This document provides an overview of day 2 of a course on integrating whole health approaches for pain and suffering. The day includes sessions on integrative health and whole health in practice, as well as mind-body skills training. Specific mind-body skills covered are diaphragmatic breathing, progressive muscle relaxation, autogenic training, guided imagery, and biofeedback training. The benefits of these skills for reducing pain and stress are discussed. Manual therapies like chiropractic, osteopathic medicine, massage, and physical therapy are presented as professional care approaches. Complementary therapies like acupuncture are also explored, including evidence for their effectiveness in treating low back pain and other conditions.

1. Whole Health for Pain
and Suffering
An Integrative Approach
Day 2
Welcome back!

2. Add Subtitle
A Moment to Arrive
Photo: Adam Rindfleisch

3. About This Course:
What are we trying to accomplish?
1. Untangle the web of chronic pain
2. Use the Whole Health model to individualize the pain
and suffering experience
3. Gain exposure to non-pharmacologic approaches to
pain care using Whole Health
4. Develop a common language in caring for Veterans
with chronic pain and suffering
5. Network: employ the wisdom of the group

4. AM–Integrative Health:
Expanding Possibilities
PM–Whole Health in
Practice: Your Therapeutic
Stance
Photo: Adam Rindfleisch
For Today – The Path Ahead

5. PREVENTION & TREATMENT
CONVENTIONAL & COMPLEMENTARY
APPROACHES

6. Whole Health for Pain and Suffering
7. Mind-Body Skills I

7. Mind-Body Skills I
“The natural healing force
within each of us is the
greatest force in getting
well.”
—Hippocrates

8. Institute for Clinical Systems Improvement (ICSI) (57 Groups)
http://www.jfponline.com/Pages.asp?AID=7004&issue=December_2008&UID=29828

9. It All Starts with the Relaxation Response
• Term coined by Herbert Benson, MD,
a cardiologist
• The autonomic nervous system has 2
branches
– Sympathetic (fight/flight)
– Parasympathetic (feed/breed)
“Most mind-body exercises have the
parasympathetic activation and other
physiological changes as a common
endpoint.”
• The key is, which approach will best
fit any given individual?

10. The Relaxation Response

11. Relaxation Therapies
• The National Institutes of Health (NIH) states
that evidence is strong for the effectiveness of
relaxation therapies in reducing chronic pain
in a variety of medical conditions.
• Relaxation training attempts to break the
pain–muscle tension–pain cycle and helps
lower stress levels.
Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia, NIH, 1995.

12. Diaphragmatic Breathing:
Breathing Slower and Lower
• Deep breathing from
the abdomen
• Lowers SNS arousal
• Easily learned by
patients
• Effective during acute
pain flares and stress

13. 1:2 Ratio Breath 6 Breaths per Minute

14. 4-7-8 Breath 3 Breaths per Minute
7 counts

15. 6 Breaths per Minute
• Recited:
Ave Maria or the Yoga mantra:
“om-mani-padme-om”
• Breathing rate slowed to 6
breaths/min with enhanced heart
rate variability and baroreceptor
sensitivity.
BMJ 2001;323:1446-1449

16. Cognitive Behavioral Therapy
• The most widely used psychotherapeutic treatment for adults with
chronic pain, secondary depression and anxiety.
Akerblom S, et al., The Journal of Pain. 2015; 16(7): 606-615.

17. • Session 1: Interview and Assessment
• Session 2: Treatment Orientation
• Session 3: Assessment Feedback and Goal Setting
• Session 4: Exercise and Pacing
• Session 5: Relaxation Training
• Session 6-7: Pleasant Activities
• Session 8-9: Cognitive Coping
• Session 10: Sleep
• Session 11: Discharge Planning
• Session 12: Booster Session
Cognitive Behavioral Therapy for Chronic Pain (CBT-CP)

18. Beliefs and Pain
• Catastrophizing: to expect the worst to happen or to worry
about major negative consequences
– associated with poorer outcomes, more psychological distress, increased
pain levels and perceived disability
– high levels of catastrophizing are at increased risk for prescription opioid
misuse
• Perceived lack of ability to have control of pain (helplessness)
– associated with poorer outcomes, less physical functioning, higher pain
levels and more disability

19. Common Automatic Pain Thoughts
• I have no control over my pain.
• I need a medical solution to ongoing pain. There is nothing I can do to
change it.
• My life is over if I’m in pain.
• Because I can’t do what I did before, I’m not okay.
• What if my doctor abandons me?
• I’m weak because I have pain.
• My pain will get worse and worse.
• If I can’t do it the way I did it before, there is no point in doing it.
• I should have gotten better before this.
• I’m headed for a lifetime of pain.
• This should have never happened to me.

