Mini-Reports from Veterans Administration Centers

VA Butler Healthcare—VA Butler Healthcare (Abie Abraham Health Care Center) provides acupuncture services in an outpatient setting. Framed within the biopsychosocial model, the main campus provides a full-time acupuncture clinic embedded within the Physical Medicine and Rehabilitation Service department. Direct referrals are primarily for neuromusculoskeletal conditions, including back and neck pain as well as postsurgical and chronic pain states. Referrals predominantly come from patient-aligned care teams (i.e., primary care) but also from specialist providers. Although traditional, manual, and electroacupuncture strategies are utilized, emphasis remains on empowering veterans through utilization of self-management strategies and exploration of lifestyle modifications.

The acupuncture providers participate in an interdisciplinary headache team and a facility pain-management team. The clinic operates with the veterans' goals in mind with the assistance of validated outcome tools, such as the neck disability index, revised Oswestry disability index, and PROMIS® [Patient Reported Outcomes Measurement Information System] global health short form. Our clinic will also refer patients out for imaging, laboratory testing, or other service lines, such as the Center for Behavioral Health, when appropriate. The clinic has led in identifying serious pathologies, including a spinal epidural abscess¹ and metastatic cancer.

Furthermore, innovative delivery of acupuncture services has occurred outside of the outpatient clinic. Auricular acupuncture is offered weekly to veterans in the Domiciliary Residential Rehabilitation Treatment Program as part of a Relapse Prevention class. Auricular acupuncture during this class is elective, although every veteran completes a PROMIS global health short form. Acupuncture has also been provided to veterans residing in the community living center as part of palliative end-of-life care.

Michael T. Anderson, DC, DiplAc (NCCAOM)

VA Butler Healthcare

353 North Duffy Road

Butler, PA 160010

michael.anderson41@va.gov

Zachary A. Cupler, DC, DiplAc (NCCAOM)

VA Butler Healthcare

353 North Duffy Road

Butler, PA 16001

zachary.cupler@va.gov

VA Central Iowa Health Care System—After many years of private practice, I have enjoyed the unique environment that the VA offers for acupuncture. Working in an interdisciplinary setting has allowed for overall better patient care. Eliminating the financial issues of fee-for-service practice and knowing that the veterans are VA patients across the continuum of care allows for a focus on health and well-being. This is evident with the VA shift toward whole health.

I was hired by the Des Moines VA in January of 2015. Given that there was no method to hire licensed acupuncturists at that time, I was on-boarded under my chiropractic license. We have a full-time chiropractor on station in our facility, so my role was exclusively to provide acupuncture. Prior to my arriving at the Central Iowa VA, there were 2 fee-basis acupuncturists, a husband and wife, who saw patients 1 day per week each, and who had been available for veterans at the hospital for 10 years.

The majority of my patients are referred for pain conditions, and I am housed in our hospital's interdisciplinary Pain Clinic. In addition to full-body Traditional Chinese Medicine–style acupuncture, I have introduced group acupuncture with a weekly National Acupuncture Detoxification Association protocol clinic in our domiciliary (inpatient setting for substance abuse, post-traumatic stress disorder, or coping skills training). We will also begin a shared medical appointment trial for smoking cessation wherein acupuncture will be paired with behavioral coaching from our Health Promotions and Disease Prevention coordinator and pharmacy support for medication starting July 2018.

I also serve as the National Lead for Acupuncture in the VA under the Integrative Health Coordinating Center. As of February 2018, the VA has been able to hire licensed acupuncturists (LAcs) as stand-alone professionals. We are looking forward to great growth in the provision of acupuncture services within the VA. The demand for complementary and integrative modalities continues to grow from our veteran population. The VA has been moving forward on many levels to provide access to Center for Integrated Healthcare services including acupuncture. Acupuncture's greater inclusion in the largest U.S. healthcare system provides fertile soil to continue research efforts in the best uses of acupuncture.

Juli Olson, DC, MAOM, DiplAc

VA Central Iowa HCS

3600 30th Street

Des Moines, IA 50310

juli.olson@va.gov

Salt Lake City VA Hospital—We are reporting on the use of medical acupuncture in a mental health treatment setting at the Salt Lake City VA Hospital. One author (M.V.) completed the Helms Medical Institute Medical Acupuncture Training program and American Board of Medical Acupuncture board certification. He began integrating this modality into the existing outpatient psychiatric practice in 2014 and continues to use this modality today. Consistent with the philosophy of medical acupuncture, efforts were made to incorporate the treatment into an existing conventional Western medical setting where both modalities were immediately available as indicated.¹

The modality has been used both with Dr. Vukin's own patients and for some of the more-complex patients of colleagues. Both sets of patients were seen for acupuncture as an adjunctive treatment and continued to receive conventional treatments. As one author (M.V.) was trained in auricular acupuncture, and also subsequently certified as a Battlefield Acupuncture instructor, a service was created in the residential substance-abuse program, where patients could be seen weekly for auriculotherapy. Treating this microsystem with indwelling needles is well-received and allows for brief treatments and minimal disruption of conventional evidence-based programs on the unit. Patients are often seen for a series of weekly treatments at first, and then the treatments are spaced out to maintenance treatment to coincide with regular mental-health clinic visits.

