Problem:
U.S. Army Soldiers are enduring unyielding high operational tempo in garrison and the combat field of operations in order to keep pace with ongoing wartime mission requirements. The high tempo and increasingly common multiple deployments present many human physical and psychological challenges (Military Health Advisory Team IV (MHAT-IV), 2006; MHAT-V, 2008) that have a rippling effect on soldier well-being as well as army retention and recruitment. According to seminal work by Hoge et al. (2004), an estimated 17% of active duty soldiers screened positive for deployment-related Posttraumatic Stress Disorder (PTSD) post deployment to Operation Iraqi Freedom or Operation Enduring Freedom (OIF/OEF); recent estimates (MHAT V, 2008) were suggested to be within the estimated ranges. PTSD is often complicated by other behavioral health problems including depression, alcohol and other drug (AOD) use, and suicide/suicide-related behavior (e.g., Seal, Bertenthal, Miner, Sen, & Marmar, 2007). All evidence-based treatments, including cognitive-behavioral based exposure therapies (Foa, Keane, & Friedman, 2000), Eye Movement Desensitization and Reprocessing (EMDR) therapy (e.g., Rothbaum, 1997; Shapiro, 2001), and selective serotonin reuptake inhibitors (SSRIs) (e.g., Brady et al., 2000), are only partially effective (Friedman, Keane, & Resick, 2007). The complicated presentation of PTSD may likely contribute to the finding that existing evidence-based treatments are up to 50% ineffective in treating PTSD symptoms.
Based on a review in October 2007 by the Institute of Medicine (IOM) the following was identified in current PTSD treatment studies. At the request of the Department of Veterans Affairs, the Institute of Medicine’s Committee on Treatment of Posttraumatic Stress Disorder (PTSD) undertook a systematic review of the PTSD literature. After nearly 2,800 abstracts were identified, the application of inclusion criteria narrowed thelist down to 90 randomized clinical trials, 37 pharmacotherapy studies, and 53 psychotherapy studies. The principal finding of the committee is that the scientific evidence on treatment modalities for PTSD does not reach the level of certainty that would be desired for such a common and serious condition among veterans.
Most studies included in the committee’s review were characterized by methodological limitations, some serious enough to affect confidence in the studies’ results. The committee reached a strong consensus that additional high quality research is essential for every treatment modality. The Institute of Medicine also concluded that:
Treatment of PTSD has not received the level of research activity needed to support conclusions about the potential benefits of treatment modalities. The majority of drug studies were funded by pharmaceutical manufacturers and many of the psychotherapy studies were conducted by individuals who developed the techniques or their close collaborators. It is important to know whether these treatments would show the same effect if implemented in other settings, requiring the confirmation and replication of these research results by other investigators.
Available research leaves significant gaps in assessing the efficacy of interventions in important subpopulations of veterans with PTSD, especially those with traumatic brain injury, major depression, other anxiety disorders, or substance abuse, as well as ethnic and cultural minorities, women, and older individuals.
The research on treatment of PTSD in U.S. veterans is inadequate to answer questions about interventions, settings, and lengths of treatment that are applicable in this specific population. Studies of PTSD interventions have not systematically and comprehensively addressed the needs of veterans with respect to efficacy of treatment and the comparative effectiveness of treatments in clinical use.
There is no generally accepted and used definition for recovery in PTSD; selecting appropriate outcome measures would be helpful in research on recovery. The committee was unable to reach a conclusion on the value of intervention
early in the course of PTSD based on the treatment literature it reviewed. The committee was unable to draw conclusions regarding optimal length of treatment with psychopharmacology or psychotherapy.
The solution as requested by the Virtual Off ice of Acquisition is that a screening test (PhysioSympath Resilience Scan) is readily available that can provide a baseline for veterans enlisting in the military as the basis of a blueprint (physiological assessment) and repeated throughout their enlistment timeframe. This biological blueprint would form the basis of establishing a baseline of optimal physiological functioning. With soldiers developing PTSD additional screening could be easily obtained and all ongoing treatment provide to resolve PTSD could be compared to previous baseline tests and evaluated. Once the established PTSD treatments have been completed a final screening could be provided to compare to premorbid levels prior to combat. Subsequent testing in follow up care would also provide an objective measurement to assess if PTSD therapy has been effective or needs to be reintroduced for the patient.
