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Research-Program Evaluation Report(November 1, 2019 – January 10, 2020)
Alternative Treatment Options for VeteransFlorida Department of Veterans’ Affairs, Grant #12503
Date of Submission: January 10, 2020
Submitted by: Kevin E. Kip, Ph.D., FAAAS, FAHADistinguished USF Health ProfessorCollege of Public Health, Population Health SciencesUniversity of South Florida13201 Bruce B. Downs Blvd., CPH, Room 2108Tampa, FL 33612-3805813-974-9266 (phone)[email protected]
Submitted to: Nicholas ScireFlorida Department of Veterans’ AffairsMary Grizzle BLDG, Room 311-K11351 Ulmerton RoadLargo, FL 33778-1630
Prepared by: Kevin E. Kip, Ph.D., FAAAS, FAHADistinguished USF Health ProfessorCollege of Public Health, Population Health SciencesUniversity of South Florida13201 Bruce B. Downs Blvd., CPH, Room 2108Tampa, FL 33612-3805813-974-9266 (phone)[email protected]
Page 1 of 36
TABLE OF CONTENTS
SECTION TITLE PAGE
1.0 Introduction 3
2.0 Program Evaluation/Performance Task Results 6
2.1 Development of the Project Website 6
2.2 Initial Literature Review on the 5 Alternative Treatment Modalities 6
2.3 Interim Analyses of Participating Organizations and Program Evaluation 21
Data Collected to Date
2.4 Estimated Return on Investment (ROI) 34
Appendix 1. Review of Controlled Trials of HBOT for Persons with 16
Post Concussive Symptoms and Mild TBI
Page 2 of 36
1.0 INTRODUCTION
This report provides a summary of performance for the project entitled “Alternative Treatment
Options for Veterans” during the period November 1, 2019 through January 10, 2020. As
background, The University of South Florida, College of Public Health (USF-COPH) is tasked,
in accordance with Florida Senate Bill 1518 and the Florida Department of Veterans’ Affairs
(FDVA), with evaluating “alternative” treatment options and related assessment data that are
currently being provided to and collected among Veterans in Florida through a range of non-
profit community-based organizations. The five alternative treatment options that are being
provided to Florida Veterans in the community, and are the subject of this evaluation project,
include: (i) Accelerated Resolution Therapy (ART); (ii) Equine Therapy; (iii) Service Animal
Training Therapy; (iv) Music Therapy; and (v) Hyperbaric Oxygen Therapy (HBOT). A brief
description of each alternative treatment option is provided below.
Per the terms of the contract between FDVA and USF-COPH, the evaluation of alternative
treatment options for Florida Veterans is restricted to the following conditions:
Participants included in the assessment must be a U.S. Veteran who has had a prior
diagnosis, by a health care practitioner, of service-connected Post-Traumatic Stress
Disorder (PTSD) and/or Traumatic Brain Injury (TBI).
Participants must have previously sought services for PTSD and/or TBI (does not need to
have been through the Veterans Administration).
A central component of the project is development and implementation of a rigorous,
standardized program evaluation system to be used in the evaluation of all five alternative
treatment options. For all Veterans who receive alternative treatment options and are evaluated for
program effectiveness, the schedule for evaluation is as follows:
Accelerated Resolution Therapy (ART):
Before receipt of services, immediately after receipt of services, and at 1, 3, and 6-month
follow-up
Page 3 of 36
Equine Therapy:
Before receipt of services, immediately after receipt of services, and at 1, 3, and 6-month
follow-up
Service Animal Training Therapy:
Before receipt of services at 4 times as listed below, and then at 1, 3, and 6-months
follow-up after integration with the service dog
At the time of pre-approval application submission
At the time of being approved for receipt of a service dog
At the time when a service dog has been located and matched for the Veteran
At the time of initial home integration with the service dog
Music Therapy:
Before receipt of services, immediately after receipt of services, and at 1, 3, and 6-month
follow-up
Hyperbaric Oxygen Therapy (HBOT):
Before receipt of services, after 20 treatment HBOT sessions (mid treatment),
immediately after receipt of services (40 HBOT sessions), and at 1, 3, and 6-month
follow-up
Measures of health status of veterans include mental health, physical health, and substance and
prescription medication use. A brief listing of these measures, which will be completed by
Veterans before receipt of services, after receipt of services, and at 1, 3, and 6-month follow-up
is provided below.
