Outlook | A Quarterly Newsletter of the Society of Behavioral Medicine

From the Complementary and Alternative Medicine SIG

The common perception of many healthcare providers is that the Department of Defense is more conservative in their approach to healthcare than most civilian organizations. Many would probably think that military hospitals would not be interested in exploring Complementary and Alternative Medicine approaches to treatment. Submitted by Dr. Mona Bingham of the Complementary and Alternative Medicine SIG, this article provides two examples of current research efforts focused on addressing the efficacy of these holistic healing practices for military populations.

Suzanne C. Danhauer, Ph.D.
Assistant Editor to Outlook Newsletter
Complementary and Alternative Medicine SIG

Research in Integrative Medicine at the Department of Defense: Generating Quality Research to Promote Healing

Yoga Experience for Soldiers (YES)

In 2004, there was little literature on the use of yoga with military populations. However, we believed that the multi-component aspects of yoga - physical exercise, breathing and meditation - could be effective in reducing physical discomfort and mental stress for soldiers experiencing physical and emotional pain resulting from injuries or illnesses related to Operation Iraqi Freedom (OIF). This pilot project, Yoga Experience for Soldiers (YES), was uniquely designed as a medical therapeutic intervention for injured soldiers. Because Dr. Beth Whitney-Teeple had a strong background in the military, yoga, and research, she was the perfect co-researcher, with Dr. Mona Bingham, the PI for this project. She has also completed the 500-hour level Viniyoga training w/ Gary Kraftsow (Director, American Viniyoga Institute www.viniyoga.com, Author: Yoga for Wellness, 1999; Yoga for Transformation, 2002). She consulted with numerous other yoga experts to identify optimal sequencing of movements and postures to ensure a safe and healing program for soldiers with multiple types of injuries who were generally inexperienced with yoga.

Goals
The objective of this pilot project was to evaluate yoga as a complementary treatment for injured soldiers experiencing chronic pain, sleep difficulties, or stress. Goals were to offer yoga as a complementary treatment option, demonstrate feasibility, and evaluate the effectiveness of the intervention in improving short-term clinical outcomes. Hopefully, this initial effort could answer three questions: Which injured soldiers would be most interested in a yoga intervention? Would they participate in classes and practice at home? Would the intervention be helpful for their symptoms?

Design
Prior to beginning the intervention, baseline self-report measures of general health, mood state, and stressful life events were collected; however, issues with obtaining informed consent prevented us from matching pre- and post-intervention measures. Post-intervention qualitative data of participants who completed the program were collected, anonymously, from individual journal entries, instructor observations, and verbal encounters. The yoga intervention was designed to help increase body and mind awareness using gentle movement and breathing for relaxation. Consistent with Viniyoga principles, the structure of the yoga practice relied more on individual adaptation than props to achieve the purpose of the postures. It used a pattern of repetition and longer time in each posture to encourage gradual stretching and reduce risk. Classes were conducted twice weekly over 8 weeks at three different times to accommodate participants' schedules.

Recruitment
Soldiers were recruited using flyers distributed by their Case Managers and other key staff members. The headline of the flyer was entitled Tools for Managing Pain; this yoga-based program was specifically designed to help soldiers experiencing discomfort or physical limitations. The flyer listed a number of questions including the following: Are you tossing and turning at night? Do you have low back pain or shoulder pain - Pain in the neck? Have you changed the way you live because things hurt? Are you discouraged? Do you wish you felt better? Since this was a descriptive pilot study, soldiers could participate with any type of pain or injury. Of note, most soldiers complained of pain due to orthopedic injuries, primarily leg, foot, back, shoulder and neck pain.

Participant Characteristics
Participants included 23 soldiers (returning from or en route to Iraq) and one spouse (n=24). Soldiers were primarily enlisted (88%), male (58%), and relatively older (mean age = 37 years, range = 20-56 years). Most were reservists (37%); however, active duty (33%) and National Guard (25%) soldiers were also adequately represented.

Descriptive Findings
Due to limited resources, the project could not accommodate all who were interested. Almost fifty interested soldiers were interviewed but could not attend for various reasons. While the project initially targeted pain, soldiers described other significant symptoms and reasons for attending; the most frequent complaints were poor pain management (67%), unresolved stress (29%), and sleep disturbances (21%). Additional reasons for attending were to learn yoga for strength and flexibility. More than 50% of the participants attended over half of the sessions, even with significant barriers related to time and location of classes. Journal data about the intervention revealed that participants liked yoga postures the most, followed by relaxation and breathing techniques. Information in the journals revealed that participants used the yoga techniques outside of class, and showed an upward trend in use of the yoga techniques outside of class with each week. Of those who completed the program, all stated that they would continue to practice yoga techniques and seek more classes.