Treatment focus has been on overtly psychiatric presentations, although, inevitably, other related conditions are considered, using Chinese Medicine paradigms that emphasize dynamic relationships among body systems leading to symptom manifestations. The most common indications include post-traumatic stress disorder, anxiety, insomnia, substance-abuse disorders, and pain that is highly related to psychoemotional conditions. The treatments are informed by the auricular and scalp microsystem, 5 Phases paradigm, acupuncture energetics, or combinations of these modalities. Many office treatments are done within a 30–60-minute appointment. An examination room with a table is not often available, but this has not been a liability. The outpatient clinic office has a reclining chair for treatments and a privacy screen to separate the provider's desk from the reclined chair when needles are in place. A white-noise machine is often used to keep hallway noise from interfering with a relaxing experience for the patients.

Veterans have responded favorably to the addition of this modality in their care. They have voiced appreciation for being able to access the service embedded within the mental health clinic and, as organized, not requiring patients to endure long wait times to access treatment, nor imposing a limited number of treatments due to the need for the service within the institution. This service has been professionally satisfying (according to M.V.) and complements the stand-alone acupuncture services that are offered in our specialty Integrative Health Clinic.

Matt Vukin, MD, DABMA and William Marchand, MD

George E. Wahlen VA Medical Center

500 Foothill Boulevard

Salt Lake City, UT 84148

matthew.vukin@va.gov

The Edward Hines, Jr. VA Hospital Department of Physical Medicine & Rehabilitation (PM&R)—The Edward Hines, Jr. VA Department of PM&R has supported veterans with chronic pain innovatively from 2014 to 2017 through the Hines PM&R Acupuncture Clinic. Veterans who were treated unsuccessfully by conventional treatments—including opiates, physical therapies, pain injections, and/or surgery—were referred here. Individual patient presentations determined the acupuncture approaches utilized (Helms energetics, local needling, percutaneous electrical nerve stimulation, auricular, scalp acupuncture, and Traditional Chinese Medicine). Due to acupuncture being a novel treatment in Hines PM&R, a Quality Improvement project was initiated to track demographic and clinical outcomes for the first 50 veterans who were treated with acupuncture. Pain scores prior to and immediately after treatment improved an average of 61%, which was particularly impressive given the patients' complexity. A summary of the data was presented as a poster.¹

In a parallel project, the Hines VA Pharmacy Department tracked opiate use and pain scores of these same patients and found a statistically significant decrease in total number of opiate medications along with reduced pain numbers. These review projects demonstrated that acupuncture was helpful for many veterans at the Hines VA for treating pain. Future studies could be designed to evaluate optimal treatment courses for durability of effects.

The Hines PM&R acupuncture offerings have evolved and expanded since that time. One physiatrist completed a 300-hour acupuncture course and another provider trained in Battlefield Acupuncture. Additionally, when acupuncture has been offered in conjunction with osteopathic manual medicine, a synergistic pattern of improvement has been observed. Particularly in patients with somatic dysfunction that is biomechanically based, a combination of manual medicine followed by acupuncture often resolves years of chronic pain completely. Furthermore, acupuncture has often helped improve balance and movement patterns independently of whether or not acupuncture helped relieve pain. There is a special interest in exploring the underlying mechanisms responsible for these findings.

Hines PM&R has continued to innovate with the development of the Integrated Movement Clinic. Veterans with persistent limitations in movement and function, despite diligent participation in various therapies, are treated. A collaborative assessment, including multiple clinicians with different clinical skill sets, is performed, guiding the ability to provide multiple treatment trials in a single session. These trials include acupuncture, manual medicine, and prolotherapy and other injections. The results from these trials are used to formulate customized, patient-centered treatment plans, with the goal of reaching a satisfactory level of physical functioning most quickly and effectively. Clinical results and veterans' feedback have been extremely positive. As PM&R continues to offer additional whole health programs, the ongoing goal is to promote continued well-being and function using active self-care and wellness programs. The hope is to continually evolve clinical models to best improve the quality of life and function of veterans.

Vishal Kamani, MD, FAAPMR, ABIHM

Hines VA

5000 South 5th Avenue

Hines, IL 60141

vishal.kamani@va.gov