20. Cognitive Restructuring: ABCD Model
A. Activating Event
Pain Flare
B. Automatic Belief or Negative Thought
“I must be doing more damage to my body.”
C. Consequence or Emotional Response to Negative Thought
Fear, Depression, Resentment
D. Dispute Negative Thoughts
“This pain will subside.”
“This pain is normal.”
“This pain does not mean more damage to my body.”

21. Behavioral Activation and Pacing
Not Pacing Pacing
Prolonged
Rest
Overactivity
Extreme
Pain
Moderate
Activity
Limited
Rest
The Activity-Rest Cycle in Chronic Pain (Gil, Ross, & Keefe, 1988)

22. Acceptance and Commitment Therapy
• Fosters acceptance of pain
• Disengagement from the struggle
with pain
• Grieving loss of a pain free life
• Re-engagement in activity without
trying to avoid, restrict or control
pain
• Adopt a “new normal”
• Value-based actions that increase
a sense of meaning and purpose
in life despite the pain condition
Watermarkpsych.com

23. Meditation and Chronic Pain
Some studies show improved
• Pain intensity
• Disability scores
• Need for medications
• Sleep
Other Findings
• Reduced IBS symptoms in a
Veteran population
• Improvement in fibromyalgia
symptoms
Photo: Adam Rindfleisch, MD
Chiesa, A. and Serretti, A. The Journal of Alternative and Complementary Medicine. 2011. 17(1): 83-93.

24. Mindful Awareness Practice
Between stimulus
and response,
there is a space. In
that space is our
power to choose
our response. In
our response lies
our growth and
our freedom. -
- Victor Frankl MD
Photo credit: HckySo via Foter.com

25. Mindful Awareness Practice
• What distractions arose and what brought you back?
• What was it like to just observe your sensations, thoughts or
emotions without judgment or needing to react?
• Where would this benefit you during your day?
Practice for
a short time,
multiple times
during your day.

26. Whole Health for Pain and Suffering
8. Integrative Modalities
for Pain

27. Adam page 51

28. Medicare $ for LBP Treatment (10 years)
•  in epidural steroid injections by 629%
•  in opioid expenditures by 423%
•  in lumbar MRI by 307%
•  in spinal fusion rate by 220%
Deyo RA et al, J Am Board Fam Med, 2009;22(1):62-8.

29. Spinal Pain: How We’re Doing
“Expenditures on pain increased 82% from 1997 to
2006…Paradoxically, mental health and physical
functioning worsened for patients with spinal pain.”
Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures,
utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa
1976). Sep 1 2009;34(19):2077-2084

30. Why Do We Use Complementary Therapies?

31. Spinal Pain: The Treatment Gap
Analgesics
Adjunctive meds
Physical Therapy
?
Injections
Surgery

32. As you think about the circle, what would you
consider for a health plan for Adam?

33. “…moderate evidence for long term reduction of LBP
and …disability after yoga interventions.”
Cramer H et al, Clin J Pain, 2013;29:450-60.

34. -All studies favored yoga intervention
-Higher quality studies had greater magnitude of benefit
Bussing A et al, J Pain, 2012;13(1):1-9.