Perceived stress - Perceived Stress Scale (PSS)
PTSD symptoms - PTSD Checklist (PCL-5)
Anxiety, depression, and somatization - Brief Symptom Inventory (BSI-18)
Sleep quality - Insomnia and Sleep Quality Index
Resiliency - Connor-Davidson Resiliency Scale
Positive ideation (opposite of suicidal ideation) - UPPS-P Impulsive Behavior Scale,
Positive and Negative Suicidal Ideation Scale (PANSI)
Page 4 of 36
Substance and prescription medication use – Tobacco, Alcohol, Prescription Medication,
and Other Substance Use Tool (TAPS)
Recruitment of FL community-based organizations that serve Veterans are being proactively
sought, including with use of the graphic below.
Page 5 of 36
2.0 PROGRAM EVALUATION/PERFORMANCE TASK RESULTS
As the current performance period was brief (approximately 2 months), program evaluation and
performance tasks completed relate to establishing the infrastructure for the project as a whole,
as well as preliminary data collection. This included the following 4 primary activities and
deliverables:
(i) Development of the project website
(ii) Initial literature review on the 5 alternative treatment modalities
(iii) Interim analyses of participating organizations and program evaluation data collected
to date
(iv) Estimate of Return on Investment (ROI) for veterans enrolled in the alternative
treatment service programs
2.1 Development of the Project Website. The project website has been developed with
additional content being added. The website is located at:
https://atovfl.wordpress.com
2.2 Initial Literature Review on the 5 Alternative Treatment Modalities. The text that follows
provides the initial literature review on the 5 alternative treatment options for veterans being
evaluated.
Page 6 of 36
Accelerated Resolution Therapy (ART)
Brief Description: Accelerated Resolution Therapy is an exposure-based “mind-body” therapy
that has been shown to be successful in the treatment of PTSD and related comorbidities.[1-4]
Each therapy session involves 4 primary steps that include: (i) Relaxation and Orientation (i.e.
focusing on and reducing body sensations); (ii) Imaginal Exposure (i.e. “visualizing” the
previous traumatic event from beginning to end); (iii) Imagery Rescripting (imagining a new,
preferred way to visualize the original traumatic experience); and (iv) Assessment and Closeout
(i.e. verifying recall of the original memory without significant distress and easy shift to the
rescripted version).[5, 6] In all four steps, patients are directed by the clinician to perform
repeated sets of horizontal smooth pursuit eye movements,[7] by following the clinician's hand,
which is moving horizontally from side to side in close proximity to the patient's face.
Beneficial features of the ART protocol include: (i) short treatment duration; (ii) no
homework or outside work required; (iii) no requirement to write or verbalize details of
traumatic experiences; and (iv) being solution oriented to change the way that memories and
images are stored in the brain through a process known as memory reconsolidation.[6, 8, 9] In
treatment studies to date, the ART protocol has shown clinically and statistically meaningful
reductions in symptoms of PTSD in approximately 70% of cases treated, and in an average of
approximately 4 treatment sessions.[10]
In brief, there have been four studies completed on ART for the treatment of
psychological trauma, as recently summarized.[10] All resulted in peer-reviewed publications,
including multiple case series and one randomized clinical trial. The first study, conducted
principally among adult civilians, used an observational prospective cohort study design (n = 75)
with clinical assessments made pre-ART, post-treatment completion, and at 2- and 4-month
follow-up.[2] This study, with a median of 3 treatment sessions, showed a 45% reduction in
symptoms of PTSD at 2-month follow-up after treatment completion with ART.[2]
The second study was a randomized controlled trial among 57 U.S. service members and
veterans, with clinical assessments made pre-ART, post-treatment completion, and at 3-month
follow-up.[3] In this trial, ART was compared with an attention control condition that consisted
of two sessions of fitness or career counseling. This study showed that 65% of veterans treated
with ART with a mean of 3.7 sessions experienced clinically and statistically meaningful
reductions in symptoms of PTSD.[3]
Page 7 of 36
The third study was a large cohort study among U.S. service members and veterans that
used an observational prospective design (n = 160) with clinical assessments made pre-ART,
post-treatment completion, and at 6-month follow-up.[1] In this study, 75% of veterans treated
with ART, with a mean of 4 sessions, including some veterans who were homeless, experienced
clinically and statistically meaningful reductions in symptoms of PTSD.[1]
The fourth study was conducted among a small cohort of female veterans (n=6) with a
history of military sexual trauma.[11] This study showed, in a mean of 4 treatment sessions, a
46% reduction in symptoms of PTSD after treatment completion with ART.[11]
Additional publications of ART have shown substantial reductions in pain,[12] including
neuropathic pain,[13] reductions in symptoms of obsessive compulsive disorder,[14] and
effective treatment of symptoms of PTSD for veterans with a history of traumatic brain injury
and those who served in the US Special Forces.[5] In addition, a recent clinical trial of ART for
treatment of prolonged complicated grief has been completed (Clinical Trials.gov:
NCT03484338), and favorable results will be published in the near future. In aggregate, these
studies show ART as a brief, effective treatment for symptoms of PTSD and related
comorbidities.
