calling the orthomolecular approach a form of medicine has been
questioned since the 1970’s. The approach is sometimes referred to as megavitamin therapy because its
practice evolved out of, and in some cases still uses, doses of vitamins and minerals many times higher
than the recommended dietary intake. Orthomolecular practitioners may also incorporate a variety of
other styles of treatment into their approaches, including dietary restriction, megadoses of non-vitamin
nutrients and mainstream pharmaceutical drugs.
Oxidative stress
reflects an imbalance between the systemic manifestation of reactive oxygen species and
a biological system's ability to readily detoxify the reactive intermediates or to repair the resulting damage.
Disturbances in the normal redox state of cells can cause toxic effects through the production of peroxides
and free radicals that damage all components of the cell, including proteins, lipids, and DNA. Oxidative
stress from oxidative metabolism causes base damage, as well as strand breaks in DNA. Base damage is
mostly indirect and caused by reactive oxygen species (ROS) generated, e.g. O
2
− (superoxide radical),
OH (hydroxyl radical) and H
2
O
2
(hydrogen peroxide). Further, some reactive oxidative species act as
cellular messengers in redox signaling. Thus, oxidative stress can cause disruptions in normal mechanisms
19
1919
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0034.png
NATO UNCLASSIFIED
of cellular signaling.
Oxygen/ozone therapy
is a bio-oxidative therapy that involves administering small amounts of diluted
ozone and hydrogen peroxide into the body for the prevention and treatment of disease. Licensed
physicians in Germany have used ozone therapy since the early 1960's, while hydrogen peroxide primarily
Dr. C.H. Farr, nominee for the 1993 Nobel Prize in Medicine, developed therapy in the United States. The
philosophy behind bio-oxidative therapies is a simple one. The use of hydrogen peroxide and ozone in
medicine is based on the belief that the accumulation of toxins in the body is normally burnt up by the
process of oxidation, a process wherein a substance is changed chemically because of the effect of oxygen
on it. Oxidation breaks the toxins down into carbon dioxide and water, and eliminates them from the body.
However, if the oxygen system of the body is weak or deficient (whether through lack of exercise,
environmental pollution, poor diet, smoking, or improper breathing), our bodies cannot eliminate them
adequately and a toxic reaction can occur. In minor cases, a toxic build-up can lead to fatigue, while a
wide range of diseases can result when poor oxygenation is chronic.
P
value
(p
value)
is a statistical term that refers to the probability of obtaining by chance a result at least
as extreme as that observed, even when the null hypothesis is true and no real difference exists; when
P
is
<
0.05, the sample results are usually deemed significant at a statistically important level and the null
hypothesis is rejected. See also Type I
ERROR
.
Paradigm
is a distinct set of concepts or thought patterns, including theories, research methods, postulates
and standards for what constitutes legitimate contributions to field. The word paradigm comes from the
Greek “paradeigma” which means, “pattern, example, sample” and the Greek verb “paradeiknumi” which
means, “exhibit, represent, expose”. The root is from “para” which means, “beside, beyond” and
“deiknumi” which means, “to show, to point out”.
Passive Participation modality
is a treatment modality in which the individual does not engage in the
treatment. The patient has treatment protocol performed on them or medication prescribed to them.
Examples of passive participation modalities include surgery, acupuncture, and prescriptions.
Pathogenesis
is the biological mechanism that leads to the disease states.
Patient (or person)-centered care
is care that is respectful of and responsive to individual patient (or
person) preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Phytomedicine
refers to the herbal-based traditional medical practices that use various plant materials in
modalities considered both preventive and therapeutic.
Point Zero
is an auricular acupuncture point situated at the junction of the conchal ridge
and the root of the ascending helix of the ear. Functionally, point zero was initially thought
as the reference point for auricular point electro-detection
i.e. it serves to “zero” or set the
sensitivity of auricular electro-diagnostic
devices. However, it is much more than that. It is
one of the most recognized auricular points and used in the treatment of many ailments.
Point zero is known to have powerful influence in the treatment of various conditions to
include pain, sedation, addiction and and inflammation although it is not associated with
any specific organ of the body.
Zero Point A Critical Assessment through Advanced Auricular Therapy.
Frank B, Soliman N.
Post-Traumatic Stress Disorder (PTSD)
is a mental illness that can develop after an individual is
exposed to one or more traumatic events or other threats on a person’s life. Symptoms include disturbing
recurring flashbacks, avoidance behaviors, hyperarousal and a sense of numbness.
Prana
is a Hindu word meaning “breath,” considered as a life-giving
force.
20
2020
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0035.png
NATO UNCLASSIFIED
Pranic healing
is an ancient science and art of healing that utilizes prana (or chi/qi/ki) or life energy and
energy centers to heal diseased energy levels.
Prophetic Medicine
describes the Arabic medicine as practiced within the Islamic system of ethnics. It
was to be true medical knowledge derived from the revelations of the Prophet, Muhammad.
PROPresence
is a German mindfulness-training program, which was designed for the rehabilitation of
deployment related stress in German Military personnel. On one part this 3-week mindfulness-training
program is based upon traditional Buddhist meditation techniques such as sitting meditation, walking
meditation, the body scan and on the other part on exercises for the integration of the left and right
hemisphere of the brain.
Proteomics
is the large-scale study of proteins, particularly their structures and functions. Proteins are
vital parts of living organisms, as they are the main components of the physiological metabolic pathways
of cells. The term proteomics was first coined in 1997 to make an analogy with genomics, the study of the
genome.
Randomized Controlled Trial (RCT)
is a type of scientific experiment, which included randomization to
one or other treatment groups to include a “control group”. The control group is the treatment group of
the study that does not received the treatment being investigated. RCT are often considered the “gold
standard” of medical research; however, the RCT is not always applicable or achievable.
Rhazes (Muhammad ibn Zakariya al-Razi) (845 – 925 AD)
was a Persian Philosopher, Physician,
Mathematician, alchemist and chemist. He
made fundamental contributions to various fields of science to
include medicine. He is considered to be the father of pediatrics and a pioneer of ophthalmology.
Rituals
are enactments based on cultural belief and values. Rituals can be social, military, religious, or
spiritual. Traditions of a community prescribe the sequence of activities, which can involve gestures,
words and objects often performed in a sequestered place and in a set sequence.
Qi
is the basic concept of Chinese medical theory. Translated as air, gas, vapor, smell, force; pronounced
“chee” as in “cheese,” transcribed in Wade-Giles
as
ch’i,
and sometimes written as “ki” and pronounced
as the English “key” in the Japanese tradition. Qi
is the alleged energy that circulates through a network of
meridians and acupuncture points that have been described by the Chinese for over 5000 years but the
concept has not been confirmed by research.
Nigel Wiseman, Feng Ye; A Practical Dictionary of Chinese
Medicine, first edition, 1998; Paradigm Publications, Brookline, Massachusetts, USA.
Qigong:
a Chinese system of physical exercises and breathing control related to tai chi.
Quality of Life (QoL)
is the general well-being of individuals and societies. QoL has a wide range of
contexts, including the fields of international development, healthcare, politics and employment.
Reflexologists
work from maps of predefined pressure points that are located on the hands and feet. These
pressure points are reputed to connect directly through the nervous system and affect the bodily organs
and glands. The reflexologist manipulates the pressure points according to specific techniques of
reflexology therapy. By means of this touching therapy, any part of the body that is the source of pain,
illness, or potential debility can be strengthened through the application of pressure at the respective foot
or hand location.
Reflexology
Reflexology is a therapeutic method of relieving pain by stimulating predefined pressure
points on the feet and hands. This controlled pressure alleviates the source of the discomfort. In the
absence of any particular malady or abnormality, reflexology may be as effective for promoting good
21
2121
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0036.png
NATO UNCLASSIFIED
health and for preventing illness as it may be for relieving symptoms of stress, injury, and illness.
Reiki
is a healing technique based on the principle that the therapist can channel energy into the patient by
means of touch, non-touch or visualization, to activate the natural healing processes of the patient's body
and restore physical and emotional well-being.
Relaxation response
refers to one’s personal ability to make his/her body release chemicals and brain
signals that make one’s muscles and organs slow down and increases blood flow to the brain.
Religiosity
Religion is an institutional and culturally determined approach, which organizes the collective
experiences of people (faith) into a closed system of beliefs and practices (`form´). Often associated with
specific faith traditions (i.e., Christianity, Islam, Buddhism etc.) and their rituals, practices and
convictions.
Salutogenic approach
describes the approach, which focuses on factors that support human health and
well-being rather than on factors that cause disease. Aaron Antonovsky, a medical sociologist, coined the
term in 1979.
Salutogenesis
is the process of healing, recovery, and repair. The term was first used by Aaron
Antonovsky to contrast with pathogenesis.
Self-care
is any intentional actions that an individual takes to improve their physical, mental or emotional
health. Self-care techniques provide a source of
doing
by patients instead of
having something done
to
them.
Shen Men
is an auricular acupuncture point situated at the apex of the triangular fossa. It
means “Heavenly or Spirit Gate”. It is one of the most recognized auricular points and used
in most ailments. Neuropsychoemotionally, it is considered to alleviate apprehension, fear,
and anxiety and help regulate the sympathetic nervous system. It is used as acupuncture
point for it a tranquilizing effect. It is a functional point and not an anatomical point since it
is not associated with any organ or system.
Zero Point A Critical Assessment through
Advanced Auricular Therapy. Frank B, Soliman N.
Shaman
is an individual who enters an altered state of consciousness in order to acquire knowledge,
power and the ability to help others. Typically, shamans use drums to call upon spiritual allies. Shamans
are regarded as having the access to, and influence in, the world of good and evil spirits, especially among
societies of northern Asia and North America.
Shiatsu- massage therapy
is a form of Japanese bodywork based on the theoretical framework of
Traditional Chinese Medicine. The
shiatsu
means, "finger pressure". Shiatsu techniques include massages
with fingers, thumbs, and palms; assisted stretching; and joint manipulation and mobilization. To examine
a patient, a shiatsu practitioner uses palpation and, sometimes pulse diagnosis. Shiatsu derives from a
Japanese massage modality called anma which was itself adapted from tui-na. Tui-na is a Chinese
bodywork system that arrived in Japan by at least the Nara period (710–793
CE). Tokujiro Namikoshi
(1905–2000) founded a shiatsu college in the 1940’s, and is often credited with inventing modern shiatsu.
Spirituality
has multiple definitions. A basic definition is that spirituality is a complex and multi-
dimensional construct, and can be defined as an open and individual experiential approach in the search
for meaning and purpose in life (`content´). Spirituality can be found through religious engagement,
through an individual experience of the divine, and/or through a connection to others, environment and the
sacred.
22
2222
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0037.png
NATO UNCLASSIFIED
Stagnation
is reduced activity. In physiology it refers either to depressed qi dynamic (frustrated
physiological activity) or to flow stoppage due to congestion. The term also describes inhibition of normal
emotional activity, expressing itself in the form of oppression, frustration, and irascibility.
Nigel Wiseman,
Feng Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications,
Brookline, Massachusetts, USA.
Supplementation
is the use of
supplements
for a therapeutic benefit. Supplements are often described as
dietary/nutritional, performance enhancing or weight management. Supplements include herbals,
vitamins, minerals, amino acids, concentrate, metabolite, constituent or extract.
Syndrome
In Chinese medicine a syndrome or pattern is a manifestation of human sickness indicating the
nature, location, or cause of sickness. The concept of syndrome or pattern is distinct from that of disease
(as a specific kind of morbid condition). A disease may take the form of different patterns.
Nigel Wiseman,
Feng Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications,
Brookline, Massachusetts, USA.
Systems biology
is the computational and mathematical modeling of complex biological systems. An
emerging engineering approach applied to biomedical and biological scientific research, systems biology
is a biology-based inter-disciplinary field of study that focuses on complex interactions within biological
systems, using a holistic approach (holism instead of the more traditional reductionism) to biological and
biomedical research.
Systems thinking has roots in the General Systems Theory that was advanced by Ludwig von Bertalanffy
in the 1940’s and furthered by Ross Ashby in the 1950’s.
Jay Forrester and members of the Society further
developed the field for Organizational Learning at MIT, which culminated in the popular book The Fifth
Discipline by Peter Senge, which defined Systems thinking as the capstone for true organizational
learning.
Systems thinking
is the process of understanding how those things which may be regarded as systems
influence one another within a complete entity, or larger system. In nature, systems thinking examples
include ecosystems in which various elements such as air, water, movement, plants, and animals work
together to survive or perish. In organizations, systems consist of people, structures, and processes that
work together to make an organization "healthy" or "unhealthy".
T’ai chi
is a form of stylized, meditative exercise, characterized by methodically slow circular and
stretching movements and positions of bodily balance. Originally a Martial Art, it is mainly practiced
today as an excellent form of exercise with many health benefits.
Taekwondo
is an “empty-hand”
combat form
that entails the use of the whole body. Tae means "to Kick"
or "Smash with the feet," Kwon implies "punching" or "destroying with the hand or fist," and Do means
"way" or "method."
Thalamus
is an auricular acupuncture point situated on the anti-tragus. The
point is both anatomical (related to the thalamus of the brain) as well as
functional. The thalamus is located in the forebrain above the midbrain;
composed of four nuclei. The thalamus serves as the relay center between the
peripheral (body) and the cerebral cortex (brain) for the transmission of pain.
It also plays an important role in the sleep and wakefulness states.
Thoth
was an Egyptian god who was the inventor of art. His writings, part of the Hermetic Books, were
inscriptions on upon pillars of stone. Thoth is often depicted as a man with the head of an ibis or baboon.
Total Force Fitness (TFF)
is a framework for building and maintaining health, readiness and
23
2323
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0038.png
NATO UNCLASSIFIED
performance for the U.S. Department of Defense. The TFF program views health, wellness and resilience
as a holistic concept wherein optimal performance requires connections among mind, body, spirit and
family/social relationships
Traditional Chinese Medicine (TCM)
is a broad range of medical practices sharing common concepts
which have been developed in China and are based on a tradition of more than 2000 years, including
various forms of herbal medicine, acupuncture, massage, exercise and dietary therapy.
National Center for
Complementary and Integrative Health, USA.
Transcendental Meditation
is not considered to be an open-mind meditation, like mindfulness
meditation. The practice of TM is primarily based upon the use of mantras in a sitting position.
Traumatic Brain Injury (TBI)
is an injury to the brain by an external force. TBI are classified based on
severity (mild, moderate (mTBI), severe) or mechanism of injury (closed or penetrating trauma). The
symptoms and degree of resultant debilitation is related to the area of the brain injuries. Most common
symptoms of a TBI include headaches, memory difficulties and emotional disturbances. Mild TBI are
also known as a concussive event leading to a concussion.
Transcriptomics
The transcriptome is the set of all RNA molecules, including mRNA, rRNA, tRNA, and
other non-coding RNA transcribed in one cell or a population of cells. It differs from the exome in that it
includes only those RNA molecules found in a specified cell population, and usually includes the amount
or concentration of each RNA molecule in addition to the molecular identities.
Trauma
Any physical or emotional injury due to sudden or violent action, exposure to dangerous toxins
or profound shock
Unani
is the term for the Perso-Arabic traditional medicine as practiced in Mughal India and the Muslim
culture in South Asia and present day Central Asia. Unani is from the Arabic “Yunani” for “Greek”
because the system of medicine was based on the teachings
of the Greek Physicians Hippocrates and
Galen. Unani medicine is based on the classical four humours: Phlegm, Blood, Yellow Bile and Black
Bile.
United States Air Force Acupuncture and Integrative Medicine Center
is the only full time
acupuncture center in the United States Department of Defense. The mission is education, patient care and
research. It is located on Joint Base Andrews about 15 miles from Washington DC.
Vedas
are a large body of texts originating in India. The Vedas are considered to be revelations seen by
ancient sages after intense meditation. The Hindu attribute the Vedas to Brahma (Hindu creator god).
There are Vedas: Rigveda, Yajurveda, Samaveda and Atharvaveda with each subdivided into four major
text types. The text types include the Samhitas (mantras and benedictions), Aranyakas (rituals,
ceremonies, sacrifices and symbol-sacrifices), Brahmanas (rituals, ceremonies, sacrifices) and Upanishads
(meditation, philosophy, spiritual knowledge). The Upasanas are a fifth recognized text type, which
focuses on worship.
War-related, trauma spectrum response (wrTSR)
is the constellation of post-traumatic related
conditions induced by exposure to deployment and battle. Components of wrTSR include PTSD, TBI,
substance abuse, headaches, chronic pain as well as somatic, cognitive and emotional dysfunctions.
Watsu,
also known as Water-Shiatsu, is a therapeutic form of aquatic bodywork, which is performed in
warm water (35 °C). While supported by the Watsu-therapist the patient is being floated, stretched and
cradled in the water experiencing a mix of weightlessness, massage, muscle relaxation and joint-
mobilization.
24
2424
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0039.png
NATO UNCLASSIFIED
Western Medicine
is a collective group of medical practices also known as “conventional medicine.”
Western Medicine is based
on hypothetical deduction and divides health from disease. Whereas “Eastern
Medicine” adapts to the environment, Western medicine often changes the environment. The division of
“Eastern” and “Western” is an artificial constructed paradigm (see chapter
12).
Yang
is the bright, male, active principle that stands in complementary opposition to Yin.
Nigel Wiseman,
Feng Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm Publications,
Brookline, Massachusetts, USA.
Yoga
is a term derived from the Sanskrit word
yug,
which represented a theological practice believed to
lead to the unification of self with the Divine. Yoga is thought to date back to pre-Vedic
tradition. It was
considered to be given directly from God. The foundation is based on the suppression of all activities so
that one can identify and separate the self from the body, mind and will thus obtaining spiritual liberation.
The modern scientific study of yoga began in the West in the mid 1800’s. Currently, much of the West
considers yoga as a form of exercise.
Yin
is the dark, female, receptive principle that stands in complementary opposition to yang.
Nigel
Wiseman, Feng Ye; A Practical Dictionary of Chinese Medicine, first edition, 1998; Paradigm
Publications, Brookline, Massachusetts, USA.
25
2525
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0040.png
NATO UNCLASSIFIED
Terms of Reference
Origin
A. Background
The past twenty years have seen the increasing acceptance of complementary and
alternative medicine (CAM) or integrative medicine in the treatment or prevention of
an increasing number of conditions. Data show that more than 50% of the military
population, including dependents, has used CAM interventions in recent years, and
66% of active duty personnel use dietary supplements. Military personnel are
increasingly taking charge of their own health, without resorting to the usual military
medical services. More and more try to stay away from prescription or Over-The-
Counter (OTC) drugs because of the side effects, and for many, this self
empowerment is shown by their increasing use of natural products, or non-drug
therapies such as acupuncture, homeopathy, magnets, laser stimulation, yoga, mind-
body interventions„ etc.
Integrative medicine is used, either by prescription, or more frequently without
medical supervision, to increase stamina, performance and operational capacity, to
alleviate chronic pain without side effects, or to help personnel coping with PTSD
or mild TBI outcomes. For the military leadership and the health care
professionals in charge of this specific population, it is critical to acquire a better
knowledge on these integrative or CAM interventions, and the potential impact of
the use of these modalities on military medical preparedness. As increasingly
medical care within the NATO environment is carried out in a multinational
setting, it is crucial that medical personnel of each nation understand the
integrative modalities which may have been used by their patients from other
nations, and which in some cases the patients will expect to be provided for them
in the NATO environment, as they are at home (in accordance with MC 326/2 and
AJP-4.10 (A)).
B. Justification (Relevance for NATO)
The past twenty years have seen the increasing acceptance of complementary and
alternative medicine (CAM) or integrative medicine in the treatment or prevention of
an increasing number of conditions. Data show that more than 50% of the military
population, including dependents, has used CAM interventions in recent years, and
66% of active duty personnel use dietary supplements. Military personnel are
increasingly taking charge of their own health, without resorting to the usual military
medical services. More and more try to stay away from prescription or Over-The-
Counter (OTC) drugs because of the side effects, and for many, this self
empowerment is shown by their increasing use of natural products, or non-drug
therapies such as acupuncture, homeopathy, magnets, laser stimulation, yoga, mind-
body interventions„ etc.
II. Objectives
A.
The objectives of this RTG are:
i. Identify and evaluate countries' data on the use of CAM among military
personnel.
ii. Determine how personnel in each country access CAM interventions
(directly or by prescription), and with what frequency.
iii. Assess how important, accepted, and regulated is the use of CAM in the
26
2626
RTO-TR-HFM-195
I.
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0041.png
NATO UNCLASSIFIED
therapeutic arsenal
iv. Share all available research on the indications and effects of any type of
CAM interventions, as well as any possible adverse effects on military
readiness.
III.
Resources
A. Membership
Lead Nation: US
Participating Nations:
FRA, GER, HUN, ITA, NLD and USA
Chairman:
COL Richard P Petri, Jr., MD, United States
Nations Willing/Invited to Participate: Canada, Czech Republic, France,
Germany, Greece, Netherlands, Norway, United Kingdom, and United States
B.
National And/or NATO Resources Needed:
Meeting facilities
C.
RTA resources needed
The
first meeting could take place at RTA/HQ in Paris to benefit from the RTA
staff expertise on site
IV. Security Classification Level
The security level will be Unclassified/Unlimited
V. Participation By Partner Nations
All PIP, MD and preferred Contact countries are invited.
PIP Nations: all PM
invited
MD Nations: all MD invited
Contact Nations: Australia, Japan, New Zealand
VI.
Liaison
Liaison to COMEDS to be considered.
27
2727
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0042.png
NATO UNCLASSIFIED
Acknowledgements
Arndt Büssing, MD
The author acknowledges Drs. Peter Mees, Christiane Reitz and Gesine Krüger for their support of the data
analysis on German Soldiers’ needs.
COL Richard P Petri, Jr., MC
The author acknowlegdes the current leadership (COL Cox and Smyrski) at William Beaumont Army
Medical Center for allowing me the opportunity to participate in the NATO Task Force.
A sincere debt of
gratitute must be given to COL (Ret) Jean-Louis
Belard, MD, PhD and COL (Ret) Karl Friedl, PhD
for their
vision and determination for this Task Force. I am humbled by the confidence that COL Belard had in me to
lead the Task Force when he retired. I hope that I fulfilled his expectations of, and goals for, the Task Force.
Finally,
I wish to acknowledge my parents, Dick and Ann Marie (Unser) Petri for instilling the virtues of
compassion, determination and integrity. These principles have guided me throughout my life and have
allowed me to have the successes I have achieved.
Fred Zimmermann, MA
The author acknowledges the Samueli Institute and the Dr. Becker Clinic Moehnesee, Germany for
funding the evaluation of the PROPresence mindfulness-training program.
Further, the author
expresses
special thanks to Prof. Niko Kohls, PhD and Sabine Schoenfeld, PhD for sharing their valuable expertise
at the NATO meeting in Cologne.
28
2828
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0043.png
NATO UNCLASSIFIED
HFM -195 Membership
CHAIRMAN:
Richard P PETRI, Jr., MD, FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone: +1 (915) 892-7987
Phone: +1 (915) 342-2088
Fax:
+1 (915) 742-1536
[email protected]
J-Louis BELARD, MD, PhD
COL (Ret)
French Medical Corps
Former Chairman, NATO HFM-195 Task Force, Mar 2010
– Sept 2014
Integrative Medicine Interventions for Military Personnel
Contractor Henry Jackson Foundation
Research Advisor, Defense & Veterans Brain Injury Center
11300 Rockville Pike, Suite 1100 Rockville MD 20852
USA
Phone: +1 (240) 821-9333
[email protected]
MEMBERS
FRANCE
Dr. Laurent BEZIN, PhD
Scientific Director of the Institute for Epilepsy
–
Institut Des ÉpilepsiEs “IDÉE”
Head of the Translational & Integrative Group in Epilepsy Research “TIGER”
Head of the ENVironmental enrichment & EPIgenetics program “ENV’EPI”
Lyon Neuroscience Research Center “CRNL”
National Center for Scientific Research “CNRS”
French Institute of Health and Medical Research “INSERM”
University Claude Bernard Lyon 1 “UCBL1”
59 Boulevard Pinel – 69677 Bron
[email protected]
Nathalie BABOURAJ, MD
CPT (Ret) French Army
Intervention Medical Officer
Paris Military Fire Department
29
2929
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0044.png
NATO UNCLASSIFIED
Founder of Institu de Santé Intégrative
Paris
Phone: 0033614572686
[email protected]
Raphael NOGIER, MD
Senior Lecturer in Auriculotherapy
Lyon Medical Studies Association
Phone:
+33 (0)4
78 25 69 69
[email protected]
Marion TROUSSELARD, MD
COL, French Army
Head Neurophysiology of Emotions
Army Biomedical Research Institute IRBA
La Tronche
FRANCE
Phone:
+33 (0)1 78 65 12 55
Fax: +33 (0)1 69 23 72 20
[email protected]
GERMANY
Arndt BÜSSING, MD
Professor Quality of Life, Spirituality and Coping
Institute of Integrative Medicine
Witten/Herdecke University
Gerhard-Kienle-Weg 4
58313 Herdecke
Phone: +49
(0)2330 623810
Fax: +49 (0)2330 623810
[email protected]
Fred ZIMMERMAN, M.A
Captain (CPT), Reserve Officer
PhD Candidate at
GRP - Generation Research Program
Human Science Center
University of Munich (LMU)
Prof.-Max-Lange-Platz 11
83646 Bad Toelz, Germany
Samueli-Theophrastus-Fellow
Brain, Mind & Healing Program
Samueli Institute
1737 King Street, Suite 600
Alexandria, VA 22314, USA
Phone:
+49 (0)8041-44
901 00
Fax: +49
(0)8041-44 900 99
[email protected]
30
3030
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0045.png
NATO UNCLASSIFIED
HUNGARY
Gabriella HEGYI, MD, PhD, MSc
Professor of CAM and Dietary Department
Pécs University Medical School
Health Science Facility
TCM Confucius Institute at Pécs University
Leader of Professional, Strategy and Development
Pécs, 7621. Vörösmarty u4.
Head of Yamamoto Institute
Budapest Training Field
1196 Budapest, Petőfi u.79
Phone: 00 36 309225347
Fax: 00 36 12813035
[email protected]
ITALY
Paolo ROBERTI di SARSINA, MD
Observatory and Methods for Health
University of Milano-Biocca
Milano, Italy
Charity for Person Centered Medicine
Moral Entity
Bologna, Italy
Expert for Non-Conventional
Medicine (2006-2013)
High Council of Health
Ministry of Health
Phone: 00 39 3358029638
[email protected]
[email protected]
THE NETHERLANDS
Jan van der GREEF, PhD
Principal Scientist
Netherlands Organisation for Applied Scientific Research (TNO)
Earth, Life and Social Sciences
Utrechtseweg 48, 3704 HE Zeist
Phone: +31-88-8665085
[email protected]
UNITED STATES
Karl FRIEDL, PhD
COL U.S. Army (Ret)
United State Army
Professor (Adjunct), Department of Neurology
31
3131
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0046.png
NATO UNCLASSIFIED
University of California-San
Francisco
Phone +001 (301) 473-2917
[email protected]
Wayne B. JONAS, MD, FAAFP
President and Chief Executive Officer
Samueli Institute
Alexandria, Virginia
Phone +1 (703) 299-4800
Fax +1 (703) 535-6752
[email protected]
Richard C. NIEMTZOW, MD, PhD, MPH
COL (ret) USAF, MC, FS
United States Air Force Acupuncture and Integrative Medicine Center
Director
Malcolm Grow Medical Clinic and Surgery Center
79
th
Medical Group
1050 West Perimeter Road
Joint Base Andrews, Maryland 20762
Phone: +1 (619) 647-7274
[email protected]
32
3232
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0047.png
NATO UNCLASSIFIED
Keywords
Integrative Medicine
Integrative Health and Healing
Complementary and Alternative Medicine
Historical and Cultural Perspectives
CAMbrella
Legistration
Self Care
Patient-Centered Care
Acupuncture
Battlefield Acupuncture
Meditation
Mindfulness
Spirituality
Religiosity
Energy healing Techniques
Enpowerment
Auriculotherapy
Mind-body
Coping
Trauma Spectrum Response
Salutogenesis
Military
Systems Biology
Ayurveda
Watsu
Abstract
The health of a force is crucial to its Military readiness. Decreasing Military budgets, global economic
stagnation, and increasing medical health care cost threaten the sustainability of Military health care systems.
Furthermore,
these conditions risk both the individual’s as well as the organization’s collective health status
significantly. Therefore, current health care systems must adapt.
Over the past four decades, there has been a grassroots utilization of complementary and alternative medicine
(CAM) by societies to include the Militaries. However,
there is little oversight or guidance with the
utilization and implementation of CAM worldwide. Although, collaborative efforts in clinical practices,
education and research would have significant impact in reducing duplicity of efforts, expanding the
knowledge base of experiences as well as broadening the historical and cultural and perspectives of health
care systems.
The objective of the North Atlantic Treaty
Organization’s Task Force Human Factors and Medicine (HFM)-
195 (NATO TR HFM-195)
is to identify and evaluate the various countries’ data on the utilization of CAM
among Military personnel, learn about the acceptability of CAM by the leadership of Military organizations,
and review briefly the current regulatory and legal status of CAM utilization and its implementation. This Task
Force was set up as an exploratory committee in a first step for further Task Forces, conferences, and symposia
that could focus on NATO-wide implementation of selected CAM modalities with on-going analysis of
efficacy, cost-effectiveness, suitability, and acceptability. This could ultimately improve health care systems
and increase available treatment options for patients.
33
3333
RTO-TR-HFM-195
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0048.png
NATO UNCLASSIFIED
INTEGRATIVE MEDICINE INTERVENTIONS
FOR MILITARY PERSONNEL
Executive Summary
The health of a force is crucial to its Military readiness. Decreasing Military budgets, global economic
stagnation, and increasing medical health care cost threaten the sustainability of Military health care systems.
Furthermore, these conditions risk both the individual’s as well as the organization’s collective health status
significantly. Therefore, current health care systems must adapt.
Over the past four decades, there has been a grassroots utilization of complementary and alternative medicine
(CAM) by societies. Dissatisfaction with current systems and medication side effects, as well as preferences
for “natural treatments”and modalities that align with personal beliefs and values are reasons why patients are
seeking CAM. Military personnel are utilizing CAM at the same or higher rate than their civilian counterparts.
Prayer/faith, herbals and supplements, acupuncture, and meditation are some of the more frequently used
modalities.
The objective of the North Atlantic Treaty Organization’s Task Force Human Factors and Medicine (HFM)-
195 (NATO TR HFM-195) is to identify and evaluate the various countries’ data on the utilization (rationale,
frequency, accessibility) of CAM among Military personnel, learn about the acceptability of CAM by the
leadership of Military organizations, and review briefly the current regulatory and legal status of CAM
utilization and its implementation. This Task Force was set up as an exploratory committee in a first step for
further Task Forces, conferences, and symposia that could focus on NATO-wide implementation of selected
CAM modalities (e.g., acupuncture, meditation/mindfulness programs, movement/yoga), with ongoing analysis
of efficacy, cost-effectiveness, suitability, and acceptability. Furthermore, acceptable terminology, regulatory
policies, and educational literature need to be developed. Cross-cultural initiatives and research projects are
paramount to expanding perspectives and understanding. This could ultimately improve health care systems
and increase available treatment options for patients
The highlights of the Task Force report are published in this NATO report. Historical and cultural
perspectives of several medical systems are briefly reviewed to understand “what’s old may be new again.”
Health care was evaluated from the point of view of individual treatment modalities (acupuncture/Battlefield
Acupuncture BFA, meditation/mindful-ness, biofeedback, spirituality, etc.), whole medical health care
systems (Traditional Chinese Medicine, Ayurveda, Tibetan medicine), and new proposed paradigms
(integrative health and healing, systems biologic approach, trauma spectrum disorder). Available studies on
current CAM utilization and treatment programs were presented.
The overall recommendation of the Task Force was to have continued review and evaluation of Integrative Health
and Healing with specific attention to implementation of selected practices; education of patients, providers, and
policy makers; analysis of clinical outcomes and best practices; and establishment of collaborative research
endeavors focused on cost-effectiveness, new paradigms, and models of care.
ES-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0049.png
NATO UNCLASSIFIED
INTERVENTIONS DE LA MÉDECINE
INTÉGRATIVE POUR LE PERSONNEL
MILITAIRE
Synthèse
La santé de la force est essentielle à son état de préparation militaire. En diminuant les budgets militaires,
la stagnation économique mondial, et l'augmentation des coûts de soins de santé médical menacent la
durabilité des systèmes de soins de santé militaire. En outre, ces conditions risque tant l'individu ainsi que
de l'organisation collective du statut de santé de façon significative. Par conséquent, les systèmes de soins
de santé actuel doit s'adapter.
Au cours des quatre dernières décennies, il y a eu un taux d'utilisation de la base de la médecine
complémentaire et parallèle (MCP) par les sociétés. L'insatisfaction avec les systèmes et les effets
secondaires des médicaments, ainsi que les préférences de "traitements naturels"et les modalités qui
s'alignent avec les convictions et les valeurs personnelles sont des raisons pour lesquelles les patients
recherchent la came. Les militaires utilisent la came en même vitesse ou plus rapidement que leurs
homologues civils. Prière/foi, herbals et suppléments, l'acupuncture, et la méditation sont certaines des
modalités les plus fréquemment utilisés.
L'objectif de l'Organisation du Traité de l'Atlantique Nord's Task Force Facteurs humains et médecine
(HFM)-195 (OTAN TR HFM-195) est de déterminer et d'évaluer les différents pays, les données sur
l'utilisation (justification, la fréquence, l'accessibilité) de CAM parmi le personnel militaire, se renseigner
sur l'acceptabilité de la came par le leadership des organisations militaires, et passer brièvement en revue
la situation actuelle de la réglementation et le statut juridique de l'utilisation de cames et sa mise en
oeuvre. Cette Task Force a été créée comme un comité exploratoire dans une première étape pour plus
d'équipes spéciales, de conférences et de symposiums qui pourraient se concentrer sur la mise en oeuvre à
l'échelle de l'OTAN de modalités de came sélectionné (par exemple, l'acupuncture, la
méditation/mindfulness programmes, mouvement/yoga), avec une analyse continue de l'efficacité, le
rapport coût-efficacité, poursuite, et l'incapacité de l'acceptabilité. En outre, la terminologie acceptable, les
politiques de réglementation et des documents éducatifs doivent être développées. Cross-cultural
initiatives et projets de recherche sont d'une importance capitale pour élargir ses perspectives et de
compréhension. Cela pourrait en fin de compte améliorer les systèmes de soins de santé et augmenter les
options de traitement disponibles pour les patients
Les points saillants du rapport de la Task Force sont publiés dans ce rapport de l'OTAN. Perspectives
historiques et culturels de plusieurs systèmes médicaux sont brièvement examinées pour comprendre
"Quoi de vieux peuvent être encore nouveau. " Les soins de santé a été évaluée du point de vue des
modalités du traitement individuel (acupuncture/champ de bataille l'Acupuncture BFA,
méditation/mindfulness, le biofeedback, spiritualité, etc.), les systèmes de soins de santé médical entiers
(médecine traditionnelle chinoise, Ayurveda, la médecine tibétaine), et de nouveaux paradigmes proposés
(Integrative health and healing, approche biologique de systèmes, les traumatismes spectrum disorder).
Les études disponibles sur les programmes de traitement et de l'utilisation de came ont été présentés.
La recommandation d'ensemble de l'Équipe spéciale était d'avoir poursuivi l'examen et l'évaluation des
intégratif de santé et guérison avec une attention particulière à la mise en oeuvre des pratiques retenues;
ES-2
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0050.png
NATO UNCLASSIFIED
éducation des patients, fournisseurs de services et les décideurs; analyse des résultats cliniques et des
meilleures pratiques; et l'établissement d'initiatives de recherche en collaboration axée sur le rapport coût-
efficacité, de nouveaux paradigmes, et modèles de soins.
ES-3
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0051.png
UNCLASSIFIED
Chapter 1– INTEGRATIVE HEALTH AND HEALING AS THE NEW
HEALTH CARE PARADIGM FOR THE MILITARY
Richard P. Petri, Jr., M.D., FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
ABSTRACT
The Field of Integrative Health & Healing is emerging out of the dark recesses of “voodoo” stereotypes and
into the light as a new and much needed healthcare paradigm. It is a philosophy of health seeking to restore
the patient as the preeminent player in the game of health management, disease prevention, and injury
recovery. Integrative Health & Healing is a return to the “self” emphasizing patient responsibility for their
health and cooperative partnerships with qualified and competent healthcare providers. It includes a holistic
approach merging allopathic medicine with complementary. This article will explore the historical origins of
integrative medicine and investigate the future role of complementary alternative medicine within military
systems.
KEYWORDS
Integrative medicine, complementary and alternative, paradigm, integrative health and healing, Department of
Defense, initiative
1.1 INTRODUCTION
A consensus is building that our current healthcare system is unsustainable and ineffective.
Therefore, new paradigms need to be explored. This article proposes the path to the new frontier of
medicine and role of healthcare providers in the delivery of health and healing for the military forces.
It is a journey into the unknown. But is it really into the unknown? This is a challenge to think
differently, to think globally both in the context of the global world, but also in the context of a
STO-RTG-TR-HFM-195
1-1
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0052.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
holistic, multidimensional approach towards health and healing. The time has come to take the
concept of “out of the box thinking” and implement it into practices and programs that will
empower, enrich and energize both the practitioners and their clients.
1.2 OPERATIONAL DEFINITION OF COMPLEMENTARY AND ALTERNATIVE
MEDICINE
Complementary and Alternative Medicine, also known as CAM, has existed over the past 4,000 years. Our
ancient forefathers told us to eat a root for our illnesses. Yarrow and Mallow were some of the earliest recorded
roots used (Figure 1-1).
Figure 1-1: Plant form: Achillea millefolium. Permission given. © Arthur Haines, Delta Institute of
Natural History.
https://gobotany.newenglandwild.org/species/achillea/millefolium/
Retrieved 9
September 2015.
Approximately 1000 AD roots were considered to be heathen, and were replaced with prayer. 800 years later,
the prayer was deemed superstitious; therefore a potion was given. During the 20
th
century, the potion was
eventually dubbed snake oil while the pharmaceutical companies refined it into a pill and sold it for every
ailment. Hence, medications ruled as “wonder drugs.” Today, it is being realized that these wonder drugs are
synthetic, and that roots contain important medicinal properties essential for health. So the public is told to eat
the root. It is amazing how the cycle has ended where it started 4,000 years ago [1].
Over the past 60 years, in the pursuit of happiness, society has become a passive pill popping one. In fact, a pill
is expected, no demanded, for everything. But recently, there has been a rediscovering of the innate powers of
healing. No longer is there a need to entrust our health to the pharmaceutical industry, an industry that has
largely contributed to passive participation in personal healthcare. One company after another pushes the "magic
pill" for everything that society does not want to experience: pain, sadness, overweight. It is said that the pill
will transform us into incredibility good-looking people without us having to do anything. Comedian Ellen
DeGeneres pointed out that “we have become so lazy that we don't even have to swallow the pills because they
now dissolve on our tongues” [11]. At what point will society recognize that citizens are no longer participating
in their own health, their own well-being and in their own lives?
The National Center for Complementary and Integrative Health (NCCIH), formally known as the National
1-2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0053.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Center for Complementary and Alternative Medicine (NCCAM) once defined CAM as a “group of diverse
medical and healthcare practices that are not generally considered to be part of conventional medical.” [21] CAM
is everything outside what is typically defined as Western Medicine. At times these boundaries can be blurred
and somewhat contentious.
By breaking down the words, the concept of CAM can be better understood. Complementary refers to the use of
CAM modalities with conventional medicine. The treatments complement or augment “Western Medicine”.
Alternative refers to the use of CAM modalities instead of conventional medicine. This is an “instead of”
approach which limits good practices. A new term has since been developed when referring to CAM; that is the
term, Integrative Medicine (IM). Integrative medicine uses those CAM modalities, which have some evidence of
safety and effectiveness, in combination with conventional medicine. [21] Let’s take it one step further. It is
proposed, to replace the word "medicine" in Integrative Medicine with “Health and Healing” for the new term,
Integrative Health and Healing (IH
2
). Using the word “medicine” often leads many to believe that healthcare is
still embedded in the pharmaceutical solutions to disease. Besides, shouldn’t the goal of providers be to assist
patients to
Heal
in the process of obtaining
Health?
1.3 INTEGRATIVE HEALTH AND HEALING
One of the core principles of the Integrative Health and Healing model is patient-centered care. Integrative
Health and Healing places a shared responsibility for health and healing onto the shoulders of both the patient
and provider with the patient taking the lead role. This partnership centers on the patient, which is quite different
from the current disease centered model. The patient-centered model allows for individualized treatments based
on the goals and needs of the patient. The patient is the driving force of the healthcare system not the disease.
As we review IH
2
two fundamental questions emerge. One, why is it important and two, what are some of its
pitfalls?
So why is it important to consider Integrative Health and Healing model for our healthcare system? In answering
that question, the real question becomes, what are the potential problems with the implementation of this model
into our healthcare system? First, companies will claim just about anything today under the CAM label. There
is huge profit in it. Who doesn't want to say goodbye to illness. Marketing strategies lead many to believe that
illness isn't natural, old age isn’t natural, but most importantly, drugs are not natural but herbals are. Baby
boomers are being sold the much sought after “fountain of youth” and “disease free lives.” What more could be
ask for? If only Ponce de Leon knew it was that simple to find the fountain of youth. Did you know our friend
the shark can cure our bone pain and a tree can improve our memory and concentration? (Figure 1-2)
STO-RTG-TR-HFM-195
1- 3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0054.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Figure 1-2: Lemon Sharks © thediver123 Permission give. License for use purchased.
http://depositphotos.com/portfolio-1009393.html?qview=3121339.
Image ID 1009393
More impressively company advertise that besides curing nearly everything, CAM can put a person into a
whole different state. So with 100% cures, the fountain of youth, amazing looks, trim bodies and euphoric lives,
CAM offers a lot. But the same claims have been made with conventional medicine. A newspaper ad tells the
story of a British tot whose life was saved by Superglue [9]. Yes, Superglue, the stuff that glues your fingers
together for life. The Superglue was placed into the brain to "plug" the flow of blood into the skull (Figure 1-3).
Sounds very scientific and evidence based doesn't it?
1-4
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0055.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Figure 1-3: “Super Glue” Plugs Holes in Toddler’s Brain. Radiograph of superglue used for Galen
malformation. Permission Given. Dr Alejandro Berenstein. Chair, Institute of Neurology &
Neurosurgery, Mount Sinai St Luke’s-Roosevelt Hospital, New York City, NY.
http://healthmad.com/medicine/doctor-plugs-babys-brain-with-glue/
Retrieved 10 September 2015.
In fact, some CAM advertising suggests that all of CAM is “natural.” For something to be truly natural it must
be integrated with the basics of self-care and responsibility. There must be an attunement to the whole instead of
a separation into parts. It is the synergy of the parts that creates a new state unobtainable from just one part. It is
like the difference between the sound of a musical instrument and the sound of an orchestra.
1.4 LOSING THE DOCTOR-PATIENT RELATIONSHIP
Today, medicine has become a science of ordering tests to diagnose disease. Conventional Medicine is not
meeting patients’ needs. It is becoming a significant cost to society. Healthcare costs are over 17% of the GNP
in the United States and expected to rise to nearly 20% by 2024 [7]. Additionally, death due to iatrogenic causes
is the third leading cause of death in the United States with nearly 50% of the drug errors and adverse reactions
preventable [30], [19], [23], [18].
The field of medicine is evolving because of the patient's demands. It seems that providers are losing the healer’s
art and the patients are letting them know. Some hospitals across the United States have begun to use algorithms
to substitute for clinical decision-making. At times treatment decisions are based on a MRI or lab value without
a clinical examination of the patient, which can be detrimental to a patient. The doctor patient relationship is
being lost, a relationship that has been shown to be a critical component of healing. Patients want to be treated
as a person not as a lab test or disease. So many patients look outside of conventional medicine. Many patients
see CAM as natural, safer and more personal. This is a problem. So the medical community must engage the
process.
The need to investigate integrative health and healing can be understood by looking at the current prevalence
data. According to the National Health Statistics Report, 2002, up to 62% of patients in the USA used CAM
treatments in the preceding 12-months [2]. Additionally, patients spend a staggering $34 billion dollars per year
STO-RTG-TR-HFM-195
1- 5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0056.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
on CAM with an estimated 354 million visits to CAM providers [20]. Further, more patients go to CAM
practitioners than to their primary care providers [13]. Why are these trends occurring? Patients are tired of
depersonalized treatment. The increase in CAM also stems from the explosion of herbal preparations that
manufacturers advertise as effective for nearly every condition. This is troublesome. The medical field has a
responsibility to ensure that patients are choosing safe and effective treatment options through proper evaluation
and research. There is a duty to study IH
2
therapies to ensure effectiveness, safety and a cost benefit for patients.
Collaborative partnerships are needed to develop the new model of healthcare.
1.5 THE PUSH FOR THE NEW PARADIGM
Scientists and government health officials are starting to understand why IH
2
needs to be studied. The Office of
Alternative Medicine (OAM) at the National Institute of Health (NIH) was started in 1993. The very first large,
multi-centered trial of CAM therapy was on the effects of St. John’s Wort (Hypericum
perforatum)
for
depression. It was a $4 million project lead by Dr Jonathan R.T. Davidson, M.D. at Duke University Medical
Center in partnership with 12 academic facilities. The outcome showed that neither the botanical nor sertraline
were significantly different than placebo [17]. This was the start. Since then, OAM now known as National
Center for Complementary and Integrative Health (NCCIH) has increased its annual research budget from
approximately $1 million dollars in 1993 to over $123 million in 2014 [22]. The response of science has been
impressive. The number of PubMed citations in CAM has significantly increased over the years at a rate of
approximately 25% per year. In response, PubMed (
http://www.ncbi.nlm.nih.gov/pubmed
) developed a
separate category specifically for CAM.
Our medical education is being adapted to meet the needs of our future providers. In 1999, Jon Kabat-Zinn, PhD
developed the concept of the Consortium of Academic Health Centers for Integrative Medicine [8]. Today, 60
institutions are part of the consortium working towards advancing medical school curricula, establishing
standards for integrative medicine research, and integrating alternative treatments into clinical care.
1.6 WHAT IS TRULY EVIDENCE-BASED?
There is a struggle within today’s healthcare over what is an acceptable “alternative” treatment. But what is that
acceptance based on? Is it the assumed understanding that conventional medicine is “evidence-based?” But is
conventional medicine always evidence-based? In 2009 within the field of CAM, most of the publication types
were either Reviews (23%) or Clinical Trials (20%). Clearly, this is not solid evidence for the acceptance of
CAM. When it comes to the gold standard of the Randomized Controlled Trial (RCT), there were only 13% of
the publications listed as RCTs. Compared to conventional medicine, when the PubMed key word is “research”,
there are only 3% of the nearly 450,000 citations listed as RCTs. Not such a good story either. So scientists and
researchers have a long way to go with both CAM and conventional medicine research. Therefore, instead of
conventional vs. CAM, it is proposed that it should be
proven vs. unproven
practices. Isn’t that what is really
expected? Finally, the need for rigorous evidence-based research for the implementation of a treatment needs to
be tempered by the degree of invasiveness and potential harm from that treatment. A simple meditative
breathing technique shouldn’t require the same level of evidence as that needed for cardiac shent placement.
The breathing technique results in little to no harm to patients. Therefore practitioners can use it at the same
time research is conducted. In this case, practitioner’s observations can support effectiveness while efficacy can
be rigorously studied. Dr Andrew Weil, M.D. refers to this as the “sliding scale of evidence” [31].
No conversation of non-scientifically based treatments would be complete without a discussion regarding the
practice of “off label prescriptions”. Nearly 75% of pediatric medications are prescribed off-label. This leads
1-6
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0057.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
you to wonder if our children are not guinea pigs for prescriptions. The
Archives of Internal Medicine
reported
that overall 73% of off-label use has little or no scientific support [27]. Therefore, should conventional medicine
be blindly accepted as the standard practice because it is assumed to be grounded in evidence-based research?
Clearly most of it isn’t. Shouldn’t the practice of “off label prescriptions” be considered as a CAM treatment
because the practice is not the standard? Therefore, should all “indicated use prescriptions” be considered
conventional medicine? Don’t both need to follow rigorous scientific approaches for best practices? Perhaps
what is being witnessed is a double standard of the expectation that CAM modalities must be evidenced-based,
when in reality most conventional treatments are not. Thus, again, research has some work to do with respect to
translating evidence-based research and implementation into clinical practice.
1.7 INTEGRATIVE HEALTH AND HEALING IN THE FEDERAL HEALTHCARE
SYSTEM
In 2014, several high level United States Federal Healthcare offices have included IH
2
modalities into their
systems. In 2010, The Army Surgeon General released the recommendations of the Task Force on Pain
Management. The overall focus of the report was to provide a holistic, multi-disciplinary and multimodal
approach to pain management with the goal of optimal quality of life (QoL) for patients with pain. The medical
model proposed emphasizes the patient-centered model instead of the disease model in which the patients are
active, not passive participants in their care. The use of Integrative Medicine (IM) modalities such as
Acupuncture, Yoga, Manual Manipulation, Medical Massage, Biofeedback and Mind-Body Therapies were
recommended for Tier 1 implementation status. The tiered structure represented a hierarchy of implementation
based on current accepted literature supporting efficacy, safety, and widespread use or acceptability [24].
There are other initiatives underway within the U.S. Federal Healthcare System for the inclusion of IH
2
modalities. New agencies have been developed to specifically look at IH
2
modalities as possible treatments to
improve delivery of healthcare as well as the health and well-being of our patients. The National Intrepid
Center of Excellence (NICoE) in Bethesda, Maryland in partnership with The Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury (DCoE) opened a holistic integrative center for the treatment
of Traumatic Brain injured warriors. Another key initiative at The US Army Telemedicine and Advanced
Technology Research Center (TATRC) is the development of an Integrative Medicine service that focuses on
optimal healing environments, advanced pain management and resilience. The U.S. Veteran Administration
(VA) is working on the implementation of the White House Commission for Complementary and Alternative
Medicine Policy recommendations. Finally, the U.S. DoD is working with NATO on the first Integrative
Medicine Task Force (TF HFM-195).
So how do military patients compare to their civilian counterparts regarding CAM? Actually there isn’t much
difference. Low Back Pain (LBP) is the most common reason for the use of IH
2
for both [29]. Additionally, both
populations use a significant amount of herbals and supplements in self-care. The military population tends to
use a higher percentage as performance enhancers and weight loss products. Service Members (SM) are seeking
out performance enhancements to meet the demanding needs of the military; they are looking for the optimal
edge. The 2005 U.S. DoD Survey of Health Related Behaviors among military personnel showed up to 63% of
Active Duty personnel use herbals or supplements [28]. Additionally many patients will seek treatments at out-
of-pocket costs because they feel it works for them and they can’t wait for the military to meet their needs.
Within military systems, health promotion and lifestyle are promoted not as a way of life, but as a necessity of
life. SM in the military need to be functioning like elite athletes because their jobs demand it.
A comparative study on the availability of CAM at selected U.S. DoD medical treatment facilities (MTFs) was
conducted over the time period of 2005 and 2009. The study showed an expansion in the types of CAM services
STO-RTG-TR-HFM-195
1- 7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0058.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
available, the number and type of providers providing those services and a shift in funding from central to
facility funded over 2005 to 2009. This survey suggests that leadership understands the value of CAM
treatments as evident by the expansion of those services at a cost to their facility budgets [25]. (See, in this
report, Petri and Delgado: “Integrative Medicine Experience in the U.S. Department of Defense”, pp. 4.1- 4.10.)
A follow up survey of over 540 DoD MTFs and Morale, Welfare and Recreation (MWR) services was
completed. This survey looked at the prevalence of CAM but also at the leadership’s perspective towards CAM
and its inclusion in the long-term strategic plan [26].
In January 2014, the United States Defense Health Agency published the report “Integrative Medicine Health
System Report to Congress”. The report showed 120 (29% of 421) MTFs offer 275 CAM programs. Further, it
showed that during the calendar year (CY) 2012, Active Duty military members used 213,515 CAM patient
visits. The most frequent visits were chiropractic care (73%) and acupuncture treatments (11%). The most
common CAM programs were acupuncture, clinical nutrition and chiropractic care. The overall
recommendations of the report were 1) the Military Health System (MHS) will evaluate CAM programs for
safety and effectiveness as well as cost-effectiveness 2) the MHS consider widespread implementation of cost-
effective CAM programs meeting guidelines for safety and effectiveness [10].
1.8 THE NEW PARADIGM
The future of medicine depends upon our ability to listen, adapt and respond in an integrative manner. Simply
put, adding Complementary and Alternative Medicine modalities to a regimen of conventional treatments does
not make it integrative health and healing nor does it make an Integrative Health and Healing Center. Integrative
Health and Healing must emphasize wellness and the healing of the whole individual with their supportive
community utilizing all medicine system modalities in a dovetail approach with each other. IH
2
leverages all the
interactive relationships between treatments, patient, family, providers and staff as well as the subtle, often
overlooked experiences of all involved. Integrative Health and Healing (IH
2
) can represent the new system of
care, the paradigm shift from reactive, disease-based medicine to one of health-enhancing, patient-centered care;
from reductionism to holism. Hippocrates wrote physicians should seek to "cure sometimes, heal often, comfort
always” [15]. Ancient healing practices emphasized the important link between the mind, body and spirit. Only
in the Western medical view do we separate these. Hippocrates further wrote "the natural healing force within
each of us is the greatest force in getting well” [16].
Integrative Health and Healing modalities are often low tech, low cost interventions that incorporate mind, body,
spirit, and soul. Recall, our current medical practice is over 17% of our GNP and rising [7]. The annual cost of
US military healthcare has more than doubled since 2001 from $17 to $35 billion dollars. By 2015, the cost is
estimated to nearly double again. This will represent 12% of the US defense budget [14]. Healthcare could
jeopardize global military readiness. Therefore, IH
2
could offer a means to decrease the rate of rising medical
costs while helping patients help themselves.
Is this paradigm shift evolutionary or a revolutionary return to our roots? It is both. It is evolutionary in the
sense that many technologies and procedures have been refined and perfected with time’s passage, but
revolutionary in the sense that we are now adopting ideas rooted in the ancient past. It is clear that the current
system is not working. Few will disagree with that. So change must occur. The terminology to describe the
new paradigm must change as well [4], [3], [6]. The current time is disruptive, disorganized and chaotic, but it
represents a tipping point of a new age in medicine. Healthcare solutions require revolutionary thinking. Now
is the time to think outside the box and create new ways of dealing with old problems. The past can bring about
1-8
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0059.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
a new future. This all begins in the mind. IH
2
emphasizes the importance of the self: self-improvement, self-
empowerment, self-healing, self-awareness, you name the self. It allows our warriors to sharpen their sword and
push themselves to the edge. Through self-responsibility, our Service Members become a more self-confident
and balanced force, empowered to deal with adversity, both on and off the battlefield.
Progressing to a new model leads to a change in our cultural tapestry. The Military and medical field is rich with
culture. Service members are the current day warriors. The military represents a brother and sisterhood of
focus, discipline, determination, and tenacity, all to serve a greater purpose. The U.S. Army Warrior Ethos is a
way of life that applies both to a person’s professional and personnel life. Providers cannot leave our fallen
comrades behind medically. Being embedded in the ways of the past will prevent looking towards the future.
Innovation requires forward thinking. But there needs to be an openness to change. However, there needs to be
caution about openly accepting change for change sake. In 1940, Mount Holyoke College Professor Walter
Kotschnig told his students “keep their minds open -- but not so open that your brains fall out” [5].
So, how can healthcare return to the basics? The diverse cultures can be leverage to meet the challenges of the
future. The lessons from the past must be learned and applied. Mistakes are often repeated in agonizing
regularity. In the beginning of WWII, militaries approached the battlefield utilizing the same failed philosophy
of WWI. The millions of deaths in WWI should have taught that trench warfare was not an effective strategy.
(Figure 1-4)
STO-RTG-TR-HFM-195
1- 9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0060.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Figure 1-4: Berlin, Germany (E): A Ditch, Reminiscent of World War I Trenches, Runs Along the Edge
of the "Death Strip" in the Rudow District Of East Berlin. The Communist Evacuated Residents And
Razed Buildings In The Strip To Provide Border Guards With A Clear Field Of Fire At West Germans
Attempting To Escape To Freedom In The West. Source: USIS Bad Godesberg/H-38946. U.S.
Information Agency 1982-10/1/1999. U.S. Information Agency. Press and Publication Service. Visual
Services Branch. Photo Library. 1953-1977. (Predecessor). International Communications Agency.
Press and Publication Service. Publication Division. 1978-1982. (Predecessor).
Series: Master File Photographs of U.S. and Foreign Personalities, World Events, and American
Economic, Social, and Cultural Life, ca. 1953 - ca. 1994.
Unrestricted Use. Courtesy National
Archives. Identifier: 6037811 Local Identifier: 306-PS-D-61-11909 Record Group 306.
https://research.archives.gov/id/6037811
Therefore, often the road map to the future is written by the past. During the Vietnam War, Transcendental
Meditation was shown to be extremely effective in the treatment of Post-traumatic Stress Disorder. So why is
there reluctance to use this technique today? Just how many articles on the front pages of newspapers and as
lead story on news broadcasts will it take before a realization that today's treatments are not meeting the needs of
our warriors?
Upon the passing through the chaos of change, a calm will emerge from the storm. The right kind of change will
bring about exponential progress. As examples, the world has been through the ages of enlightenment, industry,
the atom, space and information resulting substantial improvements to the quality of life. Now is the New Age
of Mind, Body, Spirit and Soul. Healthcare is at the cusp of transformation. It can begin with the paradigm of
the Integrative Health and Healing model. This is a new medicine resurrected from our ancient past. An
inscription at the base of a Robert Aitken statute in Washington, D.C. reads, "What is past is prologue." Thus,
1 - 10
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0061.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
the past is simply the introduction of the future. Therefore, this returning to the basics may not be a return but
rather a following of the blueprint set up by the past. Integrative Health and Healing allows patient, providers
and society to return to the art of medicine, the doctor-patient relationship and the emphasis on self-care and
responsibility.
Conventional medicine produces disempowered and passive patients stuck in a disease-centered model. It is a
deconstructive process that focuses on cellular, organ level pathology instead of the whole person. In sharp
contrast, IH
2
seeks to understand the whole person’s complex interplay of internal and external systems. It
represents the critical piece in the healthcare puzzle because it is embedded in the philosophy of holism. It
recognizes interconnectedness. Finally the head is being put back onto the body. The natural abilities to heal
are an anchor and critical foundation for health. Providers must educate the patient on safe and effective IH
2
options and allow them to take the lead in their quest for health and healing.
1.9 THE FUTURE
The precipice of change is approaching. Things will appear to be chaotic with deterioration and degradation of
what is held as the status quo. It is this tornadic whirl that leads to question, is this right direction? (Figure 1-5)
Figure 1-5: Tornado in a glass. 3-D render of swirling storm in glass of water. © grandeduc.
Permission given. License for use purchased.
http://depositphotos.com/9733380/stock-photo-storm-
in-a-glass.html
Image ID 9733380.
The unknown is entered. Think of a lost boat on a calm sea. It moves very little and wanders aimlessly unless
someone rocks the boat. So, could the calm sea represent the status quo? Could the boat represent the current
practice of medicine and the paradigm shift represents the rocking of the boat? Can the occupants collectively,
in a concerted fashion, actually move the boat in a meaningful direction? Jennifer James, PhD, a noted
anthropologist once stated, "We are moving so fast that we cannot see the new cultural tapestry we are weaving,
we can only see the shredding of our old one."
1
This scares us.
1
Personnal Communication with Jennifer James, PhD on 8 June 2015.
1- 11
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0062.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Albert Einstein stated that the definition of insanity “is doing the same thing over and over and expecting
different results” [12]. So what will it take to stop repeating practices that are not working? The reluctance to
change comes from a hesitation to move from what has been comfortable to something new. The current chaos
could actually be the tipping point before the new world, the new medicine. It could be the storm before the
calm.
Both medicine and the military are steeped in centuries of culture that have served both well. However, it is
these very cultures that make it difficult for change to occur. Thus change comes with difficulty and suspicion
and can only be achieved with a shift in perspective. Escher’s pictures often give the perspective of two opposite
situations happening at the same time? In this style, the David Macdonald’s picture “The Terrace”, illustrates the
sense of a floor and balcony at the same time. (Figure 1-6)
Figure 1-6: Is it a floor or a balcony? In this image there is the illusion that the floor and ceiling floor
are same. © THE TERRACE by David Macdonald. Permission given.
http://users.skynet.be/fa414202/Cambiguities/Illusion_Site/Cambiguities_David_Macdonald_Illusions
___Image___Terrace_Illusion.html
Retrieved 10 September 2015.
Therefore, couldn’t “alternative medicine” co-exist with conventional medicine at the same time? Wouldn’t that
be the concept of Integrative Health and Healing? In order to go forward, change must occur. Change comes
from a willingness and inquisitiveness to see the future today. It comes from a vision of what can be. Together
the best healthcare system for the best global force can be achieved through partnerships, common goals and
most importantly by recognizing the needs of the clients. The disease does not define a patient, but rather the
patient is an individual with a condition asking the medical community for opinions and guidance. This is the
shift from doctor leader to patient-centered, from organ system to wholeness, from disease to health and healing.
1 - 12
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0063.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
Integrative Health and Healing accurately defines and embraces this shift in medicine. The shift begins now; are
you ready?
1.10 REFERENCES
[1]
[2]
Anonymous. Adapted from Short History of Medicine. [Internet]. www.izquotes.com/quote/297535.
Retrieved May 5, 2010.
Barnes, P.M., Powell-Griner, E., McFann, K. and Nahin R.L. Complementary and Alternative Medicine
use among adults: United States, 2002. Advance data from vital and health statistics; no 343. Hyattsville,
MD: National Center for Health Statistics. 2004.
Barrett, B., Marchand, L., Scheder, J., Plane, M.B., Maberry, R. Appelbaum, D., Rakel, D. and Rabago, D.
Themes of holism, empowerment, access and legitimacy define complementary, alternative, and
integrative medicine in relation to conventional biomedicine. J Altern Complement Med. 2003;9(6)937-47.
Bell, I.R., Caspi, O., Schwartz, G.E., Grant, K.L., Gaudet, T.W., Rychener, D., Maizes, V. and Weil, A.
