Treating Pain In Gulf War Illness (GWI)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Treating Pain inGulf War Illness (GWI)Gulf War – Research Advisory CommitteeJ. Wesson Ashford, MD, PhDDirector, WRIISC-CA SitePalo Alto VA Health Care Systemwes.ashford@va.govWar Related Illness & Injury Study Center (WRIISC)www.warrelatedillness.va.govSeptember 22, 2014Approaching the Treatment of Pain The WRIISC experienceUnderstanding Chronic Multi-symptom Illness?Tardive Sympathetic Dysautonomia (TDS)Symptoms Explained Pain Causation Management of Pain– Analgesics, Opioids– SNRIs (anti-depressants)– Sleep issues– rTMS– Exercise, YOGA Research – WRIISC projects
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014WRIISCA national VA program established in 2001 toaddress post-deployment health issues.Founding of the WRIISC Congressionally mandated Focus on epidemiologic research, GulfWar Registry, GW referral centers National Academy of Sciences Committeerecommended Geriatric Research,Education, and Clinical Center (GRECC)model
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014WRIISC Mission To improve the health, quality of life and functionof Veterans with post deployment concernsthrough clinical, research, education, and riskcommunication activities These include:– Chronic Multi-symptom Illness (CMI)(e.g., Gulf War Illness)– Occupational and environmental exposures– Complex and difficult-to-manage health conditions– Other conditions with unclear or controversialmechanism of disease (e.g., mild traumatic braininjury)WRIISC Service AreasCA WRIISC1-888-482-4376WRIISC.CA@va.govDr. J. Wesson AshfordNJ WRIISC1-800-248-8005WRIISC.NJ@va.govDr. Drew HelmerDC WRIISC1-800-722-8340WRIISC.DC@va.govDr. Matt Reinhard
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014The Veterans we serveMost recent deployment for interfacility consults received in FY2013Other13%Vietnam15%Gulf War andOEF/OIF/OND9%OEF/OIF/OND31%Gulf War31%Most Frequent Symptoms, Affected Systemsof Veterans from Gulf War 1Frequency of Symptoms of 53,835 Participants in VA Registry (1992–1997)Symptoms–––––––Fatigue 20.5Skin rashHeadache 18.0Muscle and joint painLoss of memoryShortness of breathSleep disturbancesSystems–––––– Musculoskeletal and connective tissueMental disordersRespiratory systemSkin and subcutaneous tissueDigestive systemChest painSymptoms of .013.411.13.5SOURCE: Murphyet al., 1999
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Results of Iowa Study – 3,695 Veterans:Symptoms, % PrevalenceNon-GWGW Veterans VeteransFibromyalgia 19.29.6Cognitive Dysfunction18.77.6Alcohol 0.8Sexual Discomfort1.51.1Chronic fatigue1.50.3Iowa Persian gulf Study Group, 1997WRIISC-CA Since its creation in 2007, WRIISC-CA has evaluated over 200complex referrals routed through Central Office from most StatesWest of the Mississippi River (and all States West of the Rockies). Of these referrals, 42% have been Veterans of the First Gulf War. The largest single problem in the WRIISC referrals has been PAIN!!
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Veterans’ Top Reported SymptomsGulf War VeteransAffected Systems icMood and CognitiveFatigueSkin What do these systems have in common?