Helpful Links: Some helpful links on ART include:
4-minute video overview of ART:
http://www.youtube.com/watch?
v=w_bi0eW_WsU&feature=share&list=UUzZzLGbYx9OHlCjN5TTSv4w&index=1
3-minute video overview of ART:
https://www.youtube.com/watch?v=2_EOL3VJ3Sw
17-minute TEDx talk on ART
https://www.youtube.com/watch?v=vP7dx03arxI
ART Websites:
www.artworksnow.com
https://artherapyinternational.org/
Page 8 of 36
Equine Therapy
Brief Description: Equine Assisted Therapy (EAT) encompasses a range of treatments,
including therapeutic horseback riding (THR) and others, each of which involve activities with
horses to enhance physical and mental health.[15] Riding skills, grooming and working with
the horse at ground level, face-to-face, enable acquisition of effective learning and coping
strategies.[16] Importantly, these skills directly affect one’s emotional state and contribute to
raising one’s sense of self-worth, self-efficacy and control of the horse and body during riding.
In this regard, EAT helps to increase the capacity to control anger, anxiety, and relationships.
[16] Therapeutically, the horse identifies identifies and responds to the moods, emotions and
body language of those around it, thus creating a mirror for human beings.[15, 17, 18]
The evidence base for EAT as a treatment modality for PTSD and related comorbidities
is limited. An EAT program that included 2-hour sessions for 6 weeks found significant
reductions in symptoms of PTSD and anxiety among persons who had experienced rape or
serious accidents.[15] A second study of 39 combat veterans who completed an 8-week study of
THR reported improvements in PTSD symptoms, social functioning and reduced interference
of emotions in daily activities.[19] Similarly, a 6-week study of THR among US post-
deployment veterans with PTSD or PTSD and TBI showed decreased PTSD symptoms,
improved social functioning and reduced interference of emotions in daily activities.[20] These
indications of efficacy have led to development of an evidence-based protocol of THR for US
Army Veterans with PTSD,[21] and a recent systematic review of EAT interventions for
veterans with service-related health conditions has been published.[22]
Helpful Links: Some helpful links on EAT include:
5-minute video of veterans describing the benefits of EAT
https://www.youtube.com/watch?v=Z7EedCwJ4ww
8-minute video on the EAGALA Model for Equine-Assisted Psychotherapy for military
personnel
https://www.youtube.com/watch?v=boVatiz-55g
Service Animal Training Therapy
Page 9 of 36
Brief Description: For the purpose of this evaluation, service animal training therapy is restricted
to service dogs that are trained to perform disability-specific tasks for their owners and are
increasingly used by veterans with combat-related physical impairments.[23] Psychiatric service
dogs are distinguished from emotional support, therapy, or companion dogs by specifically being
trained to perform a variety of commands relevant to the psychiatric needs of the individual, and
thus are legally allowed public access under the Americans with Disabilities Act.[24, 25]
These psychiatric service dogs are thought to mitigate PTSD symptomology by instilling
a sense of confidence, safety, and independence in the veteran on a day-to-day basis. Specific
tasks can range from responding to and distracting a veteran from panic or emotional distress,
“watching” their back in public, and waking them up from nightmares. PTSD service dogs may
also alleviate anxious arousal/hypervigilance, avoidance, and feelings of isolation and
detachment from others.[26-28] For example, qualitative evidence suggests that PTSD service
dogs can confer unique benefits to military veterans that address PTSD symptomology,
especially hyperarousal.[26, 29]