Integrative medicine and systemic outcomes research: issues in the emergence of a new modal for primary
health care. Arch Intern Med. 2002;162(2):133-40.
Blytheville Courier News, Professor Tells Students to Open Minds to Truth. (1940 January 27). Page 2,
Columns 2 and 3.
Caspi, O., Sechrest, L., Pitluk, H.C., Marshall, C.L., Bell, I.R. and Nichter, M. On the definition of
complementary, alternative, and integrative medicine; societal mega-stereotypes vs. The patients’
perspectives. Altern Ther Health Med. 2003;9(6):58-62.
Centers for Medicare & Medicaid Services (CMS), National Health Expenditure Projections 2014-2024
Forecast Summary CMS, Baltimore, MD. [Internet]. https://www. ems. gov/Research-Statistics -Data-
and-Systems/Statistic s-Trends-and-Reparts/NationalHealthExpendData/Downloads/Proj2014.pdf.
Retrieved 12 September 2015.
Consortium of Academic Health Centers for Integrative Medicine. [Internet].
https://www.imconsortium.org/about/history.cfm. Retrieved February 2, 2015.
Davies, M. The baby saved by a blob of superglue: Surgeons plug hole in newborn’s brain to relieve
pressure caused by deadly condition. Dailymail.com. [Internet]. http://www.dailymail.co.uk. Published
November 18, 2014. Retrieved April 4, 2015.
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] Defense Health Agency. (2014) Integrative Medicine in the Military Health System Report to Congress
(DHA) Washington, DC: DHA. [Internet]. http://health.mil/Reference-
Center/Reports?ouerv=integrative+medicine. Retrieved November 30, 2014.
[11] DeGeneres, E. Ellen DeGeneres: Here and Now. HBO, 25 June 2003.
[12] Einstein, A. [Internet]. http://www.brainyquote.com/quotes/authors/a/albert_einstein.html. Retrieved 18
November 2014.
STO-RTG-TR-HFM-195
1- 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0064.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
[13] Eisenberg, D.M., Kessler, R.C. and Foster, C. Unconventional medicine in the United States: prevalence,
costs and patterns of use. N Engl J Med. 1993;328:246-52.
[14] Government Accountability Office. (2007). Report to Congressional Committees Military Health Care:
TRICARE Cost-sharing Proposals Would Help Offset Increasing Health Care Spending but projected
Savings are Likely Overestimated (GAO-07-647) Washington, DC: GAO. [Internet]. www.gao.gov/cgi-
bin/getrpt?GAO-07-647. Retrieved November 30, 2014.
[15] Hippocrates. [Internet]. http://www.brainyquote.com/quotes/authors/h/hippocrates.html. Retrieved 28
December 2014.
[16] Hippocrates. [Internet]. http://www.quotationspage.com/quotes/Hippocrates/. Retrieved 28 December
2014.
[17] Hypericum Depression Trial Study Group, Effect of Hypericum perforatum (St John's Wort) in major
depressive disorder: a randomized controlled trial. JAMA. 2002;287(14):1807-14.
[18] Kohn, L., Corrigan, J. and Donaldson, M. eds. To Err is Human Building a Safer Health System.
Washington, D.C. National Academies Press, Committee on Quality of Health Care in America, Institute
of Medicine; 2000.
[19] Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA.
1998;279:1200-1205.
[20] Nahin, R.L., Barnes, P.M., Stussman, B.A. and Bloom, B. Costs of Complementary and Alternative
Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007. National Center for
Health Statistics. National Health statistics reports; no 18. Hyattsville, MD; National Center for Health
Statistics. 2009.
[21] National Center for Complementary and Alternative Medicine. Complementary, Alternative, or Integrative
Health: What's In A Name? [Internet]. Publication No. D347. Online document at:
https://nccih.nih.gov/health/integrative-health. Retrieved September 12, 2015.
[22] National Center for Complementary and Integrative Health. [Internet].
https://nccih.nih.gov/about/ataglance. Retrieved January 27, 2015.
[23] Null, G., Dean, C., Feldman, M., Rasio, D. and Smith, D. Death by Medicine. [Internet].
www.webdc.com/pdfs/deathbymedicine.pdf. Retrieved August 16, 2010.
[24] Office of The Army Surgeon General. Pain Management Task Force Final Report May 2010. [Internet].
www.regenesisbio.com/pdfs/journal/Pain_Management_Task_Force_Report.pdf Retrieved August 15,
2010.
[25] Petri, R., Delgado, R. Integrative Medicine experience in the United States Department of Defense.
Medical Acupuncture. 2015;27(5):pp.
[26] Petri, R., Welton, R. and Delgado, R. Survey of Complementary and Alternative Medicine Services within
the Department of Defense. (Forthcoming 2016).
1 - 14
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0065.png
UNCLASSIFIED
INTEGRATIVE HEALTH AND HEALING AS A NEW PARADIGM
[27] Radley, D., Finkelstein, S. and Stafford, R. Off-label Prescribing Among Office-Based Physicians Arch
Intern Med. 2006;166(9):1021-6.
[28] Research Triangle Institute International. (2005). Department of Defense Survey of Health Related
Behaviors among Active Duty Military Personnel A Component of the Defense Lifestyle Assessment
Program. Research Triangle Park, NC: Research Triangle Institute.
[29] Sherman, K.J., Cherkin, D.C., Connelly, M.T., Erro, J., Savetsky, J.B., Davis, R.B and Eisenberg, D.M.
Complementary and alternative medical therapies for chronic low back pain: What treatments are patients
willing to try? BMC Complement Altern Med. 2004;4:9.
[30] Starfield, B. Is US Health Really the Best in the World? JAMA. 2000;284(4);483-485.
[31] Weil, A. The Advantages of Integrative Medicine. [Internet]. www.drweil.com/drw/u/VDR00016/The-
Advantages-of-Integrative-Medicine.html. Retrieved December 8, 2014.
STO-RTG-TR-HFM-195
1- 15
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0066.png
ENTER CLASSIFICATION
Chapter 2– HISTORICAL AND CULTURAL PERSPECTIVES OF
INTEGRATIVE MEDICINE
Richard P Petri, Jr., MD FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
Roxana Delgado, Ph.D., M.S.
Senior Research Associate
Samueli Institute
1737 King St., Suite #600
Alexandria, VA
USA
Phone +1 (703) 408-6234
[email protected]
Kimberly McConnell, Ed.D.
Senior Research Associate
Samueli Institute
On location at San Antonio Military Medical Center
3851 Roger Brooke Drive
San Antonio, TX 78219
210-363-2553 (mobile)
210-916-1442 (office)
[email protected]
STO-RTG-TR-HFM-195
2-1
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0067.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
ABSTRACT
The field of medicine dates back to ancient times. Early practices were adopted by subsequent societies.
Cultures had significant influences over many aspects of life. Globally, there is a health care crisis of
inadequate delivery and less-than-optimal outcomes despite all the advancements and evidence provided by
modern biomedicine. North Atlantic Treaty Organization countries represent diverse cultures and societal
experiences and, collectively, may offer new perspectives in the evolution of health care delivery. A
retrospective review of the influences of ancient practices and cultures is provided. This can serve as a
foundation for a prospective discussion about integrating the various current systems into a better paradigm
of health care. This article discusses the impact of historical and cultural perspectives on medicine in general
and on specifically integrative medicine (IM). The origins of some IM modalities are highlighted.
History reveals that new medical paradigms were a blending of old traditions with new innovations. Changes
occurred because society questioned old methods. Today the situation is not different. The field of IM is
evolving as a result.
KEYWORDS
Historical Perspective, Integrative Medicine, Complementary and Alternative, Culture, Society
2.1 INTRODUCTION
A bureaucracy is often a barrier to an institution’s adherence to its original mission and purpose. Today’s
health care system seems to have fallen victim to its systems of management, thereby diluting the intended
goal of caring for patients. Patients are responding to a perceived system of depersonalized algorithmic care
and limited contact with providers. This is a system in which technology has often replaced human
interaction. Thus, patients have sought new means of health care to meet their needs, expectations, beliefs, and
values. Patients in Military populations have done the same as civilian patients. [22], [7], [17], [35], [30], [8]
Health care systems are deeply embedded in civilization’s economic, religious, and societal cultures.
Historical accounts are often passed down, thus permitting infusion of previous systems to be adopted into
current systems. However, this adoption occurs often with reluctance. Furthermore, it must be remembered
that historical accounts are only related stories from personal perspectives. A perspective can often be clouded
by an agenda. Nonetheless, history is the binding factor. Historical accounts document the transition from the
past to the future.
Globally, there is a health care crisis of inadequate delivery and less-than-optimal outcomes despite all the
advancements and evidence of modern biomedicine. Thus, a retrospective review of the influences of ancient
practices and cultures is necessary. This article can serve as a foundation for a prospective discussion on
integrating the various current systems into a better paradigm of health care.
2.2 HISTORICAL PERSPECTIVES
The origins of medicine are deeply rooted in a civilization’s culture and religious beliefs. Often, educated
priests practiced medicine. Early medicine dealt with experiences, observations, and reflections of the self and
one’s surroundings. There was no separation of mind and body. In the 1600’s, Rene Descartes, in an attempt
to protect the spirit from science, separated the mind from the body. [2] This set the stage for the current state
of the Western style mind–body split and evidence-based medicine versus nonconventional or complementary
medicine. This was the beginning of the reductionistic movement with the goal of understanding the parts to
2- 2
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0068.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
gain a larger understanding of the whole. Only within the past few decades, has there been an attempt to
reunite the medical systems of curing (technological, microscopic, and disease-based) with healing
(nonphysical, holistic, and relationship-based). The following is a brief history of important and relevant
world cultures that have contributed to the field of medicine, conventionally and unconventionally.
2.3 THE PERIODS
2.3.1 Mesopotamia And Egypt: 3100 BC
It is believed that the oldest civilizations were in the areas of present-day Egypt and Iraq (Mesopotamia). Given
that medicine is so often culturally based, it undoubtedly follows that the first medicine came from these
civilizations.
Thoth
(Figure 2-1) was an Egyptian god who was the inventor of art in general.
Figure 2-1 Thoth, ancient Egyptian god often depicted as an ibis-headed man. Based on New
Kingdom tomb painting. By Jeff Dahl (Own work). Licensed under Creative Commons
He is believed to have been the author of the oldest Egyptian medical work with the contents engraved upon
pillars of stone. His words formed a part of the
Hermetic Books
used by the physicians of the day. [1]
Interestingly, Egyptian medicine was divided into two degrees. The Science of higher degree consisted of
conjurations, dissolving the charms of gods by prayer, and interpretations of revelations received by the sick
person during incubations in temples. The highest class of priest performed as the physicians of the higher
Science. The Science of the lower degree was “ordinary medical practice” and was practiced by the lowest grade
of priests. They studied anatomy, pathology, pharmacology, ophthalmology, and gynecology. It is interesting,
therefore, that the higher order of Science dealt with areas, which today some have called “Voodoo” medicine.
The Egyptians developed a system of specialties described as “physicians in Egypt for each part of the body.”
[1] In fact, there were priestly physicians who followed the army and were employed by the state. In
Outlines
of the History of Medicine and the Medical Profession,
it is stated, “this specialism is per se an evidence of a
civilization of high development, indeed of one tending towards its downfall, and in Egypt it attained a
perfection which our own system, with all its completeness, has not yet reached. [1] Current day Western
biomedicine continues to pursue scientific inquiry with specialization and microscopic divisions. Thus, could
STO-RTG-TR-HFM-195
2-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0069.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
our system of intense specialization be a portent of our health care system’s downfall if it is continued without
deviation?
Aromatherapy began in ancient Egypt. The Egyptians excelled in the use of oils, salts, alabasters, and creams
for all kinds of diseases and for preservation of the dead. [25] Nefertum was the god of perfumes, incense, and
fragrant oils. His mother, Sekmer, was the goddess of healing and alchemical distillation. The use of fragrance
was the means of communication between the gods and humanity, offering health to the living and assisting
the dead in the next life. [13]
The Egyptians believed that the body could heal itself and used reflexology to restore balance and the natural
equilibrium. [25]
2.3.2 India: 2500 BC
Unlike many civilizations that imported systems of other outside cultures, Indian medicine was derived in
India and had interwoven systems of other cultures, predominately Greek, as part of India’s own system, but
this interweaving occurred only at a later time period. [1]
The ancient Indians wrote about medicine in their sacred books, known as the Vedas (Figure 2-2).
Figure 2-2 The Recording of the Vedas in Ancient India. This is the front cover of the book “The
st
Nectar of Instruction 1 edition” by A.C. Bhaktivedanta Swami, Founder of the International Society
of Krishna Consciousness. Artwork reprinted with permision from The Bhaktivedanta Book Trust
International, Inc.
2- 4
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0070.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
The Vedas are believed to be of divine origin and were passed down through oral traditions until the sixteenth
century
AD
. One of the Vedas, the
Atharvaveda,
is a collection of spells, hymns, and incantations for magical
curing of diseases, and is thought to have been the origin of the traditional Indian medicine system known as
Ayurveda. [1] Ayurveda is based on the concepts of longevity and the nourishment of life. [37] Later
commentaries on the Vedas, known as the
Brahmanas
and the
Upanishads,
explained these texts and
speculated about the nature of the universe as well as the human condition. [21]
Yoga—a
term derived from the Sanskrit word
yug—was
a theological practice that was believed to lead to the
unification of self with the Divine. Yoga’s origins are believed to date back to pre-Vedic traditions. Yoga is a
practice that was considered to be given directly from God. The foundation is based on the suppression of all
activities so that one can identify and separate the self from the body, mind, and will. In doing so, one attains
spiritual liberation. [25] Yoga, when practiced in the true Indian tradition, is more than a physical exercise
program. It has a meditative and spiritual core, and offers a meaningful purpose for life and living.
Buddhism originated in India in the sixth century
BC
under the teachings of the Buddha. These teachings were
in protest of the strict stratification of the Hindu society as well as the religious control of the Brahmanic
priests. Buddha emphasized universal love, service, and peace of mind brought about through abandonment of
desire. [21]
Unani medicine, a lesser-known India medicine subtype, is based on the theory of the Four Elements of the
human body (i.e., Fire, Water, Earth and Air). Different fluids represent these elements. When the fluids are
balanced, there is health; when the fluids are imbalanced there is illness. [28]
An esoteric form of alternative medicine described in Indian literature is the healing practice of Uropathy.
This is a method of healing with the use of one’s own urine. It is referred to as
Shivambu
or “holy liquid.” In
the Tantrik Yoga culture, it is termed
Amroli.
Amroli is derived from the word
Amar,
which means undying.
Hence,
Amroli
was a spiritual practice that was beneficial to the mind, body, and spirit for the attainment of
immortality. [31] It is believed that hundreds of ailments can be cured by urine therapy. [33] Uropathy is not
widely practiced today; however, there are World Congresses on the subject, and numerous books and articles
on this topic.
Finally, Indian medicine was weakest in the area of anatomy because of a prohibition against living people
having physical contact with dead people.
2.3.3 China: 1600 BC
It is widely believed that Traditional Chinese Medicine (TCM) has a 3000–4000-year history. TCM was
embedded in the “philosophy of Confucius who called for the ideal family ties and the promotion of social
and ethical standards of societies.” [25] The oldest Chinese medical texts are thought to be on herbal
medicine. The Yellow Emperor, Huang Di, wrote about acupuncture, the concept of Yin and Yang, and the
Five Phases in his book,
The Yellow Emperor’s Inner Classic
(Huang
Di Nei Jing).
[5]
TCM spread across Asia throughout the centuries and came eventually into the Western world in the sixteenth
to the twentieth centuries
AD
. However, only fragments of TCM are practiced in the West. Nonetheless, TCM
has influenced the delivery of Western-style health care. Likewise, TCM has not remained stagnant in practice
either. Concepts have come and gone and returned over time, depending on current societal perspectives and
political environments. Unlike the West, in which an incomplete theory or unacceptable concept is rejected
and then disappears, TCM may reject a theory but it does not disappear. It may fade in practice, but it
STO-RTG-TR-HFM-195
2-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0071.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
continues to exist and may return at a later time. In the West, it is often thought that something is is “either
this or that.” However, in TCM, opposing theories can exist. An example of this is the concept of Yin and
Yang. Although Yin and Yang oppose each other, they are also complementary to each other (Figure 2-3). [5]
Figure 2-3 Yin Yang Symbol. By Donkey-Hotey (Own work). Licensed under Creative Commons
(CCBY)
TCM is the overreaching umbrella for many disciplines. Acupuncture is one of those disciplines. The
mythological basis of acupuncture suggests that the Chinese speared human bodies to rid towns and villages
of demons and evil spirits. Acupuncture evolved over time. The practice of acupuncture was influenced
significantly by the reorganized text of the
Yellow Emperor’s Inner Classic and other earlier texts
into the text
Systematic Text of Acupuncture
(and Moxibustion) circa the third century
CE
. [5]
TCM was primarily a system for the Chinese elite rather than for the population of the entire nation. Much of
the country’s population was illiterate, and, as such, little is known about the population. It is believed that the
illiterate people’s traditions were based on folk superstitions, legends, and survival. [5]
The true history of acupuncture may never be known. Despite the fact that classical texts on acupuncture exist,
these texts often do not describe the clinical practices. The theories and concepts of Chinese acupuncture do
not always translate well and, therefore, the meaning and significance of both have been lost.
Throughout history, TCM and acupuncture have been subject to religious, cultural, and political pressures.
During the late nineteenth and early twentieth centuries TCM was politically under attack to make way for a
new and more modern China. In 1822, acupuncture was banned from the Imperial Medical Academy after
nearly 1200 years of basic Imperial medical education. [27] There was a significant movement to move
toward scientifically based medicine. Many of the scientifically trained physicians were concentrated in only
three major cities, leaving voids in the other urban and in all rural areas. Thus, the ban undercut the health care
system of the common people, because much of their care was solely based one TCM.
2- 6
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0072.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
Only after 1954, did acupuncture become reinvented. Chairman Mao ordered all Western medicine
practitioners to study acupuncture. This resulted in organization of the TCM practitioners to provide health
care. However, it is not clear if this new acupuncture actually resembled the true acupuncture of the millennia
before.
Other TCM practices include movement of invisible energies (Feng
Shui),
dietary/herbal therapies (“we are
what we eat”), and kinesiology (T’ai Chi, Qigong). This system of exercise was known as the “Frolics of Five
Animals.” [14] Similar to Indian medicine, TCM supports the holistic view of treating the mind, body, and
spirit and the individual’s experience of the disease. [25]
TCM has been practiced in the United States since the mid nineteenth century. Bache was the first American
physician to use acupuncture in his practice (in 1826). In 1901, Ah Fong Chuck was the first licensed
practitioner of TCM. Acupuncture gained greater popularity after James Reston, a reporter for
The New York
Times,
underwent an emergency appendectomy while he was in China with former President Richard Nixon
in 1971. [4]
2.3.4 Greece: 800 BC
The ancient traditions of Greece have provided the foundations of Western philosophy, science, and medicine.
[20] However, history shows that the Greeks went to Egypt for their medical training. Greek medicine was
comprised of magic and legendary beliefs. Like what occurred in preceding cultures, Greek medicine was
strongly embedded with priests, seers, and god figures. Apollo, the most powerful god–physician, would
cause epidemics as punishments. Yet, he would also revive and heal wounded people. [20]
Pythagoras, well known for his mathematical formulas, was the first Greek philosopher interested in medicine.
Mathematics influenced the concept of opposite quantities. The balancing of these opposites was important to
health and disease. [20]
Hippocrates (Figure 2-4) is considered to be the father of Western medicine. He established “medicine as an
art, science and a profession of profound value and dignity.” [20] Medicine was no longer a part of
philosophy. [9]
STO-RTG-TR-HFM-195
2-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0073.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
Figure 2-4 Hippocrates: Medicine Becomes a Science. Permission Given. Collection of the
University of Michigan Health System, Gift of Pfizer, Inc., UMHS.7.
The life of Hippocrates is not well documented, and it is argued by some scholars that Hippocrates was not an
individual person. Nonetheless, he is credited with the theory of the Four Humors to mirror the earth’s four
elements. [25] These humors, with their associated qualities (hot, cold, moist, and dry), formed the human
microcosm, which was reflective of the larger universal macrocosm. Health was achieved through a balance
and blending of the humors. Hippocrates believed that dietetics was the basis for the art of healing. Thus, food
could be used to achieve health and healing. [20]
Current standard herbal textbooks are based on the herbal medicine book written by the Greek physician
Dioscorides (Cited by Oumeish). [25] The term medica comes from the Greek mythological story of Medea,
sorcerer of the seventh century and the land Media. Media is the area of current northwestern Iran and
southwestern Turkey. The plants of Media were known as “median herbs” and their ointments,
medicamentum, the root for our current term medications, could be used to heal or poison. This implied that
medications could be used for healing or harming. [2]
2.3.5 Rome: 27 BC
In the early days of Christianity, the system of medicine had a strong overlay of mysticism (Figure 2-5). The
Christians believed that disease was the result of sinful behaviors and cure was achieved through grace or
2- 8
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0074.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
suffering. Often, the ability to touch a “holy relic” was a promise of healing. Some of the relics noted to have
these healing properties included the “finger of the Holy Ghost,” rays of the Star which led the Wise Men to
the birthplace of Jesus,” and a rib of the Word made flesh.” [6]
Figure 2-5 The
Flammarion engraving
is a
wood engraving
by an unknown artist that first appeared
in
Camille Flammarion's
L'atmosphère: météorologie populaire
(1888). The image depicts a man
crawling under the edge of the sky, depicted as if it were a solid hemisphere, to look at the
mysterious
Empyrean
beyond. The caption translates to "A medieval missionary tells that he has
found the point where heaven and Earth meet..." By unknown artist. Source: Wikimedia.org
Much of Roman medicine was adapted from the Greeks. The Romans improved aromatherapy with their spas,
saunas, and baths. [25] Roman medicine was greatly influenced by the work of the prominent physician
Galen. It was believed that imbalance in the four humors led to diseases, a belief that was originated by
Hippocrates. After Galen’s death, medicine in Rome began to stagnate. There was distrust in the system,
which is now considered to be greedy, incompetent, and dishonest. The public sought new means of treatment
from their own gardens, a principle known as
Euporista.
Books on the subject began to replace physicians. It
was believed that nature provided remedies. In the late Roman period, individuals could practice medicine
without training. Organized medicine was replaced by supernatural principles and home remedies. [26]
Public beliefs overran scientific principles.
2.3.6 Islamic Golden Age: 622 AD
During the Islamic Golden Age, Persian physicians contributed to medicine in two phases. The first was a
period of translations (750–900
BC
). The philosophers, Gerber (721 BC), Al-Kindi (801 BC), Rhazes (865
BC
), (Figure 2-6), Al-Farabi (872
BC
), Avicenna (980
BC
), and Averroës (1126
AD
) had profound effect on the
Dark Ages of Europe. The Dark Ages comprised a period of time when there was little advancement in the
STO-RTG-TR-HFM-195
2-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0075.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
field of medicine.
Figure 2-6 Muhammed ibn Zakariya al-Razi. Also known as Razis or Rhazes. Persian philosopher
and physician. This is a faithful photographic reproduction of a two-dimensional,
public domain
work of art. Source: Wikimedia.org
The previous civilizations’ medical knowledge, especially the Greek knowledge, was preserved, which
enabled its passage to Europe upon that region’s emergence from the Dark Ages period. [6] Moir, a Scottish
physician states that “medicine is incalculably indebted to the Saracens,” [a generic term for Muslim during
the later Medieval era] “for the preservation of the Greek writers; as it was only after the return of the French,
Italian and English from the Crusades, that these came to be known in Europe, through translations from the
Arabic.” [24]
The second period was a period of observations and expansion. (900–1100
BC
). During the time of
Mohammed, the culture promoted learning, arts, and sciences for intellectual development. The region
established great medical colleges with strict admission guidelines. The schools followed rigorous scientific
principles, and understood the use of anesthetics and hygiene. Their ancient materia medica rivals that of
Western medical textbooks today. [24]
Arabic medicine was practiced within the context of Islam’s system of ethnics. It became known as Prophetic
Medicine. It was believed that true medical knowledge came from revelations from the Prophet. [26] It was
supernatural, and esoteric, and filled with unconventional imagery; however, this medicine suited the majority
of the people, was inexpensive, and was widely accepted. Arabic medicine was linked to philosophy and tied
to numerical and astrological symbolism. Magicoreligious thoughts had significant influences on the system.
Some of the practices included fortune telling, exorcisms, inspirations, amulets, healing gems and crystals,
charms and spells, and cupping. The physician stressed treating the early symptoms by unconventional means
to expose disease early treatable stages. These physicians often used herbals for such treatments. [25]
Although the Arabic physicians copied much from other civilizations, these physicians did expand their
knowledge of medicine. They divided medicine into three distinct professions: physic, pharmacy and surgery.
In the areas of aromatics and purgatives, Arabic physicians added their knowledge to botanical and materia
medicas extensively. Rhazes wrote the first treatise on the diseases of children. The Arabs raised the dignity of
2- 10
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0076.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
the medical profession from one of a menial calling to a learned profession with examinations and licensing.
[9], [19]
2.3.7 The Renaissance to the Modern Era
The emergence of the Dark Ages into that of the Renaissance was largely the result of the Arabic period of
translation. The ancient works were brought forward to the modern era through translation into the common
language of the time: Latin. This was followed by an expansion in experimental investigation, particularly in
dissection of the human body. As a result, human anatomy and neurology had significant advancements.
Famous theories and principles were criticized and often debunked. Science began to replace mysticism. New
publications spurred excitement and interest. Anatomical dissection theaters flourished, attracting artists,
students, and scientists. University medical training began in Salerno and then later in Padua and Bologna,
Italy, followed by France and England. Although, this training was primarily academic it had little clinical
experience as part of the training. Medicine began its descriptive phase. [29]
During the next several centuries, medicine expanded in its scientific knowledge base exponentially.
Technological advances contributed and enabled a deeper range of observations, interactions, and
interventions. Generalities became specific. Specialization occurred at an unprecedented rate and to the point
that there was subspecialization for treating minute portions of organ systems. As such, medicine became
compartmentalized with some people stating that medicine had become depersonalized as well.
This trend was advanced and complemented by economic, political, and military powers of the times.
Powerful cultures colonized older, less-powerful cultures, so that Western medicine became global.
2.3.8 Shamans, Medicine Men
1
and Cuaranderos
The term
shaman
comes from the Tungas language of Central Siberia. A shaman is an individual who enters
altered states of consciousness in order to acquire knowledge, power and to help others. [12] Shamans use
drums to call upon spirit allies. [23] The repetitive sound of the drum facilitates the trance states in
shamanistic practices. These drums are likened to a canoe or horse that transports the shaman into “the
Lowerworld or Upperworld”. [11] Shamanism cannot be learned, but rather, shamans are born into the life.
[23] This calling is that of a healer. Shamanism represents “the most widespread and ancient methodological
system of healing known to humanity.” [11]
During the practice of shamanism, both the shaman and the patient travel on the journey together. There is a
deep level connectedness between the two; something that is often lacking in today’s doctor-patient
relationship. Despite the significant differences in the cultures and the separation by distances, shamanistic
practices across the world are similar. Thus, “the basic uniformity of shamanic methods suggests that, through
trial and error, people arrived at the same conclusions. [10] In many regions of the world, the shaman is seen
as “the great specialist of the human soul: he alone ‘sees’ it, for he knows its ‘form’ and its destiny.” [3]
Names such as witch, magic man, witchdoctor, seer, sorcerer and medicine man have been used
interchangeably for shaman. [12]
Shamanistic practices are very prevalent in traditional American Indians practices of today. These shamans
are often known as
medicine men.
Most of the pre-Columbian practices were not recorded or did not survive.
The early European settlers provided the earliest accounts. Native Americans were not a homogenous
1
In many shamanistic traditions, the shamans are typically men rather than men and women.
2 - 11
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0077.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
population and as such neither were their practices. However, a common thread of the medicine men was that
all aspects of life were intimately connected to good health and well being. Life was a circle and the healing
included all aspects of an individual’s life, family and community. The medicine man practiced a highly
advanced medicine that was effective in combating disease common to their day. Some of the widely used
herbal-based treatments included echinacea
(Echinacea spp.),
ephedrine
(Ephedraceae spp.)
and cacao
(Theobroma cacao),
which are widely used in contemporary medicine and society. [34]
Cacao was cultivated in the Mesoamerican region (current day central Mexico) dating back to 1900 BC.
Cacao was so revered that “all subjects in service to the Aztec emperor were required to bring several bags of
cacao in tribute.” [18] The Aztecs mixed cacao with other ingredients such as chilli
(Capsicum annuum),
black pepper (Piper
nigrum),
cornmeal or plantains to make the traditional drink
chocolatl.
Sugar was not
added until 1528, when Columbus introduced cacao to the Spaniards. Cacao was used for a multitude of
illnesses (weight gain, invigoration of the nervous system of the apathetic, exhausted or weak, improvement
of digestion and bowel function and stimulation of kidney) as well as a flavoring for other medicine,
especially those for children. In addition to the cacao bean, the leaves, flowers, bark and oil had medicinal
properties that were used to treat burns, cuts and skin irritations. [18]
The term
curanderismo
describes a broad healing tradition of Latin America. The word is derived from the
Spanish verb
curar,
which means, “to heal”. There are seven pillars or cultural and historical roots of
Curanderismo. These represent the blending of ancient civilizations with the native population of Latin
America. The construct of Curanderismo is based on the duality of natural and supernatural causes. Natural
causes can be treated with herbal remedies, whereas the supernatural causes require treatment only by the
supernatural manipulations performed by curanderos. Supernatural causes of illness are due to either
“espiritos malos” (evil spirits) or “brujos”. Brujos are individuals that practice malign magic. The
supernatural manipulations consist of several types of rituals such as sweeping, incensing or conjuring, which
lead to removal of negative forces. Curanderismo practices often provide better healing for chronic mental
health conditions as well as alcohol and drug addiction than that of Western psychiatry and psychology. [32]
The healing practices of curanderos are culturally meaningful to their society. This is a must for any
healthcare system to be effective. Additionally, Curanderismo blends worldwide healing traditions, ancient
and contemporary, for a true integration of different approaches. [32] Thus, lessons should be learned as the
new paradigm of Integrative Medicine is developed.
2.4 DISCUSSION
Prior cultures have shaped the present day to form the foundation of the future. Societies’ cultures are
influenced by the religious and political classes of the time. The health care of a given time period is a
reflection of those influences. Thus, the struggles of the present evolution in health care is not unlike past
turmoil, power grasps, and reluctance to “let go of the status quo.” Of all the great societies, only the Indian
and Chinese medical systems have endured as health care systems. In addition, it is not clear how well history
has recorded the true philosophies of each.
Today, priests and clerics do not control health care, unlike much of the ancient times. In fact, it is often not
permitted. The incorporation of religious practices within military cultures is often met with skepticism and
resistance. However, it seems that spirituality is more acceptable. The Human Performance Resource Center,
a U.S. Department of Defense initiative under the Force Health Protection and Readiness Program developed
the Total Force Fitness (TFF) program. It is a framework for building and maintaining health, readiness, and
2- 12
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0078.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
performance. The TFF program views health, wellness, and resilience as a holistic concept wherein optimal
performance requires connections among mind, body, spirit, and family/social relationships. Information
about the TFF program was published in a special issue of
Military Medicine
[16] with a chapter devoted to
solely to spiritual fitness. [15] In addition, there is a chapter within this current North Atlantic Treaty
Organization (NATO) Special Issue of
Medical Acupuncture
describing a systematic review of
spirituality/religiosity, and what context this can be applied to Soldiers in the course of healing (Chapter 8,
pages 8-1 through 8-11).
Regarding an area related to this concept, there is current controversy regarding implementing yoga into some
Military health care systems because “it represents a religion.” Although yoga has a religious foundation,
“Western style” yoga is no more a religious practice than many fitness classes, (Pilates,
zumba,
aerobics)
offered at most gyms. When yoga is practiced in the true Indian tradition this yoga is more concerned with
spirituality than with religiosity.
Thus, utilization of religious practices as part of health care systems is not acceptable; however, it seems that
spirituality may be a necessary component of an individual’s healing journey.
Politics has played an enormous role in shaping health care in the past. Today, this situation is not different.
Current debates regarding acupuncture are similar to those nearly 2 centuries ago. Most recently, in 1928, The
China’s National Health Council issued a resolution banning acupuncture. It is interesting how the tone of the
resolution is similar to the arguments used in opposition to IM today. In the
Resolution for Abolishing the
Native Practice Proposal,
it is stated:
The medicine of today has advanced from the curative to the preventive stage, individual to collective
medicine, personal to community emphasis. Modern public health service is based entirely on
scientific medical knowledge with the corresponding political backing. The old-style medicine of
China adopts the doctrines which are pure speculations having not a grain of truth. The diagnosis
depends wholly on the signs of the pulse. Such absurd theories are deceptive to one self [sic] and to
others. They may be classified in the same category as astrology. Since fundamentally they do not
know diagnosis, it is impossible for them to certify the causes of death, classify diseases, combat
epidemics. The evolution of civilization is from the supernatural to the human, from the philosophical
to the practical. Now while the Government is trying to combat superstition and abolish idols so as to
bring the people’s thoughts to proper scientific channels, the old-style physicians, on the other hand,
are daily deceiving the masses with their faith healing. While the Government is educating the public
as to the benefits of cleanliness and disinfection and the fact that germs are the root of most diseases,
the old-style physicians are broadcasting such theories as when one catches cold in winter, typhoid
will appear in spring; when one suffers from the heat in summer, malaria will come in autumn. These
reactionary thoughts are the greatest hindrance to scientific progress (Cited by Wong and Wu). [36]
Thus today, with improved research techniques and acceptance of new/old methods, IM modalities, such as
acupuncture, meditation, and yoga, to list only a few, are being investigated and incorporated in global health
care systems.
2.5 CONCLUSION
Culture is complex and multifactorial. It influences all aspects of society. Likewise, the society influences all
aspects of culture. However, too often, culture has been shaped/decided by the powerful classes of their times.
This applied to the field of medicine as well. Only over the past several decades, has there a renewed
STO-RTG-TR-HFM-195
2 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0079.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
grassroots effort to change the course of medicine. Society is affecting the rule of the “deciding” class. There
is a push to diminish the role of technology in patient care and return medicine to a more humanistic approach
to healing and health. However, this movement is nothing new. It has been repeated many times since ancient
cultures. As with all things, paradigms evolve, resulting in changes in philosophy, terminology, and policy. As
with all things, as understood by history, more changes will come. Thus the culture, with its impact on the
present as well as the future, will be defined.
2.6 RECOMMENDATIONS
Medical health care systems of the world are constantly changing. They must do so. As such, it is imperative
to study the cultures and societies that laid the foundations of medicine in the past. Lessons can be learned and
mistakes can be avoided. However, the greatest advantage that history provides is the ability to take
knowledge from the past and weave it into today’s knowledge to improve future knowledge. The collective
experiences of the NATO countries with their diverse cultures can facilitate this, and this resource should be
utilized.
2.7 REFERENCES
[1]
Baas JH. The Medical Culture of those Nations whose Development in Medicine is either already
closed or is stationary (or not independent). The History of the Most Ancient Medicine and the Medicine of
Primeval People. In Baas JH. Author.
Outlines of the History of Medicine and the Medical Profession.
New
York: J.H.Vail & Co.; 1889:13–78.
[2]
Chiappelli F, Prolo P, Cajulis OS. Evidence-based research in complementary and alternative
medicine I: History.
Evid Based Complement Alternat Med.
2005;2(4):453–458.
[3]
Eliade M. General Considerations. Recruiting Methods. Shamanism and Mystical Vocation. In: Eliade
M. author
Shamanism: archaic technique of ecstasy.
Bolingen Series LXXVI. Princeton, NJ. Princeton
University Press; 1964: 3-32.
[4]
Ergil, K. Chinese Medicine. In: Micozzi MS, ed.
Fundamentals of Complementary and Integrative
Medicine, 3rd ed.
St. Louis, MO: Elsevier Saunders; 2006:393-417.
[5]
Ergil, K. Traditional Medicine of China and East Asia. In: Micozzi Marc S, ed.
Fundamentals of
Complementary and Integrative Medicine, 5th ed.
St. Louis: Saunders Elsevier; 2015:477-507.
[6]
Geiger R. Homeopathy among the ancient Hindus and Arabians.
J Am Inst Homeopath.
1945:38:387.
[7]
George S, Jackson JL, Passamonti M. Complementary and alternative medicine in a military primary
care clinic: A 5-year cohort study.
Mil Med.
2011;176(6):685–688.
[8]
Goertz C, Marriott BP, Finch MD, et al. Military report more complementary and alternative
medicine use than civilians.
J Altern Complement Med.
2013;19(6):509–517.
[9]
Grammaticos PC, Diamantis A. Useful known and unknown views of the father of modern medicine,
Hippocrates, and his teacher Democritus.
Hell J Nucl Med.
2008;11(1):2–4.
2- 14
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0080.png
UNCLASSIFIED
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
[10]
Harner M. Introduction. In: Harner M. author.
The way of the shaman.
3
rd
ed. San Francisco, CA:
Harper &Row; 1990: 12-22.
[11]
Harner M. Shamanism and States of Consciousness. In: Harner M. author.
The way of the shaman.
3
rd
ed. San Francisco, CA: Harper &Row; 1990: 81-107. 29
[12]
Harner M. The Shamanic Journey: Introduction. In: Harner M. author.
The way of the shaman.
3
rd
ed.
San Francisco, CA: Harper &Row; 1990: 50-80.
[13]
Hoffman CJ. Aromatherapy. In: Micozzi MS, ed.
Fundamentals of Complementary and Integrative
Medicine 3rd ed.
St Louis, MO: Saunders Elsevier; 2006: 209-28.
[14]
84.
[15]
Hong, FF. History of Medicine in China When Medicine Took an Alternative Path.
MJM
2004;8:79-
Hufford DJ, Fritts MJ, Rhodes JE. Spiritual Fitness.
Mil Med.
2010 August Suppl: 175:73-87.
[16]
Jonas W, Deuster P, O’Connor F, Macedonia C. Total Force Fitness for the 21
st
Century A New
Paradigm.
Mil Med.
2010 August Suppl; 175:1-126.
[17]
Kroesen K, Baldwin CM, Brooks AJ, Bell IR. US Military veterans’ perceptions of the conventional
medical care system and their use of complementary and alternative medicine.
Fam Pract.
2002;19(1):57–64.
[18]
222.
Lee R, Black MJ. Chocolate: Healing ‘Food of the Gods’?
Altern Ther Health Med.
2001:7(5): 120-
[19]
Lu GD, Needham J. China and the origin of examination in medicine.
Proc R Soc Med.
1963;56(2):63–70.
[20]
Magner LN. Greco-Roman Medicine. In: Magner LN.
A History of Medicine.
New York: Marcel
Dekker; 1992:63–80.
[21]
Magner LN. The Great Medical Traditions of India and China. In: Magner LN. author.
A History of
Medicine.
New York: Marcel Dekker; 1992:37–62.
[22]
McPherson F, Schwenka MA. Use of complementary and alternative therapies among active duty
soldiers, military retirees, and family members at a military hospital.
Mil Med.
2004;169(5):354–357.
[23]
Micozzi AM, Micozzi MS. Magico-Religious Traditions and Neo-Shamanism. In: Micozzi MS.
Fundamentals of Complementary and Alterative Medicine. 5
th
ed.
St. Louis, MO: Elsevier Saunders;
2015:667-73.
[24]
Moir DM. Avenzoar-Averrhoes-and Extinction of the Arabian School. In: Moir DM. author
Outlines
of Ancient History of Medicine.
Edinburgh, Scotland: Neill and Co. Printers; 1831: 264-278.
[25]
Oumeish OY. The philosophical, cultural and historical aspects of complementary, alternative,
unconventional and integrative medicine in the Old World.
Arch Dermatol.
1998;134(11):1373–1386.
STO-RTG-TR-HFM-195
2 - 15
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0081.png
ENTER CLASSIFICATION
HISTORICAL AND CULTURAL PERSPECTIVES OF IM
[26]
325.
[27]
[28]
[29]
Prioreschi P. Alternative medicine in ancient and medieval history.
Med Hypotheses.
2000;55(4):319-
Qiu XI.
Chinese Acupuncture and Moxibustion.
New York: Churchill Livingstone; 1993.
Rahman HS.
Arab Medicine During the Ages.
Stud Hist Med Sci.
1996;XIV(1-2):1-39.
Rhodes P.
An Outline History of Medicine.
Oxford, UK: Butterworth-Heinemann; 1985.
Smith TC, Ryan MA, Smith B, et al. Complementary and alternative medicine use among US Navy
[30]
and Marine Corps personnel.
BMC Complement Altern Med.
2007;16;7:16.
[31]
Thakkar GK. History of Shivambu. In: Thakkar GK. Author.
Shivambu Gita: Which Can Bestow
upon you New Life.
Mumbai: Shree Nagesh Mudranalaya; 1996:41–47.
[32]
Trotter RT, Micozzi MS. Latin American Curanderismo. In: Micozzi MS.
Fundamentals of
Complementary and Alterative Medicine. 5
th
ed.
St. Louis, MO: Elsevier Saunders; 2015:667-73.
[33]
van der Kroon C.
The Golden Fountain The Complete Guide to Urine Therapy.
Mesa, AZ: Wishland
Publishing, Inc.; 1996.
Voss RW, Moerman DE, Micozzi MS. Native North American Healing and Herbal Remedies. In:
[34]
Micozzi MS.
Fundamentals of Complementary and Alterative Medicine. 5
th
ed.
St. Louis, MO: Elsevier
Saunders; 2015:623-38.
[35]
White MR, Jacobson IG, Smith B, et al. Health care utilization among complementary and alternative
medicine users in a large military cohort.
BMC Complement Altern Med.
2011;11:27.
Wong KC and Wu L-T. Chinese Medicine Series 6. History of Chinese Medicine, 2
nd
edition. Taipei:
[36]
Southern Materials Center, Inc. 1985. Pp. 162-163.
Zysk KG. Medicine and Buddhist Monasticism. In: Zysk KG. author.
Asceticism and Healing in
[37]
Ancient India: Medicine in the Buddhist Monastery, rev. ed.
Oxford, UK: Oxford University Press; 1988:38-
49.
2- 16
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0082.png
ENTER CLASSIFICATION
Chapter 3– Overview of Integrative Medicine Practices and Policies in
NATO Participant Countries
Gabriella HEGYI, MD, PhD, MSc
Professor of CAM and Dietary Department
Pécs University Medical School
Health Science Facility
TCM Confucius Institute at Pécs University
Leader of Professional, Strategy and Development
Pécs, 7621. Vörösmarty u4.
Head of Yamamoto Institute
Budapest Training Field
1196 Budapest, Petőfi u.79
Phone: 00 36 309225347
Fax: 00 36 12813035
[email protected]
Richard P. Petri, Jr., M.D., FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
Paolo Roberti di Sarsina, MD
Observatory and Methods for Health
University of Milano-Biocca
Milano, Italy
Charity for Person Centered Medicine
Moral Entity
Bologna, Italy
Expert for Non-Conventional Medicine (2006-2013)
High Council of Health
STO-RTG-TR-HFM-195
3-1
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0083.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
Ministry of Health
Phone: 00 39 3358029638
[email protected]
[email protected]
Richard C. NIEMTZOW, MD, PhD, MPH
COL (ret) USAF, MC, FS
United States Air Force Acupuncture and Integrative Medicine Center
Director
Malcolm Grow Medical Clinic and Surgery Center
79
th
Medical Group
1050 West Perimeter Road
Joint Base Andrews, Maryland 20762
Phone: +1 (619) 647-7274
[email protected]
ABSTRACT
CAMbrella is a European research network for complementary and alternative medicine (CAM). Between
January 2010 and December 2013 the CAMbrella consortium reviewed the status of CAM in Europe from the
perspectives of: (1) terminology for description; (2) citizens' needs and expectations; (3) patients' usage
patterns; (4) providers' practice patterns; and (5) regulatory and legal status in Europe. Together, this data was
used to form a set of recommendations to the European Commission, the European Parliament, and national
policy makers and civil society stakeholders. These recommendations can serve as a roadmap for European
CAM research. This article aims to inform the reader about CAM prevalence, usage perspectives, and the
future roadmap for CAM practices and research within the European Union. Further, the North Altantic Treaty
Organization is positioned as a potential foundation for inclusion of CAM modalities within the militaries as
well for as collaborative research on safe and cost-effective practices.
KEYWORDS
CAM, CAMbrella Pan-European Project, Legislation of CAM, Survey on Members of eU, Regulation, Usage of
CAM, Reimbursement, Provider Perspective
3.1 INTRODUCTION
“Everyone has the right to benefit from any measures enabling [him or her] to enjoy the highest
possible standard of health attainable.”
—European Social Charter adopted by the Council of Europe
(1961 revised 1996)
[6]
Complementary and alternative medicine (CAM) represents a heterogeneous group of medical practices, often
considered to be non-conventional. The public use of these modalities has been increasing over the past several
decades [2], [3], [4], [9], [10], [15], [27]. In 2004, The European Federation for Complementary and Alternative
Medicine (EFCAM) was founded to serve as a forum for specific CAM modalities as well as for national CAM
3- 2
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0084.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
umbrella organizations. The principal objective of the EFCAM is to ensure equal access to CAM modalities
throughout Europe. The EFCAM states “CAM's particular strength is the combination of individualised holistic
care, capacity to provide health maintenance, illness prevention and non-invasive illness treatment as part of an
integrated package” [12].
In 2009, the European Commission requested an evaluation of the status of CAM within Europe. The resulting
coordination project, the CAMbrella Consortium, was formed with sixteen institutions from twelve European
countries (Figure 3-1). The Consortium addressed the following areas: (1) the definition of CAM; (2) the
prevalence of CAM usage; and (3) the attitudes of providers and patients regarding CAM. CAMbrella developed
nine work packages and recommended six core areas, as a roadmap for the potential contribution of CAM for
health care needs in the European Union.
Figure 3-1. CAMbrella Consortium Organization. Regional distribution and major expertise of the
CAMbrella project partners. WP, work package; CAM, complementary and alternative medicine;
WHO, World Health Organization; EU, European Union. Reprinted with permission from © S. Karger
AG. Source: Weidenhammer et al., 2011.
There is much debate surrounding CAM also known as Integrative Medicine (IM). The status of CAM in Europe
is characterized by enormous heterogeneity in all aspects, including terminology used, methods provided,
prevalence, and national legal status and regulation [11]. As such, there is no commonly accepted definition for
CAM. There have been numerous efforts to define CAM. The U.S. National Center for Complementary and
STO-RTG-TR-HFM-195
3-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0085.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
Alternative Medicine (NCCAM) once defined CAM as “a group of diverse medical and health care systems,
practices and products that are not generally considered part of conventional medicine” [21]. Thus, once a
practice modality is accepted as a conventional medicine modality, it is no longer considered to be CAM.
Therefore, the list of CAM modalities changes, as the modalities become accepted conventional medicine
modalities. To add to confusion, the terms
complementary and alternative medicine, complementary medicine,
alternative medicine, integrative medicine,
and
integrative health and healing
are often used interchangeably.
The CAMbrella consortium reviewed numerous sources for the definition of CAM and selected the World
Health Organization's (WHO) definition of traditional medicine as the basis for a pan-European definition.
CAMbrella defines CAM as
“a variety of different medical systems and therapies based on the knowledge, skills and practices
derived from theories, philosophies and experiences used to maintain and improve health, as well as to
prevent, diagnose, relieve or treat physical and mental illness. CAM has been mainly used outside
conventional health care, but in some countries certain treatments are being adopted or adapted by
conventional health care” [14].
Adding to the difficulty in defining CAM, differences exist from country to country regarding what modalities
are considered to be part of CAM. As an example, spiritual healing is considered to be a CAM modality within
the United States and is included as a Medical Subject Heading (MeSH); however, this modality is excluded
from the European definition of Spiritual practices because of the history of CAM within Europe.
Because there is no widespread acceptable definition of CAM and the modalities of medicine that contribute to
it, this may have a negative impact on clinical practices, patient and provider perspectives, and research
endeavors, especially research on collaborative efforts between CAM and conventional medicine practices.
3.2 NEEDS AND EXPECTATIONS REGARDING CAM
Europe, like the rest of the world, faces a growing number of health care challenges. The aging population has
resulted in a transformation of health care from care for acute illness to that of chronic disease management. The
increasing development of technology and medications, coupled with the demand for their implementation,
among other factors, has resulted in ever escalating health care costs and budgets. In addition, patients are
searching for services that are consistent with personal beliefs as well as approaches that offer best results for
health. CAM may offer solutions to these challenges as innovative and cost/health-added values for health care
in Europe.
3.3 COMPLEMENTARY AND ALTERNATIVE MEDICINE UTILIZATION IN THE
EUROPEAN UNION
The prevalence of CAM utilization across the European Union is unclear. The CAMbrella consortium performed
a systematic literature review on the subject. The group reviewed 87 general population studies on CAM
utilization and concluded that the quality of reporting was poor. CAM use varied widely, with country variations
from 0.3% to 86% (Table 3-1). In addition, there were only available data from fourteen of the thirty-nine
European Union states. Therefore, making determinations on utilization based on population demographics was
not possible. However, it was possible to report on the data descriptively. Herbal medicine was the most
commonly reported CAM modality, followed by homeopathy, chiropractic, and acupuncture and reflexology
(Table 3-2).
3- 4
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0086.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
Country
Denmark
Finland
France
Ireland
Germany
Israel
Italy
Netherlands
Norway
Poland
Portugal
Slovenia
Spain
Sweden
Switzerland
Turkey
UK
Prevalence Rates %
45-59
11-43
21
15
4.6-62
5-43
16-84
17.2
9-53
14.4
43.7
6.6
15-47
5-64
5-57
48-86
0.3-71
Table 3-1. Prevalence of CAM in the EU
Therapy
Herbal
Homeopathy
Chiropractic
Acupuncture
Reflexology
Prevalence Rates %
5.9-48.3
2-27
0.4-28.8
0.44-23
0.4-21
Table 3-2. Top Five Most Commonly Reported CAM Therapies in the EU
Patients' use of CAM modalities varied. Patient dissatisfaction with conventional medicine was the most
common reason for using CAM. Other reasons for the use of CAM included associated side effects of
medications, preference for natural treatments, and a therapeutic alliance with CAM providers [8]. The
CAMbrella study supported the study by the NCCAM, which showed that CAM is most often used for
musculoskeletal conditions [8], [21]. The European Information Centre for Complementary and Alternative
Medicine suggests that more than 100 million European Union citizens are regular users of CAM, largely for
addressing chronic conditions [13]. EFCAM reports that
“between 20% and 80% of citizens in different EU countries have used CAM in their health care. They
want to choose the therapeutic approach that they consider will produce the best result for their health,
whether it is to maintain good health and to prevent illness, or to alleviate a health problem, and whether
that belongs to conventional medicine or to CAM [12].
STO-RTG-TR-HFM-195
3-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0087.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
The therapeutic spectrum of diseases seen in CAM practice differs from those seen in conventional practice.
This conclusion cannot be drawn from the statements of numerous CAM organizations, but arises from
systematic investigations of users and physician providers, such as the PEK [Programm Evaluation
Komplementärmedizin] performed in Switzerland [19]. Patients with chronic diseases that are mostly resistant
to conventional therapies tend to choose CAM therapies (e.g., symptom control for cancer, pain, psychosomatic
illness, and musculoskeletal conditions, as well as women with specific gynecologic problems, such as menstrual
difficulties, pregnancy-related complications, and menopause, and for their children, who often have self-
limiting minor problems [29].
Health care costs/budgets and patient-covered benefits have an effect on the use of CAM. Within the European
Union, access to CAM is often limited to patients who can pay for it. In the United Kingdom, it was shown in
1998 that 90% of CAM provision is purchased privately [25]. The effect of health care costs on national budgets
threatens the health care system and sustainability. Health care costs are > 17% of the gross national product
(GNP) in the United States and are expected to rise to nearly 20% of the GNP by 2025 [5]. Within the European
Union, CAM may count for ≤ 10% of service, sales, and market of the GNP in the European Union. Therefore,
globally, health care costs and utilization of CAM modalities have significant economic and social impacts.
Therefore because CAM can be a lower-cost modality, CAM may have a significant impact on national budgets.
Thus, shifts from this inequitable access, chronic disease management, and increasing costs are required. The
sustainability of health care services is at stake. The shift needs to be toward promotion and prevention of illness,
more cost-effective treatments, and manageable costs. Although more data are required, CAM treatments and the
CAM provider workforce may contribute to this needed shift [12].
3.4 PROVIDERS' PATTERNS
It is difficult to identify provider numbers within the European Union because of CAM's varying legal status
from country to country. CAMbrella reviewed various CAM societies in the European Union and crosschecked
the results with available governmental data. CAMbrella reported that there are ≈ 305,000 registered CAM
providers in the European Union. The breakdown is as follows: ≈145, 000 medical doctors (MDs) and ≈158, 000
non-medical practitioners. Comparatively, this translates to 65 CAM providers per 100,000 inhabitants versus 95
MD general practitioners (GPs) per 100,000 inhabitants. The number of practitioners in the top five CAM
methods were acupuncture (96,380), homeopathy (50,300), herbal medicine (29,000), reflexology (24,600) and
naturopathy (22,300). See Table 3-3 for data on the top 15 CAM methods [29]. MDs dominate the fields of
acupuncture and homeopathy whereas non-medical practitioners, by self-declaration, almost exclusively provide
herbal medicine and reflexology. Anthroposophic medicine has very few non-MDs and neural therapy is
practiced only by MDs. Although CAM is predominantly provided privately there is evidence that, at least in
some countries, CAM is provided collaboratively with conventional practitioners. According to the European
Federation for Complementary and Alternative Medicine, CAM practitioners “offer a whole person approach to
health with a focus on supporting the person's health-maintaining capacities and within which illness is treated
according to the distinct diagnostic and treatment methods of the modalities used” [12]. This statement was
independent of whether the CAM treatment was offered as a stand-alone method or was complementary with
conventional medicine [12].
3- 6
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0088.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
MDs + non-
medical
practitioners
Therapists
per 100'000
Inhabitants
CAM discipline
Non-medical
practitioners
MDs
(Physicians)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
Acupuncture
Individual homeopathy
Herbal medicine/ phytotherapy
Reflexology
Naturopathy
Antihomotoxicology
Humoral/drain-off therapy
Kinesiology
Shiatsu- massage therapy
Orthomolecular therapy
Manual therapies
Anthroposophic medicine
Oxygen/ozone therapy
Kneipp therapy (GER)
Neural therapy (Huneke)
Total
16‘380
4‘500
29‘000
24‘600
7‘300
20‘000
17‘000
7‘600
7‘400
7‘000
4’900
(GER: 20)
3‘000
2‘500
---
≈
158‘000
80‘000
45‘000
??
??
15‘000
10.000
?
??
?
2000
500
4‘500
??
500
1‘500
≈
145‘000
96‘380
50‘300
>29‘000
>24‘600
22‘300
>20‘000
>17‘000
> 7‘600
> 7‘400
> 7‘000
> 5’000
4‘500
> 3‘000
> 2‘500
1‘500
≈
305‘300
21
11
6.5
5.5
5.0
4.5
3.8
1.7
1.7
1.5
1.2
1.0
.6
.5
.3
65
Table 3-3. Most Frequently Provided CAM Disciplines in the EU 27+12 (by End of 2010) [29]
Reporting of CAM varies within the European Union. Geographically, the best data acquisition was possible for
MDs in northern and central Europe with limited provision in the south more than the north and the east more
than the west. Individual therapists using multiple provisions of CAM disciplines may contribute to the reporting
bias. As an example, in Switzerland, 1665 individually counted therapies were reported as being provided by
995 non-medical Traditional Chinese Medicine practitioners. As a result, CAMbrella was unable to include
30,410 practitioners in 26 countries practicing acupuncture and Chinese herbal medicine.
3.5 COMPLEMENTARY MEDICINE AND MEDICAL EDUCATION
The fact that there is increasing demand for availability of, and accessibility to, CAM modalities and an
acceptance of CAM in public health care systems of the world, CAM or IM needs to become a part of
undergraduate and postgraduate medical education [16]. However, there are sparse data on the CAM training
for providers in the European Union. Furthermore, there are substantial variations in the professional
backgrounds of identical CAM providers across the European Union. In 1986, Wharton and Lewith assessed the
attitudes of GPs regarding CAM. This study showed that about “38% of GPs had received some training in
CAM and about 10% had completed specialist training in complementary medicine. Further approximately 15%
desired to acquire CAM skills’ [30]. Steiner and Wegman founded the concept of anthroposophic medicine
(AM), a medical approach incorporating both conventional and complementary medicine in the 1920s [23].
Anthroposophic hospitals exist within the public health care systems in Germany and Switzerland and offer
STO-RTG-TR-HFM-195
3-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0089.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
postmedical education in individual holistic medicine treatments. In Europe, there are > 2000 AM trained
physicians; worldwide AM physicians practice exists in 56 countries [1].
3.6 PROVIDERS' PERSPECTIVES ON CAM
Despite the lack of significant CAM education, medical providers nonetheless use CAM modalities in their
practices. In the Wharton and Lewith study of providers' perspectives, it was shown that 59% of doctors (GPs)
thought that the complementary techniques being assessed were useful to their patients: 76% had referred
patients for this type of treatment over the past year to medically qualified colleagues and 72% had referred
patients to non-medically qualified practitioners. These researchers concluded that the GP views were influenced
positively by the observed benefit to their patients (41%) and personal or family experiences of benefit (38%)
[30]. Other studies support Wharton and Lewith's findings. Déglon-Fischer et al. queried 750 Swiss primary
care physicians regarding CAM in their practices. The researchers found that 14.2% of the physicians were
qualified in at least one CAM discipline while 62.5% referred their patients to CAM providers [7]. Three-
quarters of British fund-holding GPs want complementary medicine available through the National Health
Service, particularly osteopathy, acupuncture, chiropractic, and homeopathy [20].
3.7 STATUS OF CAM RESEARCH IN THE EUROPEAN UNION
Barriers to the integration of CAM within conventional medicine often have foundations in the lack of sufficient
scientific evidence. Clinically relevant publications were very scarce. Eight peer-reviewed papers dealing
primarily with clinical European CAM provision were identified in the last decade: Joos et al. [17], Déglon
Fischer et al. [7], van Haselen et al. [28], Thomas et al. [24], [25], Lewith et al. [18], Schmidt et al. [22] and
Thomas et al. [25]. CAM research in Europe is not well funded by the countries or research organizations,
unlike CAM research in the United States. Much of European CAM research is charitably supported. Often,
conventional medicine research receives award monies, resulting in limited research funds that must be
competed for. The impact of limited CAM research on the decision-making processes regarding CAM practices
cannot be understated. CAM research needs to be advanced, with national and international organizations in
order to achieve a systematic and unbiased view of the cost-effectiveness of CAM so as to allow integration of
CAM with conventional medicine.
3.8 IMPACT OF CROSSBORDER VARIATIONS
When practitioners cross borders, these practitioners encounter substantial variations in CAM practices within
Europe. This raises serious concerns with regard to the predictability, quality, and safety of health care delivery
to European citizens. When CAM professions in some countries are tightly regulated, while the same
professional categories in other countries are totally unregulated, an establishment of collegial common ground
is very challenging. When researchers cross borders these researchers find that research on efficacy and
effectiveness of CAM is hampered severely by the conglomerate of European regulations. Practices and
practitioners are not comparable across national boundaries, and any observational or experimental study will
therefore be generalizable only within a narrow national or cultural context.
3.9 REGULATORY AND LEGAL STATUS OF CAM IN EUROPE
There is no unifying legislative consensus of non-conventional practices within the European Union. In fact,
there seems to be two distinct streams of thought that are in conflict with each other. One concept is that only
3- 8
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0090.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
medical professionals (MDs or comparable to MDs) are entitled to practice health care and treat illnesses. The
other concept allows for anyone with a desire to practice health care to do so. This can cause significant
problems leading to unequal treatments for European citizens.
In fact, various European Union treaties have established repeatedly that health policies are national
responsibilities for the member states, even if several European Union directives, regulations, and resolutions
influence how member states organize their national health policies and services. The crossborder health care
directive of the European Parliament in 2011 respected the established differences in national health care
systems [31]. The aim of the directive was to remove obstacles to the fundamental freedom of patients to choose
health care across borders. This could potentially also include CAM treatments in countries where CAM
treatment is included in the public health services. Regional collaboration among providers, purchasers, and
regulators from the different member states can ensure safe, high-quality, and efficient crossborder health care at
regional levels. Historical and cultural similarities between neighboring countries would thus seem to have the
best chance to facilitate crossborder opportunities in the CAM area more than European Union–wide directives,
regulations, and decisions [32].
CAM treatment is either unregulated or regulated within the framework of the public health systems. The only
commonality across the European Union is that structuring legislation and regulation differs in each country. A
review of the policies of thirty-nine countries was performed. Of those thirty-nine countries, nineteen have
general CAM legislation, eleven have specific CAM laws, and six have sections on CAM included within their
health laws, such as “law on health care” or “law on health professionals.” Detailed information regarding the
European Union counties is presented in the CAMbrella deliverable report [31].
A review of twelve treatment modalities showed considerable variation as well. Acupuncture and chiropractic
are regulated in twenty-six countries, homeopathy in twenty-four countries, massage in twenty countries,
osteopathy in fifteen countries, traditional Chinese and herbal/phytotherapy medicine in ten countries,
naturopathy in eight countries, anthroposophic medicine in seven countries, Ayurveda in five countries, neural
therapy in three countries, and, finally, naprapathy in two countries. Regulation of practice is in general mostly
tied to formal education and/or training in conventional or non-conventional medicine. Regulated providers of
CAM are usually identified as: (1) MDs; (2) health professionals; or (3) non-conventional practitioners. The
latter category can include individuals with little or no medical training. Germany, Switzerland, and
Liechtenstein have established the title of
Heilpraktiker
or
Naturheilpraktiker
or health practitioner [31].
3.10 HARMONIZATION OF REGULATIONS FOR INCREASED PATIENT
SAFETY
Patient choice in health care is seen as a core value within Europe and is reflected in the diversity in CAM
legislation/regulations. Varied and inconsistent provider backgrounds makes seeking informed treatments very
challenging. Predictable and safe health care is a necessary requirement for patient care. Across Europe,
conventional medicine is predictable enough because of the passage of various directives. This is not the case
with CAM practices. The harmonization of CAM legislation and regulations may be an important step forward
for wider acceptance of CAM within the medical communities.