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014FUNDAMENTAL PROBLEMS There is no recognized “Gulf War Syndrome”– this was a transitional term “Gulf War Illness” is considered to exist (Institute of Medicine, 2009) But this term remains undefined Chronic Multi-symptom Illness” provides noindication of the nature of the condition There have been many dozen explanations thathave been considered, but none has yielded anacceptable explanationDifficulties in Addressing Chronic Multisymptom Illness(CMI) in Gulf War Veterans Difficult to come up with a single case definition(diagnosis) for Gulf War Veterans Illnessesbecause of the many symptoms, some of whichare not shared by all CMI is found in groups other than Gulf WarVeterans There are no clinically validated tests orquestionnaires for diagnosing CMI
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Potential Operation Desert Shield/Desert StormExposure Concerns CARC Paint Chemical and BiologicalWeapons (Sarin, Soman) Depleted Uranium Harsh living conditions Incoming fire, explosive events Industrial solvents andchemicals Infections Injuries, musculoskeletal wearand tear Loud noises Oil Well Fires, Smoke, andPetroleum Pesticides Physical and MentalStressors Pyridostigmine Bromide Sand, Dust, AirborneParticulate Matter VaccinationsREF: WRIISC Clinical ReportsNumerous Institute of Medicine Studies/Reportson Gulf War IllnessJanuary 1, 1995Health Consequences of Service Duringthe Persian Gulf War: Initial Findings andRecommendations for Immediate ActionJanuary 1, 2000Gulf War and Health: Volume 1. DepletedUranium, Sarin, Pyridostigmine Bromide,and VaccinesJanuary 1, 1996Health Consequences of Service Duringthe Persian Gulf War: Recommendationsfor Research and Information SystemsJuly 26, 2001Treating Symptoms and SyndromesJanuary 1, 1998Adequacy of the VA Persian Gulf Registryand Uniform Case Assessment ProtocolsAugust 20, 2004Gulf War and Health: Updated LiteratureReview of SarinJanuary 1, 1998Measuring the Health of Persian GulfVeterans: Workshop SummarySeptember 12, 2006Gulf War and Health: Volume 4. HealthEffects of Serving in the Gulf WarAugust 1, 1999Gulf War Veterans: Measuring HealthAt least 3 more from the IOM since 2006
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Gulf War Illness FindingsNo Identified Diagnostic Entity Somatic Medical - normal x-rays of joints Neurological – peripheral electrophysiological abnormalities have been reported– normal MRI, PET scans– abnormal SPECT, MR spectroscopy, replication unclear Psychiatric –– depression– neuropsychological dysfunction – questionable vs hard to measure Possible relation to other conditions– chronic fatigue syndrome, fibromyalgia, IBS (irritable bowelsyndromes), multiple chemical sensitivity, TBI (traumatic braininjury – especially from blasts)Chronic Multi-symptom IllnessGulf War One Type(see new definition from IOM 3/12/2014)Complex Exposures Can Affect Large Groups and Lead to aUnique Variety of Conditions, Symptoms and Disorders.Consider that there are many exposures and other factors thatlead combat Veterans to have a higher incidence of a particularvariety of symptoms. Those symptoms may result from amultitude of causes. Further, each conflict, having differentexposures, may induce a different constellation of symptoms.In all cases, treatments must address the symptoms of theVeterans, minimize their discomfort, and maximize their function.
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Some of Possible Causes Cholinesterase inhibitors (including chemical weapons)– Pyridostigmine Bromide (PB tablets), Organophosphate Pesticides,other chemical pesticides, Sarin and Cyclosarin Other chemical exposures CARC - Chemical Agent Resistant Coating, fuel, decontaminationsolution, oil fires Infectious Diseases– Leishmaniasis, travelers diarrhea, sandfly fever, malaria, andviscerotrophic leishmaniasis found in 12 U.S. veterans– mycoplasma fermentans (cover of Popular Science, 1999)– Travelers diarrhea (foreign bacteria affecting gut, possible side-effects Multiple vaccinations– Anthrax vaccine containing squalene as an adjuvant Depleted Uranium (as a heavy metal toxicity) Aspartame/Methonol Poisoning– At 85 F, aspartame breaks down into methanol which