Conclusions
This innovative pilot study suggests that soldiers with wartime experiences are interested in integrative and/or complementary modalities such as yoga sequences and relaxation techniques for handling chronic symptoms such as pain, sleep difficulties, and stress. While self-reported pain issues were not relieved for most soldiers as reported in their journals, there were individual improvements in coping, sleep, and perceived overall stress. Future considerations include: (1) more targeted yoga practice for individual symptoms; and (2) identification of additional chronic symptoms in this population that may be amenable to yoga interventions. Further work is needed to clarify which soldiers (i.e., diagnosis, injury) will benefit the most from complementary treatments and which symptoms would be best to measure to indicate sustained improvement. Ultimately, we hope to conduct a well-designed randomized controlled trial of yoga to improve debilitating chronic symptoms and quality of life for this unique and deserving military population.

**This pilot project was selected for presentation at the 1st Symposium on Yoga Therapy and Research (SYTAR), International Association for Yoga Therapists, Los Angeles, California, January 2007. This work has also been presented to military audiences of clinicians and researchers.
Bingham, M.O., & Whitney-Teeple, B. (2007). Using yoga for pain management with soldiers.
International Journal of Yoga Therapy. Supplement edition.

*Funding provided through the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) Directorate of Health Promotion and Wellness (DHPW).

Outcomes of Cranial Electrotherapy Stimulation (CES) with Soldiers for Combat-Related Symptoms
Cranial electrical stimulation (CES) falls within the larger arena of bioelectric medicine and has become increasingly accepted as a treatment modality for multiple conditions, with the most promise shown for centrally-mediated pain syndromes that have historically been difficult to treat effectively (Kirsch, 2008). A form of microcurrent electrical therapy (MET), CES is a noninvasive technique that involves the passing of microcurrent (µA) levels of biphasic electrical stimulation across the head via small electrodes clipped to the earlobes for 20 to 60 minutes for a few days to a few weeks.

CES has been found to be effective in controlling anxiety, depression, insomnia, and generalized stress with other populations (Kirsch & Smith, 2000). There are many Department of Defense (DoD) facilities that are using CES in clinical practice, and it has gained popularity with many military providers and patients, but there are no published data for the use of CES in soldiers with combat related symptoms post-deployment. Considering the largely positive results of preliminary studies on patients with anxiety, depression, and insomnia, we decided to examine the effects of CES as an adjunct therapy for combat-related symptoms. The purpose of an ongoing double-blind randomized controlled research study is to determine if CES for soldiers is effective in reducing irritability (and also other combat-related symptoms of anxiety, depression, pain, and sleep disturbance). The study uses a repeated measures design to measure outcomes and duration of effects up to one month following treatment. This inter-disciplinary study combines the Nursing Research Service with a Clinical Health Psychologist (Alice Inman, PsyD) as co-investigator and works closely with Case Management and Behavioral Medicine to recruit soldiers who may benefit from this treatment. Currently, this study is active and no data has been analyzed. We anticipate outcomes by 2009.

Kirsch, D. L. (2008). CES in the treatment of pain-related disorders. Practical Pain Management, 8(3), 12-25.
Kirsch, D. & Smith, R.B. (2000). The use of cranial electrotherapy stimulation in the management of chronic pain: A review. NeuroRehabilitation, 14(2), 85-94.

These studies are just two examples of integrative medicine research in military hospitals. It is our hope that we can continue to promote integrative medicine treatment and research to improve the health and healing of our military population. Thank you for the opportunity to share our work here, and we look forward to sharing our findings and discussing future ideas and collaborations with you.

*Contact information for Dr. Mona Bingham, PI for both studies, is listed below.