The scientific rationale, solution and underlying technology is as follows:
If the Central Nervous System (CNS) has two components. The Sympathetic Nervous System (SNS) and the Parasympathetic (PNS) then we can determine how each system functions and affects the physiology of an individual.
If the SNS is the arousal system and has a direct influence on the connective tissue (myofascial tissue) system of an individual then we should be able to objectively measure a normal healthy system and an affected over aroused CNS within an individual(s).
If the connective tissue system can be objectively measured in an individual than a measurement can be applied to the overall arousal level of the sympathetic nervous system allowing for a baseline objective measurement.
If the arousal of the SNS is a response of stress or ongoing stress in an individual with Posttraumatic Stress Disorder (PTSD) and we can measure its influence on the connective tissue system we can begin to quantify the amount of physiological stress that a soldier or veteran is experiencing. This provides an objective physiological measurement as opposed to trying to measure a mental state of a PTSD patient.
If we can measure the physiological stress of the fight or flight mechanism than we can create a physiological diagnostic tool (PhysioSympath Resilience Scan) to assess the effectiveness of current and developing treatment approaches being utilized for military personnel diagnosed with PTSD.
The data collected can form the basis of a pre combat, during combat test and post combat test as well as ongoing assessment of a veteran who is diagnosed with PTSD and is undergoing clinical treatment.
The human organism exhibit’s the basic evolutionary pattern of a bilaterally symmetrical form, whereby all the tissues associated with one segment are served by one pair of spinal nerves in respect of sensory, motor and autonomic innervations. The musculature associated with the segment is designated the myotome, the corresponding skin section the dermatome, the internal organs the enterotome, etc. The different tissues are connected via their segmental innervations through which each tissue component of a segment may influence, or be influenced by the others.
The concept of pain transfer was formulated by Head (1889-1896) who discovered that with diseased organs not only a direct local internal pain is felt but in addition, a projected pain in a constant skin region. Furthermore, Head discovered that the diseased organ and the skin region in which the pain was felt belonged to the same segment. The painful skin area later became known as Head’s Zone after its discoverer. The patient experiences an undefined, spontaneous burning pain in this region and/or a painful over-sensitivity or hyperalgesia (one of the primary symptoms experienced in PTSD is numbness), particularly under light contact. The segmental nature of the hyperalgesic zone is constant, although as a rule the whole dermatome is not affected, but only patches of it, which can vary in extent from individual to individual. The hyperalgesic area can easily be located by a needle or light finger contact. If the dermatome, and the segmental relationship of the associated enterotome are known, then the diseased organ can be determined from the localization of the Head’s Zone. The paired organs project the transferred pain respectively to both sides, in the single (unpaired) organs, Head’s Zones only appears on one side.
There is also scientific evidence that in the same segmentalized way hyperalgesia of the deep tissue components, such as musculature, connective tissue and periosteum etc., exists. Diseases of internal organs subsequently lead to pain projection into striated musculature, associated connective tissue etc. of the corresponding Head Zones. Pressure points can also be located, which have the same implications as the Head’s Zones (e.g. McBurney’s pressure point corresponds to the defined painful muscle component in the associated myotome, and may often be accompanied by a localized muscular rigidity in the same place). This segmental deep pain may either be spontaneous or only appear with pressure.
According to differential diagnostics, similar symptoms may also appear with the disease segmental spinal nerves, although the pain, as a rule, are then present in the whole dermatome and mostly associated with objective sensory disorders.
Knowledge of these relationships can have diagnostic implications and, for example, with diffuse upper abdominal complaints, gives an indication of which organ is affected. The projected pain may be first or only a symptom to indicate disease of an organ in a particular segment. The transferal of the pain to the left arm as in Angina Pectoralis or cardiac infarction is well known. Pancreatic diseases can give rise to transferred pain in the region of the left Thoracic 8th segment, stomach diseases, for example ulcers, are principally associated with hypersensitivity skin zones and pressure points between the Thoracic segments of 6-8, diseases of kidneys and the urethra with those of dermatome Thoracic 10-Lumbar 1.