then breaksdown into formaldehydeIdiopathic Small Fiber Neuropathy(an example of a possible explanation) Caused by diabetes, HIV, Erythromelalgia,postherpetic neuralgia, CRPS, alcoholism, and manyother nerve pain conditions There are no known causes for most cases and mosttests do not identify it This condition may provide a path to explaining thesymptoms of the First Gulf War Veterans Autonomic Nervous System (peripheral, not somatic) Parasympathetic nervous system – less relationship Sympathetic nervous system – (relation to fibromyalgia,IBS, chronic fatigue)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Plausible biological explanations for smallnerve fiber disorderin Gulf War I Veterans Anti-cholinesterase agents (insecticides, DEET,permethryn, flea collar stories, sarin exposure,combinations, PB predisposal). Spider Bites – toxin, not infectious agent, but abiological toxin that could damage small neurons Immunological response – chronic response toinfectious agent attacking small neurons (like GuillanBarre syndrome – auto-immune) Reaction of body to severe diarrhea or agent thatcaused severe diarrhea (local fruits, vegetables givento soldiers deployed early) or could be related to localbacteria (? virus) that has property of inducingirritation of peripheral neurons – anti-body, toxinAnti-Cholinesterase Withdrawal Hypothesis Acetylcholinesterase inhibitor exposure is the factor most closelyassociated with “Gulf War Illness” Golomb 2008 – (though disputed by Blazer et al., 2008) Anti-cholinesterase agent exposure was widespread, including: Insecticides (DEET, permethryn, flea collar stories)Sarin exposure (unlikely significance since no deaths)Pyridostigmine Bromide (PB) – widely administered for monthsCombinations The reported symptoms are not typical of anti-cholinesterase effects,and PB is commonly used long term with myasthenia gravis. A potential explanation is that withdrawal from the anti-cholinesteraseagents, particularly PB, could have induced a diffuse anti-cholinergicstate, with post-synaptic production of nerve-growth factor (NGF),leading to aberrant peripheral neuron sprouting (sympatheticpredominant and all of the symptoms typically reported in First GulfWar Veterans, particularly chronic pain and GI irritability. (Like tardive dyskinesia – see in withdrawal from dopamine antagonists) Alzheimer patients withdrawn from cholinesterase inhibitors often haverapid declines and unexplained early deaths
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Tardive Sympathetic Dysautonomia (TSD) Sympathetic nervous system-predominant dysautonomia iscommon in fibromyalgia, chronic fatigue syndrome, andirritable bowel syndrome, raising the possibility that suchdysautonomia could be their common clustering underlyingpathogenesis. (Martínez-Martínez et al., "Sympatheticnervous system dysfunction in fibromyalgia, chronic fatiguesyndrome, irritable bowel syndrome, and interstitial cystitis:a review of case-control studies.". J Clin Rheumatol, 2014) Occurs late in Gulf War Veterans, usually after return– (tardive; not a dystrophy – probably an excess of connections) The Gulf War Veterans have many symptoms– usually unexplained (most have possible autonomic relationship)– (cases with a clear cause get specific treatment recommendations)NGF (nerve growth factor) NGF stimulates the outgrowth of sympathetic(norepinephrine) ganglion fibers NGF injections are related to chronic painsyndromes (seen Alzheimer’s disease subjects) NGF genetic abnormalities are associated with alack of pain sensation (Carvalho et al., 2014) Sympathetic neurons also moderate gut motilityand blood flow everywhere, including the brain,and pathways to the pineal gland moderatesleep and energy levels,
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Nerve Growth Factor (NGF) effect (Right) on sympathetic ganglionLevi-Montalcini, Booker, PNAS, 1960Levi-Montalcini won the Nobel prize for this image in 1986Autonomic Nervous System