Mona Bingham, PhD, RN Lieutenant Colonel, U. S. Army Chief, Nursing Research Service Brooke Army Medical Center Fort Sam Houston, TX 78234 Mona.bingham@amedd.army.mil
Alice.Inman@Lackland.AF.Mil
whitneyteeple@comcast.net

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or reflecting the views of the U.S. Department of Defense, U.S. Army, or Army Nurse Corps


Fall 2008	Return to Outlook Main page >>
From the Complementary and Alternative Medicine SIG The common perception of many healthcare providers is that the Department of Defense is more conservative in their approach to healthcare than most civilian organizations. Many would probably think that military hospitals would not be interested in exploring Complementary and Alternative Medicine approaches to treatment. Submitted by Dr. Mona Bingham of the Complementary and Alternative Medicine SIG, this article provides two examples of current research efforts focused on addressing the efficacy of these holistic healing practices for military populations. Suzanne C. Danhauer, Ph.D. Assistant Editor to Outlook Newsletter Complementary and Alternative Medicine SIG Research in Integrative Medicine at the Department of Defense: Generating Quality Research to Promote Healing Yoga Experience for Soldiers (YES) In 2004, there was little literature on the use of yoga with military populations. However, we believed that the multi-component aspects of yoga - physical exercise, breathing and meditation - could be effective in reducing physical discomfort and mental stress for soldiers experiencing physical and emotional pain resulting from injuries or illnesses related to Operation Iraqi Freedom (OIF). This pilot project, Yoga Experience for Soldiers (YES), was uniquely designed as a medical therapeutic intervention for injured soldiers. Because Dr. Beth Whitney-Teeple had a strong background in the military, yoga, and research, she was the perfect co-researcher, with Dr. Mona Bingham, the PI for this project. She has also completed the 500-hour level Viniyoga training w/ Gary Kraftsow (Director, American Viniyoga Institute www.viniyoga.com, Author: Yoga for Wellness, 1999; Yoga for Transformation, 2002). She consulted with numerous other yoga experts to identify optimal sequencing of movements and postures to ensure a safe and healing program for soldiers with multiple types of injuries who were generally inexperienced with yoga. Goals The objective of this pilot project was to evaluate yoga as a complementary treatment for injured soldiers experiencing chronic pain, sleep difficulties, or stress. Goals were to offer yoga as a complementary treatment option, demonstrate feasibility, and evaluate the effectiveness of the intervention in improving short-term clinical outcomes. Hopefully, this initial effort could answer three questions: Which injured soldiers would be most interested in a yoga intervention? Would they participate in classes and practice at home? Would the intervention be helpful for their symptoms? Design Prior to beginning the intervention, baseline self-report measures of general health, mood state, and stressful life events were collected; however, issues with obtaining informed consent prevented us from matching pre- and post-intervention measures. Post-intervention qualitative data of participants who completed the program were collected, anonymously, from individual journal entries, instructor observations, and verbal encounters. The yoga intervention was designed to help increase body and mind awareness using gentle movement and breathing for relaxation. Consistent with Viniyoga principles, the structure of the yoga practice relied more on individual adaptation than props to achieve the purpose of the postures. It used a pattern of repetition and longer time in each posture to encourage gradual stretching and reduce risk. Classes were conducted twice weekly over 8 weeks at three different times to accommodate participants' schedules. Recruitment Soldiers were recruited using flyers distributed by their Case Managers and other key staff members. The headline of the flyer was entitled Tools for Managing Pain; this yoga-based program was specifically designed to help soldiers experiencing discomfort or physical limitations. The flyer listed a number of questions including the following: Are you tossing and turning at night? Do you have low back pain or shoulder pain - Pain in the neck? Have you changed the way you live because things hurt? Are you discouraged? Do you wish you felt better? Since this was a descriptive pilot study, soldiers could participate with any type of pain or injury. Of note, most soldiers complained of pain due to orthopedic injuries, primarily leg, foot, back, shoulder and neck pain. Participant Characteristics Participants included 23 soldiers (returning from or en route to Iraq) and one spouse (n=24). Soldiers were primarily enlisted (88%), male (58%), and relatively older (mean age = 37 years, range = 20-56 years). Most were reservists (37%); however, active duty (33%) and National Guard (25%) soldiers were also adequately represented. Descriptive Findings Due to limited resources, the project could not accommodate all who were interested. Almost fifty interested soldiers were interviewed but could not attend for various reasons. While the project initially targeted pain, soldiers described other significant symptoms and reasons for attending; the most frequent complaints were poor pain management (67%), unresolved stress (29%), and sleep disturbances (21%). Additional reasons for attending were to learn yoga for strength and flexibility. More than 50% of the participants attended over half of the sessions, even with significant barriers related to time and location of classes. Journal data about the intervention revealed that participants liked yoga postures the most, followed by relaxation and breathing techniques. Information in the journals revealed that participants used the yoga techniques outside of class, and showed an upward trend in use of the yoga techniques outside of class with each week. Of those who completed the program, all stated that they would continue to practice yoga techniques and seek more classes. Conclusions This innovative pilot study suggests that soldiers with wartime experiences are interested in integrative and/or complementary modalities such as yoga sequences and relaxation techniques for handling chronic symptoms such as pain, sleep difficulties, and stress. While self-reported pain issues were not relieved for most soldiers as reported in their journals, there were individual improvements in coping, sleep, and perceived overall stress. Future considerations include: (1) more targeted yoga practice for individual symptoms; and (2) identification of additional chronic symptoms in this population that may be amenable to yoga interventions. Further work is needed to clarify which soldiers (i.e., diagnosis, injury) will benefit the most from complementary treatments and which symptoms would be best to measure to indicate sustained improvement. Ultimately, we hope to conduct a well-designed randomized controlled trial of yoga to improve debilitating chronic symptoms and quality of life for this unique and deserving military population. *This pilot project was selected for presentation at the 1st Symposium on Yoga Therapy and Research (SYTAR), International Association for Yoga Therapists, Los Angeles, California, January 2007. This work has also been presented to military audiences of clinicians and researchers. Bingham, M.O., & Whitney-Teeple, B. (2007). Using yoga for pain management with soldiers. International Journal of Yoga Therapy.* Supplement edition. Funding provided through the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) Directorate of Health Promotion and Wellness (DHPW). Outcomes of Cranial Electrotherapy Stimulation (CES) with Soldiers for Combat-Related Symptoms Cranial electrical stimulation (CES) falls within the larger arena of bioelectric medicine and has become increasingly accepted as a treatment modality for multiple conditions, with the most promise shown for centrally-mediated pain syndromes that have historically been difficult to treat effectively (Kirsch, 2008). A form of microcurrent electrical therapy (MET), CES is a noninvasive technique that involves the passing of microcurrent (µA) levels of biphasic electrical stimulation across the head via small electrodes clipped to the earlobes for 20 to 60 minutes for a few days to a few weeks. CES has been found to be effective in controlling anxiety, depression, insomnia, and generalized stress with other populations (Kirsch & Smith, 2000). There are many Department of Defense (DoD) facilities that are using CES in clinical practice, and it has gained popularity with many military providers and patients, but there are no published data for the use of CES in soldiers with combat related symptoms post-deployment. Considering the largely positive results of preliminary studies on patients with anxiety, depression, and insomnia, we decided to examine the effects of CES as an adjunct therapy for combat-related symptoms. The purpose of an ongoing double-blind randomized controlled research study is to determine if CES for soldiers is effective in reducing irritability (and also other combat-related symptoms of anxiety, depression, pain, and sleep disturbance). The study uses a repeated measures design to measure outcomes and duration of effects up to one month following treatment. This inter-disciplinary study combines the Nursing Research Service with a Clinical Health Psychologist (Alice Inman, PsyD) as co-investigator and works closely with Case Management and Behavioral Medicine to recruit soldiers who may benefit from this treatment. Currently, this study is active and no data has been analyzed. We anticipate outcomes by 2009. Kirsch, D. L. (2008). CES in the treatment of pain-related disorders. Practical Pain Management, 8(3), 12-25. Kirsch, D. & Smith, R.B. (2000). The use of cranial electrotherapy stimulation in the management of chronic pain: A review. NeuroRehabilitation, 14(2), 85-94. These studies are just two examples of integrative medicine research in military hospitals. It is our hope that we can continue to promote integrative medicine treatment and research to improve the health and healing of our military population. Thank you for the opportunity to share our work here, and we look forward to sharing our findings and discussing future ideas and collaborations with you. Contact information for Dr. Mona Bingham, PI for both studies, is listed below. Mona Bingham, PhD, RN Lieutenant Colonel, U. S. Army Chief, Nursing Research Service Brooke Army Medical Center Fort Sam Houston, TX 78234 Mona.bingham@amedd.army.mil Alice.Inman@Lackland.AF.Mil whitneyteeple@comcast.net The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or reflecting the views of the U.S. Department of Defense, U.S. Army, or Army Nurse Corps