35. Strong evidence:
• Moderate effect on pain
relief
• Mild improvement in
functional status
Behavioral therapies
in chronic LBP

36. What professional care approaches do you
recommend for Adam?

37. Manual Therapies
• Chiropractic
• Osteopathic Medicine
• Massage
• Physical Therapy

38. Terms
• Spinal Manipulation:
– High velocity, low amplitude force on spinal segments (HVLA)
• Mobilization:
– Non-thrust manual therapies
– Many techniques fall in this category: muscle energy,
counterstrain, myofascial techniques

39. Osteopathic Medicine
1. The body is a unit of body, mind, and
spirit.
2. The body is capable of self-regulation,
self-healing, and health maintenance.
3. Structure and function are reciprocally
interrelated.
4. Rational treatment is based upon an
understanding of these basic principles

40. Techniques
• Counterstrain
• Facilitated positional release
• Myofascial release
• Muscle energy
• HVLA (thrust)

41. Spinal Manipulation: Proposed Mechanisms
• Gapping of facet joints
• Improved joint ROM
• Activation of spinal stretch reflexed

42. Spinal Manipulation for CLBP

43. Spinal manipulation for
CLBP, 2011
• Comparable results to other
therapies, such as exercise
therapy and PT
Rubinstein S et al, Cochrane Database, 2011; CD008112.

44. Manipulation for Neck Pain,
2015
• Thoracic manipulation may
be beneficial for neck pain
• Little evidence for cervical
manipulation compared with
control therapies
Gross A et al, Cochrane Database, 2015; CD004249.

45. Massage Therapy
Massage for LBP – a 2008 review
– Effective
• Moderate evidence of short and longer term
effectiveness
• Effectiveness improved when combined with
exercise and education
Mountainpeaksvet.com
Imamura M et al, Spine J, 2008;8(1):121-3.

46. Acupuncture: Principles and Practice

47. What is Acupuncture?
Needling points on the body
to relieve pain and encourage healing

49. Acupuncture
Sir William Osler: “For lumbago
acupuncture is, in acute cases, the
most efficient treatment.”
–Principles and Practice of Medicine,
1892

50. Acupuncture “Physiology”
Yin Yang
Qi Meridians

51. Beyond Qi
• Endogenous opioid system
• Central serotonergic system
• Gate control theory
• Viscerosomatic reflexes
• Neuropeptide and hormone release peripherally

52. So How Does Acupuncture Work?
• Acts at local, spinal cord and cortical levels
• Affects nervous, circulatory, lymphatic and
immune systems
• But…treatment effect lasts longer than the half-
life of endorphins and most neuropeptides… Qi?

53. A Hybrid Approach
• Utilize understanding of anatomy:
– Trigger points
– Stimulate specific spinal levels or nerves
• Take advantage of traditional acupuncture point
functions

54. An Acupuncture Treatment
• Anywhere from a few needles to 20ish
• Needles very thin, smaller than 30 gauge and no
beveled tip
• Needles either left alone, heated or attached to electrical
stimulator
• Typically lasts 30-40 minutes
• Expect some results with chronic problems within 3-5
treatments, less with acute problems

55. Does It Work?

56. Acupuncture Studies
Acupuncture in chronic
neck pain, 2016 review:
“…moderate quality
evidence that acupuncture
effective with short term
follow up.”
Trinh K et al, Cochrane Database, 2016;5: CD004870.

57. Acupuncture Studies
61

58. Yuan J et al, Spine, 2009;24(7):752-3

59. Acupuncture Studies
Conclusion:
“Acupuncture is effective for the treatment of chronic pain…”
Vickers AJ et al; Arch Intern Med, 2012;172(19):1444-53

60. Additional Advantages of Acupuncture
• Can work away from the site of pain
• Low risk
• Helps with co-existing symptoms

61. The Use of Acupuncture in the Military
Excerpt from the Movie “Escape Fire”
Find movie excerpt at:
https://www.youtube.com/watch?v=XNVHPWjSw1s

62. The Use of Acupuncture in the Military
Excerpt from the Movie “Escape Fire”

63. Introduction to Battlefield Acupuncture

64. Battlefield Acupuncture
• Designed by
Richard Niemtzow, MD
• Original study published in
2007
• Based on work from French
physician from 1950s

65. Auricular Acupuncture

66. Battlefield Acupuncture
Sequential needling of 5 auricular
acupuncture points:
1) Cingulate Gyrus
2) Thalamus
3) Omega 2
4) Point Zero
5) Shen Men