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Chronic Pain Syndromes Chronic Regional Pain Syndrome (CRPS)(described as the most painful long-term condition)– Type 1: Reflex Sympathetic Dystrophy (RSD)– No demonstrable nerve lesions– Type 2: Causalgia– Related to specific nerve injury – presumablesympathetic nerve pathways Chronic Pervasive Pain Syndrome (CPPS)– Tardive Sympathetic Dysautonomia (TSD)– possibly NGF related – excess connections– Difficult to determine histopathologicallyPossible Treatments for Pain and otherSymptoms of Gulf War Illness Pharmacologic– Avoid narcotics, tranquilizers, central anti-cholinergics May consider opioid blocking agent – naltrexone (note recent FDA action)– Consider anti-depressants with anti-pain effects With anti-cholinergic effects: Nortriptyline, doxepin (stabilize GI symptoms) Without anti-cholinergic effects: duloxetine, bupropion (note recent FDS action) Anti-convulsant agents: gabapentin, pregabalin – Consider cholinergic agents (galantamine – short acting)– Numerous adrenergic agents – alpha, beta, etc.; melatoninNon-pharmacologic Approaches– Exercise – low-impact, non-exhausting, graded 150 minutes/weekSwimming (need more use of Masters Swimming Programs – free to Vets: www.usms.org)Aerobic exercises - elliptical exercise machinesStretching and resistance routinesNew approaches needed for pain control– CAM: Yoga, Acupuncture– Noninvasive brain stimulation (rTMS)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Primary care, GWI and VA resources Without an “expert” GWI clinic, care is still accessible in the VA– WRIISC is developing SCAN-ECHO program PCP to manage endocrine, pain, sleepSleep clinic to rule out apnea and assist in restorative sleep– Teach basic sleep hygiene principles Rehab/PT/chiropractic/acupuncture to help with pain managementand develop rehab program. MOVE would need adaptation to thelimits of the illnessCardiology for autonomic dysfunction if neededPulmonary or Cardiology for shortness of breathGI Clinic for management of IBS (irritable bowel syndrome)Dermatology for management of skin problemsEndocrine for complex endocrine management, metabolic disordersComorbid conditions management as needed– Watch for PTSD and situational depression, suicide risk.Treatment Recommendations from the 2001 IOM Report:Condition/Symptom SpecificConditionsRecommendationsChronic fatigue syndrome (CFS)Cognitive behavioral therapy (CBT) and exercisetherapiesDepressionAntidepressant medication (AD meds) andpsychotherapy (CBT or interpersonal therapy)FibromyalgiaDo NOT use opioids or glucocorticoidsMonitor results of studies on physical training,tricyclic antidepressants, and acupunctureHeadacheMedication mgmt of acute episodes, prophylacticmedication for frequent headaches that disruptfunctioning, behavioral and physical tx: relaxationtraining, EMG biofeedback, CBT, or behavioraltherapy with drug therapyIrritable bowel syndrome (IBS)CBT, tricyclic antidepressants, smooth musclerelaxantsPanic disorderAntidepressant and CBTPosttraumatic stress disorder (PTSD)Antidepressants (SSRIs, trazodone), prazosin, andCBTMedically unexplained symptoms (MUS)Develop explicit criteria for MUS, stepped intensityof-care program, monitor studies of AD meds andCBT)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Treatment Recommendationsfrom the 2013 IOM Report – Focus on CMISymptomTreatmentChronic PainNSAIDs (for acute use only), SNRIs & tricyclicmed., pregabalin for central neuropathic pain,radio freq. ablation for LBP, acupuncture forLBP and headacheFatigueCBT, graded exercise (see handout), improvesleep patterns, CPAP when needed, reducemedication usageSleep DisordersPrazosin. trazodone for PTSD-relatednightmares, good sleep hygiene, exercise,acupuncture, mind-body approachesGastrointestinal DisordersTricyclic (doxepin) or SSRI medication,relaxation and stress mgmt along with CBT orinterpersonal therapyDepressionCBT, interpersonal therapy, exercise,acupuncture for mild, antidepressants formoderate, other med or tx for severeThe WRIISC-CA program has a major focus on thediagnosis and treatment development for GWI VeteransFunded Studies:rTMS (repetitive Transcranial Magnetic Stimulation) for theTreatment of Chronic Pain in GW1 VeteransWes Ashford, Ansgar Furst, Maheen Adamson, Valerie Darcy,Allyson Rosen, David Clark, Janet BaldwinFunded VA Merit Grant (10/1/2012 - 9/30/2016)Motor Cortex Excitability after rTMS Therapy for Treatment of ChronicPain: an fMRI and TMS Study (pilot)Allyson Rosen, Gary Glover, JC Lamy, Wes AshfordFunded by: France-Stanford Center for Interdisciplinary StudiesYoga for Treatment of Chronic Pain in GWIPeter Bayley, Louise MahoneyProposed StudiesLocation versus Symptom Severity in Veterans in Service August, 1990to May, 1991, web/telephone screening, WRIISC-EvaluationJoseph Cheng, Brian Yochim, Maheen Adamson, Wes AshfordTMS (paired-pulse) and MRS of rTMS Pain Therapy ResponseAllyson Rosen, Wes Ashford, Dan Spielman