In addition, use of service dogs has been associated with decreased use of pain medication and
improved emotional regulation,[30] as well as reduced medication and suicidal impulses.[31, 32]
Still, despite much of the evidence being anecdotal and retrospective reports, along with
considerable media attention (e.g. [33], recent systematic reviews of the literature on Animal-
Assisted Intervention (AAI) for PTSD reveal that there is a notable absence of peer-reviewed,
empirical studies of the efficacy of service dogs for alleviating PTSD symptoms.[17, 34]
Nonetheless, two recent studies employing controlled designs and using extensive and
innovative outcome measures provide insight into service dog programs for military veterans and
potential benefit in reducing symptoms of PTSD.[35] One non-randomized efficacy trial
compared post-9/11 veterans diagnosed with PTSD who had received and trained a service dog
in addition to participating in usual care, to a waitlist group of similar veterans who received
only usual care.[36] This study concluded that veterans with their trained service dogs had
clinically meaningful improvements in their PTSD symptomology, social functioning, and better
quality of life compared to veterans who only received usual care.[36]
A second recent two-group non-randomized study compared the cortisol levels (a
measure of stress response) and symptom-related behaviors of veterans with PTSD who had a
service dog to a group of comparable veterans on a waitlist.[37] Investigators reported that,
Page 10 of 36
compared to similar veterans on a waitlist, the veterans who had service dogs had improved
levels of salivary cortisol awakening response (CAR), reflecting lower stress and described
lower hyperarousal and PTSD symptomology and better psychosocial well-being overall.[37]
More recently, Whitworth and colleagues compared a 14-week service dog program for
veterans diagnosed with PTSD (n=15) versus 15 similar veterans in a waitlist control group
(n=15). Participants who completed the service dog training program demonstrated significant
decreases in posttraumatic symptomatology, intra/interpersonal difficulties associated with
psychological trauma, and in disabilities secondary to their PTSD.[37] In aggregate, empirical
data to date indicate that service dog programs may be efficacious for reducing symptoms of
PTSD and related comorbidities, particularly among military personnel, yet additional rigorous
empirical studies are needed.
Helpful Links:
VA Program Provides Service Dogs to Veterans with Mental Health Issues
https://www.military.com/benefits/2017/05/19/va-service-dogs-mental-health.html
VA Service Dog Fact Sheet - Veterinary Health Benefits for Mental Health Mobility Service
Dogs
https://www.va.gov/HEALTHPARTNERSHIPS/docs/CCIServiceDogFactSheet.pdf
5-minute video on Service Dogs Helping Veterans with PTSD
https://www.youtube.com/watch?v=JaVKGrWakIg
Music Therapy
Brief Description: Music therapy has been employed as a therapeutic intervention to facilitate
healing across a variety of clinical populations. A music therapist offers a tailored structure to
shape and develop the course of therapy. For instance, the patient can create his/her own music
with the therapist’s guidance as a way of expressing emotions [38], or the therapist can present
the patient with a song and encourage him/her to sing along or introduce their own words. The
structure and protocol for music therapy can vary widely across a range of instruments,
mediums, and methods of expression.[39] Group or communal music therapy is intended to
bring together individuals with a shared experience (e.g. military service, communal trauma) to
work together via group discussion or improvisation.[40] (DeNora, 2002).
