By Danielle Aslan, DC
Chronic pain is the No. 1 cause of American adults seeking integrated care in this country. In 2016, an estimated 20.4 percent of U.S. adults (50 million) had chronic pain and 8 percent of U.S. adults (19.6 million) had high-impact chronic pain, with higher prevalence associated with advancing age.1 The Veterans Health Administration is taking a new approach to this not so new problem: a holistic view including both physical and emotional well-being. The Whole Health initiative focuses not on what is the matter with the patient, but rather what matters to the patient. Patients can experience pain or exacerbate chronic symptoms through many factors in their lives, including poor sleep, poor nutrition, increased stress and mental illness. Additionally, chronic pain is known to cause neuroplasticity changes in how a person senses pain.2 It seems only logical to help our patients in a new and innovative way that strays from traditional models of care.
The Whole Health model focuses on creating a “personalized and patient-driven experience with health care service.”3 These services include yoga and tai chi classes, which can be adapted to fit the physical needs of all patients. Additional services include mindfulness-based classes, classes focusing on diet and nutrition, as well as acupuncture treatments (both full body and battlefield), and spinal manipulation. In a recent article by Kligler, et al., clinical policy recommendations were made regarding non-pharmacological approaches to the treatment of chronic pain with all of the aforementioned treatment strategies recommended as reasonable, evidence based, non-pharmacological strategies to attack the beast that is chronic pain.4
This new healthcare initiative aims to address all factors that can affect chronic pain. I have been fortunate to participate in the Whole Health initiative during my time as resident thus far at VA St. Louis, and I am hopeful and optimistic that this new approach to health care will change the prognosis of chronic pain.
Yoga is strongly recommended for the treatment of chronic low back pain, equivalent in benefit to physical therapy and non-yoga exercise.4 Yoga is offered as part of Whole Health in the VA St. Louis system at multiple sites and is performed in a group setting. Besides the physical benefit of yoga, there is also the idea of congregation and socialization, which is important for mental health and general well-being.3 Tai chi is also a class offered in a group setting, focusing on slow, controlled movements, and has been found to have good long-term effects on chronic low back pain, as well as pain caused by osteoarthritis.4 Both yoga and tai-chi are relatively cost effective and the most common adverse effect is mild soreness. The beauty of these two interventions is that veterans can perform these activities at home once practices are learned and continue to benefit long-term.
Acupuncture is a practice that can be performed by acupuncturists, chiropractors and other physicians. In my experience, it is quite a popular topic of conversation and well-liked by many of our veterans.
“In 2015, the VHA partnered with the Department of Defense to train practitioners in an auricular protocol known as Battlefield Acupuncture for the treatment of pain. Developed by Richard C. Niemtzow, MD, PhD, MPH, this protocol has enabled rapid training of providers and improved access to acupuncture. To date, the VHA has trained more than 1700 providers in this protocol; some of the early outcomes of this deployment are presented in this issue of Medical Acupuncture.”2
Acupuncture has been found to have good long-term effect for chronic pain and is strongly recommended as a first line, non-pharmacological, low-risk, cost-effective treatment.4
Spinal manipulation is another approach frequently used in integrated healthcare systems, most often performed by a chiropractic physician. Whole Health includes chiropractic visits as a consult-based appointment, meaning it is unlike yoga and tai chi where classes are conducted on a walk-in basis. In the VA Stepped Care model, access to chiropractic services requires a consult to be placed by the patient’s primary physician. Manipulation is a passive motion introduced to the joints that may result in an audible “pop”, which is intended to introduce motion into the joints, and (ideally) reduce pain. It’s been found that spinal manipulation, especially when combined with other active care modalities like home exercise programs, is effective for treatment of acute, subacute, and chronic low back pain.5 However, the evidence is limited for other conditions, including shoulder pain and ankle sprains.4 Spinal manipulation is generally safe for patients who’ve had “red flag” conditions such as primary malignancy of the bone/metastases or visceral pathology, ruled out, and is a viable treatment option for those looking for non-pharmacological care.
Overall, the Whole Health initiative is like a light at the end of a dark tunnel: a new approach to a debilitating condition that affects a majority of our country, especially our nation’s veterans. There is much more to be learned about the nature of chronic pain and its bidirectional relationship with mental and physical health. This new healthcare initiative aims to address all factors that can affect chronic pain. I have been fortunate to participate in the Whole Health initiative during my time as resident thus far at VA St. Louis, and I am hopeful and optimistic that this new approach to health care will change the prognosis of chronic pain.
Dr. Aslan is the chiropractic resident at the VA in St. Louis, Mo. She graduated summa cum laude from University of Bridgeport College of Chiropractic in May 2018, where she was a recipient of the Chiropractic Professional Award and Student Research Award. Dr. Aslan grew up in Whitestone, N.Y., and went to Adelphi University in Garden City, N.Y. for her undergraduate degree in Biology.
- Rahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., Debar, L., . . . Helmick, C. (2018). Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR. Morbidity and Mortality Weekly Report, 67(36), 1001-1006. doi:10.15585/mmwr.mm6736a2
- Reddy, K. P., Drake, D., & Kligler, B. (2018). Acupuncture and Whole Health in the Veterans Administration. Medical Acupuncture,30(5), 225-227. doi:10.1089/acu.2018.29096.rdk
- Abrams, D. I., Dolor, R., Roberts, R., Pechura, C., Dusek, J., Amoils, S., . . . Wolever, R. Q. (2013). The BraveNet prospective observational study on integrative medicine treatment approaches for pain. BMC Complementary and Alternative Medicine,13(1). doi:10.1186/1472-6882-13-146
- Kligler, B., Bair, M. J., Banerjea, R., Debar, L., Ezeji-Okoye, S., Lisi, A., . . . Cherkin, D. C. (2018). Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain. Journal of General Internal Medicine,33(S1), 16-23. doi:10.1007/s11606-018-4323-z
- Qaseem, A., Wilt, T. J., Mclean, R. M., & Forciea, M. A. (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine,166(7), 514. doi:10.7326/m16-2367