Military Medical Acupuncture and CAM: Next Steps

Introduction

Determining the future direction of acupuncture in military medicine requires insight into the essential antecedent events underpinning our current health care terrain. Starting with the landmark survey by David Eisenberg, MD, and colleagues in The New England Journal of Medicine in 1993, which reported that visits by Americans to alternative health care providers, as shown in a 1990 survey, exceeded the number of visits to allopathic primary-care physicians during the year covered by the survey, ¹ many peer-reviewed studies have been published that attest to the increased use of acupuncture and other complementary and alternative medicine (CAM) therapies in the United States and other developed countries. ²

The extensive inclusion of Acupuncture and other CAM therapies into civilian and military medical centers and schools has been driven by consumer and physician demand for strategies that focus on holistic approaches to healing and prevention of disease.^1–5 Indeed, a qualitative focus-group study of military, veterans and their significant others reported that adverse drug effects were leading reasons why active duty and retired veterans, and their dependents, have turned to acupuncture and other CAM modalities. ⁵

Review of the Evidence

A critical analysis of acupuncture research has led to increasingly rigorous design and powering of acupuncture trials in recent years. In October 2000, the German Federal Committee of Physicians and Health Insurers recommended that special model projects on acupuncture be developed in order to determine the evidence-based role of acupuncture in the treatment of certain illnesses. A summary of randomized controlled trials performed as part of these projects and the associated economic analysis published in 2009 reported that:

Overall…acupuncture is effective in practice for a range of chronic conditions, and it seems likely to have acceptable cost utility. Sham acupuncture, in the form of minimal off-point needling in a therapeutic context, also appears to be effective, being no different to prophylactic medication in migraine, and superior to guideline-based standard care in chronic low back pain” ⁶

Additionally the report noted that the response to treatment did not differ in the trials between those patients who agreed to be randomized and those who did not, suggesting applicability to the general population expressing preference for acupuncture. ⁶

Expert reviews of many additional large-scale effectiveness trials reported that acupuncture treatment demonstrates significant benefit in various acute and chronic pain conditions, ⁶ including neck pain, low-back pain, chronic knee pain, migraine, and tension-type headaches,^6–11 with fewer side-effects than conventional biomedical therapies, and is promising for anxiety and post-traumatic stress disorder (PTSD), acute management and rehabilitation of traumatic brain injury, ¹² insomnia, and depression.^13–18 Although gaps in acupuncture research remain, this research has advanced over the last 2 decades from a field consisting primarily of anecdotal and retrospective reports and erratic experimental models that correlated poorly with clinical-practice models^19,20 to reproducible predictive models derived from multiple research fields, including developmental biology, biophysics, engineering, cell biology, neurobiology, mathematics, and clinical medicine.^21,22

Emerging Acceptance and Use of Acupuncture and Cam In Military Treatment Facilities

The decade-long conflicts in Iraq and Afghanistan have resulted in a high incidence of chronic pain, PTSD, anxiety, depression, and chronic mental illness in military members returning from one or multiple deployments. A rising incidence of suicide, prescription-drug abuse, and poorly controlled mental illness and chronic pain have resulted in a critical evaluation of the limited effectiveness and barriers to treatment with respect to current biomedical approaches.^23–25 This analysis has led to review of the evidence relating to acupuncture and other CAM modalities, utilized alone or in combination with conventional approaches, for treatment of patients who do not respond to conventional approaches or who prefer holistic approaches to conventional biomedical methods.