67. Acupuncture and BFA Resources
• OPCC&CT SharePoint Site on Acupuncture:
https://vaww.infoshare.va.gov/sites/OPCC/Shared%20Docum
ents/Forms/AllItems.aspx?RootFolder=/sites/OPCC/Shared%2
0Documents/Acupuncture
• OPCC&CT SharePoint Site on BFA:
https://vaww.infoshare.va.gov/sites/OPCC/Shared%20Docum
ents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FOPCC%2F
Shared%20Documents%2FAcupuncture%2FBattlefield%20Acu
puncture%20Resources&FolderCTID=0x01200092D5EAC2534
79641B8D0A20FE4165E94&View=%7B4AD754A9%2D57D5%2
D4A13%2DA317%2DD62DAB4881EB%7D
-See BFA field guide and other key information
• Inquiries also may be directed to: VHABFASupport@va.gov

68. 73

69. 74

70. Movement
Break!

71. Take a
Break!

72. Whole Health for Pain and Suffering
9. Mind-Body Skills II

73. “The only
freedom any of
us really has is
the freedom to
choose how we
respond.”
– Victor Frankl
Photo credit: MICOLO J Thanx 4, 2.2 million+ views via Foter.

74. Progressive Muscle Relaxation
• Alternately tensing and releasing major muscle groups in a
systematic fashion
• Differentiate feelings of tension from relaxation, and apply
these skills in stressful situations
• Especially effective for tension and migraine headaches and
insomnia. May be helpful for general body pain and specific
muscular skeletal pain
Carlson CR, Hoyle RH. J. Consult. Clin. Psychol. Dec 1993;61(6):1059-1067.

75. Autogenic Training
• A form of self-hypnosis where the patient listens
and repeats phrases that suggest relaxation in the
body
– “My right arm is heavy.”
– “My legs are warm.”
– “My mind is calm.”
• Especially effective for general body pain, specific
muscular skeletal pain, tension/migraine headaches
Stetter F, Kupper S. Appl. Psychophysiol. Biofeedback. Mar 2002;27(1):45-98.

76. Guided-Imagery Relaxation
• Individually tailored sensory images (often with music)
• Images can distract from pain, induce relaxation and improve stress coping
• Used to modulate images of pain and discomfort
– e.g., substitute warmth of coolness for sensations of pain
Photos: D. Kopacz

77. Guided Imagery: Benefits
Research demonstrated that imagery can impact almost all
major physiologic control systems of the body, including:
– respiration
– heart rate
– blood pressure
– metabolic rates
– gastrointestinal motility and secretion
– cortisol levels
– blood lipids
– immune responsiveness
– depression and anxiety levels
Trakhtenberg EC. Int. J. Neurosci. Jun 2008;118(6):839-855.
Academy for Guided Imagery. Academy for Guided Imagery website.
Available at: http://www.acadgi.com.

78. Biofeedback Training
The technique of making
unconscious or involuntary
physiologic processes (such as
heartbeats, brain waves, muscle
tension, skin temperature, etc.)
perceptible to the senses either
visual or auditory in order to
manipulate them by conscious
control

79. Types of Biofeedback
• Electromyography (EMG)
• Thermal
• EEG Neurofeedback
• Electrodermal
• Pneumograph
• Heart rate variability

80. Biofeedback Efficacy
• Neck pain
• Back pain
• Muscular skeletal pain
• Computer-related syndromes
• Head pain (cluster, tension, migraine)
• TMJ
• Pelvic pain
• Incontinence (fecal, urinary)
• Paralysis - stroke, cerebral palsy
• Arthritis
• HTN (FDA approved Resperate)
• Depression, anxiety, panic, stress
• Raynaud’s
• ADHD
• COPD, Asthma
• Seizures
Moss et al, Europa Medicophysica. 2003 39(4). 165-170.

81. Heart Rate Variability

82. Emotions and Heart Rhythm
McCraty R. Bioelectromagnetic Interactions Within and Between People. HeartMath Research Center.

83. Biofeedback as Coping Skill
Stress Thermometer (Biomedical) Em Wave 2 (HeartMath)

84. Applying This to Your Practice
• How might you integrate
relaxation in your daily life?
• How can you integrate
stress awareness and
relaxation in your clinical
interactions?
Dailyheal.com

85. Clinical Hypnosis
• “A trance-like state” of inner
absorption, concentration and
focused attention
• Uses suggestion and imagery to
create changes in sensations,
perceptions, thoughts, feelings, and
behaviors
• Dissociation techniques most notably
for acute pain relief
• Alter the perception and mental
structure of pain
• Most useful when instructed in a self-
hypnosis format Photo credit: trishhartmann via Foter.com
Gurgevich S. Self-hypnosis techniques. Philadelphia, PA: Saunders Elsevier; 2007.