In principle, there are two options for achieving a higher degree of harmonization: (1) legislation and regulation
at the European Union and European Economic Area (EU/EEA) level or (2) voluntary harmonization. It is
unlikely that there will be EU/EEA level legislation/regulation in the foreseeable future because the European
Union has repeatedly upheld its position of leaving this to the individual country. Voluntary harmonization is,
STO-RTG-TR-HFM-195
3-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0091.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
however, possible within current legislation. The successful mutual recognition of physiotherapists across
Europe shows how this can be done and could be a potential template for development of harmonized regulation
also of CAM professions in Europe (Figure 3-2). As such, physiotherapists have few obstacles when they move
from one country to another. Furthermore, patients are ensured that physiotherapists across the European Union
have similar backgrounds and experience [31].
Figure 3-2.
Regulation of physiotherapy within the European Union (EU). Reprinted with
permission from © Bruce Jones Design, Inc. 2006.
3.11 DISCUSSION
The difficulty in evaluating complementary medicine across the European Union is multifactorial and is as
complex as the differences between the countries. Despite this, some general comments can be made. Health
care systems are being jeopardized largely because of escalating health care costs and budgets compounded by
the shift from acute care to chronic disease management. Furthermore, patients are increasingly dissatisfied with
conventional medicine. Therefore, patients as well as providers perceive CAM as a viable option to meet these
challenges.
The data on CAM utilization across the European Union is unclear as a result of varying education standards,
regulatory differences, and reporting mechanisms. However, it is clear that the population is using CAM and that
it is either used alone or in conjunction with conventional medicine. CAM is used to address many conditions
3- 10
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0092.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
and problems; most commonly and consistently across various countries, it is used to treat musculoskeletal
issues. In addition, patients are seeking treatments that are consistent with these patients' beliefs about health and
health care. At times, this is contradictory to the established medical communities' point of view. Therefore, the
goal needs to be cooperation and a desire to develop a new system that blends aspects of conventional medicine
with CAM to optimize health care delivery and the health of the population. The net results will be greater
patient and provider satisfaction and less strain on national budgets, with lower health care costs as well as a shift
from disease management to health maintenance.
3.12 CONCLUSIONS
CAM is leading to a rethinking of our current health care systems, albeit this is contentious at times. CAM
potentially offers a system of cost-saving, low-risk treatments that can be used in conjunction with conventional
medicine. However, there are numerous problematic areas within CAM that need to be addressed before it will
achieve wide acceptance.
First, a universally acceptable definition of the CAM terminology is needed. This lack of consistency makes
evaluation of CAM methods and modalities nearly impossible. Thus, common language would assist
collaborative partnerships, evaluations, and research endeavors to improve health care delivery systems. The
overall net effect could be a healthier population with better outcomes and patient satisfaction.
Second, there needs to be common regulations regarding provision of care, credentialing of providers, and
educational standards. In areas with little-to-no regulations, CAM providers exist with little or no medical
education. This can lead to CAM being vulnerable to the claim that CAM is nothing more than quackery.
Consistent regulations in all areas will elevate the field of CAM so that there is greater acceptability within the
established medical community; a community that often dictates policy and budgets.
Finally, collaborative research efforts in CAM modalities are necessary. Cost-effectiveness research of
individual CAM modalities as well as combined treatment plans of CAM with conventional medicine should be
emphasized.
Each area listed is pivotal to the success of the others. The ultimate goal for the medical community must be the
health of the population—locally, regionally, and globally. It is necessary to put all “egos” aside and reevaluate
the status quo of our current systems. Only when all work together will it be possible to improve health care to
one of caring for health.
3.13 RECOMMENDATIONS
There is worldwide interest and positive attitudes regarding CAM. Patients are pushing health systems to be
holistic, cost-effective, and patient-centered. CAM practices are multicultural and, therefore, international
partnerships are required. The North Atlantic Treaty Organization (NATO) medical communities can serve as
an outstanding foundation for these partnerships. Effective and safe therapies can be officially introduced in
NATO military systems. NATO-sponsored, collaborative, international, and crosscultural research on
improved performance, improved mental–psychologic–emotional well-being, and budget-reducing treatments
needs to be conducted. The high degree of receptivity suggests the need for both faculty training for MDs
working in the military systems as well as in curriculum development.
STO-RTG-TR-HFM-195
3 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0093.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
3.14 REFERENCES
[1]
Anthroposophic medicine in brief: Facts and Figures. International Federation of Anthroposophical
Medical Associations; 2005. Retrieved at
http://www.ivaa.info/IVAA_new/factsheet.htm.
Retrieved on 12
November 2014.
Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among
adults: United States, 2002.
Adv Data.
2004 May;(343):1-19.
Bodeker G, Ong CK, Grundy C, Burford G Shein K.
WHO Global Atlas of Traditional, Complementary
and Alternative Medicine.
WHO Kobe Centre World Health Organization; 2005.
Bücker B, Groenewold M, Schoefer Y, Schäfer T. The use of complementary alternative medicine (CAM)
in 1001 German adults: results of a population-based telephone survey.
Gesundheitswesen
2008;70(8-
9):e29–36.
Centers for Medicare & Medicaid Services (2013)
National Health Expenditure Projections 2013-2023
Forecast Summary
CMS, Baltimore, MD Retrieved from
http://www.cms.gov/Research-Statistics-Data-
and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2013.pdf
Retrieved on 2 Feb 2014.
Council of Europe http://conventions.coe.int/treaty/en/treaties/html/163.htm 30 April 2014.
Déglon-Fischer A, Barth J, Ausfeld-Hafter B. Complementary and alternative medicine in primary care in
Switzerland.
Forsch Komplementmed
2009 Aug:16(4):251-5.
Eardley S, Bishop F, Prescott P, et al. A Systematic Literature Review of Complementary and Alterative
Medicine Prevalence in EU.
Forschende Komplementarmedizin
2012;19(suppl 2);18-28.
Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-
1997: results of a follow up national survey.
JAMA.
1998;280(18):1569-1575
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco Tl. Unconventional medicine in
the United States: Prevalence, costs, and patterns of use.
N Engl J Med.
1993 Jan;328(4):246-52.
[11] European Commission (2012)
Final Report Summary – CAMbrella (A pan-European research network for
complementary and alternative medicine (CAM)
(Cordis) Germany: Cordis. Retrieved from
http://cordis.europa.eu/result/rcn/57185_en.htmlhttp://cordis.europa.eu/result/rcn/57185_en.html.
2
December 2014.
[12] European Federation for Complementary and Alternative Medicine (EFCAM).
www.efcam.eu.
4 April
2014.
[13] European Information Centre for Complementary & Alternative Medicine (2008)
EICCAM Brochure
EICCAM, Brussels, Belgium Retrieved from
http://www.eiccam.eu/pdfs/eiccambrochurecomplete.pdf
Retrieved 8 Aug 2014.
[14] Falkenberg T, Lewith G, di Sarsina P et al. Towards a Pan-European Definition of Complementary and
3- 12
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0094.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
Alternative Medicine – a Realistic Ambition?
Forschende Komplementarmedizin
2012;19(suppl 2);6-8.
[15] Härtel U, Volger E: Use and acceptance of classical natural and alternative medicine in Germany–findings
of a representative population-based survey.
Forsch Komplementarmed Klass Naturheilkd.
2004;11:327–
334.
[16] Heusser P, Eberhard S, Berger B, Weinzirl J, Orlow P. The subjectively perceived quality of postgraduate
medical training in integrative medicine within the public healthcare systems of Germany and Switzerland:
the example of anthroposophic hospitals.
BMC Complement Altern Med
2014 Jun;14:191.
[17] Joos S, Musselmann B, Szecsenyi J. Integration of Complementary and Alternative Medicine into Family
Practices in Germany: Results of a National Survey.
Evidence-Based Complementary and Alternative
Medicine?: eCAM,
2011, 495813.
http://doi.org/10.1093/ecam/nep019.
[18] Lewith G, Aldridge D, eds.
Complementary Medicine and the European Community.
Saffron Walden, UK,
CW Daniel Company Ltd.; 1991:1–160.
[19] Melchart D, Mitscherlich F, Amiet M, Eichenberger R, Koch P.
Programm Evaluation
Komplementärmedizin (PEK)
(2005) Schlussbericht, Bern, Switzerland Retrieved from
http://www.bag.admin.ch/themen/krankenversicherung/00263/00264/04102/index.html?lang=de
Retrieved
10 Aug 2014.
[20] National Association of Health Authorities and Trusts Research.
Complementary therapies in the NHS.
[Paper 10].
Birmingham: NAHAT, 1993.
[21] National Center for Complementary and Alternative Medicine (2012) NCCAM Publication
No. D347.
CAM Basics What Is Complementary and Alternative Medicine?
(NCCAM), Bethesda, MD: NCCAM
Retrieved from
http://nccam.nih.gov/health/whatiscam
Retrieved 15 Jul 2014.
[22] Schmidt K, Jacobs PA, Barton A. Cross-cultural differences in GPs' attitudes towards complementary and
alternative medicine: a survey comparing regions of the UK and Germany.
Complement Ther Med.
2002;10:141–147.
[23] Steiner R, Wegman I.
Extending practical medicine Fundamental principles based on the science of the
spirit.
Bristol, UK: Rudolf Steiner Press; 2000. pp. 1–144.
[24] Thomas KJ, Coleman P, Weatherley-Jones E, Luff D. Developing integrated CAM services in primary
care organisations.
Complement Ther Med.
2003;11:261–267.
[25] Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on complementary medicine in England: a
population based survey.
Complement Ther Med.
2001 Mar;9(1):2-11.
[26] Thomas KJ, Nicholl JP. Trends in access to complementary or alternative medicines via primary care in
England: 1995-2001 results from a follow-up national survey.
Fam Pract.
2003;20:575–577.
[27] Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in Use of Complementary and Alternative
Medicine by US Adults: 1997-2002.
Altern Ther Health Med.
2005 Jan-Feb;11(1):42-49.
[28] van Haselen RA, Reiber U, Nickel I, Jakob A, Fisher PAG. Providing Complementary and alternative
STO-RTG-TR-HFM-195
3 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0095.png
UNCLASSIFIED
INTEGRATIVE MEDICINE IN NATO COUNTRIES
medicine in primary care: the primary care workers' perspective.
Complement Ther Med.
2004;12:6.
[29] von Ammon K, Cardini F, Daig U, et al. (2012)
Health Technology Assessment (HTA) and a map of CAM
provision in the EU Work package No. 5 Deliverable D6 – updated
Retrieved from
https://phaidra.univie.ac.at/detail_object/o:300096
Retrieved 8 Aug 2014.
[30] Wharton R, Lewith G. Complementary Medicine and the General Practitioner.
BMJ
1986
Jun;292(6534):1498-1500.
[31] Wiesener S, Torkel F, Hegyi G, et al. (2012)
Legal status and regulation of CAM in Europe Part I - CAM
regulations in the European Countries.
Retrieved from
https://phaidra.univie.ac.at/detail_object/o:291583
Retrived 8 Aug 2014.
[32] Wiesener S, Torkel F, Hegyi G, et al. (2012)
Legal status and regulation of CAM in Europe Part II - CAM
regulations in EU/EFTA/EEA.
Retrieved from
https://phaidra.univie.ac.at/detail_object/o:291585
Retrived
8 Aug 2014.
3- 14
PUB REF NBR (e.g. STO-TR-IST-999)
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0096.png
UNCLASSIFIED
Chapter 4 – INTEGRATIVE MEDICINE EXPERIENCE IN THE
UNITED STATES DEPARTMENT OF DEFENSE
Richard P. PETRI, Jr., MD, FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
Roxana E. DELGADO, Ph.D., M.S.
Senior Research Associate
Samueli Institute
1737 King St., Suite #600
Alexandria, VA
USA
Phone +1 (703) 408-6234
[email protected]
ABSTRACT
Over the past fifteen years, the use of Complementary and Alternative Medicine (CAM) services, currently
described as Integrative Medicine (IM), has continued to rise in the United States. The trends seen in the
civilian population are mirrored within the United States Military. This article describes the change in the
prevalence of Integrative Medicine Services, budgeting of those services as well as on-going research in
Integrative Medicine within the Department of Defense Medical Treatment Facilities from 2005 through 2009.
The Deputy Chief of Clinical Services (DCCS) or Service equivalent was contacted at 14-selected Defense of
Department (DoD) Medical Treatment Facilities (MTF). Comprehensive structured telephone interviews were
conducted using a formatted 20-item questionnaire. The questionnaire design was of a mixed model with open
and closed formats as well as dichotomous yes/no questions. The initial survey was conducted in 2005 with a
follow-up survey conducted in 2009. Survey results showed there has been a steady increase in the number of
Integrative Medicine services available in the DoD Medical Treatment Facilities from 2005 through 2009.
Acupuncture, biofeedback, nutritional counseling and spiritual healing were the most prevalent Integrative
STO-TR-HFM-195
4-1
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0097.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
Medicine services in 2009. Funding sources changed from central funding (Offices of the Surgeon General) to
Congressional and local funding. It is essential that the DoD medical community provides safe and effective
treatments by providing oversight of Integrative Medicine services, collaboration of research, credentialing of
practitioners and the establishment of educational programs.
KEYWORDS
Complementary Therapies/utilization, alternative medicine, integrative medicine, prevalence, utilization,
Department of Defense, questionnaires, comparative study, military personnel/statistics and numerical data
4.1 INTRODUCTION
Health care has continued to evolve, change, and grow over the past several decades. Some of these changes
have been patient driven. People are turning to “alternative medicine” for treatment because the current model
of care is not meeting their needs. The prevalence of CAM use has increased since it was first studied in the
early 1990’s. In studies by Eisenberg et al the usage of CAM services among the general US population has
increased from 33.8% in 1990 to 42.1% in 1997 [5] and 62% in 2002 [18]. The National Health Interview
Survey (NHIS) reported similar findings with an increased prevalence of 31% over the eight year period studied
(28.9% increased to 38% from 1999 until 2007) [2]. Eisenberg also reported that the number of visits to non-
traditional providers in the United States has exceeded the number of visits to all primary care providers.
Further, Americans are willing to pay more out-of-pocket for CAM treatments than for out-of-pocket
hospitalizations [6].
The trends in the United States Military mirror those reported in the civilian medical settings. A study at
Madigan Army Medical Center showed that 81% of active duty soldiers, retirees and family members used one
or more CAM services, with 69% requesting such services be offered at the Military Treatment Facility (MTF)
[13]. Further, a study of US Navy and Marine Corps personnel showed that 37% of the personnel have used one
or more CAM services. Herbal therapies were the most common reported [17].
The Department of Veteran Affairs (VA) population is similar to that of the DoD. The Department of Veterans
Affairs Technical Advisory Group (TAG) in collaboration with the HAIG (Healthcare Analysis & Information
Group) surveyed all of the VA facilities in 1998 and 2011. Their report showed 88% (125/141) of the Veterans
Health Administration (VHA) facilities use CAM services either on site or by referral. The final conclusions of
the HAIG study questioned the direction and the goals of the medical care including CAM provider
qualifications, evidence based research and oversight. These observations were noted in 2011 as well as
guidance on documentation, privileging, credentialing and Veterans interest and utilization of CAM services
[11], [3].
There are numerous studies that evaluate the usage of CAM among military beneficiaries and their perspective
on CAM vs. convention medicine [7], [8], [9], [1], [10], [19]. One such study performed at the Southern Arizona
VA Health Care system, showed that the use of CAM was not necessarily associated with conventional care
overall but rather a few very specific areas. These included prescription side effects, lack of preventive medicine
and emphasis on nutrition and exercise and the desire to have a more holistic health care plan [12].
Commercial bombardment of promises of euphoric lives, better and trims bodies as well as pain free-living fuels
the demand. Although there has been an increasing body of research, there is much to be learned regarding
Complementary and Alternative Medicine’s (CAM) safety and efficacy. The former National Center for
4-2
STO-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0098.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
Complementary and Alternative Medicine (NCCAM) defined CAM as group of diverse medical and healthcare
systems, practices, and products that are not presently considered to be part of conventional medicine.
Integrative Medicine (IM) refers to the practice that combines both conventional and CAM treatments for which
there is evidence of safety and effectiveness [14]. Recently, the NCCAM changed its name to National Center on
Complementary and Integrative Health to better reflect the evolution in medicine.
This increasing trend in usage and the willingness to pay out of pocket has prompted the medical community to
react. It is incumbent upon us as a medical community to guide patients to make intelligent decisions about their
health and medical care. If we do not engage and provide some oversight, patients have shown that they will
seek out alternative treatments without our input.
Often the United States Military Healthcare system (MHS) has been on the forefront of medical advancements
such as air evacuation, trauma care, hemostasis and hemorrhage control as well as prosthetics technology. Often
this has been the result of an urgency to meet the needs of our battle injured. The Military is taking a lead in IM
as well. In 2009, The Army Surgeon General chartered the Pain Management Task Force to review the current
status of pain management within the Department of the Army. In 2010, the Task Force published its report
with the recommendation of a comprehensive pain management strategy focused on an interdisciplinary,
holistic, multi-modal patient centered approach [15]. As a result of this initiative, The Office of the Surgeon
General of the Army was recognized by the American Academy of Pain Medicine for its efforts of a holistic
approach in pain management; efforts that included improved anesthesia at point of injury to non-
pharmacological approaches such as mindfulness, acupuncture and biofeedback.
Therefore, to best serve the medical community, baseline information of available services, usage patterns, belief
systems and perceptions about CAM needs to be obtained. This survey will serve to identify the available CAM
services within fourteen-selected Medical Treatment Facilities (MTF) within the Department of Defense as well
as evaluate the changes over time from 2005 to 2009. Combined, the studies from 2005 and 2009 will serve to
better understand the broader context of CAM usage within the DoD and establish a baseline for further studies
regarding usage, feasibility, accessibility, acceptability and sustainability for CAM policy development as well
as the new paradigm of holistic approaches to medical management.
4.2 METHODS
The Deputy Chief of Clinical Services (DCCS) or Service equivalent was contacted at 14 selected Defense of
Department (DoD) Medical Treatment Facilities (MTF). The Medical Centers for each service were selected.
In 2009, only thirteen facilities responded, thus the N was 14 in 2005 and 13 in 2009. These MTFs represent the
Department of Defense equivalent of civilian academic hospitals. Within the DoD there are 8 Army, 3 Naval
and 2 Air Force Medical Centers. The Great Lakes Naval Health Clinic was also surveyed. These sites were
selected as a representative of each service because of their Medical Center status. Comprehensive structured
telephone interviews were conducted using a formatted 20-item questionnaire. The questionnaire design was of
a mixed model with open and closed format as well as dichotomous yes/no questions. The questions covered the
subject areas of available services, budgeting, and research. The initial survey was conducted in 2005 with a
follow-up survey conducted in 2009.
4.3 MAIN OUTCOME MEASURE
The prevalence of IM services within selected DoD facilities.
STO-TR-HFM-195
4-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0099.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
4.4 RESULTS
The 2005 initial study showed that 93% (N= 14) of the surveyed facilities offer IM services with 43% offering
six or more modalities. This increased to 100% (N=13) in 2009 with 92% offering six of more modalities.
There was one site, which offered 19 IM services in 2009 representing an increase in services of 171% compared
to 2005. However, the greatest increase in the number of services available was 333% with 3 available services
in 2005 compared to 13 in 2009. The top four IM services were acupuncture, biofeedback, nutritional
counseling and spiritual healing in 2009 compared to chiropractic, Transcutaneous Electrical Nerve Stimulation
(TENS), nutritional counseling and meditative behavioral techniques in 2005. (Figure 4-1)
Figure 4-1 Change in Integrative Medicine Service Types Available at Selected U.S. Department of
Defense Facilities from 2005 to 2009
There was not a single modality that was available at all facilities. Those modalities with the greatest increase in
availability from 2005 to 2009 were spiritual healing (500%), meditation (400%), yoga (300%), and massage
therapy (250%). 75% of the sites in 2009 added at least one new IM modalities with imagery added at seven
sites and light therapy at four sites. There were two sites that decreased the number of available modalities.
There was only one facility with a dedicated Center for Integrative Medicine in 2005 and 2009. All remaining
facilities offer the IM services with other traditional practices such as Family Practice, Physical Medicine and
Rehabilitation, Pain Management or Internal Medicine.
4-4
STO-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0100.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
There was a 400% increase in the number of individual providers providing IM services over the study period
(37 in 2005; 185 in 2009). (Figure 4-2)
Figure 4-2 Changes in Integrative Medicine Provider Types at Selected U.S. Department of Defense
Facilities from 2005 to 2009
The most common provider types were Medical Doctor in both 2005 and 2009. The provider types that had the
largest increase were Medical Doctors (69), PhD (32) and Nurse Aide (13). There were 7 additional provider
types that offered services from 2005 to 2009. This included PhD, nurse aides, RN, Nurse Practitioners,
Massage therapist, energy workers and physician assistants. (Figure 4-3)
STO-TR-HFM-195
4-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0101.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
Figure 4-3 Changes in Medical Provider Types at Selected U.S. Department of Defense Facilities
from 2005 to 2009
The funding sources for the provision of IM services changed over the study period. In 2005, there was an equal
contribution (50%) of funding from The Department of Army Office of the Surgeon General (DA OTSG) and
local facility budget with 7% received from Congressional sources. In 2009, Congressional and local facilities’
source of funding increased by 438% and 69% respectively with a decrease in DA OTSG funding by nearly
70%. (Figure 4-4)
4-6
STO-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0102.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
Figure 4-4 Changes in Integrative Medicine Funding Sources at Selected U.S. Department of Defense
Facilities from 2005 to 2009
The number of facilities actively researching IM practices doubled from three to six over the study period.
4.5 DISCUSSION
Recent studies show that up to 42% of the American population is using CAM. [5] In contrast, at a single
Military Medical Treatment Facility, 81% of military beneficiaries were using Complementary and Alternative
Medicine (CAM) [13]. The Department of Veterans Affairs in collaboration with the HAIG (Healthcare
Analysis & Information Group) showed 88% of the VHA facilities use IM services either on site or by referral
[11]. Our study showed surprising results with 93% of surveyed Department of Defense (DOD) facilities
offering IM services. In the more recent study, the most common services offered were acupuncture,
biofeedback, nutritional counseling and spiritual healing. The design was a formatted telephonic survey of the
Deputy Chief for Clinical Services or equivalent on the available IM services within their facility. The limitation
of this method is that the DCCS or equivalent could not validate their assessment of their facilities’ utilization
with a simple telephonic query. A better method of study would have been to have the DCCS query their
facilities to verify the information for the study and submit their facilities results. In 2009 there were 11 distinct
provider types providing IM services. This can lead to challenging situations. As an example, several provider
types can perform acupuncture treatments; however, not all have the same level of credentialing and privileging.
The Departments of the Defense Services (Navy, Air Force and Army) as well as the Veterans Affairs are
developing such standards for acupuncture as well as for other IM provider types and modalities. Importantly,
consensus between the DoD Services and the VA needs to be obtained to ensure consistency and standardization
across similar government agencies. This will assist in policy development, which is acceptable to all
stakeholders. Additionally, since few locations are engaged in IM research, there needs to be more emphasis on
and funding for more research in the field of IM. A central clearinghouse or agency can provide oversight to
STO-TR-HFM-195
4-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0103.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
prevent duplicity in research efforts, encourage multi-site endeavors as well as target specific needs of the
military population. A recent DOD study showed that the military population is actively using supplements to
increase their physical performance and well-being [16]. Therefore, it is of great importance that there is a
consistent and a collaborative research effort on IM services, particularly those used by Active Duty personnel,
because the use of IM can be and is often patient driven. Patients will use IM even at their own out-of-pocket
costs. Therefore, they may not choose safe options but rather opt for the latest trends and fads that circulate in
gyms and on television commercials. This emphases the importance of IM research to identify safe and effective
treatments.
This survey, like the HAIG survey, raises questions on the direction and goal of military medicine with respect
to IM. There needs to be oversight of provided and proposed services, privileging of practitioners, fiscal
accountability, standardization of treatment and research protocols, productivity and outcome measures as well
as the education of patients, practitioners and the overall community. In January 2014, the United States
Defense Health Agency published the report “Integrative Medicine Health System Report to Congress.” The
report showed 120 (29% of 421) Medical Treatment Facilities (MTFs) offer 275 CAM programs. Further, it
showed that during the calendar year (CY) 2012, Active Duty military members used 213, 515 CAM patient
visits. The most frequent visits were for chiropractic care (73%) and acupuncture treatments (11%). The most
common CAM programs were acupuncture, clinical nutrition and chiropractic care. The overall
recommendations of the report were 1) the Military Health System (MHS) will evaluate CAM programs for
safety and effectiveness as well as cost-effectiveness 2) the MHS consider widespread implementation of cost-
effective CAM programs meeting guidelines for safety and effectiveness [4].
Other areas of study are the specific usage of IM by military beneficiaries and the behaviors and perspective
towards IM services by military beneficiaries and the leadership. Additionally, these types of study should be
repeated at regular intervals to track IM services and identify developing trends.
4.6 CONCLUSION
These two studies from 2005 and 2009 established an initial baseline of Complementary and Alternative (CAM)
services within selected Department of Defense (DoD) Military Treatment Facilities (MTF). From 2005 through
2009 there has been a steady increase in the number of IM services available in the selected DoD medical
treatment facilities. In 2009, the study showed that 100% of the surveyed facilities offer IM services with 92%
offering six or more modalities. Nearly all facilities offer such services in concert with other traditional practices
such as Family Practice, Physical Medicine and Rehabilitation, Pain Management or Internal Medicine. One
facility had a dedicated Center for Integrative Medicine. Six facilities were actively researching IM practices.
There is no central proponent in the area of IM services within the DoD thus suggesting the need for a leadership
position. It is essential that the medical community provide safe and effective treatments by providing oversight
of IM services, collaboration of research, credentialing of practitioners and establishment of educational
programs. A follow up survey of all the DoD MTF is currently ongoing.
4.7 RECOMMENDATIONS
This study suggests the need for a routine comprehensive survey of participating North Atlantic Treaty
Organization (NATO) participating countries. This survey could be performed individually or as part of a
collaborative effort. The results will assist in the identification of trends, best practices, perspectives and
potential further endeavors in the integration of Integrative Medicine into the NATO Military healthcare
systems. Additionally, a NATO based study will open the potential for cross NATO collaborative research,
4-8
STO-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0104.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
clinical practices and educational opportunities. Finally, the usage of IM services by military individual must be
investigated.
4.8 REFERENCES
[1]
Baldwin, C.M., Long, K., Kroesen, K., Brookes, A.J. and Bell, I.R. A profile of military Veterans in the
southwestern United States who use complementary and alternative medicine: implications for integrated
care. Arch Intern Med. 2002 Aug 12-26; 162(15): 1697-704.
Barnes, P.M., Powell-Griner, E., McFann, K. and Nahin, R.L. Complementary and alternative medicine
use among adults: United States, 2002. CDC Advance Data from Vital and Health Statistics. 2004 May;
(343); 1-19.
Department of Veterans Affairs, Veterans Health Administration, Office of the Assistant Deputy Under
Secretary for Health for Policy and Planning, Healthcare Analysis & Information Group. Complementary
and Alternative Medicine. Washington D.C. 2011. [Internet].
www.research.va.gov/research_topics/2011cam_finalreport.pdf Retrieved April 24, 2015.
Defense Health Agency. (2014) Integrative Medicine in the Military Health System Report to Congress
(DHA) Washington, DC: DHA. [Internet].
http://tricare.mil/tma/congressionalinformation/downloads/Military%20Integrative%20Medicine.pdf.
Retrieved on 9 September 2014.
Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M. and Kessler, R.C.
Trends in alternative medicine use in the United States, 1990-1997: results of a follow up national survey.
JAMA. 1998; 280(18):1569-1575.
Eisenberg, D.M., Kessler, R.C., Foster, C., Norlock, F.E., Calkins, D.R. and Delbanco, T.L.
Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med. 1993
Jan; 328(4): 246-52.
George, S., Jackson, J.L. and Passamonti, M. Complementary and alternative medicine in a military
primary care clinic: a 5-year cohort study. Mil Med. 2011 Jun; 176(6): 685-8.
Goertz, C.M., Long, C.R., Hondras, M.A., Petri, R., Delgado, R., Lawrence, D.J., Owens, E.F. and
Meeker, W.C. Adding chiropractic manipulative therapy to standard medical care for patients with acute
low back pain: results of a pragmatic randomized comparative effective study. Spine. 2013 Apr 15; 38(8):
627-34.
Goertz, C.M., Niemtzow, R., Burns, S.M., Fritts, M.F., Crawford, C.C. and Jonas W.B. Auricular
acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med. 2006 Oct; 171(10); 1010-4.
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] Kent, J.B. and Oh, R.C. Complementary and alternative medicine use among military family medicine
patients in Hawaii. Mil Med. 2010 Jul; 175(7): 534-8.
[11] Klemm Analysis Group. Alternative medicine therapy: assessment of current VHA practices and
opportunities. Washington, DC: Klemm Group; 1999.
STO-TR-HFM-195
4-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0105.png
UNCLASSIFIED
INTEGRATIVE MEDICINE EXPERIENCE IN THE US DOD
[12] Kroesen, K., Baldwin, C.M., Brooks, A.J. and Bell, I.R. US military veteran’s perceptions of the
conventional medical care system and their use of complementary and alternative medicine. Fam Pract.
2002 Feb; 19(1): 57-64.
[13] McPherson, F. and Schwenka, M.A. Use of Complementary and Alternative Therapies among Active Duty
Soldiers, Military Retirees, and Family Members at a Military Hospital. Mil Med. 2004 May; 169(5): 354-
7.
[14] National Center for Complementary and Alternative Medicine (NCCAM). [Internet].
https://nccih.nih.gov/health/integrative-health. Retrieved on 7 May 2015.
[15] Office of The Army Surgeon General. Pain Management Task Force Final Report May 2010. Providing a
Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors
and their Families. [Internet].
http://www.regenesisbio.com/pdfs/journal/pain_management_task_force_report.pdf. Retrieved on 7 May
2014.
[16] RTI International. Department of Defense Survey of Health Related Behaviors Among Active Duty
Military Personnel A Component of the Defense Lifestyle Assessment Program (DLAP) 2005 Washington
DC. [Internet].
http://prhome.defense.gov/Portals/52/Documents/RFM/Readiness/DDRP/docs/2009.09%202008%20DoD
%20Survey%20of%20Health%20Related%20Behaviors%20Among%20Active%20Duty%20Military%20
Personnel.pdf. Retrieved on 7 May 2014.
[17] Smith TC, Ryan MA, Smith B et al. Complementary and alternative medicine use among US Navy and
Marine Corps personnel. BMC Complement Altern Med, 2007 May 16;7:16.
[18] Tindle, H.A., Davis, R.B., Phillips, R.S. and Eisenberg, D.M. Trends in Use of Complementary and
Alternative Medicine by US Adults: 1997-2002. Altern Ther Health Med. 2005 Jan-Feb; 11(1): 42-49.
[19] White, M.R., Jacobson, I.G., Smith, B. Wells, T.S, Gackstetter, G.D., Boyko, E.J., Smith, T.C. and
Millennium Cohort Study Team. Health care utilization among complementary and alternative medicine
users in a large military cohort. BMC Complement Altern Med. 2011 Apr 11; 11:27.
4 - 10
STO-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0106.png
ENTER CLASSIFICATION
Chapter 5 – INTEGRATIVE HEALTH AND HEALING PRACTICES
SPECIFICALLY FOR SERVICE MEMBERS: SELF-CARE
TECHNIQUES
Richard P Petri, Jr., MD FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
Joan Walter, PA, JD
Chief Operating Officer
Samueli Institute
1737 King St., Suite #600
Alexandria, VA
USA
Phone +1 (703) 299-4814
[email protected]
Jon Wright
Summer Intern
Volunteer
Samueli Institute
1737 King St., Suite #600
Alexandria, VA
USA
[email protected]
STO-RTG-TR-HFM-195
5-1
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0107.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
ABSTRACT
There has been an ever-increasing utilization of integrative medicine (IM) by patients to manage their health.
Dissatisfaction with depersonalized care is one of the significant factors causing patients to seek alternative
means to meet their health care needs. These patients are often motivated to find care that coincides with their
beliefs, values, and expectations. Medical health care systems must understand these concerns and work
collaboratively with patients to achieve optimal outcomes and satisfaction levels. Self-care programs, when part
of holistic treatment plans, are well suited to address these concerns. This article discusses the concepts of self-
care, and active and passive participation, as well as briefly examining some IM modalities that can be used as
self-care techniques. This overview describes the history, concepts, uses, and relevant research of several IM
modalities and their applications as self-care techniques. Recommendations for educational and clinical “next
steps” are provided. IM self-care techniques can be incorporated effectively and safely into holistic treatment
plans for North Atlantic Treaty Organization (NATO) Service members. Additional education, international
collaboration, and research are necessary to improve the use of these techniques throughout the medical health
care system.
KEYWORDS
Historical Perspective, Integrative Medicine, Complementary and Alternative, Culture, Society
5.1 INTRODUCTION
In the past 20 years, there has been increasing acceptance of complementary and alternative medicine (CAM) or
integrative medicine (IM) for treating a growing number of conditions. Data show that >50% of the Military
population, including dependents, has used CAM interventions in recent years, and up to 66% of active-duty
personnel use dietary supplements [3], [10], [20], [23], [31], [53]. Reviews of self-reporting population surveys
suggest that Military personnel may be utilizing CAM services independent of conventional medical health
services. [12] Furthermore, the U.S. Military encourages individuals to take charge of their own health and to
improve outcomes, while minimizing utilization of limited and costly services [22]. Service members try to
avoid prescription medications because of the side-effects and the potential negative impacts on Service
members' lives and their careers, especially prescription medications used to treat pain and stress. Service
members are utilizing an increasing number of IM modalities—such as prayer for one's own health, massage
therapy, and relaxation techniques—often at out-of-pocket cost [23].
Active-duty individuals may use IM either by prescription or, more frequently, without any medical supervision,
to increase stamina, performance, and operational capacity; to alleviate chronic pain; or to cope with stress-
related disorders [24], [26].
For the Military leadership and health care professionals in charge of this special population, it is critical to
acquire a better knowledge of these IM interventions and the potential impact of the use of these modalities on
Military medical services. Furthermore, it is imperative that health care providers know all the treatments their
patients are utilizing. Patient and provider must work as a team to optimize the patient's care plan, expected
outcomes, and levels of satisfaction.
5-2
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0108.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
5.2 UNDERSTANDING IM FOR NATO FORCES ON THE LARGER STAGE
North Atlantic Treaty Organization (NATO) forces are continuously deployed globally for various purposes, and
medical care is a necessary component of those missions. Given that this care is provided in a multinational
setting, it is crucial that medical personnel understand the systems used by each of the NATO participating
countries; this is particularly true regarding IM practices, because these can vary widely from country to country.
Important cultural, medical, and financial factors must be considered.
Individuals, as well as each nation's medical system, have diverse cultural expectations regarding necessary and
appropriate care. Effective medical care is dependent upon having sensitivity to these differences. An IM
modality may be considered standard care in one country while not being even recognized as a legitimate option
in another country. NATO, as a multinational organization, can serve as a forum for an expansion of ideas and
understanding among differing nations. Cooperative partnerships among countries as well as between allopathic
(Western) and nonallopathic (Eastern) practitioners are imperative. National partnerships can set the foundation
for this to occur, both within NATO as well as on the global stage. Multi-stakeholder education on the
perspectives, potential benefits, limitations, and roles each system of care has to offer must be emphasized.
Often, health care “programs are primarily funded by government subsidies and administrated by a multi-tiered
bureaucracy. Thus, any action undertaken in a public health program tends to be reactive, conservative and well-
documented” [21]. Compounding this, increasing medical costs are having a deleterious effect on the
sustainability of the system and resulting Military readiness. The addition of IM practices may provide cost-
effective solutions to this problem. Improvements to the world's health care systems would benefit both the
individual and the collective whole. The NATO Task Force can be a key to “opening the door” to achieve
improved global health and healing.
5.3 IM AS A PRACTICE FOR SELF-CARE: THE SHIFT TOWARD
EMPOWERMENT
Delivery of health care must be congruent with societal and individual beliefs and value systems to be effective
[4], [29]. Otherwise, it is an oppressive and irrelevant system imposed upon its recipients. This is a basis for the
concept of patient- or person-centered health care [15], [25]. Furthermore, to be effective, the care must be
acceptable and easy to use for patients.
Many aspects of IM support the person-centered care model. These include (1) emphasis on individuality, (2) a
holistic perspective (toward the individual as well as with respect to treatments), (3) empowerment of the patient,
(4) a premise of self-healing, self-influencing, self-care, and self-awareness, (5) listening and partnerships, (6)
exploring new models of disease, (7) illness, health and healing (energetics), (7) emphasis on healing and health
rather than on symptom management or merely obtaining a cure, and (8) understanding the concept of
“functional diseases” instead of disease-based diagnostic categories.[37] This premise of the “body heals itself”
goes beyond simply allowing a cut to heal or a cold to resolve without treatment, but rather, it is the inherent
ability of each individual to
affect
how the body heals. How people perceive themselves and the degree to which
they participate in this perception greatly affects the outcome. Thus, individuals need to participate in their own
care, with guidance from the health care community, rather than having total reliance on practitioner-dependent
practices.
Self-care techniques provide a source of
doing
by patients instead of
having something done
to them. In the U.S.
STO-RTG-TR-HFM-195
5-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0109.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
Army Surgeon General's Task Force report on pain management, IM modalities were described in terms of
passive and active participation [41]. Active participation is defined as the patient's active involvement in his or
her own care by participating in both the care plan and treatment. An example of active participation is
performing yoga for chronic low-back pain. In contrast to merely taking medication that might deliver analgesia,
the patient practicing yoga takes an active step to adopt a new practice to heal the body in a truly empowering
way, and is an active participant in the treatment delivery and lifestyle change. Conversely, in the passive-
participation model, patients have treatment performed on them or medications prescribed to cure isolated
symptoms with very minimal participation on the patients' part (swallowing a pill). The use of prescriptions is an
example of provider-based care, which is largely passive therapy. Effective medical care can be optimized
through the use of both active and passive participatory treatments. When the opportunity for active participation
is available, it should be encouraged.
Use of active treatments leads to patient empowerment and personal responsibility for health and healing. In
2014, a Working Group (WG) led by the Samueli Institute performed a systematic review of Active self-care
Complementary and Integrative Medicine therapies (ACT-CIM). One of the findings of the WG was that
incorporating ACT-CIM into health care plans improves outcomes and quality of life; allows for more diverse,
patient-centered treatment; promotes self-management; and is relatively safe and cost-effective [13].
Patient participation, empowerment, and responsibility are as important in any health care system as
technological, pharmaceutical, and surgical advancements.
It must be emphasized that the trend among Service members to seek treatment options beyond the care they are
provided within the Military health care system does not necessarily imply a desire for active participation or
patient empowerment. Rather, it should alert the medical community to potential problems and gaps within the
existing system that lead patients to become dissatisfied with it and bypass it to achieve their goals. Moreover,
Service members' motivations may include avoiding necessary care, pursuing fad regimens, or seeking drugs
(pain management) or performance-enhancement (body-building supplements).
5.4 ROLE OF SPECIFIC IM PRACTICES FOR NATO FORCES
The discussion about self-care active techniques includes two types. First, there are techniques that require some
certified-provider instruction to initiate treatment (e.g., acupressure), following which a patient may continue
without provider assistance. The second type involves techniques that do not require provider certification but
can be self-taught or performed with an assistive aid such as a digital versatile disc, compact disc, or other device
(e.g., guided imagery). However, within this group of techniques, provider instruction could be beneficial (e.g.,
for yoga), as it may facilitate safe, effective use of the techniques, and lower the risk of injuries.
Several modalities are described briefly in the sections below, including relevant research as available. Each
practice is either presented as an individual technique or in broad categories to enable ease of understanding this
article, as some practices cross multiple categories. Finally, it must be emphasized that self-care should
supplement or augment,
not
replace
appropriate provider-based care.
5.4.1 Acupuncture and Acupressure
Acupuncture is an ancient Chinese healing technique in which the stimulation of specific points along meridian
channels in the body is achieved by piercing the skin with needles in order to enhance the flow of energy, cure
disease, relieve pain and stress, and regulate the body. Acupressure achieves the same health benefits through the
5-4
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0110.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
application of pressure at the same acupuncture points, but without needle insertions. Both disciplines require
education about the point locations and the benefit(s) of stimulating the specific points. Although, as
comprehensive systems of care, both are practitioner-dependent modalities, simple acupressure regimens can be
taught to patients as self-care treatments.
For example, the application of pressure to the area between the thumb and index finger (Figure 5-1), known as
Large Intestine 4 (LI 4), is often effective for treating headaches. Patients with migraine headaches could benefit
from the practice of acupressure in the time periods between clinical appointments for maintenance and acute
exacerbations. Use of acupressure as a self-care modality can be considered to be safe with minimal-to-no side
effects (as long as acupressure is avoided in areas of infections, fractures, lesions etc.) Current research on
acupressure is limited; however, there are some compelling data on the benefits of acupuncture for pain relief.
Research on acupuncture for neck and low-back pain has shown some clinically significantly short-term
benefits, ranging from 26%–80% effectiveness. The data is encouraging for headaches as well [9], [18], [27],
[47], [50], [54], [55], [56].
Figure 5-1.
Location of the LI 4 Acupressure Point often used for the treatment of headaches.
Photograph by Richard Petri, Jr. © Photos by jocdoc.
www.jocdoc.com
One effort, the Acupuncture Training Across Clinical Settings (ATACS) program, is a current initiative within
the U.S. Department of Defense and Veterans Affairs. The goal of the initiative is to develop, pilot, evaluate, and
implement a uniform tiered acupuncture education and training program for the health care providers of the
Military Health System and Veterans Health Administration. The overarching goal is to increase capacity and
access to standardized acupuncture treatments. ATACS programs train health care providers of various types,
from medical aides to medical doctors, in Battlefield Acupuncture (BFA; refer to Chapter 5, pages 335–343) and
provides for medical acupuncture training for a select group.
In 2010, the U.S. Army Surgeon General's Pain Management Task Force Report was published and used as the
basis for the Comprehensive Pain Management Campaign Plan (CPMCP). [2] As a result of the CPMCP,
Interdisciplinary Pain Management Centers (IPMCs) were developed at the Army's medical centers. These
IPMCs are designed to provide a holistic pain-management approach, which includes acupuncture delivery by
providers trained in BFA as well as by licensed (LAc) and medical acupuncturists.
Both the ATACS program and the IPMCs can serve as models for acupuncture implementation for NATO
troops and beneficiaries, as experiential and outcomes data are gathered. An easy first step could be development
of a cadre of BFA trainers who can educate and train individuals within the various NATO medical systems.
Furthermore, education of individuals in simple acupressure regimens may provide patients with easy-to-use,
STO-RTG-TR-HFM-195
5-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0111.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
quick, self-care treatments to address conditions such as pain, stress, and anxiety.
5.4.2 Biofeedback
Biofeedback is the technique of utilizing an individual's biologic/physiologic information or processes to alter
those same processes. There are several types of biofeedback, based upon the types of information or processes
that are being monitored. Brainwaves are monitored in electroencephalographic (ECG) biofeedback;
electrocardiographic (EKG) biofeedback focuses on cardiovascular parameters, such as heart rate, blood
pressure, and ECG/EKG data.
Biofeedback was first studied in animal models to evaluate involuntary responses and determine if animals could
control those responses. This has since been expanded for use with humans. Most biofeedback is performed in
specialized treatment centers or facilities. Positive modification of numerous conditions has been shown to occur
with biofeedback. These include, but are not limited to, hyperarousal conditions, hypertension, [1] headaches,
[6], [30] and chronic pain [28].
Recently, self-administered biofeedback techniques have become available for individuals. These require
minimal instruction. The most simple of these is the use of thermal dots that sense changes in the temperature of
the skin. Skin temperature is dependent upon blood flow through the capillaries. Cooler skin temperature reflects
an increased level anxiety and stress, whereas warmer skin temperature reflects relaxation and calmness. The
scientific reasoning behind this phenomenon is that as the body relaxes, the blood capillaries dilate, resulting in
increased blood flow. This increased flow leads to increased surface temperature. (A 1960's fad that utilized this
concept was mood rings.)
Another self-administered biofeedback technique is related to heart rate variability (HRV). The heart “pumping”
is described as the heart rate (HR), which is typically expressed in beats per minute. The HR varies in response
to many factors, such as physical activity. The beat-to-beat variability of the heart rate (HRV), which is affected
by the information the heart receives from various inputs, is correlated with overall health. The autonomic
nervous system controls the “fight-or-flight” response through the sympathetic and parasympathetic subsystems.
The balance of these two systems affects the HRV. The HRV can be monitored with simple devices attached to a
person's finger. Computerized programs assist patients to alter HRV through respiratory patterns and thought
control, thereby inducing a relaxation response (RR), which optimizes HRV. [42], [44]
Both of these self-administered techniques are typically used in conjunction with other IM techniques, such as
meditation and imagery as part of self-care programs for stress management and pain control. Sophisticated
computer programs have been developed that use “video games” in which the participants learns to evoke the
RR by altering the “game.” Simple game features include rising helium balloons, racing cars, and mountain
skiing. More complicated games adjust the level of difficulty according to the degree of relaxation achieved.
5.4.3 Energy Practices
Energy medicine is an emerging field of science. Although people are aware of energy as the source that powers
lights, computers, and just about everything in daily life, few people are aware of the energy fields that are
detectable in living organisms. In this context, energy can refer to familiar and easily measurable frequencies of
the electromagnetic spectrum such as light (including color) and sound. Energy may also refer to less-familiar
influences of living systems for which measurement is currently more difficult” [48].
Many energy-based practices and techniques, such as acupuncture, deal with these less-familiar subtle energies.
5-6
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0112.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
Different cultures refer to this energy by different names. In Traditional Chinese Medicine it is known as Qi or
chi,
the “vital energy.” In Japanese tradition, it is
ki,
“life energy.” In the Indian culture, energy is referred to as
prana,
the Sanskrit word for
life force.
The basic principle of all energy practices is that disease is the result of
an imbalance in the energy. Healing is achieved through balancing the energy, using the specific practice [48].
Energy practices that can be used as self-care to balance energy in the body include Qigong, Reiki, therapeutic
touch, and Pranic healing. All include practitioner- or media-based education to begin self-care programs.
Qigong combines movement with meditation for self-healing or balancing of one's energy. Through practice, the
individual develops awareness of the body's energy and, through Qigong, can redirect and balance it [46].
Reiki, Pranic healing, and therapeutic touch are examples of instructor- or practitioner-dependent modalities.
That is, these treatments require a provider to treat the patient. While these modalities require the provider to
have specialized training and certification in the entire array of techniques, the provider can educate the patient
in simple, related self-care regimens to utilize between treatment sessions. In this way, the patient can be
empowered through the instruction of simple, effective healing techniques.
5.4.4 Herbal Medicine and Supplementation
Individuals are using supplements and herbals at an ever-increasing rate [19]. In the United States alone, more
than half of all health care consumers are estimated to have used herbs, herbal preparations, or natural-product
supplements alone or with conventional medicines [35]. Approximately 80% of the world's people use
phytomedicine as their primary form of health care [35]. Oftentimes, this use is not disclosed to providers,
especially when the goals are weight reduction, increased physical and mental performance, or muscular
development. Individuals often accept advice on what to take from friends rather than from reliable experts in
the field.
Access to nutritional supplements and herbal products is available at grocery and specialty stores, on Internet
websites, and in underground markets. In most countries, prescriptions are not necessary for purchase and the
industry is unregulated or minimally regulated. Research in the field is often limited and of poor quality.
Therefore, there are safety concerns with purity, standardization, toxicity, interactions, side effects, and legality.
Approximately 75% of all conventional medicines are derived from living plants, [35] as are herbal remedies,
and it is not uncommon to find that “natural” remedies are adulterated with active drugs [40], [45], [49].
The topics of dietary supplements and herbal remedies need to be addressed by a separate NATO Task Force, as
these subjects are too large and complex for the CAM Task Force to address. Under a grant from Samueli
Institute, funded by the U.S. Army Medical Research and Materiel Command, the RAND Corporation
assembled an expert panel to discuss the regulation of dietary supplements in the Military in 2008 [10]. Among
the recommendations the panel produced were: the need to assess safety in the contexts within which
supplements are being used; the need for evidence-based reviews of dietary supplements of particular safety
concerns; and production and dissemination of educational materials to provide information on supplement
safety. Medical communities need to begin honest dialogues with their patients regarding the significant use of
supplements and herbals, the lack of adequate research on the risks and benefits of such use, and the impact of
inappropriate use. International collaborations are necessary because countries are at varying stages with regard
to knowledge databases and regulation.
STO-RTG-TR-HFM-195
5-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0113.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
5.4.5 Meditative Practices (Mindfulness, Meditation, and Imagery)
Meditative practice is a term for an expansive category of many techniques. All have a fundamental basis in the
principle of directing one's awareness to the present. In life, it is impossible to avoid stress; therefore, the only
control people have is the ability to change their perceptions of that stress when it comes and to find ways to
cope with it. Mindfulness allows a person to focus on the absolute present moment and away from a stressful
event or other stressor. A popular analogy is looking up to the sky; rather than paying attention to the clouds, in
mindfulness, the “attention” is focused on the blue space between the clouds, while acknowledging the existence
of the clouds. An event or a stressor can be likened to a cloud. One can recognize that the stressor exists, but the
attention does not need to remain with it. More importantly, one can learn not to attach oneself to the stressor
cognitively or emotionally, which so often occurs. In doing so, less emphasis is placed on the event or stressor
and more emphasis is focused on simple acknowledgement and “letting go.” This results not only in a change of
perspective but, as described by Benson in his landmark study on the RR, mindfulness also has a profound effect
on physiologic and psychologic well being [5].
One of the misconceptions of meditation is that it is too difficult to practice. People often make excuses, such as
“I just can't get it right,” or “I can't relax.” The aim of meditative practices is not to achieve some particular aim;
rather, the goal is to train oneself to focus on the moment. Like many important behaviors, success at meditation
improves with practice. Moreover, meditation can take on various forms, and each person's success at it is tied to
the relevance of the form and acceptance of the particular behaviors it requires. For example, it takes all of one's
focus on the present to bench-press effectively and safely. Therefore, weight lifting can be a form of meditation
for some people. When it is understood that many of the focused activities we engage in on a regular basis are
really types of meditative practice, the impression that it takes years of practice and the skills of a yogi to
appreciate the benefits of meditation (a potential stressor in itself) becomes less burdensome. The key message
to patients is: “Just start.”
Meditative practices can be used to ease numerous conditions. Pain and stress-related disorders including post-
traumatic stress disorder and traumatic brain injury are especially pertinent areas for NATO populations. There
is an abundance of web- and media-based resources available as assistive materials that enable self-care
practices. Numerous organizations and corporations offer educational and practice materials. In addition,
Militaries have developed their own programs related to meditative practices for their Service members and
beneficiaries.
5.4.6 Movement Practices (Exercise, Running, Yoga, T'ai Chi, and Martial Arts)
Movement is fundamental to life. The human body is designed to move. In the words of Hippocrates,
all parts of the body which have a function, if used in moderation and exercised in labours in which each is
accustomed, become thereby healthy, well developed and age more slowly, but if unused and left idle, they
become liable to disease, defective in growth, and age quickly [17].
Within Military systems, physical activity is a necessary part of training. Over the past decade, more activities
that are regarded as IM modalities are being integrated into Military training programs. These include
t'ai chi,
Taekwondo, and jiujitsu, as well as mindfulness meditation and yoga [8], [11], [14], [36] The “warrior” aspects
of these practices make them more accepted by Service members.
Yoga is an ancient practice of linking mind, body and spirit through a combination of postures, breathing, and
conscious relaxation and meditation. Derived from the Sanskrit word meaning,
yoke, constellation, conjunction
or
union, yoga
is the integration of physical, mental, and spiritual energies that enhance health and well-being
5-8
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0114.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
[34]. Yoga, as practiced in India, is truly a lifestyle composed of physical, spiritual, and nutritional aspects.
Yoga is not so widely accepted within the Military framework, in part, because of yoga's religious origins.
Service members may be less willing to try an active-participation healing method that is strongly associated
with differing religious views from their own views. To remedy this, the movements, poses, and exercises have
been separated from the Eastern religious concepts and introduced under alternate names, such as “warrior
breathing.” This may increase the acceptance of yoga as being beneficial and consistent with promoting Military
readiness, without the need to embrace a particular religious philosophy. In general, yoga in the West is seen
more as one of many exercise programs, with numerous gyms, spas, and rehabilitation centers offering
instructional classes.
Instruction in yoga can be provider- or media-based and then practiced as a self-care technique. The IPMCs
within the U.S. Department of the Army offer yoga for treating pain conditions. The yoga taught at the IPMCs is
primarily Hatha yoga. As initially developed, Hatha (force) yoga uses body-strengthening and physical-
purification techniques as means of self-transformation and transcendence and, ultimately, to clean and improve
the condition of various physical organs.
All of the movement-oriented self-care techniques require provider instruction to learn proper techniques and
forms. There is risk of injury if these are performed incorrectly or if there is a contraindication for the patient's
condition. As an example, a person with a herniated disc should not perform forward flexing movements
because of an increased risk of exacerbating or furthering the injury with forward flexion. Therefore, provider
guidance is essential—both at the initiation of practice as well as through monitoring of the program.
Research on the benefits of exercise and movement programs is well established [51] and the World Health
Organization embraces a global strategy “to promote and protect health through healthy eating and physical
activity” [57]. If performed properly, movement self-care programs offer benefits to cardiopulmonary,
musculoskeletal, and immunologic systems as well as a heightened sense of well being, increased overall quality
of life (QoL), and improved human health and flourishing.
5.4.7 Rituals, Spirituality, and Religiosity
The areas of spirituality and religiosity can be provocative and controversial; however, there are sufficient data
to suggest growing evidence for the correlation between religious and spiritual participation and health [43]. In
addition, data show a growing positive association between pain and prayer use for health concerns [32], [52].
Therefore, these areas warrant inclusion as self-care techniques.
Rituals are defined as enactments based on cultural beliefs and values. These can be social (celebration of a
special event such as a birthday or national independence), Military (changing of command ceremonies),
religious (prayer, mass), or spiritual (prayer, gratitude) [33].
Spirituality “refers to the transcendental relationship between a person and a higher being, a quality that goes
beyond a specific religious affiliation.” The word spirituality is derived from the Latin spiritus, which means
breath, and is related to the Greek word pneuma, which refers to the vital spirit or soul [33]. Spirituality is a
complex and multidimensional construct, and can be defined as an open and individual experiential approach in
the search for meaning and purpose in life (“content”).
Religion is an institutional and culturally determined approach, which harnesses this essence and organizes the
collective experiences of people (faith) into a closed system of beliefs and practices (form) [7]. The reader is
STO-RTG-TR-HFM-195
5-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0115.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
referred to an article in this report, entitled “Spirituality/Religiosity as a Resource for Coping in Soldiers: A
Summary Report,” pages 8-1 through 8-11, for a detailed discussion on these concepts.
Numerous research studies have shown prayer to be the most commonly used IM modality [23], [39]. Prayer has
a profound effect on the healing process, even when no cure or improvement in the condition is likely. It has
been explained this way:
[O]f course, we know that the faith factor is not a panacea—the mortality rate for human beings still
remains 100%. But even when physical healing does not occur, some degree of improvement almost
always takes place, most often a sense of peace in facing a serious illness or disability. [38]
Other forms of spiritual and religious self-care techniques include experiencing gratitude, charitable works,
forgiveness, hope, peacemaking, and compassion, to name a few. It is the responsibility of care providers to
facilitate, provide, and utilize these “techniques” together with their patients. Compassion, for example, means to
suffer with. According to Viktor Frankl, a psychiatrist who wrote of his experiences in Nazi concentration
camps, “man is not destroyed by suffering; he is destroyed by suffering without meaning” [16].
Care providers are responsible for helping their patients to find meaning and solace in the midst of their physical
and mental pain and suffering; providers need to be more than just “someone in a white coat,” issuing orders and
prescribing pills. Despite the incomplete scientific evidence about how these techniques work, it is necessary that
the medical communities understand and accept that patients utilize them as part of their own healing journeys.
To minimize the use of these techniques and the impact of their use would be to minimize treatment plans as
wholes and to fail to implement patient-centered care fully.
5.5 DISCUSSION
What is vital to the success of health care is the participation of the patient in treatment. This concept of active
participation is one of the key aspects of the patient-centered care model. IM philosophy, concepts, and
modalities emphasize this model of care as necessary for improved outcomes. Many IM modalities can be used
as self-care techniques as part of comprehensive, holistic programs. This is not to advocate that patients should
depend solely upon self-care techniques for their personal care, but rather that providers, patients, and
communities need to collaborate to identify the best combinations of approaches to benefit patients. The end
result would be a more effective, comprehensive health care system that is not always provider-dependent, but
instead empowers patients to share responsibility for their own health.
5.6 CONCLUSION
Self-care practices offer patients autonomy over, empowerment regarding, and responsibility for their
conditions. Many self-care techniques can be practiced safely and effectively after some provider- or media-
based education. A self-care program must be incorporated into the overall health care treatment plan to
maximize outcomes as well as the levels of satisfaction of providers and patients.
5.7 RECOMMENDATIONS
NATO is well positioned to mediate the necessary and effective collaborations of multicountry initiatives
because of the cultural diversity and knowledge of NATO's partners. The development of a self-care handbook
5 - 10
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0116.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
for Service members and an educational handbook on the techniques for successful leadership could be a
potential next step. Furthermore, the NATO Task Force on Integrative Medicine could be continued for the
education about and implementation of best practices related to self-care. There needs to be consideration for
international research on self-care outcomes, patient QoL measures, and performance improvement (individually
or collectively as a Military organization). Finally, in the areas of herbs and supplementation, a separate NATO
Task Force should be established to review prevalence, usage patterns, risks, benefits, and regulatory
considerations.
5.8 REFERENCES
[1]
Abgrall-Barbry, G. and Consoli, S.M. [Psychological approaches in hypertension management].
Presse Med 2006;35(6 Pt 2):1088-94.
Arcand, S. Utilizing Integrative Medicine in the U.S. Army Medical Department: U.S. Army War
[2]
College 2012. U.S. Army Medical Command Operation Order (OPORD) 10–76 (USAMEDCOM
Comprehensive Pain Management Campaign Plan). Washington, DC: Office of the Army Surgeon General;
2010.
[3]
Arsenault, J. and Kennedy, J. Dietary supplement use in U.S. Army Special Operations candidates.
Mil Med 1999;164(7):495-501.
[4]
Balneaves, L., Weeks, L. and Seely, D. Patient decision making about complementary and alternative
medicine in cancer management: Context and process. In: Adams J, ed. Traditional, Complementary and
Integrative Medicine: An International Reader. London, UK: Palgrave Macmillan, 2012:71-78.
[5]
Benson, H. The relaxation response: history, physiological basis and clinical usefulness. Acta Med
Scand Suppl 1982;660:231-7.
[6]
Buse, D.C. and Andrasik, F. Behavioral medicine for migraine. Neurol Clin 2009;27(2):445-65.
[7]
Büssing, A. Measures of spirituality in health care. In: Cobb M, Puchalski C, Rumbold B, eds. Oxford
Textbook of Spirituality in Healthcare. Oxford, UK: Oxford University Press, 2012:323–31.
Club
Jiu-Jitsu,
V.M.I.
Jiu-Jitsu
Club.
[8]
www.vmi.edu/Content.aspx?id=10737419467 Accessed July 6, 2015.
Online
document
at:
Coeytaux, R.R., Kaufman, J.S., Kaptchuk, T.J., Chen, W., Miller, W.C., Callahan, L.F. and Mann,
[9]
J.D. A randomized, controlled trial of acupuncture for chronic daily headache. Headache 2005;45(9):1113-23.
[10]
Coulter, I., Newberry, S. and Hilton, L. Regulation of Dietary Supplements in the Military. Rand
Corporation Center for Military Health Policy Research Conference Proceedings; 2011; Santa Monica, CA.
Rand Corporation.
[11]
Culotti, P. Tai Chi Training for Veterans. Online document at: http://taichihealth.com/?page_id=1033
Accessed July 6, 2015.
[12]
Davis, M.T., Mulvaney-Day, N., Larson, M.J., Hoover, R. and Mauch, D. Complementary and
STO-RTG-TR-HFM-195
5 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0117.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
alternative medicine among veterans and military personnel: a synthesis of population surveys. Med Care
2014;52(12 Suppl 5):S83-90.
Delgado, R., York, A., Lee, C., Crawford, C., Buckenmaier, C., 3rd, Schoomaker, E., Crawford, P.
[13]
and Active Self-Care Therapies for Pain Working, G. Assessing the quality, efficacy, and effectiveness of the
current evidence base of active self-care complementary and integrative medicine therapies for the
management of chronic pain: a rapid evidence assessment of the literature. Pain Med 2014;15 Suppl 1:S9-20.
[14]
Dong-kyun, H. U.S. Soldiers Train at World Tae Kwon Do Headquarters. The Official Homepage of
the
United
States
Army.
.
Online
document
at:
www.army.mil/article/90372/U_S__Soldiers_train_at_World_Tae_Kwon_Do_headquarters/ Accessed July 6,
2015.
[15]
Epstein, R.M. and Street, R.L., Jr. The values and value of patient-centered care. Ann Fam Med
2011;9(2):100-3.
[16]
Frankl, V. Man's Search for Meaning. New York: Simon & Schuster, 1959.
[17]
Freeman2004, L. Exercise as an Alternative Therapy. In: Freeman L, ed. Mosby's Complementary &
Alternative Medicine A Research-Based Approach, 2nd ed. St Louis, MO: Mosby:481–516.
Freeman, L. Acupuncture. In: Freeman L, ed. Mosby's Complementary & Alternative Medicine A
[18]
Research-Based Approach, 2nd ed. St Louis, MO: Mosby, 2004:333–69.
[19]
Gahche, J., Bailey, R., Burt, V., Hughes, J., Yetley, E., Dwyer, J., Picciano, M.F., McDowell, M. and
Sempos, C. Dietary supplement use among U.S. adults has increased since NHANES III (1988-1994). NCHS
data brief 2011(61):1-8.
George, S., Jackson, J.L. and Passamonti, M. Complementary and alternative medicine in a military
[20]
primary care clinic: a 5-year cohort study. Mil Med 2011;176(6):685-8.
[21]
Giordano, J., Garcia, M. and Strickland, G. Integrating Chinese traditional medicine into a U.S. public
health paradigm. J Altern Complement Med 2004;10(4):706-10.