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Regions of the brain where healthy controls have higher activity than Fibromyalgia Syndromepatients during subjectively calibrated painful stimulation minus sensory stimulation.- Clusters corresponding to (A) the rACC, and (B) the pulvinar nucleus of thalamus.-The exact locations (x,y,z) are given in MNI coordinates.Jensen et al., 2009Gulf War Veterans’ Pittsburgh Sleep Quality Index declines with gray matter losstotalfrontalFreesurfer analysisL.L. Chao; BS. Mohlenhoff; M.W. Weiner; T.C. Neylan, 2014
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014rTMS(repetitive Transcranial Magnetic Stimulation)for the Treatment of ChronicPainin GW1 VeteransWes Ashford, Ansgar Furst, Maheen Adamson, Valerie Darcy,Allyson Rosen, David Clark, Janet Baldwin, Kathy KadorFunded VA Merit Grant(start 10/1/2012)rTMS and Pain Chronic pain is present in more than 90%of Gulf War I Veterans referred to WRIISC rTMS identified as a possible treatment forchronic pain VA ORD funding to study rTMS in GulfWar Veterans with chronic pain Raised awareness of chronic pain and itsmanagement via a regional providerconference
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014rTMS for the Treatment of Chronic Pain What is Transcranial Magnetic Stimulation?– It is NOT a drug!– rTMS is a method of non-invasive brainstimulation that is done on an outpatient basis– The participant is awake and alert duringtreatments that last approximately 20 minutes– rTMS is an FDA-approved treatment fordepression (focus – Right prefrontal cortex)The rTMS System
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Transcranial Magnetic Stimulation (TMS)*MagventureDiagram of simulated rTMS delivery
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014TMS Effect on Visual Analog Scale (VAS)in Fibromyalgia PatientsWorst painNo painLeft prefrontal rTMS reduces fibromyalgia pain (Short et al., Pain, 2011)TMS Effect on Visual Analog Scale (VAS)in Fibromyalgia PatientsVASTIME 6 monthsLong-term maintenance of rTMS analgesia in fibromyalgia (Mhalla et al., Pain, 2011)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Other significant symptomatic benefitsof rTMS in fibromyalgia patients: General activity Relationships with other people Enjoyment of life Morning tiredness Sleep Fatigue Walking StiffnessLong-term maintenance of rTMS analgesia in fibromyalgia (Mhalla et al., Pain, 2011)Weekly Pain Levels during rTMS treatment- Visual Analog Scale 0-10- Worst pain during prior 24 hours- * P 0.01Dall’Agnol et al., J. Pain, 2014
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014BDNF mean serum levels during rTMS treatment- Visual Analog Scale 0-10- Worst pain during prior 24 hours- * P 0.05BDNF – Brain Derived Neurotrophic FactorDall’Agnol et al., J. Pain, 2014AIM of the STUDYTo determine whether repetitive TranscranialMagnetic Stimulation (rTMS) can benefit thesymptoms of chronic pain of GWI Veterans This project will study 206 Veterans with Gulf War Illness (GWI)whose symptoms include chronic pain Veterans will be randomly assigned to treatment or sham(placebo) for the study. It is the intent of this study to determine if the newly FDAapproved treatment for depression, rTMS, may have somebenefit to Veterans with GWI and chronic pain
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Brief Pain Inventory 3) Please rate your pain by marking the one number that best describes your pain atits WORST in the past 24 hours. 4) Please rate your pain by marking the one number that best describes your pain atits LEAST in the past 24 hours. 5) Please rate your pain by marking the one number that best describes your pain onthe AVERAGE. 6) Please rate your pain by marking the one number that tells how much pain youhave RIGHT NOW.