86. Journaling: Benefits to Health
Journaling 3x a week can:
• Enhance immune function
• Reduce:
– Physician visits for illness
– Post-surgery days in hospital
– Alcohol consumption
– Emergency department visits
– Medication use in pain/asthma
Baikie KA, Wilhelm K. Advances in psychiatric treatment.
2005;11(5):338-346.

87. Therapeutic Journaling Protocol
Writing topic. An emotionally upsetting event
that is bothering you. If you have faced a
massive trauma, it is best not to write about it
for several weeks afterwards,
Length and frequency. Write for 15-20
minutes each day for four consecutive days if
you can.
Write continuously. Don’t worry about
spelling or grammar. If you run out of things
to say, simply repeat what you have already
written.
Considerations. If, after several sessions, you
feel you are not making progress or you
experience strong feelings that you cannot
cope with then you might need to stop and
contact a health care practitioner. Photo credit: urbanworkbench
Pennebaker JW. Psychol. Sci. 1997;8(3):162-166.

88. The Benefits of Nature Psychological:
• Higher happiness &
satisfaction
• Higher vitality & meaning in life
Cognitive:
• Improved memory & attention
Health:
• Faster recovery post-surgery
Community:
• Lower crime and violence rates
Pembrokeshire, Wales, D. Kopacz

89. Music Therapy
• 2015 review of 50 studies – high risk of bias, but half
found less anxiety and 36% less pain in people
undergoing procedures
Yinger et al. J music Ther, 2015;52(1):1-77.
• Helped with abdominal pain post surgery – pain intensity
and distress
– “…safe, inexpensive and easily used”
Vaajoki et al. J Clin Nurs 2012;21(5-6):708-17.
• 2014 systematic review – results for 17 studies
supported music as “…an adjuvant approach to pain
control in hospitalized adults.”
Cole L et al, Pain Manag Nurs, 2014;15(10:406-25.

90. Time to Pause and Create
• You have the answers
• This is time to put them into action
Pause
Be Present Proceed
Towards
Whole
Health

91. Whole Health for Pain and Suffering
10. Whole Health in
Action

92. A Whole Health visit
• We are interviewing “Adam”
• This is a new patient visit
• He completed the brief PHI prior to
the visit
–PHI on page 52

93. Lunch!

94. Whole Health for Pain and Suffering
11. Headache

95. Mike
• 33 y.o. OIF Veteran
• Long hx of migraines, tension
headaches
– 1-2 weekly
• Multiple meds tried – hates the
side effects
• Wonders about other approaches
– Acupuncture?
– Mind-body?
• Poor diet and weight gain
• Limited activity
• Sees psychiatrist and counselor
for PTSD
Blog.handmadebyheroes.com

96. Your Turn!
• At your table:
– 1 person will be Mike, page 60 PHI & page 67 PHP
– 1 person will take notes (will share with larger group)
• Co-create a Personal Health Plan (PHP)
– Up to 3 main recommendations
– 1 SMART Goal
• Sample PHP Template, page 29

97. Headaches: The Facts
• Migraine and tension headaches are the
2nd and 3rd most common condition known
to humanity
– 11% of people have MHA
– 98% of humans have at least one
• Headaches are a systemic condition
– Hypervigilance
– Nervous system hypersensitivity
– Multiple contributing factors: anything
that stresses the system contributes
• Genetics
• Lifestyle, diet, stress
– Rarely will a solitary intervention do the
trick
Horsesmouth.typepad.com

98. What is often not recognized is that the most
important treatment may not be the resolution of an
individual migraine attack, but stabilizing the
migrainous nervous system, increasing the
resilience, allowing it to tolerate environmental
changes better… The mutual goal is strengthening
the sensitive nervous system so that it is more
tolerant of change. The role of the provider is to
prepare a plan that the patient can visualize,
understand, and engage as an active participant.
-DM Ready in Integrative Pain Management
R Bonakdar (ed), New York, Oxford University Press, 2016.