Glavan, K.A., Haynes, M., Jones, D.R. and Philput, C. A military application of a medical self-care
[22]
program. Mil Med 1998;163(10):678-81.
Goertz, C., Marriott, B.P., Finch, M.D., Bray, R.M., Williams, T.V., Hourani, L.L., Hadden, L.S.,
[23]
Colleran, H.L. and Jonas, W.B. Military report more complementary and alternative medicine use than
civilians. J Altern Complement Med 2013;19(6):509-17.
Greenwood, M.R.C. and Oria, M. Use of Dietary Supplements by Military Personnel. Washington,
[24]
DC: National Academies Press 2008. Online document at: http://www.ncbi.nlm.nih.gov/pubmed/20669410
Accessed July 6, 2015.
[25]
Guyatt, G., Montori, V., Devereaux, P.J., Schunemann, H. and Bhandari, M. Patients at the center: in
our practice, and in our use of language. ACP J Club 2004;140(1):A11-2.
5 - 12
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0118.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
[26]
Hammond, M. and Vandenberg, P. Complementary and Alternative Medicine. VA Healthcare
Department
of
Veterans
Affairs
2011.
Online
document
at:
www.research.va.gov/research_topics/2011cam_finalreport.pdf Accessed April 24, 2015.
[27]
Jena, S., Witt, C.M., Brinkhaus, B., Wegscheider, K. and Willich, S.N. Acupuncture in patients with
headache. Cephalalgia 2008;28(9):969-79.
Jensen, M.P., Gertz, K.J., Kupper, A.E., Braden, A.L., Howe, J.D., Hakimian, S. and Sherlin, L.H.
[28]
Steps toward developing an EEG biofeedback treatment for chronic pain. Appl Psychophysiol Biofeedback
2013;38(2):101-8.
[29]
Jonas, W. Forward. In: Kelner M, Wellman B, Pescosolido B, Saks M, eds. Complementary and
Alternative Medicine: Challenge and Change. New York, NY: Routledge, Taylor & Francis, 2003:xi–xvi.
Kanji, N., White, A.R. and Ernst, E. Autogenic training for tension type headaches: a systematic
[30]
review of controlled trials. Complement Ther Med 2006;14(2):144-50.
Kent, J.B. and Oh, R.C. Complementary and alternative medicine use among military family medicine
[31]
patients in Hawaii. Mil Med 2010;175(7):534-8.
[32]
Kirmayer, L.J. The cultural diversity of healing: meaning, metaphor,and mechanism. Heart views : the
official journal of the Gulf Heart Association 2013;14(1):39-40.
Koopsen, C. and Young, C. Health and the Human Spirit. In: Koopsen C, Young C, eds. Integrative
[33]
Health: A Holistic Approach for Health Professionals. Sudbury, MA: Jones & Bartlett Publishers, 2009:31–
57.
[34]
Koopsen, C. and Young, C. Healing Effects of Physical Activity and Movement. In: Koopsen C,
Young C, eds. Integrative Health: A Holistic Approach for Health Professionals. Sudbury, MA: Jones &
Bartlett Publishers, 2009:317–41.
[35]
Koopsen, C. and Young, C. Integrative Nutrition. In: Koopsen C, Young C, eds. Integrative health : a
holistic approach for health professionals. Sudbury, Mass.: Jones and Bartlett Publishers, 2009:261-96.
Lynch, V. Tai Chi Classes Offered to Build Resiliency, Help Prevent Suicide. The Official Homepage
[36]
of
the
United
States
Army.
Online
document
at:
www.army.mil/article/45441/Tai_Chi_classes_offered_to_build_resiliency__help_prevent_suicide/ Accessed
July 6, 2015.
Maizes, V., Rakel, D. and Niemiec, C. Integrative medicine and patient-centered care. Explore (NY)
[37]
2009;5(5):277-89.
Matthew, D. and Clark, C. Healing the Body: Restoring Our Physical Selves. In: Matthew D, Clark C,
[38]
eds. The Faith Factor: Proof of the Healing Power of Prayer. New York, NY: Penguin Book, 1996:60-82.
[39]
Medicine, N.C.f.C.a.A. Prayer and Spirituality in Health: Ancient Practices, Modern Science. CAM at
the NIH: Focus on Complementary and Alternative Medicine. 2005:XII(1):1–4. . National Institutes of
Health:
2005.
Online
document
at:
www.jpsych.com/pdfs/NCCAM%20-
STO-RTG-TR-HFM-195
5 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0119.png
ENTER CLASSIFICATION
SELF CARE TECHNIQUES FOR SERVICE MEMBERS
%20Prayer%20and%20Spirituality%20in%20Health.pdf Accessed July 6, 2015.
Newmaster, S.G., Grguric, M., Shanmughanandhan, D., Ramalingam, S. and Ragupathy, S. DNA
[40]
barcoding detects contamination and substitution in North American herbal products. BMC Med 2013;11:222.
Pain Management Task Force. Pain Management Task Force Final Report May 2010. Office of the
[41]
Army
Surgeon
General.
.
Online
document
at:
www.regenesisbio.com/pdfs/journal/pain_management_task_force_report.pdf Accessed May 7, 2014.
Rajendra Acharya, U., Paul Joseph, K., Kannathal, N., Lim, C.M. and Suri, J.S. Heart rate variability:
[42]
a review. Med Biol Eng Comput 2006;44(12):1031-51.
[43]
Schlitz, M. Meditation, prayer and spiritual healing: the evidence. Perm J 2005;9(3):63-6.
Shaffer, F., McCraty, R. and Zerr, C.L. A healthy heart is not a metronome: an integrative review of
[44]
the heart's anatomy and heart rate variability. Front Psychol 2014;5:1040.
Snyman, T., Stewart, M.J., Grove, A. and Steenkamp, V. Adulteration of South African traditional
[45]
herbal remedies. Ther Drug Monit 2005;27(1):86-9.
[46]
Synovitz, L. and Larson, K. Energy Medicine. In: Synovitz L, Larson K, eds. Complementary and
Alternative Medicine for Health Professionals: A Holistic Approach to Consumer Health. Burlington, MA:
Jones & Bartlett Learning, 2013:219-29.
[47]
Thomas, K.J., MacPherson, H., Thorpe, L., Brazier, J., Fitter, M., Campbell, M.J., Roman, M.,
Walters, S.J. and Nicholl, J. Randomised controlled trial of a short course of traditional acupuncture compared
with usual care for persistent non-specific low back pain. Bmj 2006;333(7569):623.
Trivieri, L. Energy Medicine. In: Trivieri L, Anderson J, eds. Alternative Medicine: The Definitive
[48]
Guide, 2nd ed. Berkeley, CA: Celestial Arts, 2002:201-16.
[49]
Uttam, G. and Ferguson, A. Adulteration of herbal remedies with conventional drugs: Role of the
clinical laboratory. In: Dasgupta A, Hammett-Stabler C, eds. Herbal Supplements: Efficacy, Toxicity,
Interactions with Western Drugs, and Effects on Clinical Laboratory Tests. Hoboken, NJ: John Wiley & Sons,
2011.
[50]
Vickers, A.J., Cronin, A.M., Maschino, A.C., Lewith, G., MacPherson, H., Foster, N.E., Sherman,
K.J., Witt, C.M., Linde, K. and Acupuncture Trialists, C. Acupuncture for chronic pain: individual patient
data meta-analysis. Arch Intern Med 2012;172(19):1444-53.
[51]
Vina, J., Sanchis-Gomar, F., Martinez-Bello, V. and Gomez-Cabrera, M.C. Exercise acts as a drug;
the pharmacological benefits of exercise. Br J Pharmacol 2012;167(1):1-12.
Wachholtz, A.B. and Sambamthoori, U. National trends in prayer use as a coping mechanism for
[52]
depression: changes from 2002 to 2007. J Relig Health 2013;52(4):1356-68.
White, M.R., Jacobson, I.G., Smith, B., Wells, T.S., Gackstetter, G.D., Boyko, E.J., Smith, T.C. and
[53]
Millennium Cohort Study, T. Health care utilization among complementary and alternative medicine users in
5 - 14
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0120.png
UNCLASSIFIED
SELF-CARE TECHNIQUES FOR SERVICE MEMBERS
a large military cohort. BMC Complement Altern Med 2011;11:27.
White, P., Lewith, G., Prescott, P. and Conway, J. Acupuncture versus placebo for the treatment of
[54]
chronic mechanical neck pain: a randomized, controlled trial. Ann Intern Med 2004;141(12):911-9.
Witt, C.M., Jena, S., Brinkhaus, B., Liecker, B., Wegscheider, K. and Willich, S.N. Acupuncture for
[55]
patients with chronic neck pain. Pain 2006;125(1-2):98-106.
[56]
Witt, C.M., Jena, S., Selim, D., Brinkhaus, B., Reinhold, T., Wruck, K., Liecker, B., Linde, K.,
Wegscheider, K. and Willich, S.N. Pragmatic randomized trial evaluating the clinical and economic
effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164(5):487-96.
[57]
World Health Organization (WHO). World Health Organization Global Strategy on Diet, Physical
Activity and Health. Global Strategy on Diet, Physical Activity and Health. Online document at:
www.who.int/dietphysicalactivity/goals/en/ Accessed July 6, 2015.
STO-RTG-TR-HFM-195
5 - 15
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0121.png
ENTER CLASSIFICATION
Chapter 6– Battlefield Acupuncture in the U.S. Miltary:
A Pain Reduction Model for NATO
Richard C. NIEMTZOW, MD, PhD, MPH
COL (ret) USAF, MC, FS
United States Air Force Acupuncture and Integrative Medicine Center
Director
Malcolm Grow Medical Clinic and Surgery Center
79
th
Medical Group
1050 West Perimeter Road
Joint Base Andrews, Maryland 20762
Phone: +1 (619) 647-7274
[email protected]
J-Louis BELARD, MD, PhD
COL (Ret) French Medical Corps
Former Chairman, NATO HFM-195 Task Force, Mar 2010 – Sept 2014
Integrative Medicine Interventions for Military Personnel
Contractor Henry Jackson Foundation
Research Advisor, Defense & Veterans Brain Injury Center
11300 Rockville Pike, Suite 1100 Rockville MD 20852
USA
Phone: +1 (240) 821-9333
[email protected]
Raphael NOGIER, MD
Senior Lecturer in Auriculotherapy
Lyon Medical Studies Association
Phone: +33 (0)4 78 25 69 69
[email protected]
ABSTRACT
Acupuncture originated in China more than 5000 years ago. Battlefield Acupuncture (BFA), developed by
Niemtzow, consists of treating 5 points on each ear, using semi-permanent needles to reduce pain in a few
minutes. Easily taught to North Atlantic Treaty Organization (NATO) troops, this methodology can be explained
in 3 hours. This article describes how the BFA technique may be taught to military medical personnel in a few
hours and may be used in a NATO medical treatment facility or battlefield environment without the necessity for
patients’ disrobing. Five tiny, sterile 2-mm needles are inserted into specific points of each ear. The points are:
(1) Cingulate Gyrus, (2) Thalamus, (3) Omega 2, (4) Shen Men and (5) Point Zero. The needles may remain in
STO-RTG-TR-HFM-195
6-1
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0122.png
ENTER CLASSIFICATION
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
the ears for up to 3 days. BFA produces rapid pain relief in a few minutes with almost no side effects. This is an
ideal technique to use when pain has not responded to narcotics or when habit-forming drugs are not desired,
especially during critical military missions.
KEYWORDS
Acupuncture, Battlefield Acupuncture, Pain, US Military, NATO Acupuncture Course, Auriculotherapy
6.1 INTRODUCTION
Acupuncture is a psychobiologic therapeutic modality supplementing existing care in the interrelated
psychological and physical areas of trauma. Developed by the Chinese more than 5000 years ago, acupuncture
still forms the basis of medical care in China and is integrated with Western medicine in many hospitals. The
Chinese invented acupuncture, and the French invented auriculotherapy.
Classically, acupuncture is described as needling specific points on an acupuncture meridian that influences the
movements of Qi and has specific physiological manifestations. This movement of Qi flows in accordance to the
concept of Yin and Yang; as Yang increases, so Yin decreases, and the converse is true. When movement of the
Qi is blocked, illness is said to manifest. [3] Despite many attempts, modern biomedical science has been unable
to prove the existence of meridians, acupuncture points, or energy Qi.
Although acupuncture points are reported to be characterized by low electrical resistance points, the literature
presents various views. Histologic analysis of the acupuncture point reveals an area containing conjunctive
tissues supporting miniscule structures, nerve fibers, lymphatic and capillary vessels, and arterioles. [4] The
physiologic significance of this complex is not clearly understood. Body acupuncture points are said to be
permanently electrically active as opposed to auriculopoints that appear to be electrically active when disease is
present and that disappear when pathology is absent. No histologic analyses of ear acupuncture points have been
found in the literature by the current authors.
Despite the inability to prove the existence of acupuncture meridians and points, acupuncture is used around the
world in either a primary or adjunctive mode to treat pain and other diseases. Acupuncture is nonetheless
recognized as a low-risk, low-cost modality. [3]
A medical technique developed and promoted by Paul Nogier, MD, in the 1950’s enables treatment of pain or
functional disorders by using only ear points. This technique, is known as auriculotherapy or ear acupuncture. A
very precise somatotopy exists on the ear, and each organ of the body has a correspondence on the auricle. [10],
[11], [12]
Acupuncture utilization in the military is not a new concept. During the 5000-plus years of the history of
acupuncture in China, this modality has been well embedded into that country’s military and civilian medical
cultures. As recently as the Vietnam conflict when Hanoi was cut off from Western medical supplies, military
and civilian hospitals resorted to acupuncture as a mainstream medicine. Captured North Vietnamese military
medics carried a small number of acupuncture needles and Moxa as their only medical equipment. Moxa is a
plant that, when carefully ignited on an inserted acupuncture needle serves as a stimulant and may have apparent
healing properties as a result of absorbed vapors through the skin.
In the 1980s, acupuncture was acknowledged but not widespread in the U.S. Armed Forces. History notes that
6- 2
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0123.png
UNCLASSIFIED
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
several military physicians endeavored to practice acupuncture but it never achieved widespread popularity or
acceptance. It was not until the mid-1990’s that acupuncture truly gained a solid foothold in military medical
practice.
The fact that acupuncture is steadily achieving an increasingly prominent role in the U.S. Military is directly
attributed to the tireless efforts and innovative approaches of the first author, a radiation oncologist, COL (Ret)
Richard C. Niemtzow, MD, PhD, MPH. He started the first military acupuncture clinic at the Walson Air Force
Hospital in Fort Dix, NJ, in 1995. He transferred later to Edwards Air Force Base, CA, and started another
acupuncture clinic. The Assistant Secretary of Defense, Sue Bailey, DO, asked Dr. Niemtzow if there was any
role for acupuncture in the treatment of breast cancer. In response, he presented at a Breast Cancer Conference at
the National Naval Medical Center (NNMC) in San Diego, a lecture entitled, ‘‘The Role of Acupuncture in
Breast Cancer: Magic or Medicine?’’[8] The presentation was so well received that he was invited to become the
first full time medical acupuncturist in the history of the United States Armed Forces. He was transferred as a
guest of the United States Navy at NNMC from August 1999 to August 2002. [14] During the summer of 2001,
Dr. Niemtzow designed the well-known Battlefield Acupuncture (BFA) for acute and chronic pain relief (Figure
6-1). [6]
Figure 6-1: Sequence of Needles (Battlefield Acupuncture) for both ears. © Richard Niemtzow, MD
2013. No photocopying or duplication of this material, photo or graphics without prior consent of the
author in writing.
STO-RTG-TR-HFM-195
6-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0124.png
ENTER CLASSIFICATION
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
Using the BFA technique, Dr. Niemtzow inserted tiny sterilized <2-mm gold plated acupuncture semi-
permanent (ASP) needles developed by Paul Nogier, MD over 30 years ago (Aiguille d’ Acupuncture Semi-
Permanente, Sedatelec, Chemin des Muriers, Irigny, France) into specific points in the ear in a well-defined
unique sequence of points as follows: (1) Cingulate Gyrus; (2) Thalamus; (3) Omega 2; (4) Shen Men; and (5)
Point Zero. Paul Nogier, MD, described all of these points except Shen Men, which was described by the
Chinese). [10], [11], [12] This technique achieves pain attenuation to zero or near zero in many circumstances
and produces remissions of hours, days, weeks, or months depending on each patient’s pathology. [6]
The sterilized needles, which may be carried in the combat pocket, are easy to dispose of and may be inserted
into a patient’s outer ear in any environment—land, sea, or air—in <5 minutes. The technique may be taught in a
few hours to non-acupuncturists. Over the past decade of intense use by hundreds of health care providers, few if
any side effects or ear infections have been reported. This technique is fast, portable, and rapidly deployable in
any environment, and does not require patients to undress. [6]
The ear is considered to be a microsystem that reflects the entire body, which is represented on the outer portion
of the ear (auricle). Traditionally, pain treated by auriculotherapy utilizes known anatomical areas in the ear
corresponding to body morphology. [13] For example, if a patient experiences acute or chronic back pain,
needles are placed in the ear in known points that correspond to the spine. Dr. Niemtzow has used both electrical
and laser stimulation on the BFA points with similar results. Laser and microcurrent electrical stimulations are
appropriate for patients who fear needles (such as children).
6.2 MECHANISM OF ACTION
Theoretically, when placed in the BFA points, the needles interfere with processing of pain in the central
nervous system at the hypothalamus, thalamus, cingulate gyrus, cerebral cortex, and other structures. [9]
Functional magnetic resonance imaging research studies from Zang-Hee Cho, PhD, and Dr. Niemtzow suggest
that this is the case, and it is probable that the rapid resolution of pain may be the result of direct communication
from the ear to the brain. [1], [5], [7] The exact mechanism of action is unknown.
6.3 TECHNIQUE
ASP gold needles are semi-permanent needles that can remain in the ear acupoints for up to 3–4 days or longer
before being pushed out to the skin surface by the previous flattened epidermis.
The clinician, after obtaining proper history and performing a physical evaluation of the patient’s complaint of
pain, initiates the BFA technique by placing the patient in a sitting position and needling, sequentially, the
Cingulate Gyrus, Thalamus, Omega 2, Point Zero, and Shen Men points (see Figure 6-1). For example, a needle
would be inserted into the Cingulate Gyrus point of the left ear, and then another needle would be inserted into
the Cingulate Gyrus point of the right ear. After each needle placement, the patient would walk for 1–2 minutes.
One ear would be considered dominant when the patient’s pain drops 2 units on a visual analogue scale (VAS)
used for assessing for subjective pain. If a dominant ear is determined, the ASP needles would be continued on
that ear to achieve a pain score of <1 (on the VAS). If that is not achieved, BFA would be continued on the
nondominant ear until a total of 10 needles, 5 on each ear have been placed. [6], [7]
Note that the Thalamus and Omega 2 points are classically located in the hidden areas of the ear. However,
placing the needles in the external and visible areas of the ears appears to be easier and more effective. [6]
The patient is allowed to ambulate for about 2 minutes to determine if pain attenuation has occurred. If no pain
attenuation has occurred, an ASP needle is inserted into the Cingulate Gyrus point of the opposite ear, and the
6- 4
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0125.png
UNCLASSIFIED
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
patient ambulates to determine the new pain level.
If pain attenuation >0 has been achieved via the Cingulate Gyrus point, another ASP needle is placed in the
Thalamus point in the ear that has produced the most pain attenuation. The patient ambulates again, and the new
pain level is determined.
ASP needles are placed in a similar sequential manner into the Omega 2, Shen Men, and Point Zero points of
whichever ear produces pain attenuation. After the dominant ear has received ASP needles into all the BFA
points, the patient’s pain level is evaluated. If the pain level is 0–1/10, the therapeutic goal has been achieved.
When the patient’s pain level remains above 0, the contralateral ear is needled in a similar manner. The
maximum number of ASP needles used in each ear is 5. [6]
6.4 AIR FORCE ACUPUNCTURE AND ALTERNATIVE MEDICINE CENTER
The U.S. Air Force established the United States Air Force Acupuncture and Alternative Medicine Center
(AFAC) at Joint Base Andrews as the only full-time acupuncture center in the Department of Defense (DoD).
The purpose of the Center is to treat referred active duty and retired military personnel and their dependents, and
to teach acupuncture, principally BFA, to physicians and other health care providers in the Armed Forces.
Certified BFA and BFA ‘‘Train the Trainer’’ courses have been established. The BFA course can be
accomplished in one morning or afternoon, including practice with patients. The BFA Train the Trainer course
requires that each candidate be a physician medical acupuncturist who is actively practicing acupuncture in the
Armed Forces. This course is completed in either a single morning or afternoon. The candidate must teach one
BFA course under supervision of the AFAC to achieve certification.
A database is kept of students who have completed both courses. Estimated costs of teaching are only $50 per
student, not including transportation, lodging, and per diem expenses if required. AFAC personnel will travel to
other locations if it appears to be cost-effective to teach on site instead of requiring students to travel to the
center. To date, over 1,800 students have been trained in the DoD. The number of available certified students
varies, with physicians leaving the service after completing their military obligations and/or entering retirement.
6.5 DISCUSSION
Military use of the BFA technique centers on times when a narcotic cannot be used because the resultant
lethargy would affect a critical mission negatively. As the ears are almost always accessible, this method is very
convenient and simple to practice without undressing patients, especially during combat situations. A patient
should experience a reduced pain period of minutes, hours, days, weeks, or months, depending on the pathology
treated. BFA may be repeated many times. The clinician should observe the patient’s ear for irritation or
infection. The current authors have not noted any infections in the ears of patients. In some cases, a patient will
experience healing and will have a long lasting pain-free period. Other patients who are usually older and have
more complicated pathologies will not experience complete healing. The needles can take the place of pain
medication. Dr. Niemtzow has found that treating a patient with ASP needles biweekly is sufficient in most
cases.
The DoD and Veterans Affairs (VA), Joint Incentive Fund (JIF) recently allocated the DoD–VA $5.4 million for
BFA. This proposal obtained funding to: (1) establish a uniform training program for BFA across the DoD and
VA; (2) train a small cadre of physicians in the DoD and VA in medical acupuncture; and (3) initially establish
the availability of acupuncture as an option at all levels of care throughout the DoD and VA. This funding would
also enable establishment of uniform credentialing standards and quality-assurance processes to facilitate
integration of acupuncture safely into the mainstream of military and veterans’ care. [2]
STO-RTG-TR-HFM-195
6-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0126.png
ENTER CLASSIFICATION
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
6.6 CONCLUSIONS
BFA is a recommended technique to be promoted throughout the NATO medical system. This technique has
been received very well and is in great demand by U.S. Military health care providers and Special Forces.
6.7 RECOMMENDATIONS
Military Services members experience pain. This is independent of the Military being at war or during
peacetime. For centuries, opioids have been used to treat pain conditions; this is a form of pain management that
is widely continued today. Opioids’ side effects may be a crippling factor with respect to Military readiness.
Although, opioids have some benefit for acute pain management, habitual use of these drugs for chronic pain
management has no benefit. Rather, there are serious negative effects, which include degradation of military
performance. However, there are new programs investigating new treatments and modalities for pain
management.
One such project is the ongoing initiative of the U.S. Armed Forces and VA. It is a JIF program called
‘‘Acupuncture Training Across Clinical Settings’’ (ATACS). The goal of this program is to develop, pilot,
evaluate, and implement a tiered acupuncture education and training program for health care providers within the
DoD and VA systems, to include BFA. Despite the paucity of clinical trials in BFA use in military populations,
there is evidence that BFA may have significant benefits for treating acute and chronic pain. The preliminary
data of the ATACS project combined with other studies using BFA in military populations suggests:
(1) BFA may help reduce and possibly replace opioid usage.
(2) U.S. troops in Afghanistan and Iraq who had received BFA regarded it more favorably than
receiving habit-forming drugs.
(3) Physicians demand to be educated in and practice BFA.
(4) BFA is a safe, effective treatment option that can produce rapid pain attenuation and return to duty
without untoward effects.
(5) Patients request BFA over narcotics.
(6) BFA has been shown to have a favorable effect on operational readiness.
(7) Long-term BFA may offer significant cost savings over narcotics.
BFA can easily be used as a primary treatment or as an adjunct to various pain modalities now practiced in
NATO medical communities. It is therefore recommended that a BFA program similar to the successful program
in the U.S. DoD and VA health systems be implemented as a demonstration project at several NATO bases. The
project would include education of health care providers in BFA technique and delivery as well as the
development of a cadre of local or regional BFA trainers to ensure sustainability.
6.8 REFERENCES
[1]
Cho Z-H, Oleson, TD, Alimi D, Niemtzow RC. Acupuncture: The search for biological evidence with
functional magnetic resonance imaging and positron emission tomography techniques. J Altern
Complement Med. 2002;8(4):399–340.
Department of Veterans Affairs, Veterans Health Administration (VHA). VHA Directive 2010-040: Health
Care Resources Sharing with the Department of Defense, September 16, 2010. Online document at:
www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2290 Accessed December 13,2013.
Dictionary, Merriam Webster. Acupuncture. Online document at:
PUB REF NBR (e.g. STO-TR-IST-999)
[2]
[3]
6- 6
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0127.png
UNCLASSIFIED
BATTLEFIELD ACUPUNCTURE IN THE U.S. MILITARY
www.merriamwebster.com/dictionary/acupuncture
Accessed December 13, 2013.
[4]
Helms JM. The basic, clinical, and speculative science of acupuncture. In: Acupuncture Energetics—a
Clinical Approach for Physicians. Berkeley: Medical Acupuncture Publishers; 1997:26–27.
Litscher GL, Bauernfeind, G, Xinyan G, et al. Battlefield acupuncture and near-infrared spectroscopy-
miniaturized computer-triggered electrical stimulation of battlefield ear acupuncture points and 50 channel
near-inrared spectroscopic mapping. Med Acupunct. 2011;23(4):263–270.
Niemtzow R. Battlefield Acupuncture. Med Acupunct 2007;19(4):225–228.8.
Niemtzow RC, Litscher G, Burns SM, Helms JM. Battlefield acupuncture: Update. Med Acupunct
2009;21(1):43–46.
Niemtzow RC. The Role of acupuncture in breast cancer: Magic or medicine? [Presentation]. Department
of Defense Breast Cancer Conference. San Diego, CA, September 17, 1998.
Niemtzow RC. Transmebrane potentials of human lymphocytes. In: Transmembrane Potentials and
Characteristics of Immune and Tumor Cells. Boca Raton: CRC Press, Inc.; 1985:76:69–85.
[5]
[6]
[7]
[8]
[9]
[10] Nogier P, Mallard A, Petit, Jean F: Complementary Auricular Reflex Points. Publisher: Maisonneuve,
Sainte Ruffine. 1989.
[11] Nogier, Paul: The Auricle of the Ear: Zones and Reflex Points. Report from Acupuncture Days-Marseille-
February 1956. Bulletin of the Acupuncture Society No 20. 1956.
[12] Nogier, Paul: Treatise of Auriculotherapy.Publisher: Maisonneuve Sainte Ruffince (France) 1969.
[13] Oleson T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 3rd ed. London:
Churchill Livingstone; 2003.
[14] Pock AR. Acupuncture in the U.S. Armed Forces: A brief history and review of current educational
approaches. Med Acupunct. 2011;23(4):205–209.
STO-RTG-TR-HFM-195
6-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0128.png
UNCLASSIFIED
Chapter 7 – MINDFULNESS BASED PRACTICES AS A RESOURCE
FOR HEALTH AND WELL BEING
Fred Zimmermann
Master of Arts (MA)
Captain (CPT), Reserve Officer
PhD Candidate at
GRP - Generation Research Program
Human Science Center
University of Munich (LMU)
Prof.-Max-Lange-Platz 11
83646 Bad Toelz, Germany
Samueli-Theophrastus-Fellow
Brain, Mind & Healing Program
Samueli Institute
1737 King Street, Suite 600
Alexandria, VA 22314, USA
Phone: +49 (0)8041-44 901 00
Fax : +49 (0)8041-44 900 99
[email protected]
ABSTRACT
Background: Mindfulness-based interventions are becoming increasingly popular in clinical and nonclinical
settings. Civilian and Military policy makers responsible for corporate health management and human-
resource development are increasingly interested in mindfulness training as a useful tool for reducing stress
and enhancing cognitive performance, leadership, and well-being. Objective: This article aims to inform
readers concisely about the scope, efficacy, and adequate application of mindfulness training. Moreover,
particular interest is paid to rehabilitative and preventive applications of mindfulness in a Military
environment. Method: This overview describes mindfulness training programs that are useful for addressing
stress-related conditions for North Atlantic Treaty Organization (NATO) troops during times of peace and
conflict. Conclusions: Mindfulness has been tested successfully as an applicable measure in the military. This
modality remains to be implemented in clinical and the nonclinical, Military environments to enhance the
well-being of every soldier. First steps could include basic training and leadership programs as well as
pre/post deployment trainings. Targeted populations as educators of mindfulness include chaplains, clinical
personnel, physiotherapists, clinical psychologists, psychiatrists, and general practitioners. Finally, the
development of a NATO handbook on practical mindfulness training guidelines is recommended, addressing
the most important questions and fundamental aspects of a practice.
KEY WORDS
Mindfulness; Meditation; Soldiers; Stress; Rehabilitation; Mind–Body Practices; Watsu; Aquatic Body Work;
Military; Prevention; Army; PSTD
STO-RTG-TR-HFM-195
7- 1
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0129.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
7.1 INTRODUCTION
The practice of mindfulness, which is often referred to as ‘‘meditation,’’ is one of the oldest cultural
attainments; it dates back to 3000–2500 b.c.e. The word ‘‘meditation’’ is linked to the Sanskrit term
‘‘bhavana’’, which, translated literally, means ‘‘cultivation’’. In the context of Oriental andOccidental
contemplative traditions,meditation is understood as a way of cultivating genuine well-being and virtue, which
ultimately leads to the goal of gaining insight into the true nature of reality. [31] Many meditative practices
have a common, essential foundation, which is the ability to direct one’s awareness to all phenomena that can
arise in a given moment, such as bodily sensations (e.g., the breath), emotions, or mental objects. Object
meditative practices can be categorized as open-mind meditation (e.g., mindfulness meditation) on the one
hand or as concentrative meditation (e.g., Transcendental Meditation [TM] on the other hand). Mindfulness
training should neither be equated with relaxation techniques nor considered to be a set of techniques that is
solely practiced in a religious or spiritual context. On the contrary, mindfulness practices are currently taught
as secular techniques and serve to enable the cultivation of a nonjudgmental mindset in which thoughts and
emotions are purely observed without automatically reacting. As opposed to relaxation techniques,
mindfulness meditation does not serve the purpose of calming down the mind. Like many other benefits of
meditation, peace of mind can result as a welcome side-effect but it is not a goal that has to be attained.
If a practitioner of meditation strives for a calm state of mind, it is very likely that the practitioner would get
frustrated, as the expectation for practicing a mindfulness exercise may not be fulfilled. The mental turmoil
that builds on the divergence between the goal and actual state of mind would prevent calmness from
occurring. Thus, the practitioner is supposed to let go of ruminating on thoughts (as an expression of a
performance- and purpose-driven attitude) while focusing his or her attention on a certain object or
phenomenon such as breathing. By doing so the practitioner may discover the stillness of each moment in
which everything (thoughts, emotions, bodily sensations) occurs. This requires the practitioner to observe and
accept whatever arises in the present moment nonjudgmentally. It can be very liberating to free oneself from
distracting thoughts by focusing on the present moment, resulting in a release of any mental turmoil that can
occur by dwelling on thoughts about the past or future. Given that human beings have to plan some activities,
the question may arise if a pure experiencing of the moment is possible at all. Even this question is just a
thought in this moment while one is reading this sentence. As such, it can be asked: ‘‘What sensations are
happening while you are reading this thought? How do you experience your body posture while paying
attention to this article?’’ Being mindful is to be fully absorbed in the present moment.
7.2 DEFINITIONS OF MINDFULNESS
Mindfulness can be defined in many different ways, based on contextual perspectives. In some cases,
mindfulness is referred to as a method or a spiritual practice. Other people use the term to characterize a
mental state or as a personality trait (focusing on the long-term effects). In the psychologic context,
mindfulness is conceptualized as ‘‘a kind of non-elaborative, nonjudgmental, presentcentered awareness in
which each thought, feeling or sensation that arises in the attentional field is acknowledged and accepted as it
is.’’ [4] In common terms, mindfulness is associated with living in the here and now, having moment-to-
moment awareness, applying a nonjudgmental attitude, and observing thoughts without automatically reacting
to those thoughts.
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0130.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
7.3 TRADITIONAL MINDFULNESS TECHNIQUES
There are numerous meditation techniques, such as sitting or walking meditation, the body scan, and
mindfulness in daily activities. The sitting meditation is performed when the practitioner is sitting in a
comfortable position with a straight back. The focus of attention is on the physical sensations of the breath
(i.e., the rise and fall of the abdomen or the sensations in the nostrils or throat; Figure 7-1).
The walking meditation technique is performed during walking with the focus of attention on the physical
sensations of the feet; shifting body weight; and the subtle movements in the hips, knees, and feet (heel, ankle,
and ball of the foot; Figure 7-2).
Figure 7-1: Soldier performing sitting meditation.
Figure 7-2: Soldier performing walking meditation.
The body scan is one of the most popular mindfulness training techniques. The practitioner channels his or her
awareness consecutively to certain parts of the body from the top of the head to the tips of the toes. The body
scan can be done in a lying, sitting, or standing position (Figure 7-3).
STO-RTG-TR-HFM-195
7- 3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0131.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
Figure 7-3: Soldier performing the body scan.
Finally, mindfulness in daily activities is focusing on tasks or activities that are performed during the day,
such as washing dishes, drinking water, or eating. Mindfulness can be practiced by anyone, anywhere, and at
any time. There are no requirements for mindfulness meditation except the curiosity to explore. The more a
person practices mindfulness, the more a presence-centered mindset is cultivated (Figure 7-4).
Figure 7-4: Mindfulness can be integrated into daily activities.
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0132.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
7.4 COGNITIVE, BEHAVIORAL, AND PHYSIOLOGIC EFFECTS OF
MINDFULNESS
Within the last 3 decades, mindfulness based interventions have been extensively and successfully evaluated
in clinical and nonclinical settings, and mindfulness can be considered to be one of the best-evaluated mind–
body practices at this point in time. It has been proven by numerous studies that the practice of mindfulness
can promote a wide range of benefits, ranging from better allocation of limited attentional resources, [14; 26]
increased capacity to regulate one’s emotions, [1] improved sleep quality, [23; 29] enhanced working memory
capacity and reduction of negative affectivity, [15] reduced stress reactivity, and an increase in well-being.
[30] Although the working mechanisms that underlie meditation are still disputed, it can be said that the
continuous and serious practice of mindfulness does improve psychophysical self-regulation and promote the
capacity to recover from stress. The latter may be attributed to an increase in sleep quality on the one hand
(enhanced states of slow wave sleep and rapid eye movement sleep states) and a decreased need for sleep on
the other hand. Apart from that, recent studies have suggested that practicing mindfulness may help older
practitioners to retain the sleep patterns of younger nonpractitioners. It is of clinical interest that mindfulness
has a positive
impact on preventing relapses of depressive episodes [16; 22; 19] and of substance abuse. [32] Mindfulness-
based relapseprevention programs for substance abuse enhance the client’s ability to handle urges and to
accept the present moment by acknowledging the craving without reacting to it. Long-term meditative practice
can affect the practitioner’s traits strongly on the behavioral level but can also manifest physiologically in
mindfulness-induced changes of the functional architecture of the brain. Relatively recent studies have also
suggested that mindfulness training can facilitate protection against age-related cortical thinning [30; 18; 21]
and increase the activation of brain regions that are considered to be responsible for attention control and
conscious decision-making. Thus, this research has helped support the evidence that mindful behavior restricts
automatic responses to potential stressors. [30; 7]
7.5 MEASURING MINDFULNESS
From a first-person perspective, mindfulness can be measured by means of self-reported questionnaires and
qualitative interviews. This information can be complemented with data gained from electroencephalography,
functional magnetic resonance imaging, heart-rate variability, and hormone measurements (e.g., cortisol) as
well as cognitive performance and awareness metrics to examine effects indirectly from a third-person
perspective. As training of mindfulness can show impacts on the cognitive and perceptual level, the training
effects can also be measured in the alteration of time perception (‘‘nowness’’) and fixation of bistable images.
[25] A bistable image is one in which the image can be perceived in two different ways. An example of this is
illustrated in Figure 7-5 with the Necker Cube. [13]
STO-RTG-TR-HFM-195
7- 5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0133.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
Figure 7-5: Illustration of a bistable image: The Necker Cube by BenFrantzDale - Own work. Licensed
under Creative Commons (CCBY).
7.6 EFFICACY OF MINDFULNESS-BASED INTERVENTIONS
Over the last 30 years, a substantial amount of scientific literature has been published documenting the
efficacy of mindfulness-based interventions in various contexts. Five relatively recent meta-studies have
revealed that practice of mindfulness can produce large-to-medium effects on depression and anxiety. [2; 11;
5; 12; 10] A meta-study (or analysis) is one that summarizes the results of data collected in numerous studies
with the same methodological approach (e.g., mindfulness training) but in different contexts (e.g., cancer
therapy, drug-abuse prevention, etc.). If these results are compared with the efficacy of the newest generation
of antidepressant drugs (selective serotonin reuptake inhibitors), one can see that the effects of these
pharmacologic interventions are relatively small as well as limited because of their potential side-effects. [17]
As a result of promising properties, mindfulness-based intervention and prevention programs have increasing
applications either as stand-alone treatments or as complementary measures in various clinical and nonclinical
settings (Table 7-1). Specific interest for the Military includes chronic pain conditions, post-traumatic stress
disorder (PTSD), and deployment-related stress conditions.
Table 7-1 Clinical Applications for Mindfulness Based Interventions
•
•
•
•
•
•
•
•
•
•
•
•
•
Chronic Pain Conditions
Preventing Relapse of
Major Depression
Depression
Anxiety
Anger
Headache
Hypertension
Psychosis
Eating Disorders
Body Image Problems
Exhibitionism
Fibromyalgia
Diabetes Type I
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Substance Abuse
Nicotine Dependence
Attention-Deficit
Hyperactivity Disorder
Coronary Artery Disorder
Cancer
Chronic Fatigue Syndrome
Heart Disease
Rheumatoid Arthritis
Irritable Bowel Syndrome
Asthma/Respiratory Disorders
Psoriasis
Multiple Sclerosis
PTSD
Deployment related stress
(military environment)
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0134.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
7.7 MINDFULNESS-BASED STRESS REDUCTION
Mindfulness based stress reduction (MBSR) is one of the most popular and well-evaluated mindfulness
training concepts available in the western world. Kabat-Zinn developed this standardized 8-week mindfulness-
training program in the late 1970s. Although MBSR encompasses Buddhist meditation techniques (sitting
meditation, walking meditation, the body scan) and some Hatha Yoga exercises, it is taught as a secular
training concept. The program consists of a 2-hour session of guided meditation training, once per week. In
addition, participants are asked to practice mindfulness exercises (homework) for 30–45 minutes per
day over 8 weeks. During the MBSR course, participants learn to direct their awareness and to keep their
focus on occurring phenomena— such as thoughts, emotions and bodily sensations—without getting caught
up in a chain of thoughts. In this sense a practitioner who is observing all occurrences is like a spectator
watching a play on stage. Analogous to all other secular mindfulness-based approaches, the MBSR program is
geared toward applying mindfulness in all daily activities, such as eating, driving, walking, brushing one’s
teeth, washing dishes, etc. Because MBSR has been evaluated extensively, it is frequently used in clinical and
nonclinical contexts. MBSR courses are very popular among individuals who are willing to enhance their
quality of life (QoL) in a mindful manner.
7.8 MINDFULNESS-BASED APPROACHES EVALUATED IN A MILITARY
ENVIRONMENT
7.8.1 PROPRESENCE
PROPresence is a German mindfulness training program developed at the University of Munich (LMU). This
program was evaluated as a rehabilitative treatment for deploymentrelated stress in German Military
personnel (Figure 7-6).
STO-RTG-TR-HFM-195
7- 7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0135.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
Figure 7-6: PROPresence Recruitment Poster © Fred Zimmermann, used with permission.
The study was controlled with an evaluation period of 3 weeks.* Soldiers (N= 130) of the German Armed
Forces participated in a 2.5-hour guided meditation training, twice per week. In addition, all participants were
asked to practice, for 30 minutes, the techniques that had been taught twice per day, as homework. The
preliminary data emerging from this study appear to suggest increases in well-being, sleep quality, and
cognitive performance, and reduction of stress.* With regard to the study’s methodological setup,
PROPresence differs from meditation programs that are solely based upon traditional meditation techniques
(e.g., sitting meditation, walking meditation, the body scan), because it offers additional exercises for the
integration of the left and right hemisphere of the brain to optimize the use of mental capacities and to
promote concentration, creativity, and cognitive flexibility (skill building). Figures 7-7 and 7-8 illustrate
concurrent use of the left and right brain hemispheres by drawing or writing with both hands.
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0136.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
Figure 7-7: Ambidextrous drawing exercise.
Figure 7-8. Ambidextrous writing exercise.
One might ask: ‘‘Why does this mindfulness-training program involve additional exercises apart from
traditional meditation techniques?’’ The types of individuals (voluntary versus involuntary participation) who
participate in mindfulness programs have different types of skepticism, motivations, and expectations. For
example, corporate lead programs have higher involuntary participation because of health department
referrals. These participants typically want to reduce their stress and lack interest in meditation practices.
Therefore, the programs need to be adapted to address the different mindsets and create interest and curiosity
beyond the program. This may increase continued practice of mindfulness techniques. PROPresence follows
the principles of ‘‘flow-concept’’ conceptualized by Mihaly Csikszentmihalyi, PhD. [9; 20] According to
Csikszentmihalyi, the ‘‘flow-concept’’ requires the performed task to be neither boring nor overstraining. This
is called ‘‘being in the flow.’’ It is understood that individuals who have a keen interest in an activity become
totally absorbed in that activity. Therefore, PROPresence capitalizes on this ‘‘automatic focus’’ on their
activity as the starting point. This enables a beginning practitioner to answer the question: ‘‘What does it
actually mean to be mindful, to live in the moment?’’ In preliminary exercises, the participant discovers
playfully how to focus the mind deliberately on a certain object and, furthermore, how to redirect the focus on
the present moment by releasing thoughts. By performing these preliminary exercises, a reference point is
created so that the participant gets to know his or her state of mind when being focused and when being
‘‘caught up in circle of tumbling thoughts.’’ This distinction is pivotal for continuing mindfulness practice
during and after the course. The beginning exercises follow the principle that, the higher the physical demand,
the more attention is required by the practitioner to fulfill the respective task. For example, when one starts
writing one’s name or drawing a picture with both hands simultaneously at the same time (Fig. 8), one will not
have the cognitive capacity to do anything else other than the writing or drawing unless one has practiced that
for a long time. This technique represents right- and left-brain hemisphere integration. During this exercise,
there will be no room for ruminating on thoughts or any kinds of mental discussions, once one is focused on
the task. For this reason, PROPresence is also suitable for people with concentration deficits and for children.
After the preliminary phase, the practitioner is acquainted with traditional mindfulness techniques and the
intervalmethod. The interval-method is an approach that utilizes active thinking (with emphasis on ‘‘active’’)
to explore the stillness of each moment in which everything takes place. [3] This practical approach is
especially suited for individuals who are inclined to think a lot. In the course of the training program,
emphasis is increasingly put on the transition of mindfulness into daily activities and consolidation of the
experiences that occurred during the program. With this described methodological setting and content, the
PROPresence training program does not only aim to reduce stress but to help each practitioner to live his or
her life to the fullest by enfolding his or her inherent potential mindfully in every moment of the day.
STO-RTG-TR-HFM-195
7- 9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0137.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
*The current author is the principal investigator of the study as part of his PhD dissertation. This study is
pending PhD defense, manuscript development, and publication submission.
7.8.2 PROPRESENCE AND WATSU (AQUATIC BODY WORK)
Although mindfulness-based interventions have been tested in numerous settings with various populations,
mindfulness has never been tested in conjunction with Watsu. Watsu, also known as Water-Shiatsu, is a
therapeutic form of aquatic bodywork. In mindfulness training, many participants have difficulties engaging in
traditional meditation exercises (e.g., focusing on the breath). In addition, individuals who need ‘‘hands-on’’
activity to stay actively engaged can find meditative techniques boring during first attempts. However Watsu,
as a very subtle form of aquatic bodywork, helps the participant to focus the mind on bodily sensations
because of the uniqueness of the Watsu experience. The experience—which can be described as a mix of
sensing weightlessness, massage, muscle relaxation, and joint-mobilization (Figures 7-9, 7-10, 7-11, 7-12),
while in an aquatic environment—is of great value for the ensuing mindfulness sessions. The mindfulness
trainer can ‘‘pick up on’’ the deep relaxation experienced during the Watsu session and link this experience to
traditional mindfulness techniques, which had appeared to be of no value to the participant in the beginning of
the course. Experiencing Watsu gives a participant a taste of stillness without being boring. In this sense
Watsu functions as a ‘‘door opener’’ for mindfulness exercises. Many mindfulness-training programs fail, as
the practitioners never arrive at the stage of stillness in a short timeframe. For this reason Watsu seems to be
crucial for the success and benefit of mindfulness training. Because of this promising aspect of Watsu, a
combination of both interventions has been evaluated in the German Armed Forces. The preliminary findings
suggest that Watsu, as a supplementary component in a mindfulness training program, does promote
commitment and engagement of practitioners to a significant level.
Figure 7-9: Patient resting in the arms of the therapist.
Figure 7-10: Patient enjoying the feeling of
weightlessness during the slow and soft movements
in the water.
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0138.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
Figure 7-11: Attunement of the patient in the
beginning phase of a Watsu Session
Figure 7-12: Soft arm stretches are an
essential part of Watsu and promotes the
mobilization of the patient.
7.8.3 MINDFULNESS-BASED FITNESS TRAINING
Another mindfulness-based approach that has been evaluated in a pilot study with U.S. Marine reservists is
the socalled Mindfulness-based Mind Fitness Training (MMFT). Elisabeth A. Stanley, PhD, developed and
tested this mindfulness-training program with U.S. Marines who received the training prior to their
deployments. The results of this pilot research have indicated that continuous mindfulness training can not
only decrease perceived stress but also can enhance cognitive flexibility and conscious decisionmaking
by increasing working memory capacity. [15, 27; 28]
7.8.4 TRANSCENDENTAL MEDITATION IN A MILITARY ENVIRONMENT
Although Transcendental Meditation (TM) is not considered to be an open-mind meditation, like mindfulness
meditation, TM can also be recognized as a meditative practice that has been tested successfully in a Military
environment. Brooks and Scarano studied the use of TM, at the Denver Veterans Affairs Hospital, for treating
post-Vietnam adjustment from 1981 to 1982. The study showed that use of TM produced marked
improvement in the domains of severity of stress syndrome, anxiety level, depression, degree of alcohol use,
insomnia, employment status, and family problems. [6] More recently, Rosenthal and his colleagues examined
the effects of TMon U.S. Army Veterans who were affected with combat-related PTSD during their
deployments (Operation Enduring Freedom and Operation Iraqi Freedom). The findings of this pilot study
suggested in general that the practice of TM could help soldiers to have reduced PTSD symptoms and to
improve their QoL to significant levels. [24]
7.8.5 OTHER MINDFULNESS-BASED APPROACHES FOR THERAPEUTIC
SETTINGS
There are several mindfulness-based approaches for therapeutic settings. Three such approaches include: (1)
Mindfulness-Based Cognitive Therapy (MBCT); (2) Dialectical Behavior Therapy (DBT); and (3) Acceptance
and Commitment Therapy (ACT). John D. Teasdale, PhD, Zindel Segal, PhD, and Mark Williams, DPhil,
developed MBCT. It consists of an 8-week group intervention, which combines elements of cognitive therapy
and MBSR. MBCT is designed to prevent relapses of major depressive episodes. Marsha Linehan, PhD,
developed DBT. It is based on linking cognitive–behavioral procedures with mindfulness and is used to treat
STO-RTG-TR-HFM-195
7- 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0139.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
borderline personality disorder. Finally, Steven C. Hayes, PhD, Kelly G. Strosahl, PhD, and Kirk Wilson,
PhD, developed ACT. ACT is a psychotherapeutic intervention based on behavioral techniques combined
with mindfulness and acceptance-based strategies. These combined programs are being used for a treatment
program at the William Beaumont Army Medical Center’s Interdisciplinary Pain Management Center for
Service Members stationed at Fort Bliss, TX. Although the results are observational only, the program has
been well-received by the participants and suggests positive outcomes in the areas of stress management,
coping skills, and pain reduction. [8]
7.9 MINDFULNESS TRAINING: 25 MINUTES OF SELF-CARE
Many books have been written about mindfulness, and none of these books will provide any direct benefits, as
only the personal experiences that these books might trigger can be of value for one’s own well-being. In
essence, practicing mindfulness does not necessarily rely on specific techniques. No matter if one sits behind
one’s computer or goes shopping in a supermarket, one can be mindful in whatever posture and situation that
person is in. The illustrated techniques make it easier for a beginner to find his or her way into a mindful state.
There is no time requirement for mindfulness practice. One can practice for 25 minutes as shown in Box 7-1
or for the whole day when one is awake. The more one practices, the more one cultivates a nonjudgmental and
presence-centered mindset. Once one starts implementing mindfulness into daily activities, there will be no
beginning and no end of the practice, only continuous presence in each moment of the day.
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0140.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
Box 7-1: Example of Mindfulness Practice
Find a quiet room where you can sit alone without being disturbed. Soften the lighting and find a
comfortable place to sit for twenty-five minutes—on a chair or, if you’re comfortable, sitting cross-legged
on a cushion. You can also lie on your back on your bed, for instance, with your head resting on a pillow,
your legs straight, your arms out to the sides, palms up, and your eyes either shut or partly open. Whatever
your position, see that your back is straight and that you feel physically at ease. Now focus your attention on
your body, experiencing the sensations from the soles of your feet up to the top of your head, both within
your body and on its surfaces. Be totally present in your body, and if you note any areas that feel tight,
breathe into them (at least in your imagination), and as you exhale, breathe out that tension. Be aware of
the sensations in the muscles of your face, jaws, mouth, and forehead and relax them, letting your face be as
relaxed as a baby’s when it’s fast asleep. Especially be aware of your eyes. The poets tell us the eyes are
windows of the soul. When we’re upset, the eyes tend to feel hard and piercing, as if they’re bulging from
their sockets. Not only do our mental states influence our eyes, but we can also influence our minds by
softening the eyes. Let them be soft and relaxed, with no contraction between the eyebrows or in the
forehead. Set your whole body at ease. For the duration of these twenty-five minutes, apart from the natural
movement of respiration, let your body be as still as possible. This will help to stabilize your mind and
enable you to focus your attention with greater continuity. If you’re sitting on a chair or cross-legged,
slightly raise your sternum and keep your abdominal muscles soft and relaxed, so that when you breathe in,
you feel the sensations of the breath go right down to your belly. If your breath is shallow, you’ll feel just
the abdomen expand. If you inhale more deeply, first the abdomen, then the diaphragm will expand. And
take a very deep breath, first the belly, then the diaphragm, and finally the chest will expand. Try taking
three slow, deep breaths, feeling the sensations of respiration
throughout your body, inhaling almost to full capacity, and then release the breath effortlessly. Then return
to normal, unforced respiration, mindfully attending to the sensations of the breath wherever they arise in
the body. Breathe as effortlessly as possible, as if you were deeply asleep. And with each exhalation, think of
releasing excess tension in your body, and let go of any clinging to involuntary thoughts that have arisen in
your mind. Continue relaxing all the way through the end of the out-breath until the in-breath flows in
spontaneously like the tide. As you attend to the gentle rhythm of your respiration, you may hear your
neighbor’s dog barking, the sounds of traffic, or the voices of other people. Take note of whatever arises to
your five physical senses, moment by moment, and let it be. Notice also what goes on in your mind,
including thoughts and emotions that arise in response to stimuli from your environment. Each time your
attention gets caught up in sensory stimuli or thoughts and memories, breathe out, release your mind from
these preoccupations,
and gently return to your breath. Let your attention remain within the field of
sensations of your body, and let the world and the activities of your mind flow around you unimpeded,
without trying to control or influence them in any way.
______________________
Excerpted with permission from Wallace, 2009. [31]
STO-RTG-TR-HFM-195
7- 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0141.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
7.10 DISCUSSION
In this chapter, it was pointed out that mindfulness can promote a range of benefits and has been proven to be
an efficient and promising approach that positively affects the human body and psyche on many different
levels. Although the financial gains of mindfulness training haven’t been evaluated sufficiently in cost-
effectiveness studies, it could be that the application of mindfulness based treatments may result in significant
reduction of costs caused by mid or long term pharmacological interventions. Against the background of its
Military application, the training of mindfulness seems to be a feasible working, coping strategy and a
promising alternative for a pharmacologic intervention for deploymentrelated stress, depression and anxiety
during the deployment and post-deployment phase. Apart from that mindfulness trainings can also be utilized
as a preventative measure during the pre-deployment phase and, with regard to the clinical application, also be
a suitable adjunct intervention to a cognitive behavioral therapy for PTSD and other stress-related disorders.
7.11 CONCLUSIONS
The practice of mindfulness is one of the oldest cultural attainments. Depending on the context mindfulness
can be defined as a method, a spiritual practice, a mental state or as a personality trait. Focusing on the
training of mindfulness numerous research studies have suggested a wide range of benefits which include
improvements in the fields of attentional awareness, emotional regulation, sleep quality and memory as well
as reduced negative affectivity and decreased stress reactivity. Studies within Military populations have
furthermore indicated mindfulness training as a feasible and accepted approach. As such mindfulness training
programs remain to be implemented in the clinical and nonclinical, Military environment on the behalf of the
well-being of every soldier.
7.12 RECOMMENDATIONS
As a first step, mindfulness training could be integrated into basic training of Service members as well as into
leadership programs and pre-/postdeployment training. Thetraining formats could range from daily workshops
up to 8-or 10-week programs. A long-lasting sustainable training effect usually requires a longer training
format and continuous practice apart from formal training sessions. All training programs should be
complemented, free of charge, with training manuals, audiobooks, smartphone applications, compact discs,
and digital versatile discs with guided meditations to facilitate access to a mindful lifestyle. Similar to other
Military areas of operation the development of a North Atlantic Treaty Organization handbook for practical
mindfulness training guidelines is recommended, addressing the most important questions and fundamental
aspects of mindful practice. Apart from that, webinars, and personal and online coaching should be provided
to allow practitioners to share their experiences and obtain professional support, as increasing awareness, lack
of routine distraction, and unfamiliar resonances from the social environment can be very disturbing,
especially in the beginning of a practice. Thus, the appropriate support from a pool of professional
mindfulness trainers is crucial for the success and acceptance of this approach. Ideally, every mindfulness
trainer would have received an introduction into the field of Military duties and would have become
acquainted with the Military environment prior to the start of the work, ensuring that the training and the
coaching are adjusted to the living environment of the soldiers. A promising approach that has not been
evaluated yet is mindfulness training embedded in the training of Eastern martial arts. There are already
existing training concepts in the German Armed Forces, utilizing martial arts of the Far East as a rehabilitative
and preventive measure for addressing deployment-related stress.31 This approach seems to be particularly
appealing to Military personnel, and combines practical training exercises with mindfulness and the teaching
of ethical principles (e.g., discipline, integrity). It is therefore recommended to examine the acceptance,
7–2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0142.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
commitment, and health-relevant effects of this mindfulnessoriented martial arts training concept in pilot
projects within small units. Apart from training mindfulness as a secular set of techniques, it is recommended
to provide mindfulness training also in conjunction withMilitary chaplaincy at home bases and during the
deployments abroad. In the clinical context, mindfulness training should also be provided for clinical
personnel, physiotherapists, clinical psychologists, psychiatrists, and general practitioners, encouraging
everyone to implement mindfulness in their respective fields of work.
7.13 REFERENCES
[1]
Arch, J., & Craske, M. (2006). Mechanisms of mindfulness: Emotion regulation following a focused
breathing induction.
Behaviour Research and Therapy, 44(12),
1849–1858.
Baer, R. (2003). Mindfulness Training as a Clinical Intervention: A Conceptual and Empirical
Review.
Clinical Psychology: Science and Practice, 10(2),
125–143.
Bastinac, M., & Ziebell, F. (2013).
Zwischen den Gedanken: Ein Reiseführer in die Welt der
Gegenwärtigkeit.
Norderstedt: BoD - Books on Demand.
Bishop, S., Lau, M., Shapiro, S., Carlson, L., Anderson, N., J., C., . . . Devins, G. (2004).
Mindfulness: A Proposed Operational Definition.
Clinical Psychology: Science and Practice, 11(3),
230–241.
Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress
reduction therapy on mental health of adults with a chronic medical disease: A meta-analysis.
Journal
of Psychosomatic Research, 68(6),
539-544.
Brooks J, Scarano H. Transcendental meditation in the treatment of post-Vietnam adjustment. J
Counsel Dev. 1990;64:212–5.
Cahn, R., & Polich, J. (2006). Meditation states and traits: EEG, ERP, and neuroimaging studies. .
Psychological Bulletin, 132(2),
180-211.
Communication with COL Richard Petri, Former Director of Interdisciplinary Pain Management
Center, William Beaumont Army Medical Center, Ft Bliss, TX, April 2014.
Csikszentmihalyi, M., & Selega, I. (1988).
Optimal experience: Psychological studies of flow in
consciousness
(M. Csikszentmihalyi & I. Selega Eds.). Cambridge: Cambridge University Press.
Eberth, J., & Sedlmeier, P. (2012). The Effects of Mindfulness Meditation: A Meta-Analysis.
Mindfulness, 3(3),
174-189.
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction
and health benefits. A meta-analysis.
Journal of Psychosomatic Research, 57(1),
35-43.
Hofmann, S., Sawyer, A., Witt, A., & Oh, D. (2010). The effect of mindfulness-based therapy on
anxiety and depression: A meta-analytic review.
Journal of Consulting and Clinical Psychology,
78(2),
169-183.
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
STO-RTG-TR-HFM-195
7- 15
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0143.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELL BEING
[13]
Holzmann, W., Presentation “Use of martial arts in coping with deployment related stress”,
Force Health Protection NATO Conference 2014, Budapest, 25.6.2014
Illustration of a bistable image: The Necker Cube by BenFrantzDale - Own work. Licensed under
Creative Commons (CCBY).
Jha, A., Krompinger, J., & Baime, M. (2007). Mindfulness training modifies subsystems of attention.
Cognitive, Affective, & Behavioral Neuroscience, 7(2),
109-119.
Jha, A., Stanley, E., Kiyonaga, A., Wong, L., & Gelfand, L. (2010). Examining the Protective Effects
of Mindfulness Training on Working Memory Capacity and Affective Experience.
Emotion, 10(1),
54-64.
Kenny, M., & Williams, J. (2007). Treatment-resistant depressed patients show a good response to
Mindfulness-based Cognitive Therapy.
Behaviour Research andTtherapy, 45(3),
617-625.
Kirsch, S., Deacon, B., Huedo-Medina, T., Scoboria, A., Moore, T., & Johnson, B. (2008). Initial
Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug
Administration.
PLoS Medicine, 5(2),
0260-0268. doi: doi:10.1371/journal.pmed.0050045
Lazar, S., Kerr, C., Wasserman, R., Gray, J., Greve, D., Treadway, M., . . . Fischl, B. (2005).
Meditation experience is associated with increased cortical thickness.
Neuroreport, 16(17),
1893–
1897.
Ma, H., & Teasdale, J. (2004). Mindfulness-based Cognitive Therapy for Depression: Replication and
Exploration of Differential Relapse Prevention Effects.
Journal of Consulting and Clinical
Psychology, 72(1),
31-40.
Nakamura, J., & Csikszentmihalyi, M. (2002). The Concept of flow. In C. Snyder & S. Lopez (Eds.),
Handbook of positive psychology
(pp. 89-105). New York: Oxford University Press.
Pagnoni, G., & Cekic, M. (2007). Age effects on gray matter volume and attentional performance in
Zen meditation.
Neurobiology of Aging, 28(10),
1623–1627.
Peterson, L., & Pbert, L. (1992). Effectiveness of a meditation-based stress reduction program in the
treatment of anxiety disorders.
American Journal of Psychiatry, 149(7),
936-943.
Ravindra, P., Sulekha, S., T., S., Pradhan, N., Raju, T., & Bindu, K. (2010). Practitioners of vipassana
meditation exhibit enhanced slow wave sleep and REM sleep states across different age groups.
Sleep
and Biological Rhythms, 8(1),
34–41. doi: 10.1111/j.1479-8425.2009.00416.x
Rosenthal, J., Grosswald, S., Ross, R., & Rosenthal, N. (2011). Effects of transcendental meditation in
veterans of Operation Enduring Freedom and Operation Iraqi Freedom with posttraumatic stress
disorder: a pilot study.
Military Medicine, 176(6),
626-630.
Sauer, S., Lemke, J., Wittmann, M., Kohls, N., Mochty, U., & Walach, H. (2012). How long is now
for mindfulness meditators?
Personality and Individual Differences, 52(6),
750–754.
STO-RTG-TR-HFM-195
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
7–2
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0144.png
UNCLASSIFIED
MINDFULNESS BASED PRACTICES AS A RESOURCE FOR HEALTH AND WELLBEING
[26]
Slagter, H., Lutz, A., Greischar, L., Francis, A., Nieuwenhuis, S., Davis, J., & Davidson, R. (2007).
Mental Training Affects Distribution of Limited Brain Resources.
PLoS Biology, 5(6),
1228-1235.
Stanley, E., & Jha, A. (2009). Mind fitness: Improving operational effectiveness and building warrior
resilience.
Joint Force Quarterly, 55,
144-151.
Stanley, E., Schaldach, J., Kiyonaga, A., & Jha, A. (2011). Mindfulness-based mind fitness training:
A case study of a high-stress predeployment military cohort.
Cognitive and Behavioral Practice,
18(4),
566-576.
Sulekha, S., Thennarasu, K., Vedamurthachar, A., Raju, T., & Kutty, B. (2006). Evaluation of sleep
architecture in practitioners of Sudarshan Kriya yoga and Vipassana meditation.
Sleep and Biological
Rhythms, 4(3),
207–214.