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Treatment sessions for 4 participantsTreatmentShamTx BPI 6BPI Average Pain Scores(change from baseline) AverageWORSTLEASTAVERAGENOW 431.720.43 # Needed211521564(number needed in each group to reach p 0.05 given current trend)(NOTE: all measures favor treatment at this point)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014RTMS Subjects (2 Active, 2 Sham)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Other Outcome Measures PQSI: Pittsburgh Quality Sleep IndexFFS: Flinders Fatigue ScaleFIQ: Fibromyalgia Impact QuestionnaireISI: Insomnia Severity IndexMPQ: McGill Pain QuestionnaireHDRS: Hamilton Depression Rating ScaleOther outcome measure scores by treatment (S1-3 Sham; T1-6 Treatment)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Please Help Us Find GW1 Veterans! We are looking for Veterans deployed tothe Persian Gulf during Gulf War 1 Who have chronic pain And who can come to the VA Palo Alto for20 treatments (minimum 7 visits)– Plus visits for assessments before and afterthe treatments(Dr. Ashford will travel to give pep-talks)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Introduction to YOGA Research Project Yoga is an increasingly popular form of complementaryand alternative medicine. Current research, while limited in scope, suggests yogais “probably efficacious” for treating chronic pain. No studies have examined the benefits of yoga fortreating pain in Gulf War Illness. Evidence is needed to address questions in Gulf WarIllness about yoga efficacy, safety, duration of effect,mechanisms of action.A multimodal evaluation of the comparativeefficacy of yoga vs. a patient centered supportgroup for treating chronic pain in gulf war illnessCongressionally Directed Medical Research Programs, Department of Defense(DoD) Gulf War Illness Research Program (GWIRP) Innovative TreatmentEvaluation Award.Peter J. Bayley, Ph.D. (P.I.)Associate Director of Cognitive NeuroscienceCA WRIISC, VA Palo Alto Health Care SystemAssistant Professor (affiliated), Department of Psychiatry & BehavioralSciences, Stanford University
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014A study involving complementary medicaltreatments for chronic pain in Gulf War 1 Veterans Complementary medicine non-mainstream therapies used inconjunction with conventional medical treatment. Strong evidence that yoga is effective for some types of chronic pain No studies have examined the benefits of yoga in Veterans from thefirst Gulf War The study will compare two types of treatment for pain A yoga program designed specifically for Veterans A “pain support group” (diet, exercise, coping strategies, etc.)What is Yoga?Office of Alternative Medicine, NationalCenter for Complementary and AlternativeMedicine (OAM/NCCAM) recognizes fourCAM Domains: Mind-body medicineYogaBiologically based medicineEnergy medicineManipulative and body-based medicine
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Experimental design and proceduresN 100 (50 per group)Outcome Measures Primary– Pain (Brief Pain Inventory) Secondary–––––Quality of life (SF-36)Fatigue (6-minute walk test)Medication useMood (Profile of Mood States)Autonomic Nervous System Function Heart Rate Variability (HRV) (24 hr monitoring) Composite Autonomic Symptom Score (COMPASS)
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014Study Features Frequency & Duration: 1 day / week for 10 weeks Follow-up interviews at 18, 26, & 34 weeks Study Locations: VA Palo Alto Health Care SystemPalo Alto Division Select Community Clinics Possible Benefits Learn skills that can be used lifelong topromote health and well-being 250 compensation for completing studyFor more information please add your name tothe signup sheet
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014For More Information rTMS Study Team direct phone line– 650-852-3233 WRIISC Website– www.warrelatedillness.va.gov– Click on “Research” www.ClinicalTrials.gov– Search on “GW1 rTMS”ACKNOWLEDGEMENTS rTMS Research Team ––––––Maheen Adamson (Co-I)Ansgar Furst (C0-I)Allyson Rosen (Co-I)David Clark (Co-I)Valerie Darcy (coordinator)Janet Baldwin (research associate)Kathy Kador (research associate) WRIISC-CA Staff (VA Palo Alto -HCS)–––––––––Sandra BellLouise MahoneyStacy MoederJoseph ChengSteven ChaoKaci FairchildPeter BayleyAhmad SalehiJerome Yesavage