99. Headache Threshold
Comorbidities
Stress
Fatigue
Body Chemistry
Genetics Migraine
When it all adds up
above a certain
threshold, the body
moves into a
headache state.

100. How do we decrease
the chance of
overfilling?
Comorbidities
Stress
Fatigue
Body Chemistry
Genetics
Migraine

101. All the Information in this Module Is from…
Ch 41, Integrative HA
Management, by Ready
Module 27, Headache
Educational Overview, by
Bauman
Chapter 10, Headache, Mann
and Coeytaux

102. Around the Circle
• Me at the Center
– What is their HA story?
• Genetics
• Traumas (e.g., TBI)
• Mindful Awareness
– What triggers?
– What helps?
– How to break the cycle?
– Headache diary
• Food effects can be
delayed >24 hours

103. Food & Drink
• Don’t skip meals!
• Obesity increases migraines
• Caffeine and caffeine withdrawal can
cause
• Hydration can help

104. Elimination Diets (EDs)
(General ED Guide), (HA ED Guide)
• 8-20% of MHA sufferers
have diet triggers
• Often more than 1
• Review the list of 12
culprits in the HA ED
Guide
• Always think about
aspartame (Nutrasweet)
• Don’t underestimate
gluten

105. Working Your Body
• Exercise can be a trigger
– If so, take a fibromyalgia route
– Just a few minutes daily
• If not a trigger, 30 minutes
three times a week can lower
intensity (data on frequency
unclear so far)
• PT not so helpful on its own,
good with biofeedback

106. Power of the Mind
• Biofeedback has strong evidence
– 10 minutes daily of abdominal
breathing with thermal sensor
• E.g., Biodots!
• Relaxation training helps
– Progressive Muscle Relaxation
– Breathing
– Guided Imagery
– Comparable to medications
• Self-hypnosis can lower frequency
and intensity and be abortive too
• Cognitive Behavioral Therapy also
with solid evidence
• Music therapy helps in kids
• Meditation – small trials show
reduced intensity and better sleep
Brotherword.org

107. Recharge
• Good sleep hygiene decreases
MHA frequency
• Snoring, OSA, and other sleep
problems increase HA
• Melatonin can be helpful for
many

108. Personal Development
• Education about HA
makes a huge difference
– Quality of life
– Adherence
– Self-efficacy
– Less disability
– Less healthcare
spending
• The key is to take time –
most people prefer
detailed explanations

109. The Other Three Green Ones
• Surroundings
– Watch triggers: noise at work, fumes, lighting levels,
dust, temperature, noise
• For Spirit & Soul and Family, Friends & Coworkers, all
the same principles you have heard before apply
Mdjunction.com

110. Professional Care
• Don’t forget about Medication Overuse HA
– Noted first in 1950s with ergotamine
– Involves most meds
• Triptans after 1.7 years, 15
pills/month
• Ergotamines 2.7 years, 37 pills/month
• Analgesics 4.8 years, 114 pills/month
– Stop cold turkey
– <10 pills per month a good rule of thumb
Walter TR, J Pain Palliat Care Pharmacother, 2016;30(1):66-8.

111. Supplements
• Magnesium: 600mg/day
• Vit B2: 400mg/day
• CoQ10: 100-200mg/day
• Omega 3s: 2g/day EPA + DHA
• Feverfew: 25mg BID
• Butterbur: 75mg BID
Walter TR, J Pain Palliat Care Pharmacother, 2016;30(1):66-8.

112. Professional Care
1. Mind-body medicine – see Power of the Mind
2. Biologically-based approaches
– For supplements for HA, see the headache materials in the
Whole Health Library
3. Manipulative and body-based therapies
– Craniosacral therapy seems effective, small trials
– Massage seeming benefit
• Energy medicine (Biofield therapies) – promising
1. Whole systems of medicine
– Strongly consider acupuncture
– Recent 2016 Cochrane review very supportive
Linde K, et al, Cochrane Database 2016;6:CD001218.