Treadway, M., & Lazar, S. (2009). The Neurobiology of Mindfulness. In F. Didonna (Ed.),
Clinical
Handbook of Mindfulness
(pp. 45-57). New York: Springer.
Wallace, B. (2009).
Mind in the Balance: Meditation in Science, Buddhism, and Christianity.
New
York: Columbia University Press.
Witkiewitz, K., Marlatt, A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol
and substance use disorders.
Journal of Cognitive Psychotherapy, 19(3),
211-228.
[27]
[28]
[29]
[30]
[31]
[32]
STO-RTG-TR-HFM-195
7- 17
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0145.png
UNCLASSIFIED
Chapter 8 – SPIRITUALITY/RELIGIOSITY AS A RESOURCE FOR
COPING IN SOLDIERS: A SUMMARY REPORT
Arndt BÜSSING, MD
Professorship Quality of Life, Spirituality and Coping
Institute of Integrative Medicine
Witten/Herdecke University,
Gerhard-Kienle-Weg 4
58313 Herdecke
GERMANY
Phone: +49 (2330) 623246
Fax +49 (2330) 623810
[email protected]
ABSTRACT
Individuals often reflect on their future perspectives and vulnerable concepts of life, and ask for meaning and
purpose in life especially when confronted with stressful experiences and subsequent physical impairment
and/or mental affections. Spirituality/religiosity is a relevant resource used by individuals to cope. This
summary focuses on spirituality/religiosity as a resource for Soldiers to deal with stressful situations, and
combat-associated health affections. Specific studies indicate that spirituality can be a resource of relevance
for traumatized Soldiers. Particularly for Soldiers after combat experience, an assessment´ of their unmet
psychosocial and spiritual needs might be appropriate because this (low thresh-hold) assessment avoids a
stigmatization as a `weak´ person which would require psychological / psychotherapeutic help. For the
military context it is essential to recognize that spirituality/religiosity may be a beneficial resource to cope
and adapt. Both chronic illness and posttraumatic stress have a significant impact on life concerns and affect
physical, functional, emotional, social and spiritual well being. Research has approved that
spirituality/religiosity may have multiple beneficial effects of health and performance. Moreover, the ability to
reflect priorities and change attitudes and behavior in response to illness / trauma could be an important
factor for long term adjustment, even if symptoms may persist.
KEYWORDS
Integrative medicine, spirituality, religiosity, coping, resources, Soldiers, health affections
8.1 INTRODUCTION
Confronted with stressful experiences and subsequent physical impairment and/or mental affections, several
individuals reflect their future perspectives and vulnerable concepts of life, and ask for meaning and purpose in
life, and which beneficial sources one may rely on (religio). Affected individuals may ask for helpful spiritual
resources which can provide a `secure haven´ in their struggling with illness or impairment. In fact, for many
STO-RTG-TR-HFM-195
8-1
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0146.png
UNCLASSIFIED
SPIRITUALITY/ RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
confronted with trauma or chronic disease, spirituality/religiosity (SpR) is a relevant resource to cope - even in
secular societies. Also the special issue of the journal Military Medicine addressed spirituality as a relevant
aspect of a multidimensional Total Force Fitness model of the US Army – which includes nutritional,
psychological, behavioral, social, physical, environmental, medical, and spiritual components [23]. In that
special issue, Hufford et al. clearly stated that “for many on the front lines, spirituality and religion are the only
`safe haven´ amidst intense operational or combat experiences that can test one’s faith. The danger of spiritual
and moral trauma is real, and it can initiate a downward spiral of physical, psychological, and behavioral
problems in the Service Member” [22].
In this chapter, essential findings from scientific studies on the relevance of SpR (as an attitude) on coping with
chronic illness and trauma will be described. Then the putative impact of SpR as a resource to cope will be
discussed for the military context. Spirituality-based interventions such as mindfulness meditation will be
outlined in a separate paper, and are not addressed here.
8.2 DEFINITIONS OF SPIRITUALITY / RELIGIOSITY
There are various definitions what SpR is or might be. Depending on the cultural context, religious
denomination, worldview, or profession, these definitions may vary significantly.
First of all, spirituality and religiosity are often used as interchangeable terms, yet, from a conceptual point of
view, they are not identical. Spirituality is a complex and multi-dimensional construct, and can be defined as an
open and individual experiential approach in the search for meaning and purpose in life (`content´), while
religion is an institutional and culturally determined approach which organizes the collective experiences of
people (faith) into a closed system of beliefs and practices (`form´) [10]. Spirituality can be found through
religious engagement, through an individual experience of the divine, and/or through a connection to others,
environment and the sacred. Moreover, one should differentiate specific beliefs (cognition/emotion), well-being
in the context of spirituality and/or religiosity, and specific spiritual/religious practices (action), either within a
specific institutional context or highly individual approaches.
One of the more general and broad definitions of spirituality, i.e.,
“Spirituality refers to an attitude of search for meaning in life. The searching individual is aware of its
divine origin (either transcendent or immanent, i.e., God, Allah, JHWH, Tao, Brahman, Prajna, Unity
etc.), and feels a connection with others, nature and the Divine. Because of this awareness one strives
towards the realization of the respective teachings, experiences or insights, which have a direct impact
on conduct of life and ethical commitments.” [10]
can be reduced to six subsequent practical principles which can be a framework also for the military context
because it implies also the topics of morality / ethics and the demand to help: (1) Life has meaning; (2) We
share the same origin; (3) We are connected; (4) We have a responsibility; (5) We have an ethical commitment;
(6) We protect and shelter.
Today, spirituality is globally attributed to humans' search for meaning in life - which can but must not involve
rituals and practices about a higher power or God.4 Others would define it as a search for `transcendental truth´
may include a sense of connectedness with others, nature, and/or the divine, and thus “spirituality can call us
beyond self to concern and compassion for others” [33]. Also Ken Pargament argued that spirituality is the
search for significance in ways related to the sacred [28]. This specific “sacred” can be highly individual, and
8-2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0147.png
UNCLASSIFIED
SPIRITUALITY / RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
must not necessarily be identical with that of religious denominations.
In a more secular context, spirituality can be viewed as a more general concept, which may include specific
forms of religiosity, but shares defined aspects with secular forms of spirituality, too. While this differentiation is
important in countries with a secular and liberal background (i.e., Europe), this distinction is meaningless in
countries with conservative theistic beliefs.
To sum it up: “Spirituality is not only the `experiential core´ (content) of ritualized religiosity (form), but a
complex construct which shares relevant topics with secular aspects of spirituality. The underlying motifs found
in the various definitions are the (cognitive) `search for meaning´, the (emotional) experience of connectedness
(with God, others and nature), and the respective realization in daily life in accordance with related ethical
conducts. One may presume that spirituality could be assumed as persons´ commitment to a higher principle /
source which is embodied in their daily life” [13].
This is in line also with the definition for spirituality, which the Army Chief of Chaplains employs, “a process
transcending self and society that empowers the human spirit with purpose, identity, and meaning” [35]
1
.
8.3 ASSOCIATIONS BETWEEN SPIRITUALITY / RELIGIOSITY AND HEALTH-
RELATED VARIABLES
There are an increasing number of studies showing that specific aspects of spirituality/religiosity can be
positively associated with health-related variables [24]. Although these results are not always consistent and
often dependent on circumscribed populations, distinct cultures and specific measures, many studies found
positive associations between defined facets of SpR and psychological well-being [27], quality of life [30], and
coping [17]. A systematic review on the “potential beneficial or harmful effects of religious/spiritual coping”
indicated that this specific form of coping may be beneficial to “maintaining self-esteem, providing a sense of
meaning and purpose, giving emotional comfort and providing a sense of hope” [32].
Moreover, spiritual / religious engagement might also have positive effects on health. A recent meta-analysis
(which enrolled 69 studies with healthy populations and 22 studies with patients) showed that SpR was
“associated with reduced mortality in healthy population studies (combined hazard ratio = 0.82, 95% CI[0.76–
0.87], p < 0.001), but not in diseased population studies (combined hazard ratio = 0.98, 95% CI[0.94–1.01], p =
0.19)” [16]. Interestingly, this meta-analysis indicated that organizational activities (i.e., church attendance,
engagement in community etc.) were positively associated with reduced mortality, not intrinsic aspects
(convictions, experiences, etc.). This may indicate that spiritual / religious engagement can have preventive
effects. Further evidence comes from a systematic review, which investigated the cancer risk among members of
Christian communities. The included 17 epidemiological studies indicate a reduced cancer risk only for lifestyle-
associated cancers (i.e. those associated with tobacco smoking, alcohol consumption, diet, physical activity and
reproductive factors). Interestingly, the most important factor for this effect was the healthy lifestyle inherent in
religious practices in these communities [20]. This means specific SpR attitudes and convictions and subsequent
behavior and activities can be associated with health life style, albeit this will not necessarily guarantee health,
prevention of illness, or rapid recovery. Rather it is true that SpR is one factor among several bio-psycho-social
variables, which may contribution to health and quality of life.
1
Provided by email from staff at the Center for Spiritual Leadership (CSL), at the U.S. Army Chaplain Center and School, Fort
Jackson, SC on 14 May 2010; cited by [35]
8-3
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0148.png
UNCLASSIFIED
SPIRITUALITY/ RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
Although patients, physicians and chaplains may have high expectations, SpR cannot be used like an automatic
`wishing well´, and it cannot be prescribed. It requires a stable inner conviction (belief / faith), which was
approved by positive experiences during life. Then in case of need, one may rely on this resource to cope with
illness and suffering.
Indeed, trauma survivors relying on SpR beliefs for coping may show a greater ability for post-traumatic growth,
i.e., greater appreciation of life and changed priorities, warmer, more intimate relations with others, a greater
sense of personal strength, recognition of new possibilities, and spiritual development [37]. Moreover, even after
spinal cord injury several patients made positive experiences. Contributing factors to facilitate positive views
were, personality (confidence, assertiveness, independent person), support systems (family, friends, and/or
health care professionals), spiritual connection (hope and strength to continue with life), and acceptance of one's
disability (many felt that acceptance was ongoing, requiring time and reflection) [36].
Thus, several patients may use their SpR foremost as a `strategy´ to cope with illness and suffering [28], even in
a secular society [4,6,38,39]. Whether it can be objectified or not, it is of importance that patients with chronic
diseases regard their SpR as beneficial to manage their life more consciously, to promote inner strength,
providing feelings of inner peace, to attain a deeper connection with others and the world around, to cope better
with illness, and even to restore to mental and physical health [5].
However, one has to face the fact that a growing number of individuals in Western societies reject institutional
religiosity, but may have an interest in more secular and individual approaches. Here, specific aspects of
spirituality such as Conscious interactions (with others, self and environment) and Compassion / Generosity are
of higher relevance than a conventional religious orientation [8]. These specific aspects can be regarded as
`shared values´ among different religious and cultural approaches, and are of relevance even for a-religious
skeptics.
8.4 SPIRITUAL NEEDS
Although several individuals may have lost faith in institutional religiosity, they may nevertheless have specific
spiritual needs – which are in most cases neither recognized nor addressed by health care professionals. A recent
study among 230 patients with advanced cancer has shown that a majority of these patients (72%) reported that
their spiritual needs were supported minimally or not at all by the medical system, while 47% of them felt
supported minimally or not at all even by a religious community [1]. This means, a large proportion of patients
are left alone with unmet spiritual needs because no one feels responsible or competent to address them.
Also a survey among more secular German patients with chronic pain conditions revealed that 23% of them
talked with a chaplain / priest about their spiritual/religious needs, 20% had no partner to talk about these needs,
while for 37% it was important to talk with their medical doctor about these needs [6]. Yet, most physicians lack
the necessary time and skills to address their patients´ spiritual needs. However, this support is essential for the
patients, because supporting these needs by the medical team and pastoral care visits was significantly associated
with patients´ quality of life [2].
If it is true that several patients do have psychosocial and spiritual needs, which are important to them, then these
needs have to be identified. Only when these needs are identified, health care professionals, military supervisors,
and also patients´ relatives have the chance to react and support them in their struggle with health affections or
even chronic and fatal diseases.
For research and clinical practice a conceptual framework was suggested which categorizes four
8-4
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0149.png
UNCLASSIFIED
SPIRITUALITY / RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
(interconnected) core dimensions of psychosocial and spiritual needs, i.e., Connection (i.e., love, belonging,
alienation, partner communication, etc.), Peace (i.e., inner peace, hope, balance, forgiveness, distress, etc.),
Meaning/Purpose (meaning in life, self-actualization, role function, etc.), and Transcendence (i.e. spiritual
resources, relationship with God / Sacred, praying, etc.), which can be attributed to the underlying categories of
social, emotional, existential, and religious [9].
In US American cancer patients, spiritual and existential needs were specified by their intention to get help with
overcoming their fears, to find hope, meaning in life, spiritual resources, or someone to talk to about finding
peace of mind [26].
In German patients with chronic pain diseases and cancer, Religious needs and Existential needs scored
relatively low, while needs for Inner Peace and Giving/Generativity scored high [11]. Particularly the needs for
Giving / Generativity are of interest because they address the intention to give solace to someone, to pass their
own life experiences on to others, and to be assured that life was meaningful and valuable [11]. This ability to
care for others, to guide the next generation, and to know that their own actions and decisions were meaningful,
is of outstanding importance also for traumatized Soldiers. Similar findings were observed in predominantly
atheistic patients from Shanghai [12], and Catholic patients from Poland [14]. Interestingly, particularly this
generativity aspect of spirituality connects to three functions of the US Army chaplaincy´s definition of
spirituality, i.e., empowering people with purpose, identity, and meaning [35].
Thus, individuals with chronic health affections predominantly report needs related to inner peace and generative
relatedness on a personal level, whereas needs associated with transcendent relatedness were of minor relevance
- at least in secular societies. Nevertheless, even a-religious skeptics can express specific religious needs, and
these should be recognized.
8.5 SPIRITUALITY IN THE MILITARY CONTEXT
There are only a few empirical studies addressing the relevance of spirituality / religiosity in a military setting. A
survey of World War II veterans, two recent studies, and preliminary data from an ongoing study among German
Soldiers will be highlighted here.
A survey of World War II veterans (random national sample of 7,500 persons) found that church attendance was
more often among those who faced heavy combat and claimed that their war experience was negative, while
those who claimed their experience was positive attended church less often [34]. Thus, negative combat was
related to religious practice. One may suggest that this is a strategy of relief.
Referring to data of the “2008 Department of Defense Survey of Health Related Behaviors Among Active Duty
Military Personnel” (including datasets of 28,546 participants), Hourani and co-workers [21] reported that
spirituality buffered depression and PTSD symptoms only among those with low-moderate combat exposure,
while a medium level of spirituality was protective of self-reported suicidal ideation/attempt. Interestingly, the
authors stated, “high levels of spirituality may be associated with greater suicidal ideation or attempt in this
nondeployed subgroup of military personnel” [21]. The implication of this surprising finding is currently
unclear. However, spirituality was measured with two items only (importance of religious/spiritual beliefs, and
influence of religious/spiritual beliefs on decision making), which is pragmatic in such a large-scale study, albeit
a highly reduced approach to address a multifaceted dimension such as spirituality. Moreover, the psychological
profile of these “high spirituality” persons is unclear. It might be, as stated by the authors, that this “nondeployed
group is coming into the service with higher levels of suicidal ideation”. The findings of Hourani´s study point
clearly to the fact that “the buffering role of spirituality in mental health is limited” and that it “may be
STO-RTG-TR-HFM-195
8-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0150.png
UNCLASSIFIED
SPIRITUALITY/ RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
potentially overwhelmed by great stress, such as high levels of combat exposure“ [21].
A further study, the “Army’s Excellence in Character, Ethics, and Leadership (EXCEL) survey”, refers to data of
1,366 Soldiers with combat experience in Iraq (collected in the summer of 2009) [35]. For this study, a
multidimensional approach to measure spirituality with 15 items and three underlying factors were used, i.e., (1)
Connection to Others; (2) Religious Identification, and (3) Hopeful Outlook. While there were no significant
correlation between these three measures and the number of deployments, higher spirituality scores correlated
weakly with age and rank [35]. More interestingly, spirituality correlated moderately with variables such as
Moral Courage/Ownership, Moral Efficacy, Embracing Army Values, Intent to Report Unethical Conduct, and
Soldier Identification. However, Religious Identification correlated less strong than Hopeful Outlook or
Connection to Others. A further important finding of this study was that Soldiers´ emotional resilience was
moderately associated with their spirituality, particularly with Hopeful Outlook, while physical and
psychological fatigue was only marginally and inversely associated with spirituality [35].
A current study enrolling German Soldiers (n=1,092) addresses their psychosocial spiritual needs and mental
health affections (Büssing et al., accepted for publication) [15]. The data are in line with findings among German
patients with chronic diseases, i.e., Religious needs and Existential Needs scored low in the enrolled Soldiers,
while Inner Peace Needs and Giving/Generativity Needs were of higher relevance. Particularly Existential Needs
and Inner Peace Needs correlated moderately with Soldiers´ perceived stress (PSS scale) and PTSD symptoms
(PCL-M scale), and inversely with life satisfaction [15]. Giving/Generativity needs were moderately associated
with perceived stress and PTSD symptoms. In contrast, Religious needs were only marginally associated with
stress and PTSD symptoms, but not with life satisfaction [15]. This means, although most German Soldiers
report no specific Religious or Existential Needs, half of them have Inner Peace Needs and Giving/Generativity
Needs. Because these needs were significantly correlated with health affections and reduced life satisfaction,
they require further attention as they may indicate a chance for support beyond a stigmatizing psychotherapeutic
treatment.
The current studies show that particularly the relational and hope-associated aspects of spirituality were
associated with Soldiers´ ethical attitudes and personal resilience, while the self-ascribed importance of
religious/spiritual beliefs and their influence on decision making is not necessarily a buffer against depression of
PTSD symptoms. In fact, SpR as an attitude can be a guideline for ethical decisions and moral behavior, and can
be helpful to deal with suffering and a resource of hope. Indeed, “religious moral beliefs” of 130 male war
veterans from Bosnia and Herzegovina were helpful to protect their mental health after surviving multiple war
traumas [19]. Yet, SpR is by no means a `tool´ to create health or buffer against any harm. Rather it is true that
specific spiritual needs may indicate psycho-emotional problems, which could be supported very early to prevent
health affections and service failure.
8.6 HELP SEEKING FROM SPIRITUAL COUNSELORS AND CLERGY
In the US and Canadian Army, Soldiers´ help seeking behavior is encouraged, because (silent) mental health
affections in response to stressful missions (“suffering while functioning”) are no longer regarded as a stigma.
Nevertheless, there are still several barriers, both structural and individual (i.e., the attitude of “self-
management”, and thus masked impairment) which makes it difficult to identify the factual needs.
Nevertheless, Soldiers and veterans are seeking help for depression and PTSD from spiritual counselors and
clergy. Bonner et al. screened veterans with probable major depression and PTSD (n=761) and found that 47%
of them “endorsed being `very´ or `somewhat likely´ to seek help for emotional problems from spiritual
8-6
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0151.png
UNCLASSIFIED
SPIRITUALITY / RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
counselors”, while 12% reported “actual spiritual counselor / clergy consultation” [3]. Thus, the authors advised
to integrate spiritual counselors / clergy into care teams. Moreover, also some veterans at-risk of suicide were
actively seeking pastoral care, “demonstrating a demand for such services” [3]
8.7 DISCUSSION
Both chronic illness and posttraumatic stress have a significant impact on life concerns and affect physical,
functional, emotional, social and spiritual well-being. Research has suggested that SpR may have multiple
beneficial effects of health and performance. Moreover, the ability to reflect priorities and change attitudes and
behavior in response to illness / trauma could be an important factor for long term adjustment, even if symptoms
may persist. There is no doubt that specific beliefs (which may provide support in times of need), values (which
also have an influence on health and risky behavior) and practices / engagement (which may provide psycho-
emotional comfort) may contribute to mental stability. Yet, engagement in specific SpR issues or even strong
religious beliefs is by no means a `preventive protection´ against combat damage or health affections.
It might be a misinterpretation of research data when it is the aim to utilize spirituality as a preventive `tool´. So
far it is unclear whether or not specific training programs aiming to improve Soldiers´ “spiritual fitness”, such as
the Comprehensive Soldier Fitness (CSF) program of the US Army, which involves the core dimensions
Physical, Emotional, Social, Family, and Spiritual (including strengthening beliefs and values) to strengthen
Soldiers´ general resilience is effective with respect to the intended aims (i.e., reduce PTSD or suicide risk) [18].
Although there is no doubt that such programs can be of value for those who share the same beliefs; Soldiers
who reject these specific forms of Christianity may have problems with it.
One has to recognize that we all have specific attitudes, convictions and beliefs that may differ with respect to
the respective cultural and religious context. Simply assessing whether a Soldier has a specific belief or not, can
be a first step, yet it is not enough to assess a complex and multifaceted construct such as spirituality / religiosity.
8.8 CONCLUSION
In the Military context, it is essential to recognize that SpR is a beneficial resource for aiding coping and
adaptation. Although no all Soldiers may share the same underlying beliefs, it is nevertheless of importance to
acknowledge and support SpR attitudes and convictions of Soldiers who rely on this resource.
8.9 RECOMMENDATIONS
Studies indicate that spirituality can be a resource of relevance for traumatized Soldiers. Particularly for Soldiers
after combat experience, an assessment´ of their unmet psychosocial and spiritual needs might be appropriate
because this (low thresh-hold) assessment avoids a stigmatization as a `weak´ person which would require
psychological / psychotherapeutic help. An appropriate instrument to assess these needs might be the Spiritual
Needs Questionnaire (SpNQ) which is currently used in a study among German and French Soldiers, and
already validated for religious and a-religious patients with chronic diseases [7,11,12,14]. These individual
responses can be used to start a conversation / counseling what these needs may mean to the Soldiers and how
they can be supported.
Medical doctors, psychologists and military supervisors are not necessarily supposed to share the spiritual
attitudes and convictions of their patients and subordinates, but they should appreciate them and react adequately
STO-RTG-TR-HFM-195
8-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0152.png
UNCLASSIFIED
SPIRITUALITY/ RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
when specific needs are expressed. An appropriate support of specific spiritual needs may help to improve
relevant aspects of patients´ quality of life. Research clearly shows that health care professionals can play an
important role in enhancing patients’ psycho-spiritual well-being, i.e., self-awareness, coping and adjusting
effectively to stress, relationships, sense of faith, sense of empowerment and confidence, and living with
meaning and hope [25].
To address Soldiers´ spiritual needs, multi-professional teams (i.e., psychologists, chaplains, nurses, and medical
doctors) should care for the multifaceted needs of their patients / clients. However, military supervisors and team
comrades should be included in this process of care because they share the same responsibility to care for each
other.
With respect to the vulnerability-stress-model, one can integrate (and detect) various aspects of SpR and other
beneficial resources along a path between stressors and health, which may be a conceptual framework for
Spiritual Care approaches. Reactions towards challenges (i.e., combat trauma) depend on the interaction of
several predisposing factors involved (i.e., socialization, dispositions) and availability of social and individual
resources (i.e., supporting community, family, team, specific beliefs / convictions), which may generate a basis
sense of coherence to determine the handling of such challenges. Specific active coping strategies are the
individual processes to handle the burden of the challenges. The complex interplay between these factors
determines status of health, illness and recovery (Table 8-1).
Table 8-1: Illustration of the Complex Interplay of Stressors, Resources and Recovery Determinants
Challenges /
Stressors
Critical life events
Combat trauma
Predispositions
Resilience
Ethical values
Socialization
Education
Resources
Social Support
Self-Efficacy
Mindfulness
Spirituality
Spiritual
needs
Coping behavior
Reactive coping
strategies
Positive life
construction
Health status
Quality of Life
Health
affections/
distress
With respect to palliative care, the Pasadena Consensus Conference held in 2009 clearly advised that “spiritual
care should be integral to any compassionate and patient-centered health care system model of care”, and
recommended spiritual assessment of both patients and families [29]. These recommendations can be easily
transferred to spiritual care of persons which are not necessarily in a palliative situation but may require similar
support.
8.10 RESOURCE
The Spiritual Needs Questionnaire (SpNQ) can be used as an assessment instrument and can be obtained by the
author of this chapter (Email: [email protected])
8.10 REFERENCES
[1]
Balboni, T.A., Vanderwerker, L.C., Block, S.D., Paulk, M.E., Lathan, C.S., Peteet, J.R., and Prigerson,
H.G. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life
8-8
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0153.png
UNCLASSIFIED
SPIRITUALITY / RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
treatment preferences and quality of life. J Clin Oncol 2007;25:555-560.
[2]
Balboni, T.A., Paulk, M.E., Balboni, M.J., Phelps, A.C., Loggers, E.T., Wright, A.A., Block, S.D., Lewis,
E.F., Peteet, J.R., and Prigerson, H.G. Provision of spiritual care to patients with advanced cancer:
associations with medical care and quality of life near death. J Clin Oncol 2010;28:445-452.
Bonner, L.M., Lanto, A.B., Bolkan, C., Watson, G.S., Campbell, D.G., Chaney, E.F., Zivin, K., and
Rubenstein, L.V. Help-Seeking from Clergy and Spiritual Counselors Among Veterans with Depression
and PTSD in Primary Care, J Relig Health 2013;52(3):707-718
Büssing, A., Ostermann, T., and Koenig, H.G. Relevance of religion and spirituality in German patients
with chronic diseases, Int J Psychiatry Med. 2007;37:39-57.
Büssing, A., and Koenig, H.G. The BENEFIT through spirituality/religiosity scale. A 6-item measure for
use in health outcome studies. Int J Psychiatry Med. 2008;38:493-506.
Büssing, A., Michalsen, A., Balzat, H.J., Grünther, R.A., Ostermann, T., Neugebauer, E.A., and
Matthiessen, P.F. Are spirituality and religiosity resources for patients with chronic pain conditions? Pain
Med. 2009;10:327-339.
Büssing, A., Balzat, H.J., and Heusser, P. Spiritual needs of patients with chronic pain diseases and cancer
- validation of the spiritual needs questionnaire. Eur J Med Res 2010;15:266-273
Büssing, A., Föller-Mancini, A., Gidley, J., and Heusser, P. Aspects of Spirituality in Adolescents. Int J
Child Spiritual 2010;15(1):25-44.
Büssing, A., and Koenig, H.G. Spiritual needs of patients with chronic diseases. Religions 2010;1:18-
27.25.
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] Büssing, A. Measures of Spirituality in Health Care. In: Cobb, M.R., Puchalski, C.M., and Rumbold, B.
(Eds.). Oxford Textbook of Spirituality in Healthcare. Oxford University Press, 2012; pp. 323-331.
[11] Büssing, A., Janko, A., Baumann, K., Hvidt, N.C., and Kopf, A. Spiritual needs among patients with
chronic pain diseases and cancer living in a secular society. Pain Med 2013;14:1362–1373.
[12] Büssing, A., Zhai, X.F., Peng, W.B., and Ling, C.Q. Psychosocial and spiritual needs of patients with
chronic diseases: validation of the Chinese version of the Spiritual Needs Questionnaire. J Integr Med
2013;11:106-115
[13] Büssing, A. Health-related Quality of Life and Trust in God´s Help. In: Michalos, A.C. (Ed.). Encyclopedia
of Quality of Life Research. Dordrecht: Springer, 2014; pp. 2801-2807
[14] Büssing, A., Pilchowska, I., and Surzykiewicz, J. Spiritual Needs of Polish Patients with Chronic Diseases.
Journal of Religion and Health 2014 (Online first: doi 10.1007/s10943-014-9863-x)
[15] Büssing, A., and Recchia, D.R. Spiritual and non-spiritual needs among German soldiers and their relation
to stress perception, PTDS symptoms,
and life satisfaction - Results from a Structural Equation Modeling
STO-RTG-TR-HFM-195
8-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0154.png
UNCLASSIFIED
SPIRITUALITY/ RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
approach.
J Rel Health 2015 (Online first: doi 10.1007/s10943-015-0073-y
[16] Chida, Y., Steptoe, A., and Powell, L.H. Religiosity/spirituality and mortality. A systematic quantitative
review. Psychother Psychosom 2009;78:81-90.
[17] Cumming, J.P., and Pargament, K.I. Medicine for the Spirit: Religious Coping in Individuals with Medical
Conditions. Religions 2010;1:28-53.
[18] Edelson, R., and Soldz, S. Does Comprehensive Soldier Fitness Work? CSF Research fails the test.
Coalition for an Ethical Psychology Working. Working paper Number 1, May 2012; Online document at:
http://www.ethicalpsychology.org/Eidelson-&-Soldz-CSF_Research_Fails_the_Test.pdf.
Accessed June
23, 2015.
[19] Hasanović, M., and Pajević, I. Religious Moral Beliefs Inversely Related to Trauma Experiences Severity
and Depression Severity among War Veterans in Bosnia and Herzegovina. J Relig Health 2013;52(3):730-
739
[20] Hoff, A., Johannessen-Henry, C.T., Ross, L., Hvidt, N.C., and Johansen, C. Religion and reduced cancer
risk: what is the explanation? A review. Eur J Cancer 2008;44:2573-2579.
[21] Hourani, L.L., Williams, J., Forman-Hoffman, V., Lane, M.E., Weimer, B., and Bray, R.M. Influence of
spirituality on depression, posttraumatic stress disorder, and suicidality in active duty military personnel.
Depress Res Treat, 2012 Volume 2012, Article ID 425463 Online document at
http://www.hindawi.com/journals/drt/2012/425463/
[22] Huffort, D.J., Fritts, M.J., and Rhodes, J.E. Spiritual Fitness. Mil Med 2010;175(8):73-87
[23] Jonas, W.B., O´Connor, F.G., Deuster P, Peck , J., Shake, C., and Frost, SA.S.. Why Total Force Fitness?
Mil Med 2010;175(8):6-13
[24] Koenig, H.G., King, D., and Carson, V.B . Handbook of Religion and Health. 2nd edition. Oxford, UK:
Oxford University Press, 2010
[25] Lin, H.R., and Bauer-Wu, S.M. Psycho-spiritual well-being in patients with advanced cancer: an
integrative review of the literature. J Adv Nurs 2003;44:69-80
[26] Moadel, A., Morgan, C., Fatone, A., Grennan, J., Carter, J., Laruffa, G., Skummy, A., Dutcher, J. Seeking
meaning and hope: self-reported spiritual and existential needs among an ethnically-diverse cancer patient
population. Psychooncology 1999;8:378-385.
[27] Moreira-Almeida, A., Neto, F.L., and Koenig, H.G. Religiousness and mental health: a review. Rev Bras
Psiquiatr 2006;28:242-250
[28] Pargament, K.I. The psychology of religion and coping: Theory, research, practice. New York: Guilford,
1997
[29] Puchalski, C., Ferrell, B., Virani, R., Otis-Green, S., Baird, P., Bull, J., Chochinov, H., Handzo, G., Nelson-
Becker, H., Prince-Paul, M., Pugliese, K., and Sulmasy, D. Improving the quality of spiritual care as a
8 - 10
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0155.png
UNCLASSIFIED
SPIRITUALITY / RELIGIOSITY AS A RESOURCE TO COPE IN SOLDIERS
dimension of palliative care: the report of the Consensus Conference. J Palliat Med. 2009;12:885-904.
[30] Sawatzky, R., Ratner, P.A., and Chiu, L. A meta-analysis of the relationship between spirituality and
quality of life. Social Indicators Research 2005;72:153-188
[31] Tanyi, R.A. Nursing theory and concept development or analysis. Towards clarification of the meaning of
spirituality. J Adv Nurs 2002;39:500-509
[32] Thuné-Boyle, I.C., Stygall, J.A., Keshtgar, M.R., and Newman, S.P. Do religious/spiritual coping strategies
affect illness adjustment in patients with cancer? A systematic review of the literature. Soc Sci Med.
2006;63:151-164.
[33] Underwood, L.G., and Teresi, J.A. The Daily Spiritual Experience Scale: Development, Theoretical
Description, Reliability, Exploratory Factor Analysis, and Preliminary Construct Validity Using Health-
Related Data, Ann Behav Med 2002;24:22-33.
[34] Wansink, B., and Wansink, C.S. Are There Atheists in Foxholes? Combat Intensity and Religious
Behavior. J Relig Health 2013;52:768-779
[35] Wester, F.C. Soldier Spirituality in a Combat Zone: Preliminary Findings About Correlations with Ethics
and Resiliency. The Army’s Excellence in Character, Ethics, and Leadership (EXCEL) survey. Online
document at:
http://isme.tamu.edu/ISME11/Wester-ISME2011.pdf.
Accessed June 23, 2015.
[36] Wiechman Askay, S., and Magyar-Russell, G. Post-traumatic growth and spirituality in burn recovery. Int
Rev Psychiatry 2009; 21(6):570-579.
[37] Weitzner, E., Surca, S., Wiese, S., Dion, A., Roussos, Z., Renwick, R., and Yoshida, K. Getting on with
life: positive experiences of living with a spinal cord injury. Qual Health Res. 2011;21:1455-1468.
[38] Zwingmann, C., Wirtz, M., Müller, C., Körber, J., and Murken, S. Positive and negative religious coping in
German breast cancer patients. J Behav Med. 2006;29:533-547.
[39] Zwingmann, C., Müller, C., Körber, J., and Murken, S. Religious commitment, religious coping and
anxiety: a study in German patients with breast cancer., Eur J Cancer Care 2008;17:361-370.
STO-RTG-TR-HFM-195
8 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0156.png
Chapter 9 – TACTICS TO OPTIMIZE THE POTENTIAL (TOPS) AND
CARDIOBIOFEEDBACK (CBF) IN STRESS MANAGEMENT: THE
FRENCH EXPERIENCE
Marion Trousselard, MD, PhD
Institute of Biomedical Research
Armies' Health Service
Bretigny sur Orge, France
Frédéric Dutheil, MD, PhD
Laboratory of Metabolic Adaptations to Exercise in Physiological and Pathological conditions
EA3533, Blaise Pascal University
Clermont-Ferrand, France
Marie-Pascal Petit, MD
Paris Fire Brigade, France
Nelly Lavillunière, MD
Paris Fire Brigade, France
Marie-Hélène Ferrer, MD, PhD
Institute of Biomedical Research
Armies' Health Service, Bretigny sur Orge, France
Nathalie Babouraj, MD
Paris Fire Brigade, France
Frédéric Canini
,
MD, PhD
Institute of Biomedical Research
Armies' Health Service
Bretigny sur Orge, France
ABSTRACT
The effectiveness of two stress psychological fitness management programs based in mind-body approach
in stress perception and stress reactivity in a military population submitted to a daily operational stress
was evaluated. 180 young military fire fighter recruits were randomly assigned to a controlled
intervention trial including three groups: a cognitive stress program (tactics to Optimized the Potential -
TOP) group, an emotional CardioBioFeedback stress program (CBF) group, or a control group. The
stress programs training lasted eight weeks, with one hour training per week. A placebo was administered
as a nutriceutical in all three groups during the time of the training. Primary outcome variables included
the perceived stress; second outcome variables included stress reactivity (mindfulness, negative mood,
Immunoglobulin A levels). Post intervention effectiveness on the long-term programs’ benefits was
evaluated. Both TOP and CBF stress programs reduce operational stress in military population.
STO-RTG-TR-HFM-195
9-1
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0157.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
Although the size of the effects was small, they must be considered at the clinical level. Long-term effects
depend on the frequency of daily practice. Results were discussed with reference to mind-body theory.
Short stress programs intervention improved stress perception and stress reactivity in healthy workers.
Recommendations about mind-body interventions were proposed for the military population.
KEYWORDS
Mind-Body Intervention Training, Anxiety, Mindfulness, Perceived Stress
9.1 INTRODUCTION
Chronic stress at work is a well-known public health problem, which also concerns military populations
[32], [33], [34]. Stress response leads to specific changes in immunity [1], [23], [54], physiological
systems [40], [41], and regulation of stress hormones [7], [22]. Overexposure to stress has an important
role in the development and course of mental diseases, as well as a factor in increased abdominal obesity,
osteoporosis, infections and cardiovascular problems [42].
Among psychological fitness treatment protocols, heart coherence, a CBF approach, relies on the fact that
heart rhythm becomes more erratic with negative emotions such as anger or frustration stability [30], and
more ordered/coherent with sustained positive emotions such as appreciation, love, or compassion [30],
leading to optimal performance and well being [31], [49]. The CBF program uses feedback from a simple
pulse sensor to reflect changes in emotional/psychological state [21], [40], and to learn how to reduce
stress and stabilize emotions. CBF is also easy to learn and use; it is also cost-effective. Another treatment
protocol for psychological fitness, developed by the French Army, focuses on cognitive training to
regulate emotions, using techniques that optimize potential (TOP). TOP consists in learning easy
techniques of mental skill to improve cognitively based problem-solving [37], [38] through control of
respiration, by relaxation [11], [12], [16], [35] [45], and using visualization [25], [47]. These task-oriented
coping strategies improve performances [18], [19] and health [39]. TOP is widely practiced in air traffic
controllers, with apparently good results [32].
Among military populations, military Paris’ fire fighters (PFFs) appear to be particularly exposed to stress
and could benefit from TOP intervention [27]. To test our thesis that stress management programs (SMP)
would benefit this group, we hypothesized that 1) young recruits aiming to become PFFs will be
particularly exposed to stress, 2) stress management programs will be effective to reduce perceived stress
[9], and 3) the effects of SMP will result in lowered IgA levels. The first aim of the study was to evaluate
the effectiveness of SMP on perceived stress (primary outcome variable) which is considered being
sensitive to chronic stress stemming from a life-time of circumstances, to stress concerning expectations
with regard to future events, and also to reactions to specific events included in PFFs [6]. The second aim
was to evaluate their effectiveness on negative mood, mindfulness, and immunity (secondary outcome
variables). A comparison between the two SMP was assessed. Finally, a long-term follow-up was realized
to investigate the influence of the frequency of daily practice on the SMP’ effectiveness.
9.2 METHODS
9.2.1
Participants
New professional volunteer fire fighters (FFs) were recruited from the formation center of the army’s
PFFs unit (Paris, France). The ethics committees from the health army of Paris, France approved the
study. To be eligible, participants were: male, with no endocrine disease, no recent extraprofessional life
stress event (such as death of a near relative, divorce), no any current illness, no use of medications to
9- 2
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0158.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
modulate inflammatory diseases (corticosteroids, anti-inflammatory drugs, immunomodulatory drugs), or
use of medications with a chronotropic effect taken over the previous six months (beta blockers, diltiazem,
verapamil, anxiolytics or antidepressants).
9.2.2
Measurements
Primary outcome: perceived stress scale (PSS; [6], [9]) was measured using 14 items rated on a five-point
scale that ranges from (1) “never” to (5) “often”. Higher scores indicate higher perceived stress. Two sub-
factors were calculated: vulnerability or “perceived distress”, and uncontrolled perceived stress [6].
Regarding anxiety and depression predictivity, stress-thresholds have been considered to be pertinent
above 27 [10].
Secondary outcomes: the mood was evaluated using an abbreviated version of the profile of mood states
(POMS) [32]. It consisted in an adjective checklist of 37 items rated on a five-point scale that ranges from
(1) “not at all” to (5) “extremely”. The subjects were asked to answer according their present mood. Six
factors were then calculated: anxiety-tension, depression-dejection, anger-hostility, fatigue-inertia, vigor-
activity and confusion-bewilderment. For negative mood variable, an index was calculated for each
subject separately by adding the score in the mood subscales without the activity/vigor.
Mindfulness levels were assessed using the French version of the short form of the Freiburg Mindfulness
Inventory-14 (FMI), which is a 14-item 4-point (1-4) self-report questionnaire developed for people with
no background knowledge about mindfulness [51], [53]. It constitutes a consistent and reliable scale
evaluating several important aspects of mindfulness, and is considered as one-dimensional for practical
purposes [53]. Depending on the suggested time frame in the instructions, it can be used to assess state- or
trait-like components [53]. For the purposes of this study, this short form was used for measuring
respondents’ state of mindfulness. Higher scores indicate higher mindfulness.
Immunity assessments concerned salivary immunoglobulins A (IgA), which are antibodies that play a
critical role in mucosal immunity. They are used as immunological stress marker [28], [48]. For each
immunity measure, a 5 mL saliva sample was collected in Salivette tubes according to specification of the
provider [Salimetrics (Europe ltd.)]. Two hours before each collection, eating, drinking or smoking were
not allowed. Once filled, the tubes were centrifuged, sampled into 1.5 mL aliquots stored at -80°C until
analysis. Salivary concentrations were analyzed using the enzyme-link immunoabsorbant assay kits [Kit
Salimetrics LL-C (PA-USA)]. All samples were analysed in duplicate.
9.2.3
Compliance with the program
The PFFs’ compliance with the protocol was assessed by the frequency of daily practice evaluated using a
visual analog scale (VAS) at M12 and M18. Subjects had to respond to the following question “Can you
indicate the frequency of your daily practice on the bottom line”. The VAS was a horizontal, non-
calibrated line of 100 mm, ranging from very low (0; no daily practice) to very high (100; more than three
daily exercises of 3 min) daily practice
9.2.4
Protocol
The army’s PFFs unit includes new PFFs each month for a selective instruction of six months. New PFFs
have a one-year contract beginning by a six-month formation (Month 0 to M6) followed by a six-month
active duty period (M6 to M12). The six-month formation starts with a two-month military formation
(months 1 and 2), followed by a two-month emergency relief to the victims (months 3 and 4), and by a
two-month specific fire fighter formation (months 5 and 6). Within our study, volunteers were included at
M4 (baseline measurements) after the first four-month formation because most of the young recruits failed
during this period and are revoked. Included participants were randomly assigned (computer-generated
STO-XX-XXX-999
9-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0159.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
randomization) without stratification to one of the three following groups: TOP, CBF, control. A similar
number of PFFs were enrolled into each group at each time. Psychological training (TOP and CBF) was
performed during the last two-month (months 5 and 6) period of specific fire fighters’ formation).
The three groups received a placebo as a nutriceutical to mitigate the placebo effect. The placebo consisted
of one starch capsule per day during the last two-month period of formation (when the SMP occurred)
(Figure 9-1). Approval for placebo use was received from the French agency for the evaluation of
medicinal products and safety security. Measuring the number of capsules taken during the program
session at months 5 and 6 assessed compliance with the placebo.
Figure 9-1 Study design of the Stress Management Program (SMP)
Participants were included at M4 within those succeeding the two-month military formation and the two-
month emergency relief to the victims. All baseline assessments (M4) were repeated at the end of the
stress management programs (M6), at the end of the six-month active duty period (M12) and at M18, with
the exception of IgAs, which were only assessed at M4 and M6 (Figure 1). All assessments were realized
between 15h30 and 18h00 to avoid circadian variations.
9.2.5
Statistical analyses
Enrollment was set to end when 180 patients (60 per group) were included. We estimated that with 55
participants in each group, the study would have more than 80% power to detect a clinically important
difference among the groups in the change of perceived stress, assuming a mean between-group difference
of 2 points from control group, with a pooled standard deviation of 2.1 (on the basis of preliminary data),
at an alpha level of 5%.
For the profile of Mood States (POMS), a negative mood index was calculated for each PFFs separately
by adding the score in the mood subscales anxiety-tension, depression-dejection, anger-hostility, fatigue-
inertia, and confusion-bewilderment without the activity/vigor.
Baseline characteristics were compared between groups using an analysis of variance. Intention-to-treat
analyses were performed to assess the effectiveness of the SMP. Effects of the groups’ programs were
evaluated using ANOVAs on the changes in outcome variables. Change scores were calculated as change
by subtracting baseline (M4) scores from scores at the end of the programs (M6). This was done for each
9- 4
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0160.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
outcome variable separately. Comparisons between CBF and TOP programs were evaluated by post-hoc
analyses when results were significant between groups. Cohen's d is used in estimating sample sizes.
For long-term effects (M12 and M18), CBF and TOP groups were pooled in an SMP group for
comparisons to controls. The analyses were done per treatment protocol. Repeated measures ANOVAs
were applied on the each outcome variable score, separately. Regression equations were performed to
determine the impact of the daily practice scores.
Data are presented as mean percentage change ± SD, unless otherwise specified. Analyses were performed
with SPSS, v17.0. We judged p<0.05 as significant and p≤0.1 as a tendency to a difference.
9.3 RESULTS
9.3.1
Participants
We randomized 180 PFFs in three groups of 60 PFFs. Fourteen PFFs (7.78%) were excluded due to
traumatic injuries between the inclusion and the beginning of the stress management program (Figure 9-2).
Figure 9-2 Study Flow Chart
No dropouts were recorded between M4 and M6. Eighty-four completed the entire 14-month study. A
comparison between participants withdrawing from the study and those who remained showed no
difference in descriptive characteristics, independent of the time at which they withdrew.
The percentage of compliance was around 75% with a mean number of taken capsules of 44.32 between
STO-XX-XXX-999
9-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0161.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
M4 and M6 (73.86%) for the TOP group, 45.58 (75.96%) for the CBF, and 44.5 (74.16%) for the control
group. Compliance did not differ between groups.
Briefly, participants were males, aged from 18 to 25 years, and mainly Caucasian. 78.3% were not
engaged and half had university diploma. All PFFs practiced at least 4h per week of sport, 16.1% were
smokers. All PFFs practiced sport with a mean numbers of sport training per day of 6 hours. No difference
was observed between groups at baseline (Table 9-1). Eighty seven percent of PFFs were considered
stressed at baseline and above the clinical threshold of 27 [10].
Full group
Primary outcome:
Perceived stress
Uncontrolled stress
Distress
Secondary outcomes:
Mindfulness
Negative mood Index
IgA (μg/ml)
40.4(5.4)
18.1(17.1)
149.1(91.6)
41(5.4)
17.3(14.5)
132.4(88.2)
39.1(5.4)
19.7(20.4)
152.1(87.08)
41.1(5.2)
17.4(16)
163.6(99.7)
2.53(0.09)
0.29(0.74)
0.37(0.68)
34.6(7.4)
17.7(4.1)
17.11(3.9)
34.8(6.9)
17.71(3.7)
17.35(3.6)
35.3(7.1)
17.83(3.6)
17.11(3.8)
33.6(8.5)
17.55(4.7)
16.86(4.3)
0.77(0.46)
0.28(0.75)
0.52(0.59)
Gr TOP
Gr CBF
Gr Control
F (p)
Table 9-1. Means and Standard-Deviations (SD) at baseline for the full group and each of the
randomized groups.
9.3.2
Main outcome
The score of perceived stress change differed between groups (F=2.7; p=0.05). The TOP group had a
higher decrease than the controls (p=0.05) and tended to differ from the CBF group (p=0.09) (Figure 3).
No difference was observed on the PSS sub-factors change. However, at M6, subjects with the TOP
program tended to have a smaller score on the uncontrolled sub-factor than subjects with the HC program
(F=2.88, p=0.09).
The strength of a phenomenon is small with d=0.18 for TOP and d=0.15 for HC. The number of PFFs
decreasing their score under the clinical threshold was higher in the SMP groups (7.8%) than in controls
(0%) (7 PFFs from TOP and 7 PFFs from CBF vs. 0 PFFs in the control group, chi2=4.45, p=0.03), i.e. a
12% reduction of perceived stress occurred in the SMP group compared with the controls. The Number
Needed to Treat (NNT) with the intervention (HC and TOP) to see one-person benefit (under the
threshold) is nine.
9.3.3
Secondary outcomes
Changes in negative mood index differed between groups (F=3.32; p=0.04). The decrease was higher in
the TOP group than in the controls (p=0.04), higher in the CBF group than in the control group (p=0.05)
and tended to be higher in the TOP groups than in the CBF group (p=0.06) (Figure 9-3). The strength of a
phenomenon is small to middle with d=0.4 for TOP and d=0.1 for HC.
9- 6
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0162.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
Figure 9-3 Outcome measurements after Stress Management Program
No difference was observed in mindfulness changes.
The IgA changes tended to differ between groups (F=2.29; p=0.09) with a tendency to a smaller decrease
for TOP and CBF programs than for the control group. Comparison between programs showed a tendency
to a smaller decrease for CBF program compared to TOP program (p=0.1; Figure 9-3).
9.3.4
Long-term effects (Table 9-2)
Full group
Perceived Stress Scale
M12 (N=121)
M18 (N=121)
State-Anxiety
M12 (N=121)
M18 (N=121)
Negative mood index
M12 (N=121)
M18 (N=121)
Mindfulness
M12 (N=121)
M18 (N=121)
31,67(11.23)
32,02(9.89)
18,5((17.82)
19,13(22.64)
48,10(7.59)
41,40(5.71)
40,89 (6.38)
32,85 (8.16)
SPM group
41.13(6.31)
32.98(7.6)
30.72(11.25)
31.58(8.73)
17.15(15.97)
17.14(20.98)
48,95(8,21)
Control group
40.33(6.65)
32.47(9.7)
34.44(11.11)
32.33(12.57)
23.26(21.95)
24.47(26.37)
45.97(5.41)
41.65(6.95)
T value(p)
0.61(0.55)
0.25(0.8)
-1.65(0.1)
-0.32(0.75)
-2.27(0.08)
-0.86(0.39)
1.9(0.06)
-0.24(0.81)
41,31(5,24)
Table 9-2: Means and Standard-Deviations (SD) at M12 and M18 (follow-up) for the full, SPM and
control groups.
A time-effect was observed for the perceived stress (F=29.92; p=0.001) with a higher score at M12
(incertitude session) compared with other time of measures. All PFFs were considered stressed at M12 and
above the clinical threshold of 27 whereas around 78% of the PFFs were above the clinical threshold at
STO-XX-XXX-999
9-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0163.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
M18 (77.41 for the SPM group and 78.3 for the control group). No group effect was observed.
A time-effect was also observed for mindfulness scores (F=5.31, p=0.001) with a score higher at M12.
The significant interaction between groups (F=3.32; p=0.02) demonstrated a higher mindfulness score in
the SMP group than in controls at M12.
Negative mood index had a time-effect tendency (F=2.27, p=0.08) with a higher score at M18 (operational
session). Interaction between groups tended towards a lower negative mood index in the SMP groups than
in controls (F=2.06; p=0.1) (Figure 9-3).
TOP and CBF groups did not differ in daily practice score. If only 10% of the 62 PFFs from the SMP
group did not fulfill the VAS at M12 or at M18, the average of total daily practice in the SMP group was
2.7/10 at M12 and 2.9/10 at M18. PFFs didn’t observe their homework assignments without instructors,
whatever the SMP. At M12, the daily practice score accounted for 17.9% of the variance in the negative
mood improvement (F=2.974, p=0.03).
9.4 DISCUSSION
Our young military PFFs had high-perceived stress levels [8], [24], and were generally mindful [50], [51].
The results of our preliminary study showed a benefit for stress programs in treating stress perception
compared to the control group in terms of NNT. The significant decrease in % of subjects under the
clinical threshold after the stress programs was associated with significant decrease in negative mood and
a better mucosal immunity status. This combination of statistically significant improvements in these
diverse domains lends support to the clinical relevance of the improvements with the evaluated stress
programs.
First, these results are important insofar as research has indicated that perceived stress is often linked to
somatic distress, negative affect [8], [10], and psychological disorders such as anxiety and depression [43].
Secondly, the decrease in negative mood was of interest because it is well known that negative mood is
associated with physical and mental disorders [51], mental diseases, [17], [51], and immune mediated
diseases [54]. Thirdly, the tendency to the decrease of IgA after the program session is in accordance with
the difficulties of the military formation reported by the PFFs for becoming a FF. A high level of
perceived stress already has been associated with a low level of IgA, namely in healthcare professionals
[55]. Organizations should be more concerned about job stress, which may contribute to an increase in the
incidence of infectious diseases, and subsequent increase in days off work. Interestingly, the perceived
stress and negative mood index changes tend to be higher for cognitive-based experiential training
whereas IgA decrease tended to be lower for the emotionally-based experiential training compared to the
cognitive one or the absence of training. This result cannot be explained by a difference in sport as the
PFFs had a similar practice during their initial formation. The positive effect of CBF on IgA already has
been demonstrated [29]. The observed higher effect of the TOP on the uncontrolled stress as on negative
mood may be understand as an increase in the ability to best evaluate the situation [20], [26]. Whether
differences between TOP and CBF warrant further investigations; an association between TOP and CBF
may be successful.
Long-term effects evaluation was based on an ecological protocol characterized by an incertitude session
following by an operational one. The incertitude session appeared as a real stress period as indicated by
the increase in the perceived stress, whatever the groups. The intervention program did not appear to help
subjects deal with uncertainty as no difference was observed between groups. Nevertheless, these same
subjects revealed improved mindfulness. The concept of mindfulness is characterized by awareness and
acceptance of experiences; flexible regulation of attention; an objective receptivity to body experience and
an orientation to the here-and-now [5], [52]. This was of interest as it is well known that high levels of
9- 8
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0164.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
mindfulness are believed to be associated with well-being, and better identification and description of
feelings while low mindfulness is associated with anxiety, and depression and difficulties to cope with
stress [5], [50], and [52]. It can be proposed that the programs have not improved stress perception when
facing a stressful situation but have helped PFFs to cope better with the stressful situation by increasing
mindfulness when necessary with some possible benefits on negative mood reactivity in a quieter
situation, as it was observed in the operational session. Altogether, these results must be considered in the
mind-body connection framework [4], [13], [14], [36], a functioning, which highlights how the body
proper is involved in emotions and feelings, rather than just the brain [15]. SPM would be considered as a
tool for increasing mind-body connection, which appears particularly efficient when environmental
challenges require to cope with stress.
Furthermore, results must be considered by taking into account that the subjects regularly did not practice;
one reason can arrive from the decision of the newly promoted military FF command during the study to
introduce ethic formation in place of SPM. It is not clear whether the subjects would become more adept if
they have a military support for the practice or not. Nevertheless, it is reasonable to conclude that greater
benefits may accrue to participants if they had a daily practice
9.4.1
Strengths
Our study presents some major strength: it was a randomized, run-in design; compliance to SMP was
measured; it included a sufficient number of participants to detect differences between groups;
community-based long term intervention; because the study is unique in that both SMP and PFFs have
seldom been investigated in RCT using a combination of subjective and objective measures.
It highlights on one hand the effects of SMP in an ecological realistic environment, and on the other hand
differences in benefits between cognitive- and emotionally-based training.
9.4.2
Limitations
There are several limitations to this study: on a methodological point of view, it is not certain that giving
the three groups a nutriceutical really mitigates the placebo effect. On a clinical point of view, the clinical
benefits have not been evaluated faced to the small size of the effects; the results cannot necessarily be
generalized to all workers with occupational stress; women were not included, however, using only a male
population reduces the variability of measures; drop-outs were high, but many Paris’ fire fighters did not
have their contract renewed and there was no headquarter support during the follow-up. Compliance may
appear poor and may have decreased the benefits of the SMP. Finally, cost benefit in terms of incidence of
infectious diseases, and increase of the days off work as well as improvement in military skills and
operational performances were not evaluated.
9.5 CONCLUSION
The treatment of stress and stress effects would involve the whole person; body and brain are
interconnected in both TOP and CBF stress management programs and indicated relief of operational
stress in Paris’ fire fighters. To improve personnel performance and well being, Military, as civilian
organizations should be more concerned about occupational stress through promotion of stress
management programs. Given that the body is involved in the workings of the brain and emotions, it is
logical that treatment of diseases would also involve the whole person, that the body and brain are
interconnected.
STO-XX-XXX-999
9-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0165.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
9.6 RECOMMENDATIONS
Future studies of other stress-reducing interventions, such as meditation Qi Gong and Yoga appears
pertinent to evaluate for the military individuals. Furthermore, conducting interventional trial on stress
disease benefits warrants further investigations.
In accordance with such results, the main
recommendation would be to develop professionals (e.g. Trainers, educators) for both training military
population and to facilitate the increase in frequency of daily practice.
9.7 REFERENCES
[1] Ader, R. Conditioned immunomodulation: research needs and directions. Brain Behav Immun.
2003;17:S51-S57.
[2] Bagby, R.M., Parker, J.D. and Taylor, G.J. The twenty-item Toronto Alexithymia Scale-I. Item
selection and cross validation of factor structure. J Psychosom Res. 1994;38(1):23-32.
[3] Bagby, R.M., Taylor, G.J. and Parker, J.D. The twenty-item Toronto Alexithymia Scale-II.
Convergent, discriminant, and concurrent validity. J Psychosom Res. 1994;38(1):33-40.
[4] Bates, M., Bowles, S., Hammermeister, J., Stokes, C., Pinder, E., Moore, M., Fritts, M.,
Vythilingam, M., Yosick, T., Rhodes, J., Myatt, C., Westphal, R., Fautua, D., Hammer, P. and
Burbelo, G. Psychological fitness. Mil Med. 2010;175(8):21-39.
[5] Brown, K.W. and Ryan, R.M. The benefits of being present: mindfulness and its role in
psychological well-being. J Pers Soc Psychol. 2003;84(4):822-848.
[6] Cerclé, A., Gadéa, C., Hartmann, A. and Lourel, M. Typological and factor analysis of the
perceived stress measure by using the PSS scale. Eur Rev Appl Psychol. 2008 ;58:227-239.
[7] Charney, D.S. Psychobiological mechanisms of resilience and vulnerability: implications for
successful adaptation to extreme stress. Am J Psychiat. 2004;161:195-216.
[8] Cohen, S., Janicki-Deverts, D. and Miller, G.E. Psychological Stress and Disease. J Am Med
As. 2007;298(14):1685-1687.
[9] Cohen, S., Karmak, T. and Mermelstein, R. A global measure of perceived stress. J Health Soc
Behav. 1983;24(4):385-396.
[10] Collange, J., Bellinhausen, L., Chappé, J., Saunder, L. and Albert, E. Perceived stress: when
does it become a risk factor for anxiodepressive disorder? Archives des Maladies
Professionnelles et de l’Environnement. 2013;74:7-15.
http://dx.doi.org/10.1016/j.adm.201.2.12.009.
[11] Hoffart, M.B. and Pross, K.E. The Benefits of visualization: Research suggests that
visualization promotes relaxation, enhances sleep, reduces pain, and increases creativity. Am J
Nurs. 1998;98(12):44-47.
[12] Crosnier, S. Evaluation du sommeil des sous-mariniers en situation opérationnelle sur Sous-
marins Nucléaires lanceurs d’Engins : intérêt des Techniques d’optimisation du Potentiel
9- 10
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0166.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
(TOP) (Evaluation of the submariners’ sleep during a patrol : interests of the TOP program).
PhD thesis. University of Medicine of Brest, France;2013:180.
[13] Damasio, A.R. Descartes' Error: Emotion, Reason, and the Human Brain, New York:
Putnam; 1994:312.
[14] Damasio, A.R. The Feeling of What Happens: Body and Emotion in the Making of
Consciousness, Harcourt Brace, Orlando, Florida; 1999:387.
[15] Damasio, A.R., Tranel, D. and Damasio, H. Somatic markers and the guidance of behavior:
Theory and preliminary testing. In H. S. Levin, H. M. Eisenberg and A. L. Bendon (eds.),
Frontal Lobe Function and Dysfunction, Oxford, UK: Oxford University Press; 1991:217-229.
[16] Davis, M. and Eshelman, E.R. The Relaxation and Stress Reduction Workbook. New
Harbinger Publications, US ;2008:392.
[17] Denollet J. and De Vries J. Positive and negative affect within the realm of depression,
stress and fatigue: The two-factor distress model of the Global Mood Scale (GMS). J Affect
Disorders. 2006;91(2-3):171-180.
[18] Endler, N.S., Kantor, L. and Parker, J.D.A. State-trait coping, state-trait anxiety and
academic performance. Pers Indiv Differ. 1994;16(5):663-670.
[19] Endler, N.S., Macrodimitris, S.D. and Kocovski, N.L. Controllability in cognitive and
interpersonal tasks: is control good for you? Pers Indiv Differ. 2000;29(5):951-962.
[20] Folkman, S., Lazarus, R.S., Dunkel-Schetter, C., DeLongis, A. and Gruen, R.J. Dynamics
of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. J Pers Soc
Psychol. 1986;50 :992-1003.
[21] Friedman, B.H. and Thayer, J.F. Anxiety and autonomic flexibility: a cardiovascular
approach. Biol Psychol. 1998;47:243-263.
[22] Gray, T. Amygdaloid CRF pathways: role in autonomic, neuroendocrine and behavioural
responses to stress. Ann. N.Y. Acad. Med. 1993;697:53-60.
[23] Hauger, R., Irwin, M., Lorang, M., Aguilera, G. and Brown, M. High intracerebral levels of
CRH result in CRH receptor down regulation in the amygdale and neuroimmune
desensitization. Brain Res. 1993;676(1-2):283-292.
[24] Lane, E.M., Hourani, L.L., Bray R.M. and Williams J. Prevalence of perceived stress and
mental health indicators among reserve-component and active-duty military personnel. Am J
Public Health. 2012;102(6):1213-1220.
[25]
Lazarus, S. Stress, appraisal and coping. Edition Springer Publishing Company; 1984:456.
[26] Lazarus R.S. and Launier R. Stress-related transactions between person and environment.
In: Pervin, LA, Lewis M (Eds.), Perspectives in Interactional Psychology. Plenum, New-York;
STO-XX-XXX-999
9 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0167.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
1978: 287-327.
[27] Leifflen, D., Arvers, P. and Lavillunière, N. Occupational stress in paris Firefighters: from
PTSD to Burnout. 2nd Franco-American workshop on war traumatism. EVDG, Paris, march
2010.
[28] McClelland, D.C., Alexander, C. and Marks, E. The need for power, stress, immune
function, and illness among male prisoners. J Abnor Psychol. 1982;91(1):61-70.
[29] McCraty R., Atkinson M., Rein G. and Watkins A.D. Music enhances the effect of positive
emotional states on salivary IgA. Stress Med. 1996;12:167-175.
[30] McCraty, R., Atkinson, M., Tiller, W.A., Rein, G. and Watkins, A.D. The effects of
emotions on short term heart rate variability using power spectrum analysis. Am J Cardiol.
1995;76:1089-1093.
[31] McCraty, R., Barrios-Choplin, B., Rozman, D. and Watkins, D. The impact of a new
emotional self-management program on stress, emotions, heart rate variability, DHEA and
cortisol. Physiol Behav Sci. 1998;33(2):151-170.
[32] Morgan III, C.A., Doran, A., Steffian, G., Hazlett, G. and Southwick, S.M. Stress-induced
deficits in working memory and visuoconstructive abilities in special operations soldiers. Biol
Psychiat. 2006;60:722-729.
[33] Morgan III, C.A., Wang, S., Mason, J., Southwick, S.M., Fox, P., Hazlett, G., Charney, D.S.
and Greenfiel, G. Hormones profiles in humans experiencing military survival training. Biol
Psychiat. 2000;47:891-901.