In response to the expanding body of evidence supporting the benefits of acupuncture and other integrative approaches, there is a growing need to educate physicians and administrators on the extensive scientific literature on CAM from notable peer-reviewed journals. According to the U.S. Army Surgeon General's Pain Task Force Report from 2010:

Medical science acknowledges that there are many accepted practices that are utilized without evidence from well-designed research and data in both complementary and traditional western medicine. CAM practices, in particular, are often debunked as ineffective or merely effective due to the placebo effect.…Though CAM is increasing in popularity among patients, this popularity has yet to result in a parallel increase in acceptance and use within traditional medicine. ²⁵

The Pain Task Force further stated:

For patients seeking a treatment plan that includes more than just medication.…[t]here is a wide range of therapies and treatments, such as acupuncture and yoga therapy, that [has] proven valuable in reducing an overreliance on use of medications to treat pain. There are many reasons individuals may seek the option to use CAM, not the least of which is the failure of current treatment to relieve their pain. Current research indicates that part of the appeal of CAM includes the opportunity for greater personal involvement in health maintenance, holistic health beliefs and, for those with chronic conditions, an active coping mechanism.^25–27

In addition to describing its benefit in military treatment facilities, articles in major periodicals have recently reported on acupuncture use in Afghanistan. A recent Wall Street Journal article detailed the outcome of marines successfully treated for symptoms associated with concussion and PTSD. ²⁸ Acupuncture in operational military settings has also been reported to treat acute and chronic musculoskeletal pain effectively, and is highly sought after by soldiers and marines with problems ranging from work stress to snuff addiction.^28,29

Discussion

Conclusions

A recent study publication in the Journal of Rehabilitation, Research and Development documenting the high prevalence of polytrauma clinical triad in returning combat veterans recommended the following:

Overall, healthcare providers and researchers who specialize in helping OIF/OEF [Operation Iraqi Freedom/Operation Enduring Freedom] veterans will need to work together to gain a broader understanding of how the experience of war-related injury has affected our returning soldiers, to recognize the importance of treating the entire person rather than a particular disorder, and to prioritize the development of innovative and effective treatment approaches for this population. ³⁰

There is a growing recognition today that prolonged stress, such as that associated with chronic PTSD and chronic pain states, can significantly affect physical health by inhibiting the immune system and/or causing damaging cardiovascular reactions. ³¹ Chronic disease has been recognized as the leading cause of death in males and females in all World Health Organization (WHO), regions except Africa according to a WHO report, which estimates that there are16 million chronic disease deaths yearly in people under 70 years of age. ³²

A rapidly growing body of authoritative literature suggests that application of simple, cost-effective holistic approaches such as acupuncture can achieve dramatic reductions in the burden of chronic disease and address the primary determinants associated with the transition from acute to chronic pain.^33–37 Frentzel-Beyme and Grossarth-Maticek reported, in 2001, that, among 5716 middle-age adults followed for a 15-year observation period, adults with autonomy and good self-regulation had a 50 times lower incidence of chronic disease and death than adults with poor autonomy and self regulation. ³⁶ In 2001, Hasenbring et al. reported level A evidence demonstrating that psychological variables, especially chronic stress in daily life, catastrophizing, fear-avoidance-beliefs, and passive coping strategies, such as avoidance behavior, were clearly linked to the transition from acute to chronic pain and disability with greater prospective power than biomedical, social, or objective occupational variables. ³⁷

Just as military conflicts of the past have catapulted medicine forward in fields such as critical care medicine, trauma medicine, emergency air transport systems, and disaster management medicine, ³⁸ the current conflicts have accelerated the science of prosthetics, lighter medical devices and transport systems, and further advancements in acute trauma management, (such as the Hem-Con bandage, which can stop even severe bleeding almost instantaneously). ³⁹ These advances have resulted in the physical survival of combatants who would not had survived their injuries in previous conflicts; combatants with severe injury to mind, body, and spirit. The pioneering integration of acupuncture and other evidence-based holistic treatment systems into battlefield and military treatment facility settings has the potential to decrease significantly the vast personal and societal cost of chronic mental and physical disease associated with the recent wars against terrorism. These developments may also influence the further incorporation of acupuncture into conventional civilian inpatient and outpatient treatment facilities, as cost-saving preventive strategies become recognized drivers of wellness, productivity, patient satisfaction, and loyalty.