113. Whole Health for Pain and Suffering
12. It Starts with Me,
It’s Completed with Us

114. Layers of Whole Health
Patient
Care System
Facility
Clinic/Service
Communication, Clinician Self-Care, Innovation, Collaboration

115. VHA STATE-OF-THE-ART CHRONIC
MUSCULOSKELETAL NON-PHARM PAIN CARE
• Journal of General Internal Medicine 2018
• VHA Health Services Research and Development SOTA conference
2016
• Collaboration with DOD, NIH, private sector, academia
Workgroup recommendations
• 1.Deliver pain treatment in a team–based multimodal setting early on
• 2. Promote self-care and an activation component
• 3. Effective modalities include CBT, ACT, MBSR, Exercise, Yoga, Tai Chi,
Aquatic Exercise, Manipulation/Manual Therapy, Acupuncture,
Massage Therapy
• 4. Multimodal stepped care model with care manager, technology
Barriers include cost, time, silos, Veteran engagement, access, clinician
education

116. Discussion Topics: The Team
• How do you help a Veteran define his/her team?
• Who would you want on that team?
– Health Coaches?
– Peer Partners?
– Community practitioners/partners?
– Role of pharmacy?
– Role of mental health?
– Role of primary care PACT?

117. Whole Health for Pain and Suffering
13. Panel Discussion:
Using the Circle In Your
Practice

118. Questions?
124

119. Whole Health for Pain and Suffering
14. Whole Health for Pain
in Your Practice

120. Putting It All Together: Where to From Here?
What does a
Whole
Health
practice for
pain look
like?
Photo: Adam Rindfleisch

121. Layers of Whole Health
Patient
Care System
Facility
Clinic/Service
Communication, Clinician Self-Care, Innovation, Collaboration

122. Assets and Challenges
• What challenges do you
face?
• What are your guiding
principles?
• What keeps you on target?
• What are your assets?
• What do you need to
succeed?

123. Whole Health for
Pain and Suffering
Resources

124. Resources—Summary
VA Patient Centered Care (External–OPCC&CT resources
for Veterans & family members)
http://www.va.gov/patientcenteredcare/
OPCC&CT SharePoint Hub (Internal–OPCC&CT SharePoint)
https://vaww.infoshare.va.gov/sites/OPCC/Pages/Default.aspx
Education Hub:
https://vaww.infoshare.va.gov/sites/OPCC/Education/SitePages/Home.aspx
Whole Health Library
http://projects.hsl.wisc.edu/SERVICE
130
page 7

125. Resources – Summary (cont’d)
131
Integrative Health Coordinating Center (IHCC)
• IHCC Email
vhaopcctintegrativehealth@va.gov
• IHCC SharePoint Page
http://vaww.infoshare.va.gov/sites/OPCC/sitePages/IHCC-
home.aspx
FIT SharePoint Page
http://vaww.infoshare.va.gov/sites/OPCC/SitePages/FIT-
programs.aspx
• FIT CIH Specialty Team Email (FIT CIH engagements available)
VHAOPCCCTCIHSpecialtyTeam@va.gov

126. Whole Health Community of Practice Call
132
• First Thursday, 2 pm ET
https://vaww.infoshare.va.gov/sites/OPCC/COP/WholeHealth-
ContinueTheConversation/SitePages/Home.aspx
• For other COP call info, see link on OPCC&CT
SharePoint Education Hub.
https://vaww.infoshare.va.gov/sites/OPCC/Education/SitePag
es/Home.aspx

127. VA Pulse – Whole Health Community
133
1. OPCC&CT in general
https://www.vapulse.net/community/focus-areas/opcc
2. Integrative Health
https://www.vapulse.net/groups/integrative-health-community
3. Acupuncture and BFA
https://www.vapulse.net/groups/va-bfa-community
4. Others

128. 134

129. VA Pain Resources
• PACT Pain Roadmap
https://www.vapulse.net/groups/guidance-and-
roadmap-initiative/projects/pact-roadmap-for-
managing-pain
• VHA Pain Management Resources
http://www.va.gov/painmanagement/
• Defense & Veterans Center For Integrative Pain
Management (DVCIPM)
http://www.dvcipm.org
• Community of Practice Calls Specific to Pain
– Pain PACT Community of Practice Call
– Spotlight on Pain Management

130. Complete the “Strategies for Implementation”
Worksheet
136
page 77