[34] Morgan III C.A., Wang, S., Rasmusson, A., Hazlett, G., Anderson, G. and Charney, D.S.
Relationship among plasma cortisol, catecholamines, neuropeptides Y, and human performance
during exposure to uncontrollable stress. Psychosom Med. 2001;63:412-422.
[35] Morin, C.M., Hauri, P.J., Espie, C.A., Spielman, A.J., Buysse, D.J. and Bootzin, R.R.
Non-pharmacologic treatment of chronic insomnia. Sleep. 1999;22(8):1134-1156.
[36]
Mullen, M. On total force fitness in war and peace. Mil Med. 2010;175(8):1.
[37] Perraut-Pierre, E. La gestion mentale du stress pour la performance sportive (mental stress
regulation for performances in sport). Amphora. Paris; 2000:189.
[38] Perraut-Pierre, E. Comprendre et pratiquer les Techniques d’Optimisation du Potentiel
(TOP (Understanding and practicing the TOP). InterEditions, Paris; 2012:285.
[39] Penley, J.A., Tomaka, J. and Wiebe, J.S. The association of coping to physical and
psychological health outcomes: a meta-analytic review. J Behav Med. 2002;25:551-603.
[40] Porges, S.W. Cardiac vagal tone: a physiological index of stress. Neurosci Biobehav
R.1995;19(2):225-233.
9- 12
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0168.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
[41] Roozendahl, B., Schoorlemmer, G., Koolhaas, J. and Bohus, B. Cardiac, neuroendocrine
and behavioural effects of central amygdaloid vassopressinergic and oxytocinergic mechanisms
under stress-free conditions in rats. Brain Res Bull. 1993;32(6):573-579.
[42] Ron de Kloet, E., Joëls, M. and Holsboer, F. Stress and the brain: from adaptation to
disease. Nat Rev. 2005;6:463-475.
[43]
Shacham, S. A shortened version of profile of mood states. J Pers Assess. 1983;47:305-306.
[44] Schulkin, J. Neuroendocrine regulation of behavior. Cambridge university press, UK;
1999:323.
[45] Seaward, B.L. Managing stress: principles and strategies for health and wellbeing. Fifth
edition; Jones and Bartlett editions Massachusetts; 2006:589.
[46] Solomon, Z., Mikulincer, M. and Avitzur, E. Coping, locus of control, social support, and
combat-related post-traumatic stress disorder - A prospective study. J Pers Soc Psychol.
1988;55:279-285.
[47] Thompson, R.A. and Asquith P. Quantitation of exocrine IgA in human serum in health and
disease. Clin Exp Immunol. 1970;7(4):491-500.
[48] Trousselard, M., Perraut-Pierre, E. and Saint-Aubin, K. Impact of positive emotions
enhancement on physiological processes and psychological functioning in military pilots.
Human performance enhancement for nato military operations (sciences, technology, and
ethics). Human factors & medicine panel symposium (HFM-181), Sofia, 05-08/10; 2009.
[49] Trousselard, M., Steiler, D., Claverie, D. and Canini, F. Relationship between mindfulness
and psychological adjustment in soldiers according to their confrontation with repeated
deployments and stressors. Psychol. 2012;3(1):100-115.
[50] Trousselard, M., Steiler, D., Raphel, C., Cian, C., Duymedjian, R., Claverie, D. and Canini,
F. Validation of a French version of the Freiburg Mindfulness Inventory-short version: How
mindfulness deals with the stress in a working middle-aged population. Biopsychosoc Med.
2010;4(8):1-11.
[51] Vassend, O., Watten, R., Myhrer, T. and Syvertsen, J.L. Negative affectivity and
intellectual ability: A study of their relation to self-reported physical symptoms, perceived daily
stress and mood, and disciplinary problems in military recruits. Soc Sci Med. 1994;39(4):583-
590.
[52] Walach, H., Buchheld, N., Buttenmüller, V., Kleinknecht, N. and Schmidt, S. Measuring
mindfulness – the Freiburg Mindfulness Inventory (FMI). Pers Ind Diff. 2006,40:1543-1555.
[53] Watkins, A.D. Perception, emotions and immunity: an integrated homeostatic network. Q J
Med. 1995;88:283-294.
[54]
Wright, C.E., Strike, P.C., Brydon, L. and Steptoe, A. Acute inflammation and negative
STO-XX-XXX-999
9 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0169.png
UNCLASSIFIED
TOPS AND CBF IN STRESS MANAGEMENT
mood: mediation by cytokine activation. Brain Behav Immun. 2005;19(4):345-50.
[55]
Yang Y., Koh D., Ng V., Lee C.Y., Chan G., Dong F., Goh S.H., Anantharaman V. and Chia
S.E. Self-perceived work related stress and the relation with salivary IgA and lysozyme among
emergency department nurses. Occup Environ Med. 2002;59:836-841.
9- 14
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0170.png
Chapter 10 – INTEGRATIVE MEDICINE AND
THE TRAUMA SPECTRUM RESPONSE
Wayne Jonas, MD, FAAFP, ABHIM
LTC, MC (RET), United States Army
President and CEO
Samueli Institute
[email protected]
Joan Walter, PA, JD
COO
Samueli Institute
[email protected]
COL Richard P Petri, Jr., MD, FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Fax +1 (915) 742-1536
[email protected]
[email protected]
ABSTRACT
Post-Traumatic Stress Disorder (PTSD) is a widely recognized consequence of deployment, combat exposure
and trauma. Post deployment PTSD commonly co-occurs with other medical problems and mood disorders to
include depression, suicidality, substance abuse disorders, anxiety disorders, and chronic pain. These mind and
body injuries and their consequences often co-occur and are appropriately considered as war-related, trauma
spectrum responses (wrTSR). This article describes the potential role of complementary and integrative
medicine (CIM) in the treatment of war-related, trauma spectrum responses (wrTSR) to post-traumatic stress
disorder and the associated co-morbidities. This overview will describe the interplay between these co-
morbidities as part of the wrTSR as well as suggest how complementary and integrative medicine (IM)
approaches may address many of the challenges in the treatment of wrTSR. Complementary and IM modalities
include tools, which induce permanent healing in a whole person. Better and more-holistic approaches are
needed for healing the wrTSR. In addition, there needs to be greater emphasis on research and implementation
STO-RTG-TR-HFM-195
10- 1
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0171.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
of whole-person healing practices. Finally, it is necessary to recognize the importance of healing as much as
curing.
KEYWORDS
Trauma Spectrum Response, Post-Traumatic Stress Disorder, Traumatic Brain Injury, Pain, Complementary and
Integrative Medicine, Salutogenesis, Military
10.1 INTRODUCTION
For more than a decade, the wars in Iraq (Operation Iraqi Freedom; OIF) and Afghanistan (Operation Enduring
Freedom; OEF) have produced war-fighters with psychologic injuries, such as post-traumatic stress disorder
(PTSD) and physical injuries, often including traumatic brain injury (TBI). Many of these young men and
women are left with long-term symptomatic and functional difficulties. [24], [38] These mind and body injuries,
and their consequences, often co-occur and are appropriately considered as war-related, trauma spectrum
responses (wrTSR). [79], [80] This widespread co-occurrence of these conditions is in many ways, a hallmark of
these wars and requires a different approach to management than would be used for the usual civilian traumas.
At the Walter Reed Army Medical Center, in Washington DC, >46% of blast-injured patients and 55% of
amputees treated during the early years of the wars had also sustained brain injuries. Head and neck injuries
occurred in 15%-20% of all battle injuries, and mild TBI was estimated to afflict up to 28% of all deployed
warfighters. [79], [80] Psychologic trauma was also reported as a frequent co-occurrence. Nearly 20% of soldiers
suffer from PTSD, [18], [23] and nearly 40% report stress-related dysfunction that prevents re-integration into a
full life. Villano et al., [78] and Shipherd et al. [67] reported that depression and anxiety coincide with a
syndrome of chronic pain and heightened stress-reactivity, including PTSD, in 24%-to 66% of combat-wounded
veterans of OIF/OEF.
Cognitive impairment is common in patients with chronic pain and PTSD; the incidence and prevalence of
chronic pain, PTSD, other neuropsychiatric conditions, and cognitive deficits in wounded OIF/OEF troops in
constellation is high. [5], [26] Estimates are that nearly 60% of these soldiers have some form of brain-injury
condition or constellation of cognitive, emotional and behavioral problems resulting from neural insults. [67]
When these conditions are induced by exposure to deployment and battle, we call this constellation of post-
trauma-related conditions “war-related
trauma spectrum responses (wrTSR).”
(Figure 10-1) As noted by Potash,
the wounded veteran presents “new challenges,” including “patients with co-morbid chronic pain…brain trauma
and…attendant cognitive issues.”[61]
The various manifestations of wrTSR may share common causal and recovery mechanisms. Variations in the
internal and external environments result in genotypic factors coding for phenotypes that are differentially
expressed after mind or body injury. Predisposed individuals express a core constellation of common symptoms
that include: (1) mental and emotional distress (e.g., depression, anxiety, anger); (2) cognitive impairment; (3)
chronic pain; (4) drug or opioid desensitization; and, (5) somatic (sleep, appetite, sexual, energy) difficulties. The
result is that rates of comorbidities are higher than after civilian injuries. For example, in a survey published in
2014 of a single combat brigade 3 months after the warriors returned from Afghanistan, rates of chronic pain
were 43% and opioid use in the month prior to participation in the survey was 23%. [72]
10- 2
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0172.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
Figure 10.1 Trauma Spectrum Response Components
10.2 COMPONENTS OF wrTSR
PTSD is a widely recognized consequence of deployment, combat exposure and trauma. Between 15.6% and
17.1% of warriors in OIF suffered from some severe emotional difficulties, including PTSD. [37] A study by the
RAND Corporation put the number at 20%. [18] These rates are not unique to OIF and OEF. Survey researchers
have found that >15% of male Vietnam theatre Veterans (VTVs) met criteria for current PTSD and 30% met
diagnostic criteria for lifetime PTSD. [46] Nearly 9% of female VTVs met current PTSD criteria and 27% met
lifetime criteria for PTSD related to Vietnam combat trauma.
Post deployment PTSD commonly co-occurs with other medical problems and mood disorders, and the majority
of individuals with PTSD meet criteria for one other psychiatric disorder; many individuals have three or more.
[12], [32] Comorbidities include depression, [9], [10] suicidality, [59], [65], [69] substance abuse disorders, [14],
[46] anxiety disorders, [12] and chronic pain. [6], [7], [52], [81] Comorbid diagnoses in warriors with combat-
related PTSD occur in >50%. [25], [44] This complicates the treatment process and weakens the prognosis for
recovery. [32], [63], [82]
10.3 PTSD AND SUBSTANCE
ABUSE
Substance use disorders are another class of disorders often co-occurring with PTSD. In studies of Vietnam
veterans with PTSD, 22% [46] and 39% [14] had alcohol abuse or dependence. People with PTSD may use
alcohol and drugs to self-medicate their symptoms. [12] However, an individual with PTSD (particularly a male)
is more likely to have an alcohol use disorder that preceded the PTSD. [20], [68]
Whatever the cause of comorbidity, it is clear that excessive alcohol use can worsen the symptoms of PTSD,
including sleep disturbance, difficulty with concentrating, emotional numbing, social isolation, anger and
irritability, depression, and hyper-vigilance. Alcohol also reduces a person’s ability to cope with stress. A
STO-RTG-TR-HFM-195
10 - 3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0173.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
number of factors complicate the treatment of comorbid PTSD and alcohol use disorder. While alcohol may
decrease the severity and number of nightmares that are characteristic of PTSD, alcohol may also exacerbate
treatment avoidance. [43] People with PTSD and alcohol abuse/dependence take longer times to respond to
treatment and prematurely terminate therapy more often. [63], [82]
10.4 PTSD AND PAIN
PTSD and chronic pain often co-occur. More than 10% of 225 patients referred to one VA pain clinic for
chronic pain also met diagnostic criteria for PTSD. [7] In a cohort of patients seeking treatment at a
multidisciplinary chronic pain center, 9.5% had “posttraumatic chronic pain syndrome”. [56] Assessments of
139 injured workers with chronic pain who were referred to a rehabilitation program showed that 34.7% had
symptoms of PTSD. [3] PTSD rates in patients with pain secondary to a motor vehicle accident range from 30%-
50%. [15], [36], [71] Patients with accident-related pain and PTSD symptoms reported higher levels of pain and
distress, compared to accident-related pain in patients without PTSD. [27] Pain was the most common complaint
(45% had back pain and 34% had headaches) in patients with PTSD reporting physical symptoms. [52] In
Vietnam veterans with PTSD, [6] 80% reported the presence of a chronic-pain condition. Nearly 60% of 543
veterans treated for PTSD had medical problems including 1 in 4 with some type of musculoskeletal or pain
problem. [81]
Having pain and PTSD makes both problems worse. Patients with chronic pain and PTSD report having more
intense pain and distress, [27], [73] higher life interference, [74] and greater disability than patients who had pain
without PTSD. [66] Patients with PTSD and traumatic headache pain [34] had higher levels of depression than
patients who had pain without PTSD. [15] In one significant study, patients with post-traumatic headache (the
most common chronic pain following TBI) generally reported having more frequent pain and had poorer
prognoses than patients with non-traumatic headache. [51] In another study, patients with PTSD and post-
traumatic headache pain had higher levels of depression than patients who had non-PTSD post-traumatic
headache pain. [15] Thus, the co-occurrence of PTSD and chronic pain may worsen either or both conditions.
This continues to be an active area of research, especially in the military. [57], [64]
10.5 TRAUMATIC BRAIN INJURY AND wrTSR
Traumatic Brain Injury (TBI) is a major cause of death and disability in young people. More than 5 million
Americans are affected annually at a cost of nearly $50 billion. [2], [47], [50] The VA and Military hospitals
have admitted more than 7,000 noncombat patients for TBI annually. [79], [80] Twenty-eight percent of battle
injuries requiring emergency evacuation include TBI. [79] Trauma to the head and neck occurs in 15%-20%
of battle injuries, and mild TBI may afflict up to 28% of all deployed war fighters. [79], [80] More than 46%
of patients with blast-related injuries and 55% of amputees at Walter Reed Bethesda have sustained brain
injuries. [16], [21]
Symptoms and dysfunction resulting from mild to moderate TBI (mTBI) cross the entire spectrum of wrTSRs
including physical symptoms, cognitive dysfunction, and psychologic or behavioral problems. [11], [17], [75],
[76], [77] Patients admitted to the hospital for non-head injuries may have sustained unrecognized concussive
brain injuries. The mechanisms and manifestations of TBI from combat blast injury seem to have different and
more complex characteristics than blunt head injury. [54], [55]
Military personnel may have one or more unique sets of demographic factors that cause injuries to manifest in
particular ways. This patient population is younger, tends to have multiple, compound traumas, and requires
10- 4
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0174.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
acute and long-term treatment that is both curative and palliative. [29] In addition, military Kevlar head-and-
torso-protective equipment has undergone significant improvements that have reduced combat-related
mortality. This improved protective gear has meant increased survivability following improvised explosive
device-induced injuries, including limb fractures, penetrating projectile wounds, traumatic amputation(s),
compression/crush injuries, and concussive injuries. [79] Finally, external blast-TBI in military settings is
more often accompanied by skull fractures, subsequent seizures and limb amputation(s). [79], [80]
Postconcussive symptoms occur at increased frequency in warriors, compared to civilian populations. [79]
mTBI sustained in battle is often accompanied by PTSD. mTBI and PTSD often manifest with similar sets of
symptoms and dysfunction, and may be hard to distinguish. [70]
10.6 FAILURE TO ADDRESS THE wrTSR ADEQUATELY
The wrTSR complex often manifests following treatment with signs and symptoms reflective of progression
along this spectrum in military personnel. [77] This progression may be the result of interactions from social,
familial, occupational, and/or economic stressors, and launches a patient down a slippery slope of treatment
failure, worsening symptoms, stress, and life disruption. [17]
Our increasingly subspecialized health care delivery system classifies patients into categories based on mind,
brain, or bodily damage, and sends patients to psychiatry, neurology, rehabilitation medicine, etc., to address
isolated components of the wrTSR. This complicates the coordination of care and places additional burdens on
patients and their families. Often, patients simply do not show up for care (especially for visits that carry social
stigmas) or show up repeatedly in primary care clinics with somatic, nonspecific complaints about sleep,
appetite, energy and/or sexual activity. The former behavior results in underdiagnosis and treatment, and the
latter behavior increases the burden on primary care to treat “subthreshold” PTSD or mTBI, which may go
undiagnosed or treated ineffectively. [28] These patients may present weeks to months after trauma exposure and
chronically burden the Defense or veteran’s health care delivery systems. [11], [78] This situation is
incompatible with the best practice of medicine and calls for a more efficient and holistic approach to addressing
the full consequences of the wrTSR.
10.7 THE NEED FOR A WHOLE-PERSON wrTSR STRATEGY
The data presented in this article point to a large and growing clinical problem [39] and the need for “the
development of intervention based on a new integrated care model”. [67] In addition, the impact of these mind-
brain/body injuries goes far beyond individuals, affecting their families and communities and the health care
system. [28] Thus, from the perspective of each person, family and community, there is good reason to
investigate integrative, multi-dimensional (mind, body, symptom, function) approaches to wrTSR. The current
standards of care for wrTSR are not maximally effective, nor do they address the full biopsychosocial spectrum
of wrTSR. Thus, there is a need to define and understand the wrTSR more completely and to develop
interventions based upon new integrative care models. Such care should address the whole person and seek to
facilitate healing as an integrated paradigm. [78]
10.8 COMPLEMENTARY AND INTEGRATIVE MEDICINE PRACTICES
Because they tend to be holistic and seek to induce salutogenic solutions to recovery and reintegration,
complementary and integrative approaches may address many of these challenges and offer long-term healing
for Service members. [41] Complementary and Integrative Medicine (IM) involves holistic practices used in
STO-RTG-TR-HFM-195
10 - 5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0175.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
conjunction with conventional medicine that are designed to enhance healing, stimulate recovery and reduce
side-effects. Complementary and IM therapies are increasingly used as part of comprehensive care models [4]
and may offer major contributions to recovery and healing.
Surveys have shown that up to 70% of Department of Defense (DoD) beneficiaries use complementary and IM.
[53] A large survey of active duty military members conducted by the Samueli Institute, in conjunction with the
DoD Health Behaviors Survey showed that >45% used complementary and IM and more than two-thirds used
dietary and nutritional supplements in a 12-month period. Surveys, such as the Klemm [42] and HAIG [35]
reports, showed extensive use of complementary and IM by Veterans Health Administration practitioners. [45]
The wide acceptance of complementary and IM suggests that, were a particular complementary and IM approach
to prove effective for addressing PTSD; many people who avoid psychiatric treatment might use it. [49] Current
research is shifting from management and mitigation of PTSD to examining ways to promote posttraumatic
adaptation, development, and growth. This is consistent with trends in mental health research showing (1) a
broader view of the positive psychology movement, (2) recognition of the role of spirituality and religion in
health and well-being, and (3) a broader view of stress-related and post-traumatic growth.[1] Research by
Samueli Institute and partners on the use of optimal healing environments for the treatment and prevention of the
negative effects of wrTSR demonstrates this. [60]
Complementary and IM approaches fall into two basic categories: (1) self-care approaches and (2) drugless
treatments delivered by practitioners.
10.8.1 Self-Care
Self-care encompasses actions people do for themselves that enhance self-care and self-treatment skills, such as
mind-body practices [31] (imagery, relaxation response, [8] mindfulness training, [33] yoga [62]); self-care skills
(community self-care practices, diet and exercise training); device-assisted biofeedback (heart-rate monitoring,
breathing, virtual reality); and diet and supplements for enhancing cognitive/physical fitness and psychologic
resilience. Samueli Institute completed a large set of systematic reviews on self-care complementary and IM for
addressing chronic pain. [13] Current evidence favors the use of yoga, tai chi, and music for treating chronic
pain.
10.8.2 Drugless Treatments
Drugless treatments encompass non-drug and non-psychiatric approaches that are used by complementary
professionals to complement conventional treatments and facilitate healing, such as acupuncture, [30], [58]
Reiki, osteopathic manipulation, [19] chiropractic and integrative medicine team approaches. Samueli Institute
has performed a comprehensive systematic review of acupuncture for the full spectrum of the wrTSR. [48]
Complementary and IM approaches are often of a different nature than symptom-based treatments for isolated
manifestations of the wrTSR. These practices can result in healing and recovery of the entire spectrum of
symptoms and dysfunction of wrTSR simultaneously. In addition, once reduced, these dysfunctions tend to
remain improved without further treatment. When self-care skills and practices have been acquired, the result
may be permanently empowered patients with skills to treat and manage their symptoms with minimal or no
further professional input. For example, Battlefield Acupuncture involves the insertion of ear studs to allow
patients to take control of the frequency and intensity of point stimulation. [22], [30] In studies of acupuncture,
healing touch and guided imagery for PTSD, these approaches resulted in reduction of all symptoms and
dysfunctions of the wrTSR and reduction in the need for medications. [22], [40] Symptoms continued to be
improved even when the interventions were stopped, which is a hallmark of true healing and recovery.
10- 6
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0176.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
1.9 CONCLUSIONS
We need better and more-holistic approaches for healing the wrTSR. Complementary and IM is not just another
set of disease treatments; rather, it includes tools to induce permanent healing in a whole person. If we are to
truly help and heal our Service members suffering the consequences of more than a decade of war, we must
place a much greater emphasis on research and implementation of these whole-person healing practices. We
need to invest in making healing as important as curing.
10.10 RECOMMENDATIONS
1. Military medicine should make a clear distinction between “pathogenic” and “salutogenic”
approaches for managing the wrTSR.
2. Whole-person approaches that do not separate the components of the wrTSR into distinct treatment
processes are needed.
3. A person-centric approach to the wrTSR and reintegration after deployment is needed.
4. The Military should place a much greater emphasis and investment in both research and practice
seeking strategies that accelerate salutogenesis seeking to “reset” and permanently heal service
members after deployment.
5. Strategies that coordinate all services, such as the U.S. DoD Total Force Fitness framework, should be
developed and standardized.
6. Society should fulfill its social contract with individuals who are sent to war, guaranteeing that all
become successful to their maximum capacity when they return.
7. Integrative healthcare approaches can play a key role in that success and need greater investment by
the public and private sectors
10.11 REFERENCES
[1]
[2]
Ai, A.L. and Park, C.L. Possibilities of the positive following violence and trauma: informing
the coming decade of research. J Interpers Violence. 2005;20(2):242-50.
Armed Forces Health Surveillance Center. Traumatic brain injury among members of active
components, US Armed Forces, 1997-2006. MSMR: A publication of the Armed Forces
Health Surveillance Center 2007;14(5):2-7.
Asmundson, G.J., Norton, G.R., Allerdings, M.D., Norton, P.J. and Larsen, D.K.
Posttraumatic stress disorder and work-related injury. J Anxiety Disord. 1998;12(1):57-69.
Barnes, P., Powell-Griner, P., McFann, K. and Nahin, R. Complementary and Alternative
Medicine use among adults: United States, 2002. Advance data from vital and health
statistics; no 343. Hyattsville, Maryland: National Center for Health Statistics, 2002.
Beck, J., Palyo, S., Winer, E., Schwagler, B. and Ang, E. Virtual Reality Exposure Therapy
for PTSD symptoms after a road accident: an uncontrolled case series. Behavior Therapy.
2007;38(1):39-48.
Beckham, J.C., Crawford, A.L., Feldman, M.E., Kirby, A.C., Hertzberg, M.A., Davidson,
[3]
[4]
[5]
[6]
STO-RTG-TR-HFM-195
10 - 7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0177.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
J.R. and Moore, S.D. Chronic posttraumatic stress disorder and chronic pain in Vietnam
combat veterans. J Psychosom Res. 1997;43(4):379-89.
[7]
[8]
Benedikt, R.A. and Kolb, L.C. Preliminary findings on chronic pain and posttraumatic stress
disorder. Am J Psychiatry. 1986;143(7):908-10.
Benson, H., Greenwood, M.M. and Klemchuk, H. The relaxation response:
psychophysiologic aspects and clinical applications. International journal of psychiatry in
medicine. 1975;6(1-2):87-98.
Berlim, M., Perizzolo, J. and Fleck, M. Posttraumatic stress disorder and major depression.
Rev Bras Psiquiatr. 2003;25(1):51-4.
Bleich, A., Koslowsky, M., Doley, A. and Lerer, B. Post-Traumatic Stress Disorder and
depression. An analysis of comobidity. British Journal of Psychiatry 1997;170:479-82.
Bolzenius, J.D., Roskos, P.T., Salminen, L.E., Paul, R.H. and Bucholz, R.D. Cognitive and
self-reported psychological outcomes of blast-induced mild traumatic brain injury in
veterans: a preliminary study. Applied neuropsychology. Adult 2015;22(2):79-87.
Brady, K., Killeen, T., Brewerton, T. and Lucerini, S. Comorbidity of psychiatric disorders
and Posttraumatic Stress Disorder. Journal of Clinical Psychiatry. 2000;61(7):22-32.
Buckenmaier, C., Crawford, C., Lee, C. and Schoomaker, E. Special Issue: Are Active Self-
Care Complementary and Integrative Therapies Effective for Management of Chronic Pain?
A Rapid Evidence Assessment of the Literature and Recommendations for the Field. Pain
Med. 2014;Supplement S1:S1–S113.
Centers for Disease Control and Prevention. Health status of Vietnam veterans. I.
Psychosocial characteristics. The Centers for Disease Control Vietnam Experience Study.
JAMA. 1988;259(18):2701-07.
Chibnall, J.T. and Duckro, P.N. Post-traumatic stress disorder in chronic post-traumatic
headache patients. Headache 1994;34(6):357-61.
Clark, M.E., Bair, M.J., Buckenmaier, C.C., 3rd, Gironda, R.J. and Walker, R.L. Pain and
combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom:
Implications for research and practice. J Rehabil Res Dev. 2007;44(2):179-94.
Cogan, A.M. Occupational needs and intervention strategies for military personnel with mild
traumatic brain injury and persistent post-concussion symptoms: a review. OTJR: (Thorofare
N J). 2014;34(3):150-9.
Coulter, I., Ellison, M., Hilton, L., Rhodes, H. and Ryan, G.
Hospital-Based Integrative
Medicine: A Case Study of the Barriers and Factors Facilitating the Creation of a Center.
Santa Monica, Calif: RAND Corporation, 2008.
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
10- 8
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0178.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
[19]
Cutler, M.J., Holland, B.S., Stupski, B.A., Gamber, R.G. and Smith, M.L. Cranial
manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study.
J Altern Complement Med. 2005;11(1):103-8.
Davidson, J., Kudler, H., Saunders, W. and Smith, R. Symptom and comorbidity patterns in
world war II and Vietnam veterans with Posttrauamtic Stress Disorder. Compr Psychiatry.
1990;31:162-70.
Traumatic brain injury planning conference. National Conference Center; 2007 June 25-26;
Lansdowne,VA.
Engel, C.C., Cordova, E.H., Benedek, D.M., Liu, X., Gore, K.L., Goertz, C., Freed, M.C.,
Crawford, C., Jonas, W.B. and Ursano, R.J. Randomized effectiveness trial of a brief course
of acupuncture for posttraumatic stress disorder. Medical care 2014;52(12 Suppl 5):S57-64.
Engelhard, I.M., Huijding, J., van den Hout, M.A. and de Jong, P.J. Vulnerability
associations and symptoms of post-traumatic stress disorder in soldiers deployed to Iraq.
Behav Res Ther. 2007.
Erbes, C., Westermeyer, J., Engdahl, B. and Johnsen, E. Post-traumatic stress disorder and
service utilization in a sample of service members from Iraq and Afghanistan. Mil Med.
2007;172(4):359-63.
Forbes, D., Creamer, M., Hawthorne, G., Allen, N. and McHugh, T. Comorbidity as a
predictor of symptom change after treatment in combat-related Posttraumatic Stress Disorder.
J Nerv Ment Dis. 2003;191(2):93-99.
Gayle Beck, J., Gudmundsdottir, B. and Shipherd, J. PTSD and emotional distress symptoms
measured after a motor vehicle accident: Relationship with pain coping profiles. J
Psychopathol Behav Assess 2003;54(4):219-27.
Geisser, M.E., Roth, R.S., Bachman, J.E. and Eckert, T.A. The relationship between
symptoms of post-traumatic stress disorder and pain, affective disturbance and disability
among patients with accident and non-accident related pain. Pain. 1996;66(2-3):207-14.
Giordano, J. Changing the practice of pain medicine writ large and small through identifying
problems and establishing goals. Pain Physician. 2006;9(4):283-5.
Gironda, R.J., Clark, M.E., Massengale, J.P. and Walker, R.L. Pain among veterans of
Operations Enduring Freedom and Iraqi Freedom. Pain Med. 2006;7(4):339-43.
Goertz, C., Niemtzow, R., Burns, S., Fritts, M., Crawford, C. and Jonas, W.B. Auricular
acupuncture in the treatment of acute pain syndromes: A pilot study. Mil Med.
2006;171(10):1010-14.
Gordon, J.S., Staples, J.K., Blyta, A. and Bytyqi, M. Treatment of posttraumatic stress
disorder in postwar Kosovo high school students using mind-body skills groups: a pilot study.
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
STO-RTG-TR-HFM-195
10 - 9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0179.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
J Trauma Stress. 2004;17(2):143-7.
[32]
[33]
[34]
Grinage, B.D. Diagnosis and management of post-traumatic stress disorder. Am Fam
Physician. 2003;68(12):2401-8.
Grossman, P., Niemann, L., Schmidt, S. and Walach, H. Mindfulness-based stress reduction
and health benefits. A meta-analysis. J Psychosom Res. 2004;57(1):35-43.
Headache Classification Committee of the International Headache Society (IHS). The
International Classification of Headache Disorders, 3rd edition (beta version).
http://www.ihs-classification.org/_downloads/mixed/International-Headache-Classification-
III-ICHD-III-2013-Beta.pdf.
Cephalgia. 2013;33:629–808.
Healthcare Analysis & Information Group (HAIG). Complementary and Alternative
Medicine Report. Washington, DC: Department of Veterans Affairs; 2002.
Hickling, E.J. and Blanchard, E.B. Post-traumatic stress disorder and motor vehicle accidents.
J Anxiety Disord 1992(6):285-91.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I. and Koffman, R.L.
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J
Med. 2004;351(1):13-22.
Hoge, C.W., Auchterlonie, J.L. and Milliken, C.S. Mental health problems, use of mental
health services, and attrition from military service after returning from deployment to Iraq or
Afghanistan. JAMA. 2006;295(9):1023-32.
icasualties.org. Iraq coalition casualty count. Secondary Iraq coalition casualty count.
http://icasualties.org.
Jain, S., McMahon, G.F., Hasen, P., Kozub, M.P., Porter, V., King, R. and Guarneri, E.M.
Healing Touch with Guided Imagery for PTSD in returning active duty military: a
randomized controlled trial. Mil Med. 2012;177(9):1015-21.
Jonas, W.B., Chez, R.A., Smith, K. and Sakallaris, B. Salutogenesis: the defining concept for
a new healthcare system. Global advances in health and medicine : improving healthcare
outcomes worldwide 2014;3(3):82-91.
Klemm Analysis Group. Alternative Medicine Therapy: Assessment of Current VHA Practices
and Opportunities. Washington, DC: Department of Veterans Affairs; 1999.
Kofoed, L., Friedman, M.J. and Peck, R. Alcoholism and drug abuse in patients with PTSD.
Psychiatr Q. 1993;64(2):151-71.
Kozaric-Kovacic, D. and Borovecki, A. Prevalence of psychotic comorbidity in combat-
related post-traumatic stress disorder. Mil Med. 2005;170(3):223-6.
Kroesen, K., Baldwin, C.M., Brooks, A.J. and Bell, I.R. US military veterans' perceptions of
STO-RTG-TR-HFM-195
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
10- 10
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0180.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
the conventional medical care system and their use of complementary and alternative
medicine. Fam Pract. 2002;19(1):57-64.
[46]
[47]
Kulka, R.
Trauma and the Vietnam War Generation: Report of Findings From the National
Vietnam Veterans Readjustment Study.
. New York: Brunner/Mazel, 1990.
Langlois, J. Traumatic brain injury in the United States: Assessing outcomes in children.
Atlanta: National Center for Injury Prevention and Control of the Centers for Disease Control
and Prevention, 2001.
Lee, C., Crawford, C., Wallerstedt, D., York, A., Duncan, A., Smith, J., Sprengel, M.,
Welton, R. and Jonas, W. The effectiveness of acupuncture research across components of
the trauma spectrum response (tsr): a systematic review of reviews. Syst Rev. 2012;1:46.
Levine, E.G., Eckhardt, J. and Targ, E. Change in post-traumatic stress symptoms following
psychosocial treatment for breast cancer. Psychooncology. 2005;14(8):618-35.
Lewin, J. and Sumners, D. Anorexia due to brain injury. Brain Inj. 1992;6(2):199-201.
Marcus, D.A. Disability and chronic posttraumatic headache. Headache. 2003;43(2):117-21.
McFarlane, A.C., Atchison, M., Rafalowicz, E. and Papay, P. Physical symptoms in post-
traumatic stress disorder. J Psychosom Res. 1994;38(7):715-26.
McPherson, F. and Schwenka, M.A. Use of complementary and alternative therapies among
active duty soldiers, military retirees, and family members at a military hospital. Mil Med.
2004;169(5):354-7.
Mendez, M.F., Owens, E.M., Jimenez, E.E., Peppers, D. and Licht, E.A. Changes in
personality after mild traumatic brain injury from primary blast vs. blunt forces. Brain Inj.
2013;27(1):10-8.
Mendez, M.F., Owens, E.M., Reza Berenji, G., Peppers, D.C., Liang, L.J. and Licht, E.A.
Mild traumatic brain injury from primary blast vs. blunt forces: post-concussion
consequences and functional neuroimaging. NeuroRehabilitation. 2013;32(2):397-407.
Muse, M. Stress-related, posttraumatic chronic pain syndrome: behavioral treatment
approach. Pain. 1986;25(3):389-94.
Neely, E.T., Midgette, L.A. and Scher, A.I. Clinical review and epidemiology of headache
disorders in US service members: with emphasis on post-traumatic headache. Headache.
2009;49(7):1089-96.
Niemtzow, R. Battlefield Acupuncture. Med Acupunct. 2007;19(4):225-28.
Oquendo, M.A., Friend, J.M., Halberstam, B., Brodsky, B.S., Burke, A.K., Grunebaum, M.F.,
Malone, K.M. and Mann, J.J. Association of comorbid posttraumatic stress disorder and
[48]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
[56]
[57]
[58]
[59]
STO-RTG-TR-HFM-195
10 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0181.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
major depression with greater risk for suicidal behavior. Am J Psychiatry. 2003;160(3):580-2.
[60]
Osuch, E. and Engel, C.C., Jr. Research on the treatment of trauma spectrum responses: the
role of the optimal healing environment and neurobiology. J Altern Complement Med.
2004;10 Suppl 1:S211-21.
Potash, M. Chronic pain and co-morbid brain injury from IED trauma. Prac Pain
Management. 2007;7(5):12-17.
Raub, J.A. Psychophysiologic effects of Hatha Yoga on musculoskeletal and
cardiopulmonary function: a literature review. J Altern Complement Med. 2002;8(6):797-
812.
Riggs, D.S., Rukstalis, M., Volpicelli, J.R., Kalmanson, D. and Foa, E.B. Demographic and
social adjustment characteristics of patients with comorbid posttraumatic stress disorder and
alcohol dependence: potential pitfalls to PTSD treatment. Addict Behav. 2003;28(9):1717-30.
Scher, A.I. and Monteith, T.S. Epidemiology and classification of post-traumatic headache:
what do we know and how do we move forward? Comment on Lucas et al., "Prevalence and
characterization of headache following mild TBI". Cephalalgia. 2014;34(2):83-5.
Shalev, A.Y., Freedman, S., Peri, T., Brandes, D., Sahar, T., Orr, S.P. and Pitman, R.K.
Prospective study of posttraumatic stress disorder and depression following trauma. Am J
Psychiatry. 1998;155(5):630-7.
Sherman, J.J., Turk, D.C. and Okifuji, A. Prevalence and impact of posttraumatic stress
disorder-like symptoms on patients with fibromyalgia syndrome. Clin J Pain.
2000;16(2):127-34.
Shipherd, J.C., Keyes, M., Jovanovic, T., Ready, D.J., Baltzell, D., Worley, V., Gordon-
Brown, V., Hayslett, C. and Duncan, E. Veterans seeking treatment for posttraumatic stress
disorder: What about comorbid chronic pain? J Rehabil Res Dev. 2007;44(2):153-66.
Sonne, S.C., Back, S.E., Diaz Zuniga, C., Randall, C.L. and Brady, K.T. Gender differences
in individuals with comorbid alcohol dependence and post-traumatic stress disorder. Am J
Addict. 2003;12(5):412-23.
Stein, D.J., Bandelow, B., Hollander, E., Nutt, D.J., Okasha, A., Pollack, M.H., Swinson,
R.P. and Zohar, J. WCA Recommendations for the long-term treatment of posttraumatic
stress disorder. CNS Spectr. 2003;8(8 Suppl 1):31-9.
Taber, K., Warden, D. and Hurley, R. Blast-related traumatic brain injury: What is known? J
Neuropsychiatry Clin Neurosci. 2006;18:141-45.
Taylor, S. and Koch, W.J. Anxiety disorders due to motor vehicle accidents: Nature and
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
10- 12
STO-RTG-TR-HFM-195
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0182.png
UNCLASSIFIED
INTEGRATIVE MEDICINE AND THE TRAUMA SPECTRUM RESPONSE
treatment. Clin Psychol Rev. 1995(15):721-38.
[72]
[73]
Toblin, R.L., Quartana, P.J., Riviere, L.A., Walper, K.C. and Hoge, C.W. Chronic pain and
opioid use in US soldiers after combat deployment. JAMA Intern Med. 2014;174(8):1400-1.
Toomey, T.C., Seville, J.L., Abashian, S.W., Finkel, A.G. and Mann, J.D. Circumstances of
chronic pain onset: Relationship to pain description, coping and psychological distress
[abstract]. Miami Beach (FL): American Pain Society, 1994.
Turk, D.C., Okifuji, A., Starz, T.W. and Sinclair, J.D. Effects of type of symptom onset on
psychological distress and disability in fibromyalgia syndrome patients. Pain. 1996;68(2-
3):423-30.
Vanderploeg, R.D., Curtiss, G. and Belanger, H.G. Long-term neuropsychological outcomes
following mild traumatic brain injury. J Int Neuropsychol Soc. 2005;11(3):228-36.
Vanderploeg, R.D., Curtiss, G., Luis, C.A. and Salazar, A.M. Long-term morbidities
following self-reported mild traumatic brain injury. J Clin Exp Neuropsychol.
2007;29(6):585-98.
Vanderploeg, R.D., Belanger, H.G. and Curtiss, G. Mild traumatic brain injury and
posttraumatic stress disorder and their associations with health symptoms. Arch Phys Med
Rehabil. 2009;90(7):1084-93.
Villano, C., Rosenblum, A. and Magura, S. Prevalence and correlate of posttraumatic stress
disorder and chronic severe pain in psychiatric outpatients. J Rehab Research Devel
2007;44(2):167-78.
Warden, D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil.
2006;21(5):398-402.
Warden, D.L. and French, L. Traumatic brain injury in the war zone. N Engl J Med.
2005;353(6):633-4.
White, P. and Faustman, W. Coexisting physical conditions among inpatients with post-
traumatic stress disorder. Mil Med. 1989;154(2):66-71.
Zlotnick, C., Warshaw, M., Shea, M., Allsworth, J., Pearlstein, T. and Keller, M. Chronicity
in Posttraumatic Stress Disorder (PTSD) and prediction of course of comorbid PTSD in
patients with anxiety disorders. J Trauma Stress. 1999;12(1):89-100.
[74]
[75]
[76]
[77]
[78]
[79]
[80]
[81]
[82]
STO-RTG-TR-HFM-195
10 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0183.png
Chapter 11 – SYSTEMATIC APPROACHES TO EVALUATION AND
INTEGRATION OF EASTERN AND WESTERN MEDICAL
PRACTICES
Jan van der Greef, PhD
The Netherlands Organization for Applied Scientific Research
Utrechtseweg, Zeist
The Netherlands
Herman van Wietmarschen, PhD
Sino Dutch Centre for Preventive and Personalized Medicine
Utrechtseweg, Zeist
The Netherlands
Yan Schroën, PhD
Sino Dutch Centre for Preventive and Personalized Medicine
Utrechtseweg, Zeist
The Netherlands
Nathalie Babouraj, MD
Paris Fire Brigade, France
Marion Trousselard, MD, PhD
Institute of Biomedical Research
Armies' Health Service
Bretigny sur Orge, France
ABSTRACT
The current health care system faces increasing costs and demands while the presence of chronic conditions
in the general populations is rising. A shift from disease fighting toward health promotion is needed to
prevent these conditions and empower people to work on their own health. In the Military setting, health
promotion is equally important. Many Veterans are returning from missions with traumatic experiences.
Therefore, in the field of mental health, it is also important to focus on building mental resilience before
deployment, instead of starting treating after the damage is done. Throughout the ages, Eastern medicine
systems have developed different views on health, disease, and resilience. These systems generally focus
more on health promotion and strengthening the self-healing properties of the body, and are, therefore,
complementary to Western medical developments. A better understanding and integration of those
complementary views might reveal new avenues for treatments. In this chapter, Chinese Medicine, Ayurveda,
and endobiogeny thinking are reviewed. Examples are then given of how systems biology can be applied to
study Eastern medicine systems and reveal biologic information about certain diagnostic principles. These
examples show how combined Western and Eastern diagnosis can be used to discover new patient subtypes.
Those subtypes can then be used to study responses to medications and lifestyle interventions, leading
toward personalized treatment in the future. Different studies open a field of exploration to combine systems
biology into global health practice. This review shows that systems biology is successful in revealing
biologic information about Eastern medicine practices. This new comprehensive approach, bridging the
East and the West, creates novel opportunities for Military health care systems. More targeted and
personalized treatment options can be developed for Soldiers, as well as novel health-promotion strategies
based on foods, herbs, acupuncture, and other modalities.
STO-RTG-TR-HFM-195
11 - 1
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0184.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
KEYWORDS
Systems biology, Traditional Chinese Medicine, Ayurveda, Ayurgenomics, Macrocosm, microcosm, the role
of the terrain in health and disease
11.1 INTRODUCTION
Various cultures across the globe have given rise to a variety of sciences, resulting in different medical
practices. Each of these medical systems makes use of particular concepts of health, wellness, resilience, and
healing. In Western medicine, health is currently redefined as the ability to adapt and self-manage in the face
of social, physical, and emotional challenges [7]. In Chinese and Indian medicine, the concept of health is
more related to being one with nature and the rhythms of life. An integration of medical systems is needed to
take full advantage of the various viewpoints and enlarge our understanding of resilience, wellness, health,
and the means of promoting health and resilience [12].
Western and Asian medicine apply very different methods for assessing health. Western science is very good
at measuring molecules and has generally followed a bottom–up approach with regard to the pyramid of life
described by Oltvai and Barabási [10] (Figure 11-1). Elucidating higher levels of system organization is the
concern of psychology. Overcoming the body–mind divide has proven to be very difficult. Knowledge of
health and maintaining health is very limited, compared to the knowledge that has been gained about the
molecular basis of diseases.
Figure 11-1: A representation of levels of system organization, techniques for measuring these
levels of organization, and the convergence of Chinese and Western science. EEG,
electroencephalograph, LEU,; BAT,; ILV,; ATP, adenotriphosphate; ADP, adenosine
diphosphate; UMP, uridine monophosphate; UDP, uridine diphosphate; UTP, uridine
triphosphate; CTP, cytidine triphosphate. Adapted from Oltvai and Barabási, 2002, with
permission from American Association for the Advancement of Science (AAAS).
11- 2
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0185.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Asian medicine systems on the contrary have evolved as
top–down
approaches, phenomenological
approaches, based on the organization and dynamics of symptom patterns. These dynamic symptom patterns
consist of both physical as well as mental aspects, because the body–mind split has never occurred in Asian
medicine. Therefore, Asian medicine provides an excellent opportunity to reconcile the body and mind in
Western medicine. A half a decade ago, significant steps were taken to develop what is called
middle–out
approach toward integration of measurements of these diverse levels of system organization [13].
In this chapter, various cultures of medicine are described briefly, within a systems medicine context. Then,
approaches to scientific evaluation and integration of various systems of medicine are discussed and
illustrated with some examples from recent scientific literature.
11.2 WESTERN AND EASTERN SCIENCES
When we use the word
science,
there is no need for explanation. Every reader, anywhere in the world, will
immediately assume that we are talking about the methodology used in the last 400 years and based on the
ideas of Newton and Descartes, to try to understand our reality. Medicine is part of this scientific thinking.
What science makes science are the rules that scientific philosophers such as Kühne and Popper have
defined. However, what gave them the authority to devise these rules—that is, the embedding of their ideas
in the Western cultural philosophy, which is rooted in our Western civilization?
If we were to conclude that there is only one science, the subsequent conclusion would also, necessarily, be
that there is only one civilization in this world. If we were to assume that this was not the case, we could do
the previous thinking exercise in reverse. Let us take a random civilization: the Chinese civilization. Do they
have cultural philosophers? Lao Zi, Kong Zi, Mo Zi.…So they have. Do they also have scientific
philosophers? Yang Hui, Li Shizhen, Fung Yulan.…Given that they do have scientific philosophers, who
formulated ideas about how to approach and examine our reality? In addition, would it not be logical that
these ideas were totally different from Western ones because of their different cultural bases? So, the
Chinese approach to health and healing would also be different from our Western approach. To understand
the methodology of Chinese medicine, we have to find a way to bridge the gap between the two paradigms
[13] (Figure 11-2).
Chinese medicine is not object-oriented but is much more interested in the relationships between objects. In
addition, Chinese medicine is much more focused on the quality then on the quantity of measurements. What
Chinese medicine does is map patterns of relationships, relationships among symptoms, pulse characteristics,
tongue features, and other factors. These are the exact characteristics of systems thinking—a new scientific
way of thinking developed in the West after World War II, characterized by mapping relationships. Could
this systems thinking be the bridge, the meta-language, between Western medicine and other systematic
medical systems?
11.3 AYURVEDA: A SYSTEMS SCIENCE
Ayurveda, one of the oldest medical systems in the world, can bring new keys to understanding the
complexity of health.
Ayur
means
life
in Sanskrit.
Veda
means
science
or
knowledge.
Ayurveda developed
∼
3000 years bc and was organized into eight different branches: (1) general medicine; (2) pediatrics (including
Cesarean sections for mothers); (3) psychiatric treatment; (4) ophthalmology (including cataract surgery); (5)
surgery; (6) toxicology; (7) rejuvenation treatment (geriatrics); and (8) and sexology. Ayurveda is based on
the body type of the individual that has to be taken into account, as well as the environment the person lives
in, to determine a specific treatment for that individual patient.
According to Ayurvedic knowledge, the human being is the microcosmos, which is completely
STO-XX-XXX-999
11 - 3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0186.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Figure 11-2: Systems biology as a bridge between Chinese and Western medicine. As migration
moved populations apart in space and time, the Western and Chinese cultures evolved
separately, giving rise to specific cultural philosophies. These philosophies gave rise to
philosophies of science, which led to types of science. This evolution allowed different types of
science to exist alongside one another. Figure reproduced from van der Greef, et al., 2010.
Reprinted with permission from © Georg Thieme Verlag KG.
interconnected with his or her environment, the macrocosmos. Healthy relationships among every living
system are primordial for global health, because everything is made of the five basic elements: Space; Air;
Fire; Water; and Earth. In today's language, a rough translation would be: carbon, hydrogen and oxygen
atoms that are omnipresent in living and nonliving forms.
Ancient texts [11] emphasize the importance of taking care of health before disease occurs, which would be
proof of an imbalance of the body's original state. This is represented today by the term allostasis, which is
explained in more detail in the following section. The aim of Ayurvedic treatment is to help a patient
transition from a disease state to an allostatic state, or even to homeostasis, following the dynamic functional
changes of the person's type.
It is worthwhile to focus a little bit more on the mechanisms of Ayurveda. An interesting view of these
ancient texts is the concept that every human being is unique, and the physiology of each biologic system is
ruled by forces—or doshas—that could be translated into functional phenotypes. In order to go a bit deeper
into Ayurvedic diagnosis, it is helpful to focus on the doshas, or mind–body principle, that involve the five
basic elements. Space and Earth give birth to the Vata dosha (Air); Fire and Water give birth to the Pitta
dosha (Fire); and Water and Earth give rise to the Kapha dosha (Water). Everyone has a specific percentage
of Fire-type (Pitta), a specific percentage of Water-type (Kapha) and a percentage of Air-type (Vata). It is
during conception that human beings get their primary constitutions, Prakriti (Figure 11-3).
11- 4
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0187.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Figure 11-3: The right balance of the three forces characterizes the healthy situation: Wind (V);
Fire (P); and Water (K).
The force of Fire is responsible for all the digestive and metabolic processes of the body and the mind. The
force of Water is the key to the structures of the body and the mind. Finally, the Air force is the guarantee for
conduction and mobility in the body and the mind (digestion peristalsis, blood circulation, nerve impulses,
breathing). When we translate this into a more physiologic process, every cell has these three forces it needs:
structural components; metabolic capacity; and mobility capacity.
Other points are included in elaboration of the diagnosis, such as physical features (the quality of the tongue
can also indicate dosha imbalances, as well as the study of the pulse, as in Chinese medicine). In addition to
these physical semiologic features, an important part of the consultation is based on questioning regarding
the patient's lifestyle and habits spanning his or her life.
With the years, and the effects of age and stressful situations, we divert from our Prakriti into a new state of
imbalance known as
Vikriti
(Figure 11-4). It is opportune for disease development. The initial percentages of
the three functional forces are now disturbed—whether they are increased or decreased. The whole aim of
the global treatment is to use herbal medicines, massages, diet, yoga, and adaptation of the individual's
environment to restore the Prakriti of the patient, in his or her
five bodies,
which are known as the
five koshas
[5] (Figure 11-5).
STO-XX-XXX-999
11 - 5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0188.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Figure 11-4: The state in which the three forces—Wind (V); Fire (P); and Water (K)—are out of
balance.
Figure 11-5:
The five bodies or five koshas according to Ayurveda.
11- 6
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0189.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
11.4 THE SYSTEMS BIOLOGY APPROACH TO HEALTH IN EASTERN
MEDICINE
In systems biology, an organism can be considered to be a dynamic, self-organizing system [2], [6]. Not only
the physiology and anatomy of the human body can be approached in this fashion—pathology also appears
to be dynamically organized.
Symptoms arise in groups and create a dynamic balance. In Chinese medicine, it is said that symptoms group
around virtual centers, for which poetic names, such as
Spleen Qi Deficiency
or
Liver Yang Rising,
are used
in Chinese diagnosis. Ayurvedic, Tibetan, and other Asian medicine systems have their own sets of names
for such virtual centers. However, these labels should not distract us, although these exotic names are far
from our Western scientific reality. Statically, we can see that the grouping of the symptoms is very
consistent. In addition, if a symptom appears that does not primarily belong to a stable group of symptoms,
the system tends to behave chaotically. Such a symptom is called a “bridge symptom.” It brings the
dynamically balanced system of a diseased body into a new dynamic steady state in which the patient can
feel better or worse.
This could indicate that health is a dynamic state in which an organism's system responds between a
maximum and minimum: the homeostatic state. Actually, we could say that a person is at maximum health
when that person's dynamic self-organized system is as open as possible and exchanges the largest possible
amount of information with its environment, without losing its identity.
When the system is challenged, it can go into an allostatic state in which the dynamic system is stretched to a
maximum but can recuperate by itself. When the system is frequently challenged to the allostatic state, the
system can adapt to that state and become part of the homeostatic state. When the system is challenged to a
level that it cannot recuperate by itself, the system goes into a disease level. The system organizes itself into
a new dynamic balance, which is not perceived as pleasant or healthy by the patient. When the system is not
helped to make the move back into the allostatic or homeostatic state, the system will move into a next
disease level (Figure 11-6).
Figure 11-6: Conceptual positioning of the relationships among health, resilience, and allostasis. Health is
challenged by acute stressors and by chronic stressors that could build up allostatic load over time. The
response to sudden challenges is often conceptualized as resilience.
STO-XX-XXX-999
11 - 7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0190.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
11.5 SYMPTOMS AS INTERMEDIARIES BETWEEN WESTERN AND ASIAN
DIAGNOSES
A Chinese syndrome is characterized by a specific pattern of symptoms, just like a Western disease is
characterized by a specific group of symptoms. However, Chinese syndromes and Western disease
patterns are determined by different sets of diagnostic tools. Chinese diagnosis makes use of questioning a
patient, observing the tongue, and taking the pulse, among other ways of obtaining information about the
patient. Western medicine developed many measurement techniques to identify changes in, for instance,
blood parameters. A Western disease can consist of many different Chinese syndromes. Conversely, a
Chinese syndrome can belong to many different Western diseases. In this way, symptoms can bridge the
Western and Chinese diagnoses and help us subtype Western diseases and find new relationships among
the different Western diseases we have not been able to observe yet. Discovering relevant subtypes of
diseases, such as rheumatoid arthritis (RA) and Diabetes Mellitus Type II is very important for optimizing
treatment strategies and moving toward personalized medicine approaches.
Figure 11-7 shows an example of this approach in which RA symptoms were compared to symptoms of
Chinese syndromes. In addition, the symptoms of some other rheumatic diseases were also compared to
the same Chinese syndromes. This resulted in a network of relationships as shown in the figure, showing
that RA is indeed related to many Chinese syndromes. After checking these observations with Chinese
medicine experts, a combination of two general TCM subtypes with RA was chosen for further study,
Cold RA and Heat RA. Another argument for this choice was that those two subtypes of patients with RA
are treated very differently in Chinese medicine. Therefore, great differences in disease mechanisms can
be expected as well as differences in responses to Western medications.
Figure 11-7: Overlapping symptom patterns between Western rheumatic diseases and Chinese arthritis
related syndromes. The blue hexagons represent the Western disease categories while the orange hexagons
represent the Chinese syndromes. The small circles represent symptoms. Only those symptoms are shown
that are representative of at least two syndromes, diseases or disease/syndrome combinations (bridge
symptoms). SLE, systemic lupus erythematosus; OA, osteoarthritis; JIA, juvenile idiopathic arthritis; RA,
rheumatoid arthritis.
11- 8
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0191.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
11.6 METABOLOMICS TECHNOLOGY FOR VALIDATING AND
UNDERSTANDING SYMPTOM PATTERNS
An approach was needed to build a bridge between symptom patterns observed and used in Asian medicine
and the molecular biologic approach on which Western medicine is founded. The Netherlands Organization
for Applied Scientific Research (TNO), Utrechtseweg, Zeist, The Netherlands, together with the Sino Dutch
Centre for Preventive and Personalized Medicine, Utrechtseweg, Zeist, The Netherlands, pioneered two
research lines in which metabolomics was used to characterize patient subtypes [14]. Western patient classes,
RA, and type 2 diabetes, were subtyped using Chinese diagnosis. Then blood and urine samples were
collected from these patients for metabolomics analysis with the aim of finding biologic molecular
mechanisms behind the Chinese subtypes.
Figure 11-8 summarizes the systems biology approach in which metabolomics is one of the technologies that
can be complemented by others, such as proteomics and transciptomics. Metabolomics focuses on measuring
metabolites, which represent the state of the body at a certain moment and can give indications of many
processes, such as inflammation, energy balance, oxidative stress, metabolism, hormone organization, etc.
Figure 11-8: Systems biology approach involves measuring large numbers of metabolites from
various tissues and cells. Next, the approach involves using multivariate data analysis
techniques to determine the most relevant variables, which are subsequently used for
interpretation.
Analysis of the data is a critical step. Various multivariate data analysis techniques especially suited to
working with metabolomics data have been developed over the years. More than a decade ago, nonlinear
data analyses had begun to evolve in order to supplement the linear ones
[9].
Two subtypes of RA, RA Cold and RA Heat, could be classified based on symptom and clinical chemistry
profiles with a classification error of 15%. The same patients could also be classified based on urine
metabolite profiles with a classification error of 14% [15]. Figure 11-9 shows how the results of a principal
component analysis are presented. In the left panel, differences between patients with RA Cold and RA Heat
are shown. Both groups are almost separated, but there is some overlap. In the right panel, the symptoms and
clinical chemistry measurements that are responsible for most of the variation in the patient groups are
shown. The ones pointing toward the left are most related to RA Cold, and those pointing toward the right
STO-XX-XXX-999
11 - 9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0192.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
are most related to RA Heat.
Figure 11-9: The left panel shows the scores of the patients with Cold and Heat rheumatoid
arthritis (RA) obtained by the optimal principal component analysis principal component
analysis model. The right panel shows the loadings of the variables used in the PCA model. The
variables pointing toward the right are mostly related to the Heat RA group while the variables
pointing toward the left are related to the Cold RA group. CHOL = cholesterol; ALT = alanine
aminotransferase; LY# = lymphocyte number; MCHC = mean corpuscular hemoglobin
concentration; BUN = blood–urea–nitrogen; CCP = citrullinated protein antibodies; RDW = red
blood cell distribution width; PLT = platelet count; IGM (IgM) = immunoglobulin M; IGG (IgG) =
Immunoglobulin G).
A similar study was performed with patients with prediabetes who were diagnosed by three TCM
practitioners in three patient groups: (1) Qi and Yin Deficiency; (2) Qi and Yin Deficiency with Dampness;
and (3) Qi and Yin Deficiency with Stagnation. Metabolomics measurements of urine samples revealed
differences in carbohydrate metabolism and renal function between the Stagnation group and the other two
groups [12] (Figure 11-10).
Similar to the TCM/systems biology studies on RA Heat and RA Cold, it is possible to define subtypes
based on Ayurvedic symptoms, involving Ayurvedic symptom patterns matching with Western
rheumatoid arthritis
[1]
.
According to presence or absence of Dampness, the patient will be Kapha- aggravated (excess of Water)
or Kapha-lacking. The presence of symptoms of Pitta (inflammation) will make the patient Pitta-positive
or Pitta-negative, and dryness will be a sign of Vata aggravation. If subgroups of patients could be
recruited, their specific metabolomic profiles could be measured, conventional treatment plus the specific
Ayurvedic corrections could be given, and the evolution of the patients' symptoms could be followed.
Many research teams focusing on this field of Ayurgenomics are finding interesting patterns for use in
preventive medicine
[4]
. An example of subtyping chronic back pain after a Military mission is shown in
11- 10
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0193.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Figure 11-11.
Figure 11-10: Principal component analysis score plot for three groups of patients with prediabetes. The
Stagnation group is separated from the Dampness group, indicating that different concentrations of urine
metabolites have been measured for those subgroups. PC1 = principal component 1.
Figure 11-11: A simplified clinical case including conventional Western diagnosis and Ayurvedic specificities
for chronic low-back pain.
STO-XX-XXX-999
11 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0194.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
11.7 ENDOBIOGENY: A SYSTEMS ENDOCRINOLOGY APPROACH
Another interesting systems biology approach is endobiogeny. The French medical physicians, Jean-
Claude Lapraz, MD and Christian Duraffourd, MD invented endobiogeny in the early 1970s
[8]
.
Endobiogeny's focus is on the relationships among the different endocrine regulation loops and predicting
the stage of an individual (homeostasis, allostasis or disease) according to various indexes reflecting the
endocrine functions (Figure 11-12).
Figure 11-12: Relationships among the endocrine functions. Metabolism begins with catabolism and ends
with anabolism. The various axes alternate in their metabolic effects and complement each other by starting
or ending the activity of the axis that precedes an axis in a continuous loop of metabolic activity.
Each function is quantified by an
index,
specified by a
level of activity,
and qualified by a
score.
The index
expresses the resulting effectiveness of the function's activity, both in itself and in relation to the metabolic
needs of the organism. The whole set of indexes gives a very precise longitudinal assessment of an
individual body's functionality, system-by-system, organ by organ.
These indexes are calculated mostly from commonly used blood analysis data using formulae that reflect the
modalities of functionality. Reliability and reproducibility are provided by a computer-based model that
simultaneously determines the whole set of indexes.
This biology of functions allows one to determine the pathogenic tendencies of an organism, its stage of
development, and the degree of severity of a potential pathology. Biology of functions can also be used as a
tool to track the natural development of the pathology and its development under treatment, in order to adjust
the latter better. A flow chart of a study conducted within the French military is presented in Figure 11-13.
11- 12
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0195.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
Figure 11-13: Flowchart of an endobiogeny study conducted in the French military. ISAF = International
Security Assistance Force; IED = Improvised explosive device; SAS = Special Air Service.
11.8 MODELING INTEGRATIVE MEDICINE PERSPECTIVES
An essential element for integration of the various types of information obtained from Western scientific
approaches and Asian scientific approaches is a method for modeling relationships and dynamics
[3]
.
Mechanistic modeling can be useful in this integration, because mechanistic modeling provides the means
to connect both approaches. Suppose we have a model that describes some physiologic variables that are
also used for diagnosis in Chinese medicine. Such a model can be extended with a set of variables that
describe certain aspects of health from a Chinese perspective, based on a set of equations or rules.
Simulations for a number of well-chosen conditions can then be used to display, side by side, the effects of
these conditions on Western and Chinese indicators of health. This enables mutual understanding and a
common ground for discussions about, and exchanges of, knowledge between Western and Chinese
experts.
Recall Figure 11-10 shows an example of how the above can work in practice. TNO developed a first
prototype model of a systems health model that describes various aspects of health, including glucose
metabolism, mental stress, and inflammation. The inputs of the model are factors related to lifestyle, such
as food intake, exercise, and sleep. This model was built in MARVEL, a modeling tool that combines a
relatively simple representation of the system of interest [17] with an easy-to-use interface. The interface
allows the use of a touch table in interactive discussion sessions with domain experts and stakeholders.
Although a simple representation has some drawbacks, it also has a number of clear advantages: it can
intuitively be understood by people who are not familiar with modeling and it allows fast simulation of the
effects of changes in input variables, allowing for vivid interaction with experts. Panel A of Figure 11-14
STO-XX-XXX-999
11 - 13
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0196.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
shows the variables and their interactions (the shapes of the arrows in the figure indicate strengths and
speeds or interactions). The simulation view in Panel B shows the dynamics of a simulation in which
cumulative overfeeding leads to the onset of type 2 diabetes. The radar chart in Panel C provides an
alternative visualization of cause–effect relationships derived from simulation results.