Appendix APresentation 4 - J. Wesson AshfordRAC-GWVI Meeting MinutesSeptember 22-23, 2014References Murphy FM, Kang H, Dalager NA, et al.: The health status of Gulf War veterans:lessons learned from the Department of Veterans Affairs Health Registry. MilMed. 164(5), 327-31 (1999).Iowa Persian Gulf Study Group: Self-reported illness and health status amongGulf War veterans. A population-based study. The Iowa Persian Gulf StudyGroup. Jama. 277(3), 238-45 (1997).Jensen KB, Kosek E, Petzke F, et al.: Evidence of dysfunctional pain inhibition inFibromyalgia reflected in rACC during provoked pain. Pain. 144(1-2), 95-100(2009).Chao LL, Mohlenhoff BS, Weiner MW, Neylan TC, Associations betweenSubjective Sleep Quality and Brain Volume in Gulf War Veterans. Sleep.37(3):445-52 (2014).Carvalho et al. A novel NGF mutation clarifies the molecular mechanism andextends the phenotypic spectrum of the HSAN5 neuropathy. J Med Genet. 2011Feb;48(2):131-5.Levi-Montalcini & Booker. Excessive growth of the sympathetic ganglia evokedby a protein isolated from mouse salivary gland. Proc Natl Acad Sci U S A. 1960;46(3):373-84.Dall'Agnol et al. Repetitive transcranial magnetic stimulation increases thecorticospinal inhibition and the brain-derived neurotrophic factor in chronicmyofascial pain syndrome: an explanatory double-blinded, randomized, shamcontrolled trial. J Pain. 2014; 15(8):845-55.Final Points Health Care is the responsibility of all Weight, smoking, diet need control The most widely recommended treatmentfor everything is exercise – and chronicpain is no exception rTMS may artificially induce exerciseeffects in the brain YOGA involves exercise Consider swimming – www.usms.org
Uranium, Sarin, Pyridostigmine Bromide, and Vaccines. July 26, 2001 Treating Symptoms and Syndromes. August 20, 2004 Gulf War and Health: Updated Literature Review of Sarin. September 12, 2006 Gulf War and Health: Volume 4. Health Effects of Serving in the Gulf War. At least 3
pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .
Short-term pain, such as when you suffer a sprained ankle, is called 'acute' pain. Long-term pain, such as back pain that persists for months or years, is called 'chronic' pain. Pain that comes and goes, like a headache, is called 'recurrent' pain. It is not unusual to have more than one sort of pain or to have pain in several places
General discussions of pain often refer simply to three types: 1) Acute (brief that subsides as healing takes place) 2) Cancer 3) Chronic non-malignant pain - "persistent pain" Classification of pain by inferred pathology: 1) Nociceptive Pain 2) Neuropathic Pain (McCaffery & Pasero, 1999) Nociceptive Pain A. Somatic Pain B. Visceral Pain
Knee Pain 1 Knee Pain 2 Knee Pain 3 Knee Pain 4 Knee Pain 5 Lateral Knee Pain Medial Knee Pain Patella Pain 1 Patella Pain 2 Shin Splint. 7 Section 6 Ankle/Foot Big Toe 89 . For additional support, wrap another tape around the last finger joint. Step 3. No stretch is applied during application. 30 Step 1 Step 2 Finger Pain. 31 Requires;
based recommendations for management of postopera-tive pain. The target audience is all clinicians who manage postoperative pain. Management of chronic pain, acute nonsurgical pain, dental pain, trauma pain, and periprocedural (nonsurgical) pain are outside the scope of this guideline. Evidence Rev
severe pain. Treatment of acute pain When assessing a patient with acute pain, the nurse should consider: The patient's report of pain or observation of pain (such as the number on a 1 to 10 scale). The patient's functional ability. The patient's level of consciousness. The site of pain and the cause.
Bockus, John Civil War 0-48 Knapp, Leonard Civil War 0-62 Bryson, Frank T. Civil War 0-6 Lampson, G. W. Civil War 0-25 Burkley, John I. Civil War 0-65A Martin, Jacob A. Civil War 0-49 Carr, Asa M. Civil War 0-39 Martin, Pembrooke Civil War 0-9A Carr, Julius Civil War 0-39 Mather, Jonathan War of 1812 0-78
Trading A-B-C Patterns . Nick Radge . Many trend trading techniques rely on a breakout of price, that is, price continuing to move in the direction of the trend with uninterrupted momentum. However, price tends to ebb and flow back and forth within the larger trend which can in turn offer up other low risk entry points that are not as recognizable as a pattern or resistance breakout. Then .