The connection as a reciprocal relationship between myotome, dermatome enterotome etc. can be used for therapeutically testing with PTSD. Functional disorder in the associated myotome and enterotome can be positively influenced respectively by physio-therapeutic and physical-therapeutic measures on the dermatome. By application of specified stimuli of the relevant dermatome, gall bladder colic can be arrested and spasm or other functional disturbances in the enterotome alleviated. This rational can also be used as a measuring tool for homeostasis in healthy soldiers and patients with PTSD.
The underlying technology is that cost effective and objective measurement screening tools can be made readily available to assess, screen and monitor PSTD in veterans. They are being used for other medical purposes and can be readily adapted to provide objective PTSD measurements with the SNS as the target system. This testing would provide a diagnostic scan to monitor the efficacy of current PTSD treatments (e.g. Cognitive-Behavioral Based Exposure Therapies, Eye Movement Desensitization and Reprocessing Therapy and Selective Serotonin Reuptake Inhibitors) and a PTSD patient’s functional progress. PTSD therapy not demonstrating objective clinical progress could be discontinued allowing the redirection of funds for other promising therapies.
The technical maturity of this project is at a level of continuation of active research and development. This would include analytical studies, collaboration with key military PTSD healthcare providers to demonstrate, promote and validate the use of this screening tool with PTSD veterans and healthy soldiers. Due to current medical technology that has been proven to work integration of the final product could be rapidly developed with the formation and coordination of various partnerships, identifying biomedical manufacturing companies and additional technical support.
Measured performance characteristics, reliability and validity studies would be the next ongoing phase of deployment of a PhysioSympath Resilience Scan. Maturation and testing could be feasibly accomplished within a 10-12 month timeframe based on dedicated resources and collaboration with PTSD medical personnel and facilities.
Initial funding being sought is to create a theoretical framework, create the necessary medical infrastructure, present the theoretical concept to key VA medical and military personnel and establish a high level of credibility and understanding about a new diagnostic tool for assessing and monitoring PTSD veterans and potential soldiers showing initial symptomatology.
This research can be accomplished in a 6-8 month timeframe. Initial funding was initially to be obtained through the DoD Defense Medical and Development Program Basic Research Grant (W81XWH-10-DMRDP-BRA).
This is the first phase. The screening of soldiers/veterans with and without PTSD. The second phase that would be initiated with substantial funding is the development of conceptualized treatment approaches and the integration of therapeutic modalities which are in the technology readiness level to be initiated.
As a chronic pain health care provider for the past 20 years treating patients with PTSD a member of the IOM and other medical affiliations I have the clinical expertise of having provided over 76,000 treatments to over 14,000 patients. As an expert witness for PTSD patients I have the scientific training and background to implement these concepts and provide the VA system and military with advancing their objectives of improving care to soldiers diagnosed with PTSD.
Neurophysiotherapy treatments with evidence based functional outcomes need to be utilized prior to psychological care. The scientific and clinical evidence to be pursued advances the VA’s Office of Acquisition problem of “ Perform Research and Development to Enhance the Long-Term Health and Well-Being of Veterans”.
To improve clinical outcome PTSD treatment an objective measuring tool needs to be implemented to create baseline assessments, provide measurable data during ongoing treatment and assist in discharge planning. The second phase is to implement therapeutic modalities and treatments utilizing neurophysiology therapy to address the derailment of the sympathetic nervous system. In principle all humans are born with the same blue print. It is during combat experiences involving trauma that the psycho-socio-somatic fields are altered and cause derailment of the sympathetic nervous system. Long standing depletion of the SNS remains and is not being adequately treated with current PTSD treatment approaches. This supports current findings of the IOM finding that evidence-based treatments are up to 50% ineffective in treating PTSD symptoms. The clinical solution is to address the dysfunction of the SNS not the symptoms associated with PTSD.
Gary J. Maguire, PT, MSPT: Physical Therapist (C)
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