Figure 11-14 A, B, C: Prototype systems health model built in MARVEL. Panel A shows the variables and their
interactions (shapes of arrows indicate strengths and speeds or interactions). Panel B shows a simulation of
the dynamics in which cumulative overfeeding leads to the onset of Diabetes Mellitus Type II. The radar chart
in Panel C provides an alternative visualization of cause–effect relationships derived from simulation results.
11- 14
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0197.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
11.9 CONCLUSIONS
This new comprehensive approach, bridging the East and the West, creates novel opportunities for Military
health care systems. More targeted and personalized treatment options can be developed for Soldiers, as well
as novel health-promotion strategies based on foods, herbs, acupuncture, and other modalities.
11.10 RECOMMENDATIONS FOR FUTURE RESEARCH
Asian science and medicine is essential for the future of health care. There is a clear need to bridge the
chasm between psychology and biology, which appears to be marginally successful in current scientific
approaches. Asian medicine can provide an integrative perspective on many diseases, allowing opportunities
for better treatment and more personalized treatment.
Two essential focus points can be identified to move the field forward from a scientific point of view. First,
techniques should be developed further to obtain Asian symptom patterns from patients in an objective
manner. This involves a shift from developing questionnaires, which are linear in nature, toward developing
expert systems. Expert systems are ideally suited to address the nonlinear nature of gathering patient
information and discovering underlying disease patterns. Such expert systems can be installed easily on
mobile devices for use in the field.
Second, approaches should be developed to integrate the variety of types of data using state-of-the-art
dynamic mechanistic modeling techniques. Effort needs to be made to develop such models with currently
available knowledge in the literature and from experts.
Both of the above elements are relevant in a Military setting. The expert systems based on Asian dynamic
symptom patterns provide a unique diagnostic system for tracking aspects of resilience, fitness and health.
The dynamic models can also be installed on mobile devices, enabling tracking of many sources of data,
such as food intake, activity patterns, physiologic measures, mood, etc. The model can then be used to
simulate the effects of possible interventions on the performance of an individual. Such models can therefore
be used by an individual but also by commanders for monitoring unit resilience. At many levels of a Military
organization, these tools can provide hypotheses for interventions, directions for spending research money,
tracking resilience and health, and empowerment for individuals.
11.11 REFERENCES
[1] Chopra, A., Lavin, P., Patwardhan, B., and Chitre, D. A 32-week randomized placebo-controlled clinical
evaluation of RA-11, an Ayurvedic drug, on osteoarthritis of the knees. J Clin Rheumatol. 2004;10(5):236–
245.
[2] Dallmann, R., Viola, A.U., Tarokh, L., Cajochen, C., and Brown, S.A. The human circadian metabolome.
Proc Natl Acad Sci U S A. 2012;109(7):2625–2629.
[3] De Graaf, A.A., Freidig, A.P., De Roos, B., et al. Nutritional systems biology modeling: From molecular
mechanisms to physiology. PLoS Comput Biol. 2009;5(11):e1000554.
[4] Dey, S., and Phawa. P. Prakriti and its associations with metabolism, chronic diseases, and genotypes:
Possibilities of new born screening and a lifetime of personalized prevention. J Ayurveda Integr Med.
2014;5(1):15–24.
[5] Garodia, P., Ichikawa, H., Malani, N., Sethi, G., and Aggarwal, B.B. From ancient medicine to modern
medicine: Ayurvedic concepts of health and their role in inflammation and cancer. J Soc Integr Oncol.
STO-XX-XXX-999
11 - 15
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0198.png
UNCLASSIFIED
EASTERN AND WESTERN MEDICAL PRACTICES
2007;5(1):25–37.
[6] Glass, L. Sychronization and rhythmic processes in physiology. Nature. 2001;410(6825):277–284.
[7] Huber, M., Knottnerus, J.A., Green, L., et al. How should we define health? BMJ. 2011;343:d4163–
d4163.
[8] Lapraz, J.C., and Hedayat, K.M. Endobiogeny: A global approach to systems biology (part 1 of 2). Glob
Adv Health Med. 2013;2(1):64–78.
[9] Meulman, J.J., van der Kooij, A.J., and Heiser, W.J. Principal components analysis with nonlinear
optimal scaling transformations for ordinal and nominal data. In: DW Kaplan, ed. The SAGE Handbook of
Quantitative Methodology for the Social Sciences. Thousand Oaks, CA. Sage Publications; 2004:49–70.
[10] Oltvai, Z.N., and Barabási, A.L. Systems biology. Life's Complexity pyramid. Science.
2002;298(5594):763–764.
[11] Valiathan, M.S. The Legacy of Caraka. Himayatnagar, Hyderabad, India: Orient Blackswan Private;
2003.
[12] van der Greef, J. Perspective: All systems go. Nature 2011;480(7378):S87–S87.
[13] van der Greef, J., van Wietmarschen, H., Schroën, J., Wang, M., Hankemeier, T., and Xu, G. Systems
biology-based diagnostic principles as pillars of the bridge between Chinese and Western medicine. Planta
Med. 2010;76(17):2036–2047.
[14] van der Greef, J., van Wietmarschen, H., van Ommen, B., and Verheij, E. Looking back into the future:
30 years of metabolomics at TNO. Mass Spectrom Rev. 2013;32(5):399–415.
[15] van Wietmarschen, H., Yuan, K., Lu, C., et al. Systems biology guided by Chinese medicine reveals
new markers for sub-typing rheumatoid arthritis patients. J Clin Rheumatol. 2009;15(7):330–337.
[16] Wei, H., Pasman, W., Rubingh, C., et al. Urine metabolomics combined with the personalized diagnosis
guided by Chinese medicine reveals subtypes of pre-diabetes. Mol Biosyst. 2012;8(5):1482–1491.
[17] Zijderveld, E. MARVEL - Principles of a Method for Semi-Qualitative System Behaviour and Policy
Analysis [presentation]. System Dynamics Society Conference. Boston; (2007:1–21). Online document at:
http://systemdynamics.org/conferences/2007/proceed/papers/VAN%20Z213.pdf Accessed September 14,
2015.
11- 16
STO-XX-XXX-999
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0199.png
ENTER CLASSIFICATION
Chapter 12– Current and Future Directions for Integrative Health and
Healing: A Summary of the NATO HFM Task Force
Richard P Petri, Jr., MD FAAPMR, FAAIM
COL, MC
United States Army
Chairman, NATO HFM-195 Task Force
Integrative Medicine Interventions for Military Personnel
Staff Physician
William Beaumont Army Medical Center
Ft Bliss, Texas
El Paso, Texas 79920
USA
Phone +1 (915) 892-7987
Phone +1 (915) 342-2088
Fax +1 (915) 742-1536
[email protected]
[email protected]
Fred Zimmermann, MA, PhD(c)
Captain (CPT), Reserve Officer, German Army
PhD Candidate at
GRP - Generation Research Program
Human Science Center
University of Munich (LMU)
Prof.-Max-Lange-Platz 11
83646 Bad Toelz, Germany
Samueli-Theophrastus-Fellow
Brain, Mind & Healing Program
Samueli Institute
1737 King Street, Suite 600
Alexandria, VA 22314, USA
Phone: +49 (0)8041-44 901 00
Fax: +49 (0)8041-44 900 99
[email protected]
Marion TROUSSELARD, MD
COL, French Army
Head Neurophysiology of Emotions
Army Biomedical Research Institute IRBA
La Tronche
FRANCE
Phone: +33 (0)1 78 65 12 55
Fax: +33 (0)1 69 23 72 20
[email protected]
STO-RTG-TR-HFM-195
2-1
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0200.png
ENTER CLASSIFICATION
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
Richard C. NIEMTZOW, MD, PhD, MPH
COL (ret) USAF, MC, FS
United States Air Force Acupuncture and Integrative Medicine Center
Director
Malcolm Grow Medical Clinic and Surgery Center
79
th
Medical Group
1050 West Perimeter Road
Joint Base Andrews, Maryland 20762
Phone: +1 (619) 647-7274
Fax: N/A
[email protected]
ABSTRACT
Simply put, medicine is culturally based and alternative medicine is a polarizing field. However, because
healthcare delivery systems must constantly change to meet societal healthcare needs, consideration of
different cultures and perspectives must occur to develop new paradigms in healthcare delivery. Integrative
health and healing (IH
2
) offers a model of holistic care that has potential substantial benefit for military
organizations. This article is a summary of the results and recommendations of the NATO Task Force HFM
195, Integrative Medicine Interventions for Military Personnel. Next steps and quick wins with the
implementation of meditative and acupuncture techniques are discussed. The NATO Task Force HFM-195
was formed to evaluate the current status of complementary and integrative medicine within the military units
of the NATO participating countries. The Task Force recommends that IH
2
offers a new perspective on
healthcare delivery in military organizations. Specifically, this includes implementation of selected IH
2
practices; development of educational programs for patients, providers, and policy makers; and review of
clinical outcomes and best practices. Collaborative research partnerships need further exploration.
KEYWORDS
Complementary and Alternative Medicine, Integrative Health and Healing, Integrative Medicine, NATO, Task
Force
12.1 INTRODUCTION
It is more important to know what sort of person has a disease than to know
what sort of disease a person has.” [2] Hippocrates
Simply put, medicine is culturally based and alternative medicine is a polarizing field. However, because
healthcare delivery systems must constantly change to meet societal healthcare needs, consideration of different
cultures and perspectives must occur to develop new paradigms in healthcare delivery. Therefore, over the past 5
decades, a new paradigm, called alternative medicine, has been emerging. Like healthcare, alternative medicine
has “matured” as the knowledge of the related practices and science becomes better understood. Thus, the
nomenclature has changed to reflect the evolutionary process: from alternative to complementary to integrative
medicine to integrative health and healing, with the latter term as suggested in this report. The polarization is
therefore reduced somewhat.
2- 2
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0201.png
UNCLASSIFIED
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
Effecting changes to long-standing cultures is difficult. It is even more difficult to change military medicine
because it abuts two cultures: that of medicine and that of the military. Integrative health and healing (IH
2
) offers
a model of holistic care that has potential significant benefit for military organizations, a model that embraces the
cultures of medicine and military.
Improvements to the world’s healthcare systems will benefit both the individual and the collective whole.
Collaborative teams must develop a pluralistic healthcare system of understanding, listening, guidance, and
respect. Cultural fluency has been defined as “having the capacity to embrace and flow within many various
cultural environments, and the ability to utilize diversity for understanding and growth.” [8] Thus, cultural
fluency can be used to guide the establishment of a new military model of health and healing through the
expansion of viewpoints. This will only lead to improved outcomes.
Multinational organizations such as NATO are the best place to begin these partnerships. The new healthcare
paradigm should be void of hierarchical structures with the understanding that there is no single correct system.
The paradigm incorporates treatments plans designed for individuals. A treatment program that best suits and
treats the patient is the correct one. This is achieved only when all options are considered. The countries within
the NATO framework offer differing cultural perspectives, experiences, and philosophies that collectively will
benefit all organizations. Therefore, the NATO Task Force is the first step to opening this door to improved
global military health and healing.
12.2 CULTURAL CONCEPT OF HEALTHCARE SYSTEMS: THE NEED TO
UNDERSTAND AND EMBRACE
The culture of a society is embedded within the healthcare systems of that society. This has been true since
ancient times. As a result of globalization of the world, the differences in cultures and healthcare systems
become more apparent. Adding to the complexity, healthcare systems used to treat military members must adapt
to the military culture to be effective within the military framework. Leveraging the NATO military perspectives
of differing healthcare systems will lead to improvements for all systems.
Table 12-1 compares the cultural aspects of global healthcare systems, specifically from the “Western” and
“Eastern” points of view. Although tables give visible structure to a discussion, there are limitations. A two-
column table would be oversimplified. It would fail to illustrate that differing healthcare systems are not
represented as an either/or choice but rather that systems should flow from one to another. Thus, a third column
has been added. This center column represents this flow from one system to another; however, the descriptors
need to be developed as the new paradigm of healthcare emerges.
Thus, the table reinforces the concept that healthcare systems are complex and require multidimensional views
and explanations. There are hundreds of treatments, systems, approaches, and subspecialties. Many of these are
culturally based. Some are full medical treatment systems. Others are simple techniques that can be used in
specific situations. The list of “what is what” can go on and on. Certainly, many systems cannot be honestly and
adequately compared to others because labeling is artificial, grouping is artificial, and comparisons are artificial.
Often, attempts to label, group, and compare reveal biases, prejudices, ignorance, and misunderstandings.
However, attempts to identify new means of delivering health and healing must be undertaken. Simply stated,
improvements to all systems are needed. Over the past few decades, there have been meaningful strides and
efforts toward this. The NATO Task Force on Integrative Medicine is evidence of this. As the system is
evaluated and critiqued, flexibility in understanding and acceptance of difference is an upmost necessity. Table
12-1 is a first step to provoke intellectual and emotional discussions. The hope is that as a result, there will be an
STO-RTG-TR-HFM-195
2-3
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0202.png
ENTER CLASSIFICATION
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
understanding of each system’s value and a cooperative willingness to consider change. Ultimately, patients will
benefit from the larger available “toolbox” of treatment options to meet their needs and goals of health and
healing.
Table 12-1: Cultural Aspects of Global Healthcare Systems
Descriptive Term
Biomedical Construct
Balance
between the
two systems
Relational Construct
Terms *
Allopathic, Western,
Standardized, Scientific,
Modern, Conventional,
Ontological, Materialistic
Nouns, states of being
Reductionist, Categorical,
Newtonian physics, Cartesian,
Mind-Body Dualism,
Rationalized
Mechanical, Machine, “Body”
Eastern, Alternative, Complementary,
Integrative, Traditional, Holistic, Non-
materialistic, homeodynamic
Described in Terms of
Embedded Theories †
Verbs, dynamism and balance
Holistic, Quantum physics, non-scientific,
patient-centered, relational
View of Body ‡
Psychosocial, energetic process, spiritual,
“Mind”, person, body-person
Curanderismo, TCM, Ayurveda, psychiatry,
Shamanistism
Examples §
“Western” specialties and
subspecialties e.g. Cardiology,
Internal Medicine, Orthopedics
Objective, measureable
phenomena and technology to
achieve a diagnosis,
abnormality based on
“standardized ranges”,
organ/system centered
Distinct disease entity
(symptom related illness)
Physical body (organ, tissue,
cellular level)
External (pathogens,
environmental impact on
individual)
Disease, pathogenic origin with
distinctive symptoms/signs,
single causes, specific
treatments
Trauma, acute illness, end-
stage physical malfunction,
minimal preventive care
Focus
Individuality and why
this
person has
this
condition at
this
time
Treatment Focus
Restoration of balance (energetic flow and
homeodynamic)
Energetic (vital spirit, qi, ch’i, ki, prana),
psychosocial, social bodies
Internal energetic imbalances, dysfunction
(disruptive flow and homeodynamics) leading to
somatic disease
Deep rooted causation, multiple level energetic
imbalances
Body Focus
Model of Disorder
(Primarily)
Underlying Issues for Seeking
Treatment
Entry Point
Pre-somatic/physical manifestation of energetic
dysfunction/imbalance, wellness, preventive care
2- 4
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0203.png
UNCLASSIFIED
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
Table 12-1: Cultural Aspects of Global Healthcare Systems (Continued)
Descriptive Term
Biomedical Construct
Balance between
the two systems
Relational Construct
Variability of Disorder
All individuals react in the same way
to the same pathogen (e.g. diabetes is
diabetes in all individuals with the
disease)
Passive
Diseased based (e.g. HTN requires
anti-hypertensive medication)
Each individual reacts differently from
others and temporally with self
Individual Locus of Control
Treatment
Active, responsible
Individualistic (individual’s
energy/constitution lead to the imbalance),
Law of Cure ll **
Natural outcome for some
Facilitator
Healing, Wellness, Quality of Life
Death
Provider Participation
Therapeutic Goal
Failure of treatment
Authoritative
Cure, recent emphasis on
management of disease
Formal education with examination
at discrete steps, legal criteria for
practice
Education of
Practitioner #
Apprenticeship with evaluation of quality
of care determined by preceptor and
community
Formal education with examination at
discrete steps, legal criteria for practice
Research Model &
Randomized, placebo controlled
double blinded trial, “evidence
based”
One practitioner-one patient at a
time, community based, hospital,
home care
Chronic illness, degenerative
conditions, stress related disorders,
technology based, tends to be high
cost,
Care of the patient
Care of the patient
Model validity, whole systems research,
mixed methods research, “evidence based”
Practice Type
One practitioner-one patient at a time,
community based, hospital, home care
Challenges
Acceptance by dominant Allopathic
systems, minimally evidence-based based
on biomedical perspectives
Ultimate Goal
Care of the patient
Legend
* Defining medical systems is nearly impossible, especially confining the definitions to a bimodal pattern. The terms used are those found in the
literature, related to each of the main categories. Every term has potential critiques and challenges. Many could be used in both columns. As an
example, using the term “standardized” for biomedicine is more of an attempt to place biomedicine in a position over other forms of medical care. This
is not the reality. Additionally, “standardized medicine” has not been proven to be “good” or “safe” in all cases. The incidences of iatrogenic harm
from standardized treatments confirm this. As a result, numerous organizations have evaluated “standardized practices” and recommended steps to
improve safety and effectiveness. Further, no individual treatment is truly holistic. When relational treatments are used in isolation, the paradigm of
holistic care is missed. This is a significant potential pitfall for the relational treatments; i.e. using a relational treatment can lead to the
misunderstanding that one is treating in a holistic approach, just because the treatment term is from the right-sided column.
** Constantine Hering described healing in terms of the concept known as the law of cures. Although Dr Hering was a homeopath, the law of cures can
be applied to any system. Specifically, healing occurs
STO-RTG-TR-HFM-195
2-5
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0204.png
ENTER CLASSIFICATION
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
1. Symptoms heal from the deepest (most limiting) level to the most superficial. This means often from the mental into the emotional and
finally into the physical, although it can also be simultaneous on two or more levels.
2. Symptoms resolve in the reverse order that they came: the most recent going away first.
3. Symptoms should improve from above downwards.
4. Symptoms heal from the most important organ to the least important organ (i.e. generally from the heart to the skin which is the most
superficial organ).
5. Symptoms improve from the center of the body to the periphery (hands and feet)
† Scientific endeavor is deeply embedded in the “randomized control trial” approach of research to describe acceptable practice. However,
observations, experience, analytic and clinical assessments nonetheless add valuable information. At times, it is the only means to gain insight. The
medical field continues to support RCT to define effectiveness, safety and acceptability of a modality. However, RCT cannot adequately view many of
the relational modalities. It just doesn’t fit. All represent science. Therefore, neither side of the table is truly “non-scientific” despite the appearance
the table gives.
‡ With time, the biomedical construct has been forced to understand that the body without the mind is an inadequate view of the paradigm. Viewing
outcomes in a singular term did not lead to an understanding in how the effect was achieved. Therefore, a broader view of the “body” and “something
else” was developed. This includes concepts of “placebo” and “suggestion” to help define the construct. In the relational construct, the emphasis has
been on respond of the “whole.” That is to say a medication used to treat hypertension, which works on the cardiovascular system (biomedical
thinking) has an effect on the entire person as well as the supportive community of the individual. A way to understand this is to understand that a
person with well-controlled hypertension may bring happiness to their family and friends because they can now participate in shared-interest activities.
The relational model recognizes that both interactions and interventions impact the patient; biomedicine minimizes interactions and emphases
interventions.
§ Biomedicine reduces itself into specialties, such as cardiology, orthopedics. Each, in isolation is not a fully formed medical system. This is the
hallmark of reductionism. Relational modalities can have sub specialization as well. However, many of terms in the right side column represent
“world medical systems.” Some of these systems are whole medical care practices. Thus it is difficult for any type of comparison of the two models.
Those involved in the biomedical construct put “all other systems that are not biomedical” in the relational construct. This is the fallacy that because
something isn’t fit it one category, it automatically fits into the other and subsequently there is an appropriate direct comparison.
# The use of the apprenticeship approach can be locale and medicine specific. However, this approach is becoming rare for any system training. In fact,
internships and residencies (biomedical construct) are, in the true definition, types of apprenticeships (system of training a new generation of
practitioners of a trade with on the job training and accompanying studies).
& The term “evidence based” applies to both constructs, although the perspective of what is evidence based may be different from the point of view of
one onto the other.
12.3 INTEGRATIVE HEALTH AND HEALING PRACTICES
A clinic or center that provides just acupuncture, meditation, yoga, and other such integrative medicine
modalities is an integrative center in name only. Numerous hospitals, centers, clinics, and healthcare systems that
have incorporated integrative medicine into practice have failed for various reasons: the lack of political and
financial support, challenges with credentialing and privileging status, standards with educational requirements,
sparse evidence-based science, and a system of fragmented care. [4], [5] These barriers must be overcome with
continued well-designed research and policies that result in improved political and financial support and
acceptance. However, the manner in which a treatment is provided is the crucial challenge to developing a truly
IH2 practice. Therefore, fragmentation of care must be addressed and resolved. As Rakel and Weil write,
“Simply adding CAM therapies without changing our healthcare model is like increasing the number of
specialists with no primary care infrastructure, an approach that increases cost and reduces the quality of care.”
[7]
IH2 practices must provide the “milieu of care” that embraces the true integrative philosophy and concepts of
participation, responsibility, and empowerment. This applies not just to the integrative modalities. It also applies
to the entire treatment plan, whether that includes acupuncture, medications, or surgery. The whole system must
be set up so that the patient “flows” within the system of well-coordinated healthcare instead of our current
disjointed system of appointments across several specialties. Modalities need to complement each other instead
of “competing” with offsetting side effects and results. Individuals need to be empowered to be truly active and
2- 6
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0205.png
UNCLASSIFIED
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
not passive. IH2 practices can leverage the philosophy of developing health behaviors by promoting individuals’
resources that improve understanding of health and personal development. The participant as well as the system
itself must be empowered to provide the best care for the optimal outcomes.
Cure is not the determinant of success; rather, an improved quality of life, which supports the process of healing,
is the measure of success. Curing is often misinterpreted as healing. This is not to say that curing cannot be
healing; however, curing is often perceived to have removed the origin of the disease when it fact it often only
removes the obvious symptoms of the illness. Healing occurs when the patient begins to be aware of the causal
factors that led to the disease processes (i.e., the root causes). In the current “Western” paradigm, we excel at
symptom management instead of assisting with awareness of cause. We must now begin to excel at health and
healing and align our strategic and operational actions to the holistic perspective that underlies a healthcare
system based on IH2. Figure 12-1 shows a NATO Task Force–proposed matrix illustrating the use of integrative
medicine modalities for service members from prevention to intervention.
Figure 12-1 Proposed matrix for integrative medicine treatments. HRV, heart rate variability; MMFT,
Mind Fitness Training Institute; MBSR, mindfulness-based stress reduction; MBSR ACT, MBSR with
acceptance and commitment therapy; PTSD, post-traumatic stress disorder; RP, relapse prevention;
TCM, Traditional Chinese Medicine; TFF, total force fitness; TOP, Tactics to Optimize the Potential;
TM, Transcendental Meditation.
Throughout the NATO medical systems and communities, new methods of practice are being used and
evaluated. Examples of this include the U.S. Department of the Army’s Interdisciplinary Pain Management
STO-RTG-TR-HFM-195
2-7
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0206.png
ENTER CLASSIFICATION
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
Centers, which are devoted to a holistic approach to pain. [6] The French Military Fire Fighters are using stress
management programs based on cognitive and emotional interventions for stress perception and reactivity. The
reader is referred to the article in this issue of the journal titled "Tactics to Optimize the Potential (TOP) and
Cardiobiofeedback (CBF) in Stress Management: The French Experience" for details. (Chapter 9, pages 9-1
through 9-14) The use of mindfulness practices (see the article in this issue titled "Mindfulness Based Practices
as a Resource for Health and Well Being" for details) and the concept of spirituality/religiosity [3] for health,
well being, and adaptive coping resources are under evaluation within the German military. Finally, battlefield
acupuncture and auricular trauma protocol are used by several militaries for the treatment of pain and early
manifestations of post-traumatic stress, especially following an exposure to a major trauma or disaster. [1]
Some collaborative projects resulting from the NATO meetings include (1) a French–German collaboration to
explore relationships between mindfulness and life satisfaction and stress levels, (2) the evaluation of the cultural
differences in rates of post-traumatic stress disorder based on psychological factors in the International Security
Assistance Force troops, and (3) a French–German collaboration on the beneficial resources and unmet
psychosocial and spiritual needs of military personnel.
12.4 DISCUSSION
The overreaching construct of a paradigm of IH2 cannot be developed within the confines of a single Task Force
Group. The basic goal of the Task Force was to review the current state of CIM or IH2 within the global
healthcare system, particularly that of the NATO participant countries.
12.4.1 An Exploratory Task Force
This Task Force, HFM-195, Integrative Medicine Interventions for Military Personnel, was primarily of an
exploratory nature. World healthcare systems, such as Traditional Chinese Medicine, Ayurveda, and Tibetan
medicine, were explored as potential models of new perspectives on healthcare delivery. Modalities such as
mindfulness, meditation, acupuncture, spirituality, religiosity, mascots, protective environments,
nutrition/supplementation, and yoga were discussed with particular emphasis on the use within military
healthcare systems. Paradigm shifts using systems approaches and the concept of personalized medicine for
resiliency, trauma spectrum disorder, pain, and stress disorders were introduced as a system of health and
healing instead of the current system of disease management.
Common themes emerged from the NATO Task Force HFM-195. First, the use of IH2 modalities is common,
although statistics showed significant variations. Second, the most challenging barrier for IH2 is the lack of
standard, accepted terminology. This lack of uniformity affects communications, collaborations (clinical,
research, education), regulatory policy development, reimbursements, acceptance, and comparative evaluations.
This is a much-needed first step. Third, the increasing popularity of integrative medicine modalities has been due
to consumer demand. Policy makers need to recognize the rationale for the dissatisfaction with the current
healthcare system. Open-minded discussions with all stakeholders will only result in improved systems of
healing. Fourth, several modalities can be implemented into the military systems, with evidence that the
treatments are safe, cost-effective, and efficacious for the military population. These include acupuncture,
particularly battlefield acupuncture; mindfulness/meditation; and movement/yoga. At the same time,
international regulations, credentialing policies, education requirements, treatment protocols, tiered provider-
level approaches, and research opportunities relevant to NATO, as well as appropriate recommendations, must
be thoroughly reviewed for these modalities. Fifth, financial consideration of healthcare is paramount given the
ever-decreasing military and national budgets. IH2 modalities offer high-touch, low-cost, safe, and effective
treatment options. Therefore, the financial burden that medical healthcare imposes on budgets and the potential
2- 8
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0207.png
UNCLASSIFIED
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
effect of IH2 on those budgets need to be evaluated.
Finally, pain and stress-related conditions are high-value targets for implementation of IH2 modalities. These
conditions affect a substantial portion of the military personnel and place a large financial burden on the overall
system. Therefore, specific programs for the treatment of pain and stress-related conditions need to be
implemented and monitored.
12.4.2 The Need for Collaborations
As new practices are refined and researched, new policies, standards, and guidelines will be established.
Currently, envelopes are being pushed. Limits are being stretched. And the status quo is being challenged. The
pushing, the stretching, and the challenging must continue if the current medical systems will have any success
with sustainability or if the patient’s health is to be improved. However, few international, collaborative efforts
are being made to define terminology, leverage best practices, maximize the coordination of efforts, develop
research partnerships, or adopt strategic policies. Such partnerships would improve global health. International
collaborations need to occur.
12.5 RECOMMENDATIONS
The NATO Task Force HFM 195 made recommendations based on the broad categories of clinical, educational,
and research aspects.
12.5.1 Clinical Aspects
Implement multinational programs of those modalities with minimal side effects and potential benefit to the
individual and military organizations, such as yoga, mindfulness, movement, biofeedback, and battlefield
acupuncture. Concurrently, an international core of professionals or subject matter experts should be developed.
Once established, “train the trainer” programs should be taught to minimize expenditures and maximize
resources of local experts. Battlefield acupuncture and mindfulness programs could easily be implemented
quickly and widely in the proposed manner. Throughout, the monitoring of best practices and outcomes, with
recommendations and modifications as indicated, is necessary.
12.5.2 Educational Aspects
Handbooks, guides, and pamphlets for service members, practitioners, and leadership should be written.
Examples could be “A Service Member's Guide to Meditation Techniques” or “Vital Information a Commander
Needs to Know About Integrative Health and Healing.” These instructional aids would educate patients on
modality use and proper techniques, explore the various perceptions regarding IH2, or explain the importance of
a shift in practice. Further, information and education on the importance of military culture and its uniqueness
could be addressed so modalities could be adapted for optimal acceptance and utilization within a military
framework.
12.5.3 Research Aspects
International collaborations in multiple areas of research are necessary. Multicenter and multicultural studies
would yield valuable information not obtainable from a single-center study. Potential areas of research include
the financial benefits of IH2 inclusion in the current healthcare systems, comparative cost-effectiveness of
STO-RTG-TR-HFM-195
2-9
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0208.png
ENTER CLASSIFICATION
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
various modalities and for various conditions, and effect and benefits of IH2 on the collective (such as military
unit cohesion, readiness, resiliency, and overall unit performance) as well as individual (such as an improved
sense of well-being and quality of life and the social impact for the individual). Collaborations with other NATO
task forces, hospitals/healthcare centers, academia, and international organizations should be sought out.
12.6 REMAINING QUESTIONS
In the final analysis, the Task Force had more questions than answers. This suggests that further investigations
with additional task forces, symposia, or conferences are indicated. The following is a list of some of the
questions raised by the Task Force.
1. What is acceptable terminology of IH2 and related practices?
2. How can international cultural and perspective differences be used to develop improved global
healthcare?
3. How is IH2 accessed in and out of the military healthcare systems?
4. What are the costs to implement IH2 practices?
5. How will IH2 affect the organization and the individual?
6. Can other partners fund the implementation? International versus national?
7. What is the broader economical context to family and society? Can this be used to leverage civilian
partnerships?
8. How should the continuity of care from active duty to veteran be managed to include partnerships
between military and civilian agencies?
9. Can the integrative medicine modalities be translated into an active exercise (i.e., passive versus active
participation)?
10. How can IH2 be used in developing the “new normal” for injured service members?
11. How can bias be minimized to allow for the best practices to be implemented both at individual and
policy levels?
12. How can IH2 fit into the current healthcare systems as complementary (e.g., pharmacologic
interventions or surgical procedures)?
13. Can IH2 alter addiction and suicide rates?
14. Can cultural differences and experiences between countries help to treat difficult conditions? Can
overlapping systems help to explain condition treatment failures?
15. Could personalized medicine benefit the current system?
12.7 CONCLUSIONS
Use of CIM is increasing among civilian and military populations. Financial support and standardized policy
regarding CIM lags behind utilization. In response, the NATO Task Force HFM-195, Integrative Medicine
Interventions for Military Personnel, was formed to evaluate the current status of CIM within the militaries of
the NATO participating countries. Although the Task Force was primarily an exploratory committee, CIM or
IH2 offers a new perspective on healthcare delivery in military organizations. Additional reviews and
evaluations of IH2 with specific attention to the implementation of selected practices; development of
educational programs for patients, providers, and policy makers; evaluations of clinical outcomes and best
practices; establishment of collaborative research endeavors focused on cost-effectiveness of individual
modalities; and new paradigms and models of care must be considered. Improved international military
healthcare systems will ultimately benefit the readiness of troops, improve optimal performance of military
personnel and organizations, and sustain financial stability of military organizations.
2- 10
PUB REF NBR (e.g. STO-TR-IST-999)
ENTER CLASSIFICATION
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0209.png
UNCLASSIFIED
CURRENT AND FUTURE DIRECTIONS FOR INTEGRATIVE HEALTH AND HEALING
12.8 REFERENCES
[1]
Belard JL, Pock AR. Acupuncture and NATO.
Med Acupunct.
2011;23(4):271–273.
[2]
BrainyQuote. Hippocrates quotes. Online document at:
www.brainyquote.com/quotes/authors/h/hippocrates.html
Accessed December 28, 2014.
[3]
Büssing A, Recchia DR. Spiritual and non-spiritual needs among German soldiers and their relation to
stress perception, PTSD symptoms, and life satisfaction: results from a structural equation modeling approach.
J Relig Health.
Published online June
[4]
9, 2015.
[5]
Cant S, Watts P, Ruston A. The rise and fall of complementary medicine in National Health Service
hospitals in England.
Complement Ther Clin Pract.
2012;18(3):135–139.
[6]
Coulter ID, Ellison MA, Hilton L, Rhodes HJ, Ryan GW. Hospital-Based Integrative Medicine: A
Case Study of the Barriers and Factors Facilitating the Creation of a Center. Santa Monica, CA: RAND
Corporation; 2007. Online document at: www.rand.org/pubs/monographs/MG591 Accessed June 10, 2015.
[7]
Office of the Army Surgeon General. Pain Management Task Force Final Report May 2010 Online
document at: www.regenesisbio.com/pdfs/journal/Pain_Management_Task_Force_Report.pdf Accessed May
7, 2014.
[8]
Rakel D, Weil A. Philosophy of integrative medicine. In: Rakel D, ed.
Integrative Medicine
Philadelphia, PA: Elsevier; 2012:2–11.
[9]
Weir T. Developing cultural fluency. ExecutivƎ. May 1, 2004. Online document at:
www.executive-
magazine/buzz/developing-cultural-fluency
Accessed June 10, 2015.
STO-RTG-TR-HFM-195
2 - 11
UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0210.png
NATO UNCLASSIFIED
ANNEX A
Summary Report of First Meeting, 21-23 March 2011
Theme: Group Kickoff and Organization
Venue: Val de Grace, Paris, France
A1 PARTICIPANTS/PROGRAMME COMMITTEE
Member Nations
France (Meeting Host)
Germany
Hungary
Italy
The Netherlands
United States
Attendees
COL Marion Trousselard
Dr. Arndt Büssing
Dr. Gabriella Hegyi
Dr. Paolo Roberti di Sarsina (Absent)
Dr. Van de Greef (Participant by phone)
Dr. Jean Louis Belard (Chair)
Dr. Wayne Jonas
COL Richard Petri, Jr.
Captain Nathalie Babouraj (France)
Frederick Zimmermann (Germany)
COL Karl Friedl (United States) (Rapporteur)
Dr. Lee Sanghoon, KMD, PhD, Dipl Ac, LAc (Korea)
MAJ David Williams (United Kingdom)
LtCol Ron Verkerk (HFM Panel Exective)
Consultants and Guests
NATO STO Office
STO-TR-HFM-195
ANNEX A-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0211.png
NATO UNCLASSIFIED
ANNEX A SUMMARY REPORT OF THE FIRST MEETING 21-23 MARCH 2011
A2 SUMMARY OF PRESENTATIONS
A2.1 NATO RTO Orientation (Ltcol Ron Verkerk)
LtCol Verkerk outlined current trends and transformation in NATO (e.g., more international humanitarian
missions), emphasized the need to articulate the value of integrative medicine to NATO, and talked about
possible panel outcomes including development of a STANAG to standardize procedures (e.g., pain
management methods involving complementary and alternative medicine). He described the makeup of the
Human Factors and Medicine group, with three panels: Health and Medicine; Human Effectiveness; and
Systems Integration. He provided information about countries that participate in NATO panels, the rules
concerning NATO support for up to two consultants to attend a workgroup meeting, and travel funding that can
be made available for some country participants (e.g., POR, BUL, POL, TUR, EST, ROU, etc.). Korea and
Singapore are relevant examples of other countries that may be included in our workgroup. The purposes of the
NATO RTO workgroups are to promote collaborative research, increase information exchange, maintain a
technological lead, and advise NATO leadership on topics linked to military need. There is one other current
workgroup with some related interests (HFM-174, Lifestyle Effects on Military Fitness, headed by COL Leyk,
Koblenz, Germany).
A2.2. Chairman’s Opening Comments, Introductions and Initial Discussion (Dr. Jean-Louis
Belard)
Dr. Belard outlined the membership (see “Programme Committee”) and made introductions. He outlined the
near-term plan for meetings:
Fall 2011
Spring 2012
Bologna, Italy (tentative)
Budapest, Hungary
Dr. Belard emphasized several key objectives for this meeting: What is available right now in your military
medical facilities, and in the civilian sector? What is the trend? More demand?
What is the most frequently used CAM interventions? We need to learn about each other’s country, in order not
to reinvent the wheel. Several examples of topics for inclusion in future workgroup discussion were suggested:
placebo, phytotherapy, magnetic fields, and virtual reality.
A2.3. Overview Of U.S. Department Of Defense CAM Research And Applications (Col Karl
Friedl)
COL Friedl outlined current research interests and clinical applications of CAM in the US Department of
Defense. Current emphasis in the DoD is on effects of improvised explosive devices (IEDs), which include mild
traumatic brain injury and PTSD as important public issues. Technological improvements such as better body
armor protection for the torso have focused the injury emphasis on age-old problems of brain dysfunction and
serious peripheral limb injuries. Virtual reality is being extensively applied in psychomotor training
rehabilitation of amputees, as exposure therapy assist in treatment of traumatic spectrum disorders, in distraction
therapy to reduce the need for pain medications, and for virtual human interactions to coach Service Members
through an advanced social networking system. Integrative medicine concepts have reached high visibility
within the US DoD thanks to extensive efforts of numerous individuals at military facilities, receptive leadership
as well as civilian partners such as the Samueli Institute. Current research efforts are focused on providing
ANNEX A - 2
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0212.png
NATO UNCLASSIFIED
ANNEX A SUMMARY REPORT OF THE FIRST MEETING 21-23 MARCH 2011
accurate information and evaluating effectiveness of CAM approaches in military applications. Acupuncture
and comprehensive/integrative approaches are being extensively tested in pain management. Meditation and
mindfulness training is being used to promote resilience, along with new studies to develop a better
understanding of the scientific basis for aerobic exercise benefits to cognition and mental health. Technologies
such as automated neuropsychological testing, cell phone-based monitoring and feedback, and neuroimaging are
important to research and delivery of some of the interventions. COL Friedl emphasized some areas of
importance to this panel for NATO consensus/standardization including acupuncture for battlefield pain and
reduction of medication; mindfulness training to enhance psychological stress resilience (possibly synchronized
with HFM 174); and neuroprotective nutrition and supplements.
A2.4. Emerging Trends In CAM (Dr. Wayne Jonas)
Dr. Jonas presented a high level view of integrative health and healing with a special focus on healing, the
natural process of repair (healing is not the same as cure!). Dr. Jonas and the Samueli Institute have been
important partners and subject matter experts advising the US DoD on integrative medicine evaluation and
implementation. The investment in CAM is relatively small in the United States; back and head pain is one of
the top reasons for using CAM. One practical way to organize components of integrative health is into
psychological resilience, physical exercise and sleep, optimal nutrition and substance use, and social integration.
This is surrounded by system wellness, integrative medicine, lifestyle/behaviour, and healing environments.
There is a range of militarily-relevant problems that can be described as related aspects of “trauma spectrum
disorder,” including pain; PTSD; anxiety; post concussive syndrome; substance dependence; abuse and
tolerance; depression; and somatic dysfunction, sleep, appetite, sex, energy. These are highly relevant military
problems described variously as “mind-brain injury” by psychiatrists, “war-related trauma” by neurologists, and
“exposure to blast head injury” by orthopedic/trauma surgeons. Pouring money into pharmaceutical research
gives us the results we paid for – a focus on medication. Placebo is a highly effective treatment and should be
renamed to highlight its specific benefits, and it should be given much more attention and study. One conclusion
was that “placebo” should be a major focus for future workshops by this group, both from the standpoint of an
effective intervention and for its proper interpretation and comparison in some CAM studies.
A2.5. Integrative/Complementary Medicine In Germany – Spirituality As A Resource To
Cope (Prof. Dr. Arndt Büssing)
Dr. Bussing discussed utilization of CAM in Germany and outlined some of the types of occidental (non-Asian)
CAM such as anthroposophic medicine, homeopathy, osteopathy, natural products, mind-body medicine,
alternative medicine, and spirituality that are the focus of research at the Center for Integrative Medicine. Age,
gender, attitudes and convictions are important demographics in use; older adults, women, and individuals with
chronic disease use more CAM interventions. CAM may or may not include other adjuncts such as praying or
use of vitamins; prayer is a popular CAM modality in both US and German surveys. Use of medications does
not heal suffering; suffering is an affective implication between symptoms and quality of life that requires a
multimodal integrative strategy spanning mind, emotion, and physiology. Mindfulness was discovered to be the
key predictor of “inner congruence and peaceful harmony (ICPH)” that came from various mind-body
interventions such as yoga and meditation. Mindfulness (which can be trained, as an intervention) is statistically
associated with quality of life mediated through ICPH, life satisfaction, and lightheartedness/easiness.
Spirituality/religiosity (SpR) can improve long-term adjustment to chronic disease or trauma through a range of
effects ranging from “life has meaning” to emotional comfort to compassion for others. For some, religious
terms such as God, Jesus, and church are a turnoff but are not required for discussion of spirituality. Spiritual
needs range through a theoretical hierarchy including social (connection), emotional (peace), existential
(meaning/purpose), to religious (transcendence). Belonging and partner communication are examples of
STO-TR-HFM-195
ANNEX A - 3
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0213.png
NATO UNCLASSIFIED
ANNEX A SUMMARY REPORT OF THE FIRST MEETING 21-23 MARCH 2011
spiritual needs at the social level, while meaning in life and self-actualization are needs at the existential level.
SpR is an important coping resource and affects resilience, moderating life stressors, enhancing coping ability
(reducing vulnerability), and benefiting health outcomes. Dr. Bussing explained a concept called SpREUK (SpR
in chronic illness) as a reflective process involving search, trust, and reflection. He traced a relationship in
chronically ill patients between pain severity, levels of perception/experience of God, positive experiences, and
happiness. Educated women with chronic pain were most receptive to SpREUK. Happiness, inner peace, active
giving, empathy, and consciousness are all important parts of this SpREUK model. Although spiritual support is
significantly associated with QoL, patients with chronic disease do not feel that their spiritual needs are
adequately met within the medical system or by the medical doctors; this should not only be provided at the end
of life. Life satisfaction and emotional acceptance of disease are associations/predictors of depression and
addiction. The presentation ended with discussion of the putative relevance to military personnel especially for
coping strategies that affect psychological resilience (e.g., the role of unit cohesion and personal relationships
within military units). Fred Zimmerman suggested that religiosity might be substituted by beliefs within a
military group where personal relationships are central motivations.
A2.6. CAM In Hungary – CAM In Military Medicine, New Techniques (Dr. Gabrielle Hegyi)
Dr. Hegyi outlined a large variety of CAM techniques employed in the Central Military Hospital including
acupressure, acupuncture, and massage. Acupuncture and laser acupuncture has been applied to more than
100,000 men and women in the military hospital for a wide variety of pain conditions with long lasting good
results. The usual protocol is 15 sessions per treatment course and 2 courses of treatment per patient in a year.
A new technique of permanent acupuncture was described; fMRI and thermography of the hands demonstrated
changes in response to the de qi (needling sensation). Indices of joint tenderness and range of motion were
described and applied in studies using acupuncture with placement of monofilament in stroke and other brain
damaged patients. Preliminary results suggest good results with reduction in medications and better patient
outlook. The Yamamoto (YNSA – Yamamoto Neue Schadelakupunktur) acupuncture method based on a scalp
somatoform is used in a special clinic in the military hospital. A wide variety of successful cancer treatments
using hyperthermia (“oncotherapy”) were described.
A2.7. Is Integrative Medicine The New World Practice? (COL Richard Petri)
COL Petri presented a formal lecture based on an award-winning presentation at the AMSUS (the key
military/federal medicine) meeting last year focused on new CAM paradigms for today’s ineffective medicine;
he is a pioneering leader for integrative health in the DoD. He called for a holistic multidisciplinary approach to
health and healing; a return to our “roots” (literally depicted as a caveman eating roots for therapy – suggesting
that we have come in a full circle back to acquired wisdom that may still not be scientifically understood);
participation in our own health; the misdirection of medicine focused on diagnosing disease; a call for
distinguishing between proven and unproven therapies instead of conventional vs. unconventional; evidence-
based medicine versus patient-centered care; use of natural abilities to heal rather than substitution with
medications. The Army pain management task force report was discussed; this calls for an integrative approach
to pain management that is less reliant on use of drugs. Overall, COL Petri made a strong case for culture
change and highlighted how a shift to integrative medicine that includes CAM is occurring in military medicine.
A2.8. Systems Approach To Integration Of Occidental And Eastern Wellness And Healing
Traditions (Dr. Jan Van Der Greef)
Dr. van der Greef outlined an integrative (systems biology) approach to reducing health care costs while
providing improved personalized care (“get the right drugs to the right patients – right route, right dose, right
ANNEX A - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0214.png
NATO UNCLASSIFIED
ANNEX A SUMMARY REPORT OF THE FIRST MEETING 21-23 MARCH 2011
time”). He highlighted the large number of patients who suffer side effects and no benefits from standard
medications. Several examples highlight the need for a systematic approach to complex dynamic systems,
especially in the integration of different points of view (e.g., occidental and eastern medicine). There are things
that can’t be learned from a genome (e.g., the same genome does not distinguish between the caterpillar and the
butterfly – one genome but two very different states). A key goal of an integrative holistic approach to medicine
is to detect homeostatic changes even before current ability to diagnose disease. Then, interventions can keep
the process in check or even reverse pathology and sustain normal health (i.e., instead of “disease management,”
the emphasis can be on “health promotion”). Several examples of systems biology studies were presented to
highlight the complex relationships between genomic, transcriptomic, proteomic, and metabolomic
measurements. Comparison of the correlation networks between control, disease, and drug treated animal
models of type2 diabetes highlighted the unmet biochemical need that remains after standard drug treatment as
well as biochemical side effects that arise. These are highly interconnected, dynamic, and nonlinear. Patterns of
self-organization are the key! Western medicine has been focused on “the war against...” and often focused on
biochemical (drug) interventions, with less consideration to social, psychological, and behavioural dimensions.
Other problems involve the translation of data into wisdom (the DIKW paradigm). A systems approach can be
applied to bring western and Chinese medicine into one model with a scientific fusion without having to first
resolve philosophical differences. The salutogenic model that supports human health and well-being rather than
on factors that cause disease was discussed as the overarching concept of detecting and moderating allostatic
load and promoting resilience in the systems approach. Rheumatoid arthritis was used as an example to compare
the 1 disease-1 target-1 drug fits all blockbuster approach compared to an integrated intervention involving life
style, nutrition, multi-dimensional pharmacology, and psychology. A final systems approach example was
provided with the antimicrobial action of berberine (from a medicinal plant) and how the benefits are overlooked
in a reductionist evaluation. Dr. van der Greef concluded with a brief description of the Sino-Dutch Centre for
Preventive and Personalized Medicine consortium that is focused on new systems insights to health and disease
and the fusion of western and eastern perspectives for “personalized system wellness.”
A2.9. French Military Effort In Integrative Medicine (Médecin En Chef Marion Trousselard)
MC Trousselard described the use of integrative medicine in the French military to maintain health of soldiers
from enlistment to retirement. Osteopathy and homeopathy are accepted in France; primary use is of
homeopathy, with higher prevalence of use by women. There is no medical reimbursement for use of CAM.
Systematic military data is lacking but CAM practices are often reported, even though CAM is stigmatized in the
military environment. The Air Force has been a leader in advancing integrative approaches in stress reduction.
These include deep breathing exercises, hypnotherapy, progressive relaxation, and guided imagery; these are
used in various combinations before, during, and after stressful activities. A team program has been developed
for the implementation of this TOP (Techniques d’Optimisation du Potentiel) program, and is widely used by air
traffic controllers and pilots, as well as some physicians in complex shifts in the intensive care unit and troops in
Afghanistan. A new program combining TOP and cardiac coherence (CC, Heart Math) was evaluated. This
focuses on breathing and emotional states, using the autonomic nervous system (heart rate variability) for
biofeedback. Heart rate variability responses are different between the TOP and CC programs; CC appears to
increase the mindfulness state. Mindfulness is important to reducing psychological reactivity, improving
appropriateness of responses to stressful challenges, and improving self-acceptance. Mindfulness has old
traditions in Buddhism and in the Samurai (goal: uncluttered mind and not emotionally attached to an outcome).
Meditation techniques take more time than CC practice. A comparison study with first year medical students
was conducted with CC (1h/wk. x 6 wk.), TOP (1h/wk. x 6 wk.), and control groups. Preliminary data indicates
markers of dopamine and serotonin turnover were increased in the CC and TOP groups compared to controls
post-training and pre-examination. Another study with firefighters showed sex differences in heart rate
variability responses, especially with TOP. Both TOP and CC programs can modify Allostatic load. The
STO-TR-HFM-195
ANNEX A - 5
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0215.png
NATO UNCLASSIFIED
ANNEX A SUMMARY REPORT OF THE FIRST MEETING 21-23 MARCH 2011
endobiogenic approach considers multiple interdependent neuroendocrine axes in psychological distress that
may all be normalized with effective integrative interventions. Two loops were described in detail: Loop 1 –
prepares organism for response with preponderance of catabolic responses; Loop 2 – returns organism to
“baseline” prior to stressor response with more anabolic responses; maladaptation is due to a failure in this loop
and continued new response. A study of allostatic responses and psychopathological vulnerability was
described; this involves forces deploying to Afghanistan. MC Trousselard speculated on the future use of CAM
in French military medicine to include TOP and CC to reduce risk of PTSD and endobiogenic index to screen for
early integrative medicine interventions.
A3
SUMMARY OF DISCUSSION
The group agreed on important early steps to include:
•
Defining CAM, focusing on “Integrative Health and Healing” rather than “Integrative Medicine.” We
should not try to change the name of the HFM but this improved title that better captures the correct
emphasis on health instead of disease can be the first committee recommendation for the final report.
Description of why this is important to the modern military. This needs to be emphasized in every
workshop, with an eye to providing recommendations for standardization and scientifically mature
interventions across NATO forces.
Outlining legislation/rules for CAM by participant countries. Some of this was accomplished in the
presentations at this first meeting. A chapter or appendix of the final report should summarize primary
categories of CAM (perhaps the 5 categories outlined by Dr. Belard) and levels of acceptance and use in
the countries represented in this workgroup (FR, GE, HU, IT, NL, NO, US). This would include what is
reimbursed/provided on a national level, acceptance and use in military medicine, and current national
research and trends.
Choosing an approach to organize the work effort centered on therapies (e.g. acupuncture) or problems
(e.g., pain). Initial proposal is to focus on three main themes in workgroup meetings:
o
o
o
•
Pain management
Resilience/performance optimization
Trauma spectrum response.
•
•
•
The next meeting is tentative scheduled to occur in October 2011.
Annex Completed by HFM-195 Rapporteur, COL Karl E. Friedl
ANNEX A - 6
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0216.png
NATO UNCLASSIFIED
ANNEX B
Summary Report of Second Meeting, 19-21 October 2011
Theme: Acupuncture and Acute Pain Management
Venue: Ordine dei Medici Chirurghi e degli Odontoiatri di Bologna,
Bologna, Italy
B1 PARTICIPANTS/PROGRAMME COMMITTEE
Member Nations
France
Attendees
COL Marion Trousselard
Captain Nathalie Babouraj
Dr. Rafael Nogier
Dr. Laurent Bezin
Dr. Arndt Bussing
Fred Zimmerman
Dr. Gabriella Hegyi
Dr. Paolo Roberti di Sarsina
Dr. Jan van der Greef (Absent)
Dr. Jean Louis Belard (Chair)
Dr. Wayne Jonas
COL Richard Petri, Jr.
Dr. Richard Niemtzow
COL Karl Friedl (Rapporteur)
Dr Sanghoon Lee (Republic of Korea)
Dr David Williams (United Kingdom)
Germany
Hungary
Italy (Meeting Host)
Netherlands
United States
Consultants and Guests
STO-TR-HFM-195
ANNEX B-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0217.png
NATO UNCLASSIFIED
ANNEX B SUMMARY REPORT OF THE SECOND MEETING 19-21 OCTOBER 2011
B2
SUMMARY OF PRESENTATIONS
B2.1 Chairman’s Opening Comments, Introductions, And Initial Discussion (Dr. Jean-Louis
Belard).
Dr. Belard reviewed the membership (see “Programme Committee”) and made introductions. He
outlined the near-term plan for meetings:
Spring 2012
16,17,18 April
Budapest, Hungary
Fall 2012 Date TDB Amsterdam area, Netherlands
Dr. Belard emphasized several key objectives for this meeting:
•
•
•
Presentations on national and military CAM practices from countries that had not previously
presented
Pain management approaches, with a special focus on acupuncture treatment
Continuing discussion of standardization of procedures, and recommendations and specific
products for NATO
B2.2. Considerations for Generalizable Use of Acupuncture for Acute Pain Management in
NATO (COL Karl Friedl)
COL Friedl outlined approaches and considerations (Doctrine, Organization, Training, Leader,
Development, Material, Personnel, Facilities DOTLMPF) for military implementation and for
NATO standardization of acupuncture as a first set of recommendations for CAM use in the military
forces. Key questions posed at the end of the presentation were:
•
Can we reach consensus on accepted standards for acupuncture and acute pain?
•
Can we describe the regulations and laws of each represented country that are relevant to
NATO-wide recommendations?
•
Can we outline a process for standard use of acupuncture for acute pain by NATO healthcare
providers? For medics?
He summarized some relevant conclusions from the U.S. DoD Pain Management Task Force
1
and
highlighted these two quotes from the report:
Pain medicine should be managed by integrated care teams, which employ a biopsychosocial
model of care. The standard of care should have objectives to decrease overreliance on
medication driven solutions and create an interdisciplinary approach that encourages
collaboration among providers from differing specialties.
1
Pain Management Task Force, Final Report, May 2010, Office of the Army Surgeon General
https://www.apsoc.org.au/PDF/Research/1_US-DoD-Pain-Task-Force-Final-Report-May-2010.pdf
STO-TRG-TR-HFM-195
ANNEX B - 2
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0218.png
NATO UNCLASSIFFIED
ANNEX B SUMMARY REPORT OF THE SECOND MEETING 19-21 OCTOBER 2011
The DoD should continue to responsibly explore safe and effective use of advanced and non-
traditional approaches to pain management and support efforts to make these modalities covered
benefits once they prove safe, effective, and cost efficient.
B2.3 Psychosocial and spiritual needs (Dr. Arndt Bussing/Colonel Marion Trousselard)
Dr. Bussing summarized multimodel treatment strategies that address psychosocial and spiritual
needs in an overall integrative wellness program, and he described specific research collaborations
that have developed since the HFM-195 meeting in Paris.
The overarching model involves four levels: social (connection) – emotional (peace) – existential
(meaning/purpose) – religious (transcendence). Primary outcome measures relate to life
satisfaction, which, in turn, affects specific needs, salutogenic resources, cognition, emotion, and
eventually palliative care.
A French-German collaboration was initiated following the Paris HFM meeting to identify specific
needs and salutogenic resources and further explore relationships between mindfulness and life
satisfaction, stress, and other factors (sports involvement, years in a job, age, etc.). Survey data has
been collected and is being analyzed.
B2.4 Overview of CAM practices in Italy and introduction to CAMbrella (Prof. Paolo Roberti
di Sarsina)
Dr. Roberti di Sarsina reviewed CAM useage and policies in Italy. Only physicians and dentists are
allowed to practice CAM. Needs better regulation as Italy has too many very different regional
policies. Person-centered medicine is at the interface of traditional CAM and non-conventional
medicine. He described the European Association for Predictive, Preventive, and Personalized
Medicine (EPMA) World Congress, as well as the CAMbrella network
2
and their efforts to
standardize and promote use of CAM. He described the CAM philosophy as “a way to observe
nature.”
Key goals are to provide treatment choices, solve reimbursement issues, and ensure attention to
safety aspects. Progress to these goals is hampered by the diverse classification systems for CAM
practices, diverse legislation (even within Italy), education and training, and clear treatment
definitions.
B2.5 Auriculotherapy (Dr. Raphael Nogier)
Dr. Nogier gave a succinct overview of the basis of auricular acupuncture. He started with a simple
example of the concept where a thumb pinched by a large clip causes the upper ear to be especially
sensitive to pain. Identification of such painful points in the ear can be used to treat pain. Another
example is the treatment of trauma spectrum disorder where a patient talks about a trauma in their
life while needled along specific auricular points (the “sensory line” or “sound line”, along the lower
2
www.cambrella.eu
ANNEX B - 3
STO-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0219.png
NATO UNCLASSIFIED
ANNEX B SUMMARY REPORT OF THE SECOND MEETING 19-21 OCTOBER 2011
portion of the ear) and the traumatic association dissipates. There was discussion about specific
points Shen Men, Point Zero, Master Cerebral, etc. and consistency between other acupuncture
philosophies and the unifying auricular approach.
Some of the physiological bases of the effects were discussed, culminating with a very interesting
mammalian exception – the naked mole rat (Heterocephalus
glaber).
This species does not regulate
body temperature well (unlike all other mammals), has no auricle (!), and has no Substance P (a key
neurotransmitter modulator of pain associated with noxious chemicals). This species does not
develop cancer and has extraordinarily long life. Somehow all these pieces are related and will be
further explained now that the complete genome has been sequenced.
B2.6 Protective Environments (Dr. Laurent Bezin)
Dr. Bezin provided an overview of the multiple dimensions affecting cognitive reserve and
emotional stability, including current scientific studies in animals. Protective environments or
“safe/secure environments” enhance this reserve and stability. He offered a definition of resilience:
Psychological resilience comprises the sum total of psychological processes that allow subjects to
retain or return to baseline functioning following some kind of adverse experiences.
The
presentation included discussion of the emerging understanding of neurophysiological mechanisms
based on studies of key markers of “perception of wellness” such as p11 protein and TP-13 and 5HT-
2A receptor antagonist studies.
B2.7 TOP Interventions and Yogatherapy (Captain Nathalie Babouraj)
Captain Babouraj described the Yoga concept and illustrated the practical and safe applications for
the military (including a practical demonstration at the start of the daily session). She described the 5
Kashas involved in Yoga principles (symbolically summarized in the image of Krishna in the
frontispiece image at the beginning of this report): physical body (physical/biological substratum),
energy (sensations- “Prana”), mental (experimental –visualization exercises), wisdom, and bliss.
There was also a concise summary of other related parts of the concept (yamas, nuamas, asanas, etc.
– nonviolence against self etc.). The goal of yoga and meditation is to quiet the mind, pushing out
intrusive thoughts that contribute to adverse health, and to move through the levels to achieve
wisdom and bliss. There are parallels to Herbert Benson’s concepts of relaxation therapy and these
approaches contribute to mental and physical resilience. Capt. Babouraj emphasized the concept of a
three-legged stool in medicine that involves pharmaceuticals, surgery/medical procedures, and
individual self-care; this third leg is central to integrative wellness. In a second portion of the
presentation, Capt Babouraj talked about the TOPS program and new experiments and advances in
required military training.
B2.8 Yoga in Clinical Studies and Acupuncture in Emergency Medicine (Dr. Arndt Bussing)
Dr Bussing presented a summary of the effects of yoga in clinical studies and the first interim results
regarding the effects of acupuncture in emergency medicine. After outlining the multimodal
concepts in the treatment of patients with chronic pain and the integrative strategy, the impact of
yoga was shown on performance, physiology, psychology and spirituality. Yoga shows positive
ANNEX B - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0220.png
NATO UNCLASSIFFIED
ANNEX B SUMMARY REPORT OF THE SECOND MEETING 19-21 OCTOBER 2011
effects on the treatment of depression, anxiety, stress and pain. Studies indicate that yoga reduces
perceived stress as effectively as relaxation or cognitive behavioral therapy. Yoga appears to provide
preventive medicine benefits in cardiovascular diseases, diabetes mellitus management, and lung
function.
The second part of his presentation focused on the impact of acupuncture in emergency medicine.
Preliminary results of the evaluation of acupuncture in emergency rooms show that acupuncture can
be an analgesic intervention for patients with acute injury to the extremities and that acupuncture and
conventional treatment are equally effective to reduce pain. Also, simple auricular acupressure is an
effective treatment for anxiety in prehospital emergency settings. Dr. Bussing suggested that the use
of acupuncture treatment should be to relieve symptoms and rapidly stabilize patients (within 3 to 5
minutes), or otherwise use standard conventional treatment.
B2.9 Mindfulness Clinical Applications (Frederick Zimmerman)
Fred Zimmerman presented the highlights of a comprehensive review of mindful techniques (MBSR,
MBCT, DBT, ACT, DP). He took a few indepth examples with Mindfulness-based Stress Reduction
(MBSR), Mindfulness-based Mind Fitness Training (MMFT), and Emotional Freedom Technique
(EFT); all include aspects of developing “meta-awareness”. He offered a definition of mindfulness
as
nonjudgmental awareness where each feeling or emotion is acknowledged and accepted for
what it is.
Buddhist precepts were also presented in the context of mindfulness and similar to the
Yoga concepts presented by Natalie Babouraj:
freeing oneself from distracting thoughts and
cultivating a nonjudgmental mindset by being aware of the present moment.
One can only be
angry about past events and anxious about future events; mindfulness training deals with both of
these. A demonstration of mindfulness techniques was presented at the start of the last day of the
meeting.
Various research concepts were proposed that could include ISAF troops and a concept to look at
cultural differences in PTSD rates based on psychosocial factors such as Chinese concepts of “me as
a partner, me with a specific function in a unit, etc.” vs “individual”.
B2.10 Yamamoto Scalp Acupuncture in Pain (Dr. Gabriella Hegyi)
Dr. Hegyi provided a detailed summary of the Yamomoto method of acupuncture that is practiced in
her clinic for military members. This method is based on scalp locations. Various techniques for
chronic use such as implanted filaments were described. The Yamamoto New Scalp Acupuncture
(YNSA) is especially used for pain associated with locomotion.
B2.11 Acupuncture in Traditional Korean Medicine (Dr. Sunghoon Lee)
Dr. Lee reviewed Korean use of traditional medical practices and provided an overview of the very
elaborate system of determining beneficial acupuncture points for individual patients based on
multiple factors. This included the use of grids covering the side of the head, including many points
on the ear. The ROK relies on medication for anesthesia but can also use acupuncture. The ROK has
traditional medical doctors in all branches and in public service (as part of the 36 month public
STO-TR-HFM-195
ANNEX B - 5
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0221.png
NATO UNCLASSIFIED
ANNEX B SUMMARY REPORT OF THE SECOND MEETING 19-21 OCTOBER 2011
service requirement for all males). The philosophy behind the treatment approaches were also
discussed involving the four elements (sky, earth, fire and water), “Saam”- the four needle technique,
and specialized forms of acupuncture were also described such as bee venom acupuncture and herbal
acupuncture.