Page 11 of 36
Music therapy in the United States must be practiced by accredited music therapists
certified by the Certification Board and can serve as an adjunctive therapeutic program or stand
on its own (AMTA).[41] Mental health providers must refer clients to music therapists if they
want to incorporate music therapy into treatment. The therapist then formulates a treatment plan
that can involve musical improvisation, listening exercises, singing, music making, the playing
of an instrument, and a discussion of the emotions conveyed through a piece of music heard by
the patient.[42]
Two recent studies have suggested that music therapy can improve PTSD or TBI for
military service members through songwriting and a variety of interventions.[43, 44] This
includes the potential to increase the neuroplasticity of the brain and rebuild damaged neural
communications, and listening with a consistent tempo also regulate breath and heart beat
pattern.[44] A randomized-controlled trial recruited 17 patients with PTSD from a specialized
clinic that provided Trauma-Focused CBT. Of those eligible, half were randomly assigned to
receive an additional ten weeks of music therapy consisting of one, one-hour session of group
improvisational instrumental therapy provided weekly. The control group was not offered music
therapy or any other intervention. Compared to the control group, patients in the music therapy
condition demonstrated a significantly greater reduction in posttraumatic stress symptoms.[45]
A non-controlled pre-post examination of music therapy for military veterans with PTSD
looked at the efficacy of group drumming therapy among six male subjects aged 20–23 who had
experienced traumatic events during military service and had a diagnosis of PTSD. They
participated in group drumming music therapy for 16 weekly 90-minute sessions. Therapist
observations indicated a significant reduction of specific symptoms including isolation, lack of
connectedness, avoidance of traumatic memories, rage, and anxiety.[39]
A small pilot study conducted at the Zablocki VA Medical Center in Milwaukee, WI
consisted of Veterans receiving an hour of individual guitar training each week and a weekly
group instruction session. Results showed a positive benefit in relieving PTSD symptoms as a
result of the intervention. In addition, findings suggest that the music therapy was effective in
reducing depression symptoms and improving health-related quality of life.[46]
From a theoretical perspective, music therapy may potentially alleviate symptoms of
PTSD. Still, with respect to the use of music therapy for military populations, integrated
examination of the theoretical mechanisms and processes with empirical evidence for music
Page 12 of 36
therapy for PTSD and related comorbidities is limited.[41] For example, music may address
emotion dysregulation associated with intrusive memories that leave individuals feeling triggered
and distressed.[47] Negative feelings such as anger, guilt, shame, fear, and anxiety may be
addressed by music’s ability to activate reward pathways in the brain and suppress the release of
stress hormones.[48] Similarly, listening to and playing music have also been shown to reduce
the production of the stress hormone cortisol.[49]
In aggregate, music therapy appears to be a promising alternative treatment options for
military personnel suffering from symptoms of PTSD and related comorbidities. Additional
empirical evidence is required to fully assess the potential benefits of music therapy.
Helpful Links:
Music Therapy and Military Populations
https://www.musictherapy.org/research/music_therapy_and_military_populations/
13-minute video on Musical healing for TBI and PTSD
https://www.brainline.org/article/musical-healing-tbi-and-ptsd
Hyperbaric Oxygen Therapy (HBOT)
Brief Description: Administration of hyperbaric oxygen therapy (HBOT) involves breathing high
levels of medical grade oxygen, usually 100% oxygen, at a pressure at least 1.4 times greater
than the atmospheric absolute pressure at sea level (1 atmosphere absolute or ATA, which is
equivalent to 760 mm Hg partial pressure of oxygen). Of note, in normal air, the oxygen level is
only around 21%. The intent of HBOT is to increase the oxygenation of the patient’s blood and
tissues to supraphysiological levels.[50] The partial pressure of oxygen increases proportionally
with an increase in the hyperbaric chamber compression pressure. One theory proposed to
support the use of HBOT in TBI patients is that exposure to HBOT allows functionally
retrievable neurons adjacent to severely damaged or dead neurons to return to more normal
function by reactivating metabolic or electrical pathways.[51] In addition, HBOT has been
proposed as a treatment option for PTSD. The rationale for this is based, in part, by the fact that
neurobiological characteristics of PTSD show multiple regions of the brain being affected. These
include hippocampal atrophy and altered activity of the insular cortex, as well as hypoactivity of
the hypothalamic–pituitary–adrenal axis.[52] In addition, for treatment of symptoms of both TBI
Page 13 of 36
and PTSD, potential beneficial mechanisms associated with HBOT include stem cell migration,
reduced inflammation, alterations in cerebral blood flow, and increased angiogenesis and
neurogenesis.[53, 54] While treatment protocols differ, a common regimen of treatment with
HBOT consists of approximately 40 daily sessions within the hyperbaric chamber, with sessions
lasting 30 minutes to 2 hours in length.