B2.12 Battlefield Acupuncture (Dr. Richard Niemtzow)
Dr. Niemtzow described the approach to battlefield acupuncture (BAC) using 5 points in the ear that
has been taught to many physicians in the US Air Force. He outlined a demonstration project that
used this technique with injured soldiers during air evacuation from Afghanistan to Landstuhl,
Germany. He also reported on several forthcoming publications and a new journal that he edits
(Medical Acupuncture, Mary Liebert Press). Special Operations Command gives out needles instead
of narcotics as a first choice for pain management. The approach is effective, works rapidly, and is
easy to use. The five points in the ear used in BAC are shen men, cingulated gyrus, omega 2,
thalamus, and point zero. Pilots grounded for pain treatment medications but not for acupuncture.
Risks associated with BAC could be covering up pathology so the technique needs to be
incorporated into good medical practices (e.g., pain from a leg fracture was treated with BAC and the
individual continued to walk on it when they should have been treated for fracture). The ear sites are
very convenient for access when other parts of the body may be more difficult to treat.
B3
SUMMARY OF DISCUSSION
The group discussed:
•
•
•
Could we collect the information from each NATO country on CAM useage? Perhaps start
with CAMbrella data, include US, and bring in the military?
Trauma spectrum gets to the tip of the spear and should be a key focus.
Sharing published reports and resources – Dr. Roberti di Sarsina offered access to i-cloud
sharing at project place.com. He shared a vast bibliography on acupuncture which has been
stored on the RTG195 website. Dr. Jonas shared copies of a special Military Medicine
journal supplement on Integrative Health.
How to organize the final report. Sharply defined chapters vs one continuous essay?
Organize around prehospitalization, hospitalization, and rehabilitation? Systematic review??
•
The next meeting is scheduled for 16, 17, 18 April 2012 in Budapest.
Annex Completed by HFM-195 Rapporteur, COL Karl E. Friedl.
ANNEX B - 6
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0222.png
NATO UNCLASSIFIED
ANNEX C
Summary Report of Third Meeting, 16-18 April 2012
Theme: Integrative Health Interventions to Improve Resilience
Venue: Stefania Palota, Budapest, Hungary
C1 PARTICIPANTS/PROGRAMME COMMITTEE
Member Nations
France
Attendees
COL Marion Trousselard (Absent)
Captain Nathalie Babouraj
Dr. Rafael Nogier (Absent)
Dr. Laurent Bezin
Dr. Arndt Bussing (Absent)
Fred Zimmerman
Dr. Gabriella Hegyi
Dr. Paolo Roberti di Sarsina
Dr. Jan van der Greef (Absent)
Dr. Jean Louis Belard (Chair)
Dr. Wayne Jonas (Absent)
COL Richard Petri, MC
Dr. Richard Niemtzow (Absent)
COL Karl Friedl (Rapporteur)
Dr Nisha N. Money (United States)
Germany
Hungary (Meeting Host)
Italy
Netherlands
United States
Consultants and Guests
C2 SUMMARY OF PRESENTATIONS
C2.1 Chairman’s Opening Comments, Introductions, and Initial Discussion (Dr. Jean-Louis
Belard)
Dr. Belard outlined the tasks for the meeting and reviewed the agenda. In some respects, this meeting agenda
is structured to accomplish a deeper-than-previous discussion of traditional medicine approaches (e.g.,
Tibetan, Japnaese/Chinese, and Indian Ayurvedic medicine) and their potential applications (and actual
implementation) in US and European medicine today.
He also revisited several key questions that have been carried over from previous meetings: 1) Can we collect
STO-TR-HFM-195
ANNEX C-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0223.png
NATO UNCLASSIFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
info on CAM usage for each NATO country? 2) Should we focus on trauma spectrum? 3) How do we share
published reports and resources? The organization of the report was also to be discussed and writing
assignments made.
The remainder of the group’s meetings have been planned and dates assigned:
•
•
•
Amsterdam 2012: October 8, 9, 10 (Point of contact: Dr. van der Greef) -
East/West integration and CAM
interventions metrics
Cologne 2013: April 22, 23, 24 (POC: Fred Zimmermann) -
IM as a tool to enhance performance and
wellness
Paris 2013: October (to be determined) -
Finalization of our recommendations to the leadership
Dr. Belard concluded with a summary of the new issue of Medical Acupuncture, edited by Dr. Niemtzow that
focused on military acupuncture, with great relevance to the key theme and presentations of the previous
meeting in Bologna.
C2.2 Welcome and Overview of Yamamoto Acupuncture and Resilience (Dr. Gabrielle Hegyi)
Dr. Hegyi provided a very generous welcome and overview to the group on Hungary, Budapest, and then
described CAM activities in the military and civilian communities. CAM and natural healing is a legally
approved component of Hungarian patient care since 1997 legislation, and the Hungarian Academy of
Sciences has been increasingly accepting of CAM procedures as scientifically proven and acceptable for use
by physicians, and some procedures by non-physicians. Acupuncture is one of those techniques, with
approved applications in substance abuse treatment. Dr. Hegyi described one of her longterm studies on the
application of permanent biostimuli on acupoints in the scalps of military personnel to aid in stroke
rehabilitation. She also described participation in a CAMbrella grant to evaluate the use of CAM in 12
European countries. Dr. Hegyi reported on a recent National Health Service of Hungary survey that found
44% of Hungarian military personnel use CAM procedures (including 24% herbal therapies and 9%
acupuncture; and others used yoga and meditation). Most common treatments were for cervicobrachiale
syndrome and migraine. There is concern that older military physicians skilled in acupuncture are retiring but
there is resurgence in young medical students in civilian universities where the techniques are being taught
(not in the military medical curriculum). CAM procedures offered at the Central Military Hospital in
Budapest include laser and magnet field therapy and these are being taught to military students. Dr. Hegyi
presented a very comprehensive overview of the Yamamoto acupuncture foundations and techniques,
particularly the MAPS (microacupuncture point systems) and the wide range of conditions that are treated
through this treatment modality.
C2.3 Tibetan Personalized Medicine (Prof. Paolo Roberti di Sarsina)
Professor Roberti di Sarsina presented a talk that was largely based on his recent publication on Tibetan
medicine.
1
He described one of the world’s oldest traditional medicine systems that include diagnostics,
preventive medicine, and individualized medical treatments, offering this as a model with lessons for today’s
integrative medicine programs. Early shamanistic practices were incorporated into every important aspect of
life and involved practices for balancing one’s body internally and externally. Herbal remedies were
developed for wound healing and other medical treatments in harsh environments. The spread of Buddhism in
1
Roberti di Sarsina P, Ottaviani L, Mella J. Tibetan medicine: a unique heritage of person-centered medicine. EPMA Journal
2011;2:385-389
STO-TRG-TR-HFM-195
ANNEX C - 2
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0224.png
NATO UNCLASSIFFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
Tibet provided an overarching spiritual focus but incorporated medical knowledge from the indigenous Bon
doctors as well as Indian and Chinese practices. Early in life, ones disease susceptibilities are identified
according to their humor (wind; fire; earth and water) and appropriate preventive measures can then be
recommended to optimize individual lifetime health (e.g., those with fire humor are prone to skin diseases and
infection and can take steps to avoid these problems); a modern parallel would be to use genetic testing and
family history to identify disease susceptibilities and then advocate practices to reduce those risks. In the
Tibetan tradition, the doctor works with the patient and their community to support balance and health,
including such interventions as herbal remedies, meditations, and Tibetan Yantra Yoga exercises. Current day
translation and preservation of these practices includes efforts by groups such as the Shang Shung Institute to
promote some of the techniques such as Kunye Tibetan massage in western medicine. There is an urgent need
to rescue, translate, and document these practices before they are lost in the Tibetan cultural upheaval. Expert
translations of existing texts are lacking and especially difficult because of the nuanced Dharmic literary
language. Research into the properties of Tibetan herbal formulas is also vitally important, and difficult
because of the combination of herbal ingredients that are central to Tibetan medicines (e.g., multi-ingredient
formulas from the Padma Company that produces a few standardized Tibetan medicines from Switzerland
following traditional Tibetan practices).
Professor Roberti di Sarsina also provided a copy of an extensive briefing (211 slides) entitled “Le Medicine
Tradizionali e Non Convenzionali – Dal data epistemologico alla realta sociale – Verso la Medicina Centrata
sulla Persona” as well as copies of 5 recently published articles from his group (added to this report
bibliography).
C2.4 Integrative Strategies Involving Neuroprotective Nutrition (COL Karl Friedl)
COL Friedl presented an overview of the scientific basis of neuroprotective nutrition, drawing heavily on the
recent 400+ page report from the Committee on Military Nutrition Research (Food and Nutrition Board,
Institute of Medicine)
2
Based on emerging data, there are several reasons to consider whole food or dietary
supplements to moderate soldier health and performance in the context of integrative health: there is clear
evidence that some food derivatives may restore neuronal homeostasis and promote neural repair; other diets
(e.g., rich in fats and sugar) have detrimental effects on neuronal function and plasticity; this is a potentially
safer intervention than the use of neuroprotective drugs; nutritional/metabolic interventions fit the concept of
integrative health strategies, including an important interaction with exercise; and nutritional intake may
significantly optimize neurophysiological resilience. There are numerous candidate biological mechanisms
for nutritional interventions in neuroprotection including: oxygen scavenging properties (antioxidants), anti-
inflammatory properties, effects on brain blood flow, reduction of neuronal cell death, regulation of iron
homeostasis, and many other potential intervention points/benefits such as moderating pain and edema. Key
candidates for potential military use include: omega 3 fatty acids (notably EPA and DHA), caffeine, creatine,
polyphenols including flavanols (many compounds in this category such as galli-catechins, resveratrol, and
curcumin), and other specific vitamins and minerals such as zinc, Vitamin D, and Vitamin E. In many cases
these are reflected in whole food sources and the combinations (instead of isolated compound) may be more
beneficial; some of these foods include: ginseng, turmeric, blueberries, cherries, onions, red wine, green tea,
dark chocolate, etc. It was emphasized that it is important to conduct evaluation of safety of the supplements
because if they are biologically effective, they probably have potential for adverse effects in unnatural doses
(e.g., Vitamin D). The other key point of this presentation was the importance of understanding the scientific
basis for the action of these foods or supplements in order to be able to use them most effectively (e.g., if the
2
Erdman J, Oria M, Pillsbury L (eds.). Nutrition and Traumatic Brain Injury. Improving Acute and Subacute Health Outcomes in
Military Personnel. Committee on Nutrition, Trauma, and the Brain. Food and Nutrition Board. Institute of Medicine. National
Academy Press: Washington DC. 2011
ANNEX C - 3
STO-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0225.png
NATO UNCLASSIFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
primary neuroprotective benefits of omega-3 are provided by the metabolic conversion of EPA and DHA to
protectins and resolvins, acting on microglial cells in the brain to dampen inflammatory responses after a head
injury event such as blast induced TBI, the ratio of these compounds may be an important consideration, etc.).
Approaches to integrating neuroprotective nutrition into use were also discussed, with the Samueli-led
“superchicken” study used as a novel example (i.e., chickens with elevated tissue levels of omega-3s, that do
not taste fishy and, when consumed, boost circulating levels in humans). Several urgently needed studies
were briefly outlined and discussed.
C2.5 Resilience Program at Fort Bliss, Texas (COL Richard Petri)
COL Petri presented an update on the Integrative Health and Healing initiatives at Fort Bliss, Texas. He
described how this significant US DoD effort began in November 2003 with the establishment of the Center
for Integrative Medicine, which initially provided acupuncture, and chiropractic services and now offers a
holistic approach to pain with a full range of modalities. The Center provides complementary modalities
especially for difficult medical conditions. A new facility was opened in December 2008 and the name
changed to the Interdisciplinary Pain Management Center (IPMC) in 2012. The Center includes research and
conducted the first military chiropractic study for acute low back pain in the US, in collaboration with the
Samueli Institute and Palmer College of Chiropractic. As a result of the study, Congress mandated a follow
up study with $7.2M funding.
COL Petri described typical stove-piped systems of separate clinics for separate forms of care and then
described the integrative model that is gaining traction in the US DoD, including community, patient, and
provider, with the patient taking increased responsibility for their wellness, and with interlocking components
of education, clinical care, and research. He highlighted the integration of conventional and complementary
medicine approaches, and described specific types of integrative medicine modalities offered in the IPMC.
Research was described for three projects: a survey of CAM services in the DoD; a needs assessment among
military spouses of active duty personnel; and a study of relaxation response training for PTSD prevention in
soldiers.
The concept of operations for a much more ambitious change in the way medical care is delivered was
described as part of the new Wellness Fusion Center. The intent of this Center is to provide a centralized
approach to comprehensive fitness for soldiers and family members, bringing in all the available resources
from other centers and community activities and incorporating each of the comprehensive fitness core
dimensions (physical, emotional, social, family, and spiritual). He described the hierarchy of integrative
treatments provided at various tiers, the organization and staffing of the center, and the focus on pain
management and the recommendations of the pain management task force. COL Petri summarized recent
results on who uses CAM in the DoD, who provides the services, who pays for it, and the increase in services
offered at most Army medical facilities between 2005 and 2009.
C2.6 Yoga Data on Resilience (Captain Nathalie Babouraj)
Captain Babouraj gave a new talk on the application of yoga to improve resilience. The concept of resilience
was defined and presented in the context of PTSD prevention and mitigation. Behavioral health interventions
that may have a huge impact on soldier health and readiness are among the most unappreciated and
underfunded efforts, compared to other healthcare investments such as providing medical care for disease
treatment. Capt. Babouraj outlined behavioral education and mind-body programs that are currently being
investigated in the French military including yoga, TOP, and mindfulness. Hypotheses for the mechanisms
involved in resilience enhancement include enriching an individual’s “emotional bank account”, enhancing
ANNEX C - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0226.png
NATO UNCLASSIFFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
the ability to bounce between the 5 Kosha layers (through postures, breathing exercises, sensory awareness,
concentration, and meditation), mindfulness with the battle image and capacity for witnessing, and a process
of “here and now” that avoids entrenchment of a trauma memory. A review of the literature and some
specific studies and surveys highlighted the emerging understanding of empirical benefits and effectiveness of
yoga, relaxation, and mindfulness training; the mechanisms of stress mitigation and enhancement of well
being, resilience, and soldier performance; and approaches to building a resilience healthcare model.
Information about the 1
st
World Congress on Resilience (Paris, 7-10 June 2010) was also provided.
C2.7 Global Healing Techniques and Initiatives to Maximize Treatment, Resilience, and
Human Performance for Military and Veteran Communities (Dr. Nisha N. Money)
Dr. Money provided a comprehensive overview of the US DoD investment in CAM research and
implementation. Many interesting concepts on how the US DoD program is organized and summaries of the
funded programs were presented from a detailed 108-slide presentation deck.
•
According to one U.S. survey, prayer is the most used CAM therapy in the civilian population
3
,
ahead of natural products, meditation, yoga, etc., while, in another survey, U.S. physicians tend to
recommend relaxation and biofeedback techniques ahead of other techniques.
In a military population, CAM was most prescribed for anxiety and depression and for physical pain
conditions.
Approximately one third of U.S. active duty seamen and Marines used some form of CAM, primarily
herbal therapy, massage, high dose vitamins, and relaxation.
•
•
Congress has repeatedly mandated CAM therapies, integrative health and wellness treatment services for
military personnel and CAM research to advance the agenda.
CAM therapies have been applied to PTSD, TBI, and comorbidities in the Defense Department; detailed
information on this was provided.
The ten TATRC-funded CAM research projects involving TBI and PTSD treatments from the FY07 budget
were presented. These involve the use of acupuncture, psychiatric dogs, virtual reality and cell phones, yoga,
mindfulness treatment, and meditation on TBI and PTSD. A total of $24 million has been spent on CAM-
related research applications in PTSD and TBI treatment (2007-2011).
War stressors and co-morbid concerns in combat veterans were summarized. Summaries of total force fitness
and health protection/treatment programs in the military services and across domains (physical, spiritual,
mental, social, etc.) were provided.
Dr. Money also summarized manipulative body-based practices such as multiple breathing control techniques,
TRM, TRE, Yoga, MMFT, MBSR, etc. Meditation was also described in detail, distinguishing concentration
from mindfulness meditation techniques. Many techniques currently used or being explored in the U.S. DoD
were summarized in detail.
3
Barnes PM, Powell-Griner E, McFann K, Nahin RL.
Adv Data.
2004 May 27;(343):1-19.
ANNEX C - 5
STO-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0227.png
NATO UNCLASSIFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
C2.8 Mindfulness Trainings and Watsu as a Rehabilitative Treatment for Deployment Related
Stress (Zimmermann)
Mindfulness based interventions are becoming increasingly popular in clinical and non-clinical settings.
Civilian and military policy makers responsible for corporate health management and human resource
development are more and more interested in mindfulness trainings as a useful tool to reduce stress and
enhance cognitive performance, leadership and well-being. Mr Zimmermann concisely discussed the scope,
efficacy and adequate applications of mindfulness trainings. Moreover a particular interest was paid to
rehabilitative and preventive applications of mindfulness in a military environment. He also discussed how
mindfulness has been tested successfully as an applicable measure in the military. Howver, it remains to be
implemented in the clinical and the non-clinical, military environment on behalf of the well being of every
soldier. First steps could include basic training and leadership programs as well as pre/post deployment
trainings. Targeted populations as educator of mindfulness include chaplains, clinical personnel,
physiotherapists, clinical psychologists, psychiatrists and GPs. Finally, the development of a NATO-handbook
for practical mindfulness training guidelines is recommended addressing the most important questions and
fundamental aspects of a practice.
C2.9 TFF Matrix (Fred Zimmermann)
Fred Zimmermann presented a proposal for an organizational structure for the committee. This was well
received by the group. A discussion point was on the proper labels for the dimensions, with suggestions to
change “nutrition” to something like “individual health behaviors.”
ANNEX C - 6
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0228.png
NATO UNCLASSIFFIED
ANNEX C SUMMARY REPORT OF THE THIRD MEETING 16-18 APRIL 2012
C3 SUMMARY OF DISCUSSION
The group discussed:
•
Dr. Laurent Bezin led discussion of definitions of resilience and what wellness or well being really
means. There was considerable discussion about true integration of wellness strategies (versus stove
piped discipline-based approaches), pulling together a recurrent theme of all of the presentations in
this meeting.
The organization of the report with chapters largely focused on comprehensive integrative models was
narrowed to about 10 chapters with provisional author assignments. Refined versions of any of these
chapters should be strongly considered for submission to peer reviewed journals for critical appraisal
and much higher visibility and sharing of the work products of the group; if possible, the
acknowledgments should include a reference to the group such as “this paper prepared as part of the
work product of NATO Research Technology Organization Task Group (RTG) 195, Integrative
Medicine Interventions for Military Personnel.
An accumulation of key publications most relevant to this RTG, including all relevant papers
published by the participants, will be developed in a reference list for this report. Prof. Roberti di
Sarsina led the way by providing access to various key documents for a group reference library.
The next meeting is scheduled for 8-10 October 2012 in Amsterdam.
•
•
•
Annex Completed by HFM-195 Rapporteur, COL Karl E. Friedl.
STO-TR-HFM-195
ANNEX C - 7
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0229.png
NATO UNCLASSIFIED
ANNEX D
Summary Report of Fourth Meeting, 8 – 10 October 2012
Theme: East West Integration and the Metrics of Integrative Medicine
Interventions
Venue: Sino-Dutch Centre for Preventive and Personalized Medicine
(DICP-Chinese Academy of Sciences, University of Leiden and TNO
collaboration) Utrechtseweg 48, Zeist The Netherlands
D1
PARTICIPANTS/PROGRAMME COMMITTEE
Attendees
COL Marion Trousselard
Captain Nathalie Babouraj
Dr. Rafael Nogier (Absent)
Dr. Laurent Bezin
Dr. Arndt Büssing
Frederick Zimmerman
Dr. Gabriella Hegyi (Absent)
Dr. Paolo Roberti di Sarsina (Absent)
Dr. Jan van der Greef (Meeting chair)
Dr. Jean Louis Belard (Chair) (Absent)
Dr. Wayne Jonas (Absent)
COL Richard Petri, Jr. (Rapporteur)
Dr. Richard Niemtzow
Dr. Karl Friedl (Absent)
Dr. John Ives (United States)
Dr. Jain Shamini (United States)
Dr. E van Wijk (The Netherlands)
Dr. R van Wijk (The Netherlands)
Dr. H van Wietmarschen (The Netherlands)
Dr. J Schröen (The Netherlands)
Member Nations
France
Germany
Hungary
Italy
Netherlands (Meeting Host)
United States
Consultants and Guests
D2 SUMMARY OF PRESENTATIONS
D2.1 Meeting host’s opening Comments, Introductions, and Initial Discussion (Dr. Jan van der
STO-TR-HFM-195
ANNEX D-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0230.png
NATO UNCLASSIFIED
ANNEX D SUMMARY REPORT OF THE FOURTH MEETING 8-10 OCTOBER 2012
Greef).
Dr Jan van der Greef welcomed participants to the Fourth Meeting of the NATO Task Force on Integrative
Medicine in Zeist. He stated that Dr. Belard, TF chairman, would not be able to attend this meeting and
therefore he would chair the meeting. Further, in the absence of COL Friedl, COL Petri would be the
meeting’s rapporteur. It was asked that all speakers provide a brief synopsis of their lectures for the NATO
report.
The key focus of this meeting is the East and West integration as well as the metrics of integrative medicine
interventions.
Key areas of discussion for this meeting are
•
•
Systems biology
Concept and construct for the integration of “Eastern” with “Western” philosophies and treatments
The follow on meetings are scheduled as follows:
22-24 April 2013 Cologne, Germany
Fall 2013 France
D2.2 Bridging Western and Chinese Medicine via Systems Biology (Dr Jan van der Greef)
Jan van der Greef addressed in his presentation the importance of defining health as ability not as a state and
outlined the systems approach to health and disease. Important aspects as homeostasis, allostasis and disease
states were schematically discussed to come to systems biology based measurement of resilience. The
important aspect of personalized health/medicine in the research of the Sino-Dutch center for Preventive and
Personalized Medicine, a collaboration of TNO, University of Leiden and the Chinese Academy of Sciences,
was discussed. Merging Western and Chinese based diagnosis is the basis for integration and for applying a
personalized approach in Western health Care. Moreover to be able to measure impact on preventive
strategies dynamic systems measurements needs to be performed to understand the self-organization aspects.
It enables the paradigm switch to approach health care form the health promotion perspective instead of from
the disease management perspective. The use of herbal medicine for a systems intervention was discussed
underlining the synergetic nature of the components involved and an example was shown of the first Chinese
Medicine product that was produced in China and that was registered under the new EU guidelines of tHMP.
The product definition was based on quality of production (EU GMP) and scientific evidence for efficacy and
safety. Finally the shift that occurs in Life Sciences was addresses and the role Chinese Medicine could play
in the future of health care.
D2.3 Mascots in the Army (COL Trousselard)
For many soldiers confronted with exposure to stressful situations, an animal-mascot bond is considered
effective help for dealing with the stress. While most studies carried out on animals’ needs concentrate on the
care of civilian individuals, our focus was on determining the reliability of an instrument to measure
emotional, rational and psychosocial needs of the military engaged in numerous conflicts around the world;
and to analyze its external validation. Methods: In an anonymous cross-sectional retrospective survey, we
ANNEX D - 2
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0231.png
NATO UNCLASSIFFIED
ANNEX D SUMMARY REPORT OF THE THIRD MEETING 8-10 OCTOBER 2012
applied the animal-mascot bond questionnaire (AMBS) associated with Coping Inventory Stressful Scale
(CISS), Post-Traumatic Stress Disorder (PTSD) and Check List Scale (PCL-S) assessments to 168 soldiers
after their deployment in theatre. Results: Factor analyses of the 23-item construct (Cronbach’s alpha =
0.962) pointed to a 3-factor solution, which revealed 77.03 % of variance: (1) Animal-group bond, (2)
Individual-animal emotional bond, and (3) Individual-animal rational bond. All these factors were positively
correlated with the emotional-centered coping style. Human-animal bonds were greater for soldiers with the
provisional diagnosis of PTSD. Limited responsibility was the strongest predictor for animal-mascot bonds.
The PTSD status and emotional coping also predicted both individual animal bonds. Conclusions: The
evaluation of the AMBS revealed that the instrument has good psychometric properties. Soldiers with less
responsibility, PTSD and emotional-coping scored the highest on the AMBS suggesting that they expressed
the highest needs for a bond with an animal-mascot. One may assume that the animal-mascot bonds will result
in a therapeutic coping process for mitigating distress for soldiers.
D2.4 Acupuncture in NATO (Dr Niemtzow)
Dr Niemtzow discussed the use of Battlefield Acupuncture (BFA) within the military (Refer to lecture
description 2.2.11). The neuroanatomy of pain processing and the rationale for the selection of the five BFA
points was discussed. Dr Niemtzow reviewed numerous studies of BFA and pain syndromes. He described
the work done by Dr Cho, Neuroscience Research Institute, Incheon, Korea on cortical activation studies. It
illustrated the decreased cingulated cortex activation using acupuncture in pain-stimulated subjects.
Examples of anterior cingulated cortex, frontal and posterior parietal lobes changes with acupuncture
treatments in pain induced (left finger) subjects utilizing fMRI were reviewed. Dr Niemtzow described a
study of the effect of BFA on oxygen changes in the CNS. The study showed a changed in regional
oxyhemoglobin (O
2
Hb) and deoxyhemoglobing (HHb) in brain tissues of the frontal area in the 50-channel
recordings. A study of auricular acupuncture in the treatment of acute pain syndromes performed at a US
military hospital ER showed 23% in the pain level (NRS) during the ER visits compared to a standard medical
group (control). Both groups had similar pain reduction at 24 hours after ER visit. In the study performed by
Spira (“Acupuncture: a useful tool for health care in an operational medicine environment”, Mil Med,
173,7:629,2008) was briefly discussed. It is a descriptive report of acupuncture use in a deployed theater
during Iraqi Freedom (summer 2006). Conditions that were evaluate included back, neck, hip, pelvis,
shoulder or elbow conditions due to injuries (92%) and illnesses (8%). The study showed that acupuncture
hastened the return to duty rate by an average of 2 days for all injuries and 82% of subjects with some to
significant improvement. Only 17% of the subjects stated there was no improvement with the acupuncture
treatment. A cost analysis showed that weekly costs for acupuncture was $1.82 whereas NSAID was $10-20
(Ibuprofen $10.08, Celcoxib $20.58). An observational study conducted at an acupuncture clinic at a US
Military hospital, acupuncture was demonstrated to have significant improvements in the mental and physical
subscales of the SF-8 quality of life metric at 4 weeks following the first acupuncture treatment. Finally, data
from the USAF acupuncture program (Helms Medical Institute) from 2009 showed that acupuncture
(auricular, PENS and Chinese scalp) has significant operational impact on pain conditions. The data was
compiles by Dr Arnyce Pock.
D2.5 Principles of Ayurveda (Dr Babouraj)
Dr Babouraj discussed the general philosophy of one of the most ancient healing systems of the eastern world;
Ayurvedic medicine. She discussed the core concepts of Ayurveda and proposed it as a global health
approach. She Ayurveda is based on the interdependence of man with nature and the dynamic forces that
determine health and disease. Although Ayurveda has been practiced since approximately 1500 BC, several
key principles can be integrated into our “modern” medical practice to improve diagnostic tools, treatment
STO-TR-HFM-195
ANNEX D - 3
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0232.png
NATO UNCLASSIFIED
ANNEX D SUMMARY REPORT OF THE FOURTH MEETING 8-10 OCTOBER 2012
axis as well as preventive approaches. The question was raised on the method to evaluate a combination of
integrative medicine modalities. A clinical case illustrated that “identical” back pain is not always identical
when viewed utilizing different system overlays (Conventional i.e. diagnosis of back pain and Ayurveda ie
difference with body and pain type air vs. fire). In fact one treatment for a conventional diagnosis may
actually worsen the condition when evaluated using another systems approach. Ayurvedic profiles and the
differences these profiles can make toward approaches in health care were introduced. The concept of the
mind-body technique known as Powernap was briefly discussed.
D2.6 Mindfulness and Spiritual Needs (Dr Arndt Büssing)
Dr Büssing discussed a general overview of spirituality and religiosity (SpR) and health. SpR can improve
long-term adjustment to chronic disease or trauma through a range of effects ranging from “life has meaning’
to emotional comfort to compassion for others (1.2.5). Mind-body medicine describes the interplay and
interaction between the mind, emotion, vitalities and physis. Physis (Greek: φύσις) is a Greek theological,
philosophical, and scientific term usually translated into English as "nature". Descriptive of the differentiation
of specific beliefs (cognition/emotion) and practices (action) was presented. Religious orientation,
transcendence conviction and quest orientation increase with age whereas conscious interactions,
compassion/generosity and aspiring beauty/insight were noted to be expressed at high levels in adolescents
from a study by Dr Büssing. Increasing research showed a connection between SpR and physical and
psychological health with better coping capabilities. Additionally, positive emotions and growth follow
trauma when survivors rely on SpR beliefs for coping. Dr Büssing described a study he conducted on the
spirituality and the meaning of illness (Pain Medicine 2009). He postulated whether positive appraisal lead to
transformational growth in SpR individuals. He further described studies on intrinsic religiosity/spiritual
well-being and quality of life (QoL), the benefit of SpR, if indeed there is one, in a secular society. Based on
research with German cancer patients, patients want their doctors to be interested in their spiritual orientation.
Therefore, Dr Büssing presented a conceptual framework of spiritual needed related to the ERG model. ERG
refers to existence (safety), relatedness and growth. Spiritual needs could be regarded as patient’s longing for
psycho-spiritual well-being, which should be supported by health care professionals as an independent
resource of relevance. Thus the questions was raised, how can we offer spiritual support when in secular
societies there is up to 50% of patient with chronic disease who regard themselves as R-S-? Dr Büssing
described the research project “Beneficial Resources and Unmet Psychosocial and Spiritual Needs of Military
Personnel. This is an ongoing joint project between the Germany and France Military.
D2.7 Biophotonics as a Diagnostic Tool in Health and Disease (E van Wijk/R van Wijk)
Bioluminescence is the process of production and emission of light by a living organism via
chemiluminescence-based processes. In fact, all cells produce some form of light emission, but most of this
light is not visible to the unaided human eye. This photonic emission has characteristic wavelengths, duration,
timing and patterns of flashes. These are features often associated with information and, while not proof in
and of itself, it is reasonable to assume that these light emissions contain and carry information about the
biological systems that produced it.
D2.8 Integration of Chinese and Western Medicine – A Key Role for Systems Diagnosis (Drs
van Wietmarschen/Schroen)
Chinese and Western medicine have evolved in different cultural settings throughout history and have led to
two different ways of conducting science and medicine. Western medicine is currently facing the challenge of
rapidly rising costs and decreasing new effective drugs. The future lies in personalized medicine, which can
ANNEX D - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0233.png
NATO UNCLASSIFFIED
ANNEX D SUMMARY REPORT OF THE THIRD MEETING 8-10 OCTOBER 2012
be developed by the integration of Chinese and Western medicine. The Sino-Dutch Centre for Personalized
and Preventive Medicine aims for this integration. A systems biology approach is used to capture Chinese
and Western types of patient information. Rheumatoid arthritis and pre-diabetes are taken as examples to
show how a systems biology approach together with Chinese symptom profiles has resulted in finding
relevant sub-types of patients and understanding the biology of these sub-types. Drs van Wietmarschen and
Schroen described two studies of Cold and Heat sub-types of rheumatoid arthritis patients, which were
extensively, characterized using a Chinese symptom questionnaire, a Chinese diagnosis, metabolomics and
clinical chemistry measurements. PLS-DA and PCA were used to discover differences between the sub-
groups. The relationships between the symptoms and Chinese concepts were visualized and the biology
behind the sub-groups was discovered. Another study focussed on discovering metabolite differences between
two sub-types of pre-diabetes patients. The findings of the studies were that the two sets of symptoms were
found to be closely related to either the RA Cold or the RA Heat group of patients. Apoptosis regulation was
found to be differently regulated in RA Cold and RA Heat patients. A number of acylcarnitine levels in urine
were found to be lower in Cold RA than in Heat RA patients. Metabolomics analysis resulted in a model that
was able to classify 85% of the patients correctly into the Cold or Heat RA group. Urine metabolite
differences were found between two sub-types of pre-diabetes patients. Rehmannia 6 formula was found to
reduce Yin deficiency symptoms first and subsequently relieve Qi deficiency symptoms. Differences in
plasma metabolite changes during treatment were found for patients treated with R6 and a modified R6
formula. The research shows that systems diagnosis methods are useful to characterize sub-groups of RA and
pre-diabetes patients and increase biological knowledge of Chinese diagnostic concepts. Treatment strategies
can then be optimized for these sub-types of patients. Increasing understanding of Chinese diagnosis is
necessary to target Chinese herbal medicine to the right sub-groups of patients. Translation of work in RA
and DM to pain conditions may help to explain differences in treatment outcomes with “standardized”
treatment for “western” diagnosis.
D2.9 Resilience, Allostasis and Health- Development of a Systems Model (Dr Jain)
This presentation provided an overview of the current state of the science surrounding the study of resilience,
and proposed a preliminary framework aimed at tracking resilience from a systems-based perspective. The
relationship of the proposed resilience model to allostasis and health was discussed, particularly within the
context of military health and wellness. There is a great need for systems-based bioinformatics tools that will
help examine and evaluate treatment services for enhancing resilience. Resilience is revealed when an
individual is faced with a stressor and succeeds in thriving or maintaining optimal functioning despite these
challenges. This is related to the concept of allostasis, a dynamic process that serves not as “bouncing back”
to maintain homeostasis after a stressor, but rather a process that promotes “evolving forward” to promote
healthy functioning within specific stressor contexts. While resilience continues to be examined and
described within specific scientific disciplines such as psychology or biology, these efforts are generally
examined “piecemeal” without an examination nor integration of the various inputs and domains that work
together to confer enhanced resilience. The Samueli Institute’s DOD-funded project, “Central Evaluation of
Resilience Programs” which aims to create a systems-based model for understanding and tracking resilience
was described. The model includes inputs from systems biology, psychoneuroendocrinology, systems
neuroscience, psychology and behavioral science, and consciousness and spirituality.
STO-TR-HFM-195
ANNEX D - 5
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0234.png
NATO UNCLASSIFIED
ANNEX D SUMMARY REPORT OF THE FOURTH MEETING 8-10 OCTOBER 2012
D2.10 Documentary
Escape Fire: The Fight to Rescue American Healthcare
(Matthew
Heineman, Susan Froemke, Directors)
The documentary
Escape Fire: The Fight to Rescue American Healthcare
was presented.
1
The synopsis of
the film is as follows.
Escape Fire: The Fight to Rescue American Healthcare
tackles one of the most pressing issues of our time:
how can we save our badly broken healthcare system? American healthcare costs are rising so rapidly that
they could reach $D2 trillion annually, roughly 20% of our gross domestic product, within ten years. We
spend $300 billion a year on pharmaceutical drugs – almost as much as the rest of the world combined. We
pay more, yet our health outcomes are worse. About 65% of Americans are overweight and almost 75% of
healthcare spending goes to preventable diseases that are the major causes of disability and death in our
society. It’s not surprising that healthcare is at the top of many Americans' concerns and at the center of an
intense political firestorm in our nation's Capitol. But the current battle over cost and access does not
ultimately address the root of the problem: we have a disease-care system, not a healthcare system. The film
examines the powerful forces maintaining the status quo, a medical industry designed for quick fixes rather
than prevention, for profit-driven care rather than patient-driven care.
ESCAPE FIRE
also presents attainable
solutions. After decades of resistance, a movement to bring innovative high-touch, low-cost methods of
prevention and healing into our high-tech, costly system is finally gaining ground. Filmmakers Matthew
Heineman and Susan Froemke interweave dramatic personal arcs of patients and physicians with the stories of
leaders battling to transform healthcare at the highest levels of medicine, industry, government, and even the
U.S. military.
Escape Fire
is about finding a way out of our current crisis. It’s about saving the health of a
nation.
D3
SUMMARY OF DISCUSSION
The group discussed:
•
A question of the format for the remaining two meetings was discussed. Is it best to have continued
lectures on meeting topics or is it more efficient to have working meeting to develop the chapter and
NATO reports? Consensus was that
o
Individuals with interests in identified chapters or new chapters need to inform Dr Belard by
year end (Dec 2012)
A more definitive structure to the reports will be developed and approval via email
networking
Chapter team leaders will be identified
Status reports on each chapter will be presented at the next meeting in April 2013 in Cologne,
Germany.
o
o
o
•
Following the lectures given during this meeting, it was agreed that the current matrix could be
improved to incorporate systems approaches with whole system (holism) view.
1
http://escapefiremovie.com/pdf/EscapeFire_PressKit.pdf
STO-TRG-TR-HFM-195
ANNEX D - 6
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0235.png
NATO UNCLASSIFFIED
ANNEX D SUMMARY REPORT OF THE THIRD MEETING 8-10 OCTOBER 2012
•
•
Suggested format for each chapter should follow the scientific journal format (title, author, abstract,
key words, introduction, material/methods, results, discussion, conclusion, references)
At the request of the participants the idea of project development should be discussed at the next
meeting. Collaborative, multi-national projects will serve as good outcomes for this Task Force as
well as assist to anchor further projects and or meeting opportunities.
The next meeting is scheduled for 22, 23, 24 April 2013 in Cologne, Germany. Host will be Fred
Zimmermann.
•
Annex Completed by HFM-195 Rapporteur, COL Richard P. Petri, Jr., MC
STO-TR-HFM-195
ANNEX D - 7
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0236.png
NATO UNCLASSIFIED
ANNEX E
Summary Report of Fifth Meeting, 22 – 24 April 2013
Theme: Integrative Medicine as a Tool to Enhance Performance and
Wellness
Venue: Germany Air Force Facility, Cologne, Germany
E.1
PARTICIPANTS/PROGRAMME COMMITTEE
Attendees
COL Marion Trousselard
Captain Nathalie Babouraj
Dr. Rafael Nogier (Absent)
Dr. Laurent Bezin
Dr. Arndt Büssing
Frederick Zimmerman (Meeting Chair)
Dr. Gabriella Hegyi (Absent)
Dr. Paolo Roberti di Sarsina (Absent)
Dr. Jan van der Greef
Dr. Jean Louis Belard (Chair) (Absent)
Dr. Wayne Jonas (Absent)
COL Richard Petri, Jr. (Rapporteur)
Dr. Richard Niemtzow (Absent)
Dr. Karl Friedl (Absent)
Dr. Karl Kubowitsch (Germany)
Dr. N Kohls (Germany)
Dr. S. Schöenfeld (Germany)
Dr. P Kruit (Germany)
COL Peter Mees
Member Nations
France
Germany (Meeting Host)
Hungary
Italy
Netherlands
United States
Consultants and Guest
NATO
STO-TR-HFM-195
ANNEX E-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0237.png
NATO UNCLASSIFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 - 24 APRIL 2013
E2
SUMMARY OF PRESENTATIONS
E2.1 Chairman’s Opening Comments, Introductions, And Initial Discussion (Frederick
Zimmerman).
Frederick Zimmermann reviewed the membership (see “Programme Committee”) and made introductions. He
went over the agenda and presented general logistic housekeeping items. Mr Zimmermann emphasized several
key objectives for this meeting:
•
•
Confirmation of chapter authors and leads
Defined time for groups to work on chapter on the afternoon of the second day.
COL Peter Mees, German Air Force spoke to the group. COL Peter is a member of another NATO Task Force
and spoke about a recent meeting. It was requested for a program in Battlefield Acupuncture to be funded and
implemented within NATO Forces. However, NATO will not support any CAM treatments until there is a
report that details and supports CAM usage. Many countries are waiting for the report of the STO-HFM 195 as
that evidence. There exist the possibility for symposia and lecture series after the report.
E2.2 Usage of a Basic Breathing Meditation Technique to Attenuate Perioperative Stress (A
Büssing).
Basic breathing meditation can be used to cope with acute stressors. Presented is its application to attenuate
perioperative psychological stress in cancer patients. This breathing meditation does not require extensive
training and can be supplemented with self-chosen affirmations which may help to focus on the breathing
process and to assure hope and confidence, and thus decreasing distress and increasing positive mood states.
Findings from a pilot study with 21 cancer patients showed that most have used the mediation technique prior to
surgery (11 often, 3 very often, 5 rarely, and 2 not), and that it was beneficial to attenuate their perioperative
stress (stated `very helpful´ in 9 patients, `somewhat helpful´ in 8, and `not helpful´ in 3 patients). This self-
administered, low threshold breathing meditation technique can be used whenever the patient feels anxious or
stressed.
E2.3 Enhancing Performance and Health: Bio-Neurofeedback as an Integrative Approach for
Assessment and Training (Dr Karl Kubowitsch, PhD).
Bio-/Neurofeedback is a scientific sound approach with rich empirical evidence in the fields of performance,
prevention and intervention. It is embedded in a theoretical framework (neurosciences and applied
psychophysiology). For the purposes of assessment, training and interventions, fields of application for military
personnel are introduced (e.g. integration of self-regulation techniques in military training and exercises;
qualification programs for military psychologists; promoting mental health / resilience programs). Additionally,
contributions for human factors in the military field are highlighted.
Current projects and programs in the German Air Force were briefly outlined. Practical examples and case
studies with measurement data illustrated how this approach verifiably contributes to the improvement of fitness
and performance. Practical applications of bio-/neurofeedback for pilot selection and training are focused, as
well as pre-deployment CSI training and exercises for aircraft crews (combat, survival, resistance to
ANNEX E - 2
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0238.png
NATO UNCLASSIFFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 – 24 APRIL 2013
interrogation).
E2.4 Harnessing the Placebo Effect for Health Promotion and Resilience (Dr. N Kohls).
Empirical findings have identified placebo effects as psychophysiological phenomena serving as a potential
health resource. Whereas older research has interpreted such effects with psychological mechanisms, newer
conceptualizations propose that placebo effects engage neural "top-down" processes that are involved in health-
related effects. It is therefore reasonable to interpret placebo effects as the body`s innate capacity to heal itself.
Empirical evidence suggest that mind body practices such as mindfulness meditation or yoga may actually
engage similar mechanisms that can be used for building salutogenetic potential. In this way, this paradigm of
interpreting placebo expresses our most current understanding of the physiological, psychological and socio-
cultural aspects of these effects, and may also increase the likelihood of eliciting self-healing processes both in
clinical and non-clinical contexts.
E2.5 Efficiency of Tactic To Optimize the Potential (TOPS) and Cardiac Coherence on
Professional Stress (COL M Trousselard).
The effectiveness of two stress management programs based on cognitive or emotional intervention in stress
perception and stress reactivity in healthy workers with operational stress were discussed. The study
consisted of 180 young fire-fighters recruits that were randomly assigned to a controlled intervention trial into
three groups: a cognitive stress program (optimized potential technics - TOPS) group, an emotional
biofeedback stress program (heart coherence - HC) group or a control group. A placebo was given as a
nutriceutical for each of the three groups during the time of the training. The stress programs training lasted
eight weeks, with one hour training per week. The primary outcome variables included the perceived stress
and the second outcome variables included stress reactivity (mindfulness, negative mood, Immunoglobulin
A). Post intervention effectiveness, long-term benefits as influence of the anxiety on the programs’ benefits
was evaluated.
The results of the study showed that both TOP and HC stress programs reduced operational stress in healthy
workers by improving stress perception, stress reactivity and immunity. Long-term effects were recorded.
Anxiety influenced the benefits of the treatment and highlighted a placebo response to stress.
Therefore, it is suggested that short stress program interventions improved stress perception and stress
reactivity in healthy workers. Organizations should be more concerned about strategy of management of
working stress.
E2.6 Benefits and Neurophysiological Mechanisms of Mindfulness and Training (Frederick
Zimmermann).
Description of the benefits and neurophysiological mechanisms of mindfulness. The practice of Mindfulness
can be used as either a treatment or prevention. The cognitive and behavioral effects of mindfulness include 1)
better allocation of attentional resources 2) enhanced working memory capacity 3) improved emotional
regulation 4) empathy 5) reduced startle response 6) decreased need for sleep 7) more detached sense of self
including metacognitive processes and 8) increase cognitive vitality and protection against age related cortical
thinning. EEG has shown a right to left shift with meditation; however, this is inconsistent with fMRI findings.
Brain activity patterns correspond consistently with meditation style. The predominant areas of the brain that are
activitated with meditation include the Dorsolateral prefrontal cortex (DLPFC- function area of the brain
involved in executive functions such as working memory, cogntive flexibiliy, planning, inhibition and abstract
STO-TR-HFM-195
ANNEX E - 3
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0239.png
NATO UNCLASSIFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 - 24 APRIL 2013
reasoning), Anterior Cingulate Cortex (ACC –physiological area of the brain involved in rational cognitive
functions such as reward anticipation, decision making, empathy, inpulse control and emotions. Addtionally the
Insula has a role in the autonomic functions such as regulating blood pressure and heart rate) and Insula (area of
the brain involved in consciousness, functions related to emotions and the body’s homeostasis). Further, studies
have shown there is increased telemerase activity with implications for telomere length and immune cell
longevity with meditative practice.
E2.7 From the Lab to the Therapy Room- Process Oriented and Evidence Based Standard
Methods in the Treatment of PTSD (Sabine Schöenfeld).
Aim of the presentation was to point out the benefits and limits of evidence based standard treatments for PTSD,
by presenting state of the art / commonly used interventions & their empirical support, both for single
traumatization and chronic traumatization. Three interventions were looked at more closely, 1. an effective
treatment where mechanisms are partly not understood (exposure therapy, Foa), 2. an effective treatment, based
on basic research and empirical support (Cogitive Behavior Therapy, CBT by Ehlers & Clark), 3. a very popular
and widely used (in Germany) but not empirically supported treatment (Psychodynamisch Imaginative
Traumatherapie PITT, Reddemann). The CBT intervention by Ehlers & Clark was used as a step-by-step
example for translational research.
E2.8 Whole Systems Resiliency Assessment - Health, Resilience and Dynamic Modelling (Drs. J
van der Greef/H van Wietmarschen/ J Schröen).
Various cultures across the globe have given rise to a variety of sciences resulting in different medical practices.
Each of these medical systems makes use of particular concepts of health, wellness, resilience and healing. In
Western medicine ‘health’ is currently redefined as the ability to adapt and self-manage in the face of social,
physical and emotional challenges. In Chinese and Indian medicine the concept of health is more related to being
one with nature and the rhythms of life. An integration of medical systems is needed to fully take advantage of
the various viewpoints and enlarge understanding of resilience, wellness, health and the means to promote health
and resilience.
Western and Asian medicine apply very different methods for assessing health. Western science is very good at
measuring molecules and has generally followed a bottom up approach with regard to ‘the pyramid of life’ as
described by Oltvai et al. Elucidating higher levels of system organization has proven to be difficult. Knowledge
of health and maintaining health is very limited compared to the knowledge that is gained about the molecular
basis of diseases. Asian medicine systems on contrary have evolved as top down approaches, phenomenological
approaches based on the organization and dynamics of symptom patterns. Recently, significant steps have been
taken to develop what is called a ‘middle out’ approach towards the integration of measurements of these diverse
levels of system organization.
In this presentation, various cultures of medicine were briefly described. Then, approaches for the scientific
evaluation and integration of various systems of medicine were discussed, illustrated with some examples from
recent scientific literature.
E2.9 Historical Findings in PTSD Research (Dr. Peter Kruit)
Description of the Netherlands participation in WWII and the medical casualty system to document wounded
Soldiers.
ANNEX E - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0240.png
NATO UNCLASSIFFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 – 24 APRIL 2013
D3
SUMMARY OF DISCUSSION
The group discussed:
•
Rough Outline for the Report and suggested chapters. Most chapters have been assigned
with lead authors identified. (Appendix 1)
o
Chapter length guideline of 10 pages maximum
o
The chapters need to be concise with tables and figures to be used liberally.
o
Extra materials related to the chapter can be placed in the appendices.
o
Chapters organized in 1-3 per phase of pre- during and post-deployment. The chapter’s
framework could be based on the Total Force Fitness adapted matrix presented by
Zimmermann at meeting 3.
Overall structure of the report should focus on a cohesive program of modalties in a holistic
program, e.g. the U.S. Interdisciplinary Pain Management Center (IPMC) initiative.
Vingettes of Soldiers stories could be included in the report as stand-alone boxes.
Agreed upon time line as follows;
1 May 2013 Agreement on chapter leads and authorships.
1 June 2013 Abstract of 250 words.
15 August 2013 First draft.
1 Sept 2013 Final draft.
8 Sept 2013 HFM-195 Draft report to group.
o
Suggested framework for the chapters;
Brief introduction of the topic with definition(s)
Description of the field with scientific findings
Concrete applications
Recommendations including contribution of modality into a holistic program, including
preventive approaches.
Multi-dimensions of man (physical, emotional, mental/psychological, cognitive, spiritual,
creative)
o
o
o
STO-TR-HFM-195
ANNEX E - 5
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0241.png
NATO UNCLASSIFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 - 24 APRIL 2013
Connectivity to the larger e.g. cell to universe nodal systems theory.
Integrative Health and Healing Concepts (Community-wide Involvement and Everyday
Personal Practices) as part of every chapter
Annex
Bibliography
Glossary
•
•
Task Force consensus on definitions
The next meeting is scheduled for October 2013 in Washington D.C or Paris, France. Agenda
to be the d
iscussion of Clinical pathway of conditions such as pain, psychological issues e.g. Royal
London Hospital for IM framework as well as the discussion of the final chapter.
Annex Completed by HFM-195 Rapporteur, COL Richard P. Petri, Jr., MC.
ANNEX E - 6
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0242.png
NATO UNCLASSIFFIED
ANNEX E SUMMARY REPORT OF THE FIFTH MEETING 22 – 24 APRIL 2013
Appendix 1
Chapter 1 – Overview of Integrative Wellness/CAM Practices and Policies in NATO Participant Countries.
(Paolo/Gaby/Wayne/Belard/Jan/Babouraj)
Chapter 2 – Acupuncture and Potential Applications for Military Medical Pain Management. (Bart-Knauer,
Niemtzow, Nogier, Petri)
Chapter 3 – Mind-body principles/practices with subsections in Yoga, Mindfulnes and Spirituality.
(Zimmermann, Babouraj, Trousselard, Büssing)
Chapter 4 – Current Research on Practices Not Generally Accepted in NATO Medicine – Energy Medicine,
Homeopathy, Hyperbaric Oxygen Therapy. (Niemtzow, Hegyi, Belard)
Chapter 5 – Biologically-based Practices that could be Incorporated into Rations and Over-the-Counter
Supplements to Optimize Soldier Resilience, Performance, and Wellness. (Bart-Knauer, Belard, Jonas, Hegyi,
Friedl)
Chapter 6 – Trauma Spectrum Response. (Jonas, Petri, Bezin)
Chapter 7 – Wholistic strategies such as Ayurvedic Medicine. (Babouraj)
Chapter 8 – Integrative Medicine Practices Specifically for the Deploying Soldier. (Petri)
Chapter 9 – Systematic Approaches to Evaluation and Integration of Eastern and Western Medical Practices.
(van Wietmarschen, Schöen, Babouraj)
Chapter 10 – Conclusions and Recommendations –Integrative medicine and the multi-dimensional approaches
in the context of multi-health systems diagnoses and tailored treatment programs (All).
STO-TR-HFM-195
ANNEX E - 7
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0243.png
NATO UNCLASSIFIED
ANNEX F
Summary Report of Sixth Meeting, 30 April – 2 May 2014
Theme: The NATO Report Working Meeting
Venue: Radisson Airport Hotel, El Paso, Texas
F1
PARTICIPANTS/PROGRAMME COMMITTEE
Attendees
COL Marion Trousselard
Captain Nathalie Babouraj (Absent)
Dr. Rafael Nogier (Absent)
Dr. Laurent Bezin (Absent)
Dr. Arndt Büssing (Absent)
Frederick Zimmerman
Dr. Gabriella Hegyi (Absent)
Dr. Paolo Roberti di Sarsina (Absent)
Dr. Jan van der Greef (Absent)
Dr. Jean Louis Belard (Absent)
Dr. Wayne Jonas (Absent)
COL Richard Petri, Jr. (Chair) (Rapporteur)
Dr. Richard Niemtzow
Dr. Karl Friedl (Absent)
Member Nations
France
Germany (Meeting Host)
Hungary
Italy
Netherlands
United States
F2
SUMMARY OF PRESENTATIONS
F2.1 Chairman’s Opening Comments, Introductions, And Initial Discussion (COL Richard
Petri, Jr).
COL Petri welcomed the task force members to El Paso, Texas. The agenda for the meeting was to develop the outline
of the NATO report and recommendation for Integrative Health and Healing for NATO.
F2.2 Areas Of Interest For Report (Group).
Germany – Stress management
STO-TR-HFM-195
ANNEX F-1
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0244.png
NATO UNCLASSIFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
France – Stress management
USA – Pain management and prevention, Stress management, Suicide prevention
F2.3 Executive Summary (Group).
Discuss the financial impact of CAM implementation in relationship to delayed onset of disease
Acute prevention vs chronic management
Budget constraint dictates the need for cost saving modalities
F2.4 Recommendations (Group).
•
Develop professionals (eg Trainers, educators) in the individual’s area of interest related to Integrative
Health and Healing (IH2) modalities. Understand that 30% of patients do not practice after being
taught, 30% practice with a teacher and 30% perform self-practice.
•
Recognize the importance of Integrative Medicine (IH2) modalities and the impact on the Military and
the required support to include appropriate and necessary funding.
•
Understand that IH2 modalities represent a shift in military practices in fitness e.g. Service Members
(SM) would rather run than perform yoga.
•
Develop the best clinical practices for the NATO participants Militaries.
F2.5 Questions (Can Be Answered On A Collective/Organizational And/Or Individual Level)
(Group).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Why can Integrative Medcine (IM) be implemented into the Military?
How much will it cost to implement?
Will it save the Military any money at any point?
How will IM affect the organization and the individual?
Can IM be tailored to the Military constraints?
Are there any other partners that can fund the implementation? International vs national?
What are the broader economical contexts to family, society?
Can these contexts be used to leverage civilian partnerships?
Does the proposed program pas the FAST test =feasible, acceptable, sustainable and timely for the
individual/organization?
Can the IM modalities be translated into an active exercise i.e. passive vs active participation?
What is the role of IM in developing the “new normal” for injured Service Members (SM)?
Will individual/leadership’s consciousness be changed by the implementation of IM into the Service?
How can any bias (leadership/practitiioners/advocates) be minimized to allow for the best practices to be
implemented? (Policy level)
Can IM affect an individuals/leaders ability to make decisions, cognitive performance, ethical behaviors,
or self-regulation?
How does IM fit into the currently healthcare systems, e.g. pharmacological interventions, surgical
procedures?
ANNEX F - 2
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0245.png
NATO UNCLASSIFFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
16. Are there any adverse effects of implementing IM into the Military?
17. Could IM change the existing culture and identity of the Military? And if so, would this be a benefit or
detriment to the organization or indvidual?
18. Can IM alter addiction and suicide rates?
19. Can cultural differences and experiences between countries help to treat difficult cases of a country?
20. Could overlapping systems e.g. Traditional Chinese Medicine (TCM) and “Western” approaches, help to
explain condition treatment failures?
21. Could personalized medicine help or harm the current system?
22. Can the military organizations wait the necessary time to fully understand the benefits of the IM
paradigm?
F2.6 Proposed Quick Wins Of The Task Force And Impact On Military (Group).
1. Discuss financial gains of presently used modalities within the military (may need to use civilian data)-
check articles on the NATO website (keywords - economic impact, IM, decreased absentee, sick
days, return to work rates) - Data suggest that IM reduces sick days, absenteeism/presenteeism rate,
improves performances, quality of life, however, there are few military studies on cost-effective
(collective benefits e.g. unit cohesiveness/cohesion readiness, resiliency, overall unit performance vs
individual benefits e.g. improved sense of well-being, quality of life, social impact surrounding
individual i.e. family).
2. Develop a core of professionals in each of the CAM areas of interest i.e. identify the SME (subject
matters experts) and train the trainer programs.
3. Understand the need to address/change the perception/education of the end user/policy makers of the
benefits of the shift in practice i.e. there is a need to make these practices as a part of every day life
instead of an additional practice.
4. Discuss the quick win modalities for implementation such as mindfulness, movement, Battlefield
Acupuncture (BFA) and biofeedback.
5. Understand the need to adapt IM modalities to the Military e.g. yoga infused into Military sport.
6. Leverage improved performance as a signficant benefit for the utilization of the modalities into Militaries.
7. Education end users/policy makers that sometimes the mechanism of how IM works is less important
than the effect of IM especially in modalities that are generally safe but lack signficant research and
evidence at this point.
F2.7 Proposed Long Term Gains Of Additional Related Task Forces (Group).
These are outside the time range of this current Task Group. This would require extension of HFM-195 or new
Task Forces to address these issues.
F2.7.1 Develop international collaborations in research, clinical practices, cultural differences
F2.7.2 Understand the uniqueness of each military and tailor modalities to those populations
F2.7.3 Develop handbook/cheat sheets/guides for the Service Members, leadership
F2.7.4 Develop TF on implementation of recommendations
STO-TR-HFM-195
ANNEX F - 3
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0246.png
NATO UNCLASSIFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
F2.7.5 Develop collaborations with other international organizations (NIH)
F2.7.6 Perform cost-effectiveness research on IM within the militaries
F2.8 NATO Reports (Group)
The following could serve as models for the development of this report.
Impact of Lifestyle and Health Status on Military Fitness
RTO-TR-HFM-178
Stress and Psychological Support in Modern Military Operations
RTO-TR-HFM-081
F2.9 Proposed Medical Acupuncture Journal And NATO Report With Lead Authors (Group)
Preface/Editorial (Niemtzow)
Executive Summary (Petri)
Chapter 1 Integrative Medicine as the new Healthcare Paradigm within the Military (Petri)
Chapter 2 Overview of Integrative Wellness/CAM Practices and Policies in NATO participant
countries (Heygi)
Chapter 3 Integrative Medicine (IM) experience in the United States Department of Defense (Petri)
Chapter 4 Acupuncture and Potential Applications for Military Medical Pain Management
(Niemtzow)
Chapter 5 Mindfulness Practices as a Resource for Health and Well-being (Zimmermann)
Chapter 6 Yoga (Babouraj)
Chapter 7 Spirituality (Bussing)
Chapter 8 Biofeedback in Stress management: The France experience (Trousselard)
Chapter 9 Biological based Practices for PTSD, Pain and Optimal Soldier Resilience (Friedl)
ANNEX F - 4
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0247.png
NATO UNCLASSIFFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
Chapter 10 Trauma Spectrum Disorder and Integrative Medicine (Jonas)
Chapter 11 Integrative Medicine Practices Specifically for Soldiers (Petri)
Chapter 12 Systematic Approaches to Evaluation and Integration of Eastern and Western Medical
Practices (van der Greef)
Chapter 13 Discussion, Conclusion and Recommendations (Petri)
F2.10 Format For Medicine Acupuncture (Niemtzow)
Title
Abstract
Keywords
Introduction/Definitions
Main body/Subsections
Discussion
Conclusion/Recommendations/Financial Implications
F2.11 Format For Nato Report (Group)
Chapter 1 - INTRODUCTION
Chapter Author’s Name (not obligatory)
Author’s Address (not obligatory)
Start Chapters, Annexes, Appendices here.
Please start each new Chapter, Annex or
Appendix on a new page.
The following shows the various levels of headings and text that should be used. Note that the format for each of these
are stored under a separate style names RTO First Level Heading, RTO Text etc. and are available from the Styles and
Formatting menu. In addition, it provides information on to how to enter the headings and footers that are based upon the
DOCUMENT PROPERTIES.
1.1
RTO FIRST LEVEL HEADING
RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text
STO-TR-HFM-195
ANNEX F - 5
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0248.png
NATO UNCLASSIFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text RTO text.
1.1.1
1.1.1.1
1.1.1.1.1
RTO Second Level Heading
RTO Third Level Heading
RTO Fourth Level Heading
Table 1: Enter text (RTO Table Caption)
Figure 1: Enter text (RTO Figure Caption)
NOTE: http or www Internet addresses appear as ‘dark blue’ text
•
•
RTO Bullet (1
st
Level)
RTO Sample Bullet (2
nd
Level)
See following page for “Header/Footer” information
ANNEX F - 6
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0249.png
NATO UNCLASSIFFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
The Headers and Footers in the templates contain specific information about the RTO Report and the document itself. In
order to automatically generate this information, the following data must be entered into the Document Properties
Summary Tab as follows – see Figure 1 and Table below:
Figure 1: Screenshot of the Document Properties Summary Tab.
(from the Menu, File – Properties – Summary Tab)
Title
Subject
Author/
Company
Comments
Enter the title of the Report
Enter the Report Reference (e.g. RTO-TR-IST-999)
Leave the text as RTA/
RTA-NATO
Enter the CLASSIFICATION of the Report in CAPITAL LETTERS. This field can be left
BLANK if the Report is open for public release
Please note that the Headers and Footers will NOT be visible until you display the document in Print Preview mode
(from the Menu, File – Print Preview – Close).
STO-TR-HFM-195
ANNEX F - 7
NATO UNCLASSIFIED
 FOU, Alm.del - 2016-17 - Bilag 23: Henvendelse af 24/11-16 vedrørende udvidelse af sundhedstilbuddene for veteraner, fra Nordic Integrative Medicine, NIM
1693642_0250.png
NATO UNCLASSIFIED
ANNEX F SUMMARY REPORT OF THE SIXTH MEETING 30 APRIL – 2 MAY 2014
F3
•
•
•
SUMMARY OF DISCUSSION
This is the final formal meeting of Task Force HFM-195 Integrative Medicine Interventions for Military
Personnel.
Overall the group set the foundation for the final report.
The possible next steps for this task force and the possibility for follow-on Task Forces were discussed.
Draft Annex Completed by THE HFM-195 Rapporteur, COL Richard P. Petri, Jr., MC
ANNEX F - 8
STO-TRG-TR-HFM-195
NATO UNCLASSIFIED