The empirical evidence for the effectiveness of HBOT in the treatment of symptoms of
TBI and/or PTSD is mixed, and highly controversial. Several peer-reviewed scientific studies
have reported beneficial effects of HBOT in subjects with chronic residual effects of moderate to
severe TBI.[55-59] Similarly, positive effects of HBOT have been reported in significantly
reducing symptoms of PTSD among veterans with concomitant mild to moderate TBI/post-
concussion syndrome (PCS),[60] However, the randomized controlled trial design is considered
the gold-standard in terms of methodological rigor and the ability to draw causal inferences from
evaluation of treatment approaches. In this regards, several randomized controlled clinical trials
have been performed using HBOT to treat symptoms of TBI and PTSD with varied results that
are open to interpretation. A summary of major trials is provided in Appendix 1.
In brief, 5 double blind randomized “sham-controlled” trials have been recently
published.[61-65] In these trials, ATA pressures varied considerably between the “active” and
“sham-controlled” treatment arms, and one of the trials included a “no-chamber” control
regimen. In aggregate, these trials show small to medium effects in terms of reductions in
symptoms of PCS and TBI, and at varying doses of oxygenation. Of note, the Miller (2015) trial
reported overall larger reductions in symptoms of PCS and TBI in the “sham” condition (1.2
ATA), as compared to the presumed therapeutically “active” condition (1.5 ATA).[63] Both
groups performed better than the no chamber condition. Thus, the trial data tend to show
comparable therapeutic results between the “active” and “sham” treatment regimens. In 2018,
investigators from the VA Evidence-based Synthesis Program (ESP) conducted an independent
and objective re-analysis of 16 randomized controlled trials and found inconclusive evidence of
HBOT’s benefits at least for mild TBI and PTSD, no obvious indication that bias led to flaws in
VA/DoD randomized controlled trials, and that current evidence does not clearly support any one
argument over another for or against HBOT.[66]
With respect to findings from the above referenced “sham-controlled” randomized trials,
challenges from the scientific community have been vocal and extensive. In brief, it has been
Page 14 of 36
postulated that the hyperbaric treatments in the sham arms of the trials (such as at 1.2 ATA) were
in fact medicinal, including potentially increasing (significantly) the amount of dissolved oxygen
in the blood and simultaneously inducing cascades of positive metabolic changes and gene
activations.[67] Thus, critics of the results of the sham-controlled” randomized trials argue that
the design employed was actually dose response (i.e. lower versus higher levels of oxygenation)
rather than “placebo.” On the other hand, military PTSD scholars have suggested that the
chamber treatment environment, in and of itself (i.e. irrespective of oxygen level) is therapeutic,
[68], possibly due to factors such as enhanced expectancy, conditioning, the authoritative context
of care, and social reinforcement.[69] They also suggest the possibility that daily ritual
visitations during 8 to 10 weeks of treatment foster organic narrative processes between study
participants and with their compassionate staff members, consistent with core components of
effective PTSD and depression psychotherapy.[70] Despite this controversy, the amount of
pressure needed to potentially induce positive clinical benefits in both TBI and PTSD patients is
unknown. Therefore, it is conceivable that even at small pressures, HBOT may offer significant
clinical benefit to military personnel with a history of TBI and/or PTSD.(e.g.[65]).
Helpful Links: Some helpful links on HBOT include:
VA Health Services Research and Development: Evidence Brief: Hyperbaric Oxygen Therapy
(HBOT) for Traumatic Brain Injury and/or Post-traumatic Stress Disorder
https://www.hsrd.research.va.gov/publications/esp/hbot.cfm
5-minute video of VA to offer HBOT for some veterans with PTSD and TBI
https://www.youtube.com/watch?v=zoGyt9C5hlA
Page 15 of 36
Appendix 1. Review of Controlled Trials of HBOT for Persons with Post Concussive Symptoms and Mild TBI
Ref #
Author / Year
Design Population HBOT schedule
Groups Primary Outcome
Secondary Outcomes
1 Wolf / 2012
Double blind randomized sham controlled RCT
Service members with combat-related mTBI
30 daily sessions
(1) 100% oxygen at 2.4 ATA (n=25)
PCS and cognitive testing at baseline and 6 weeks after intervention
PTSD Symptoms (PCL-M)
(2) 21% oxygen at 1.3 ATA (n=25)
Main Results Both groups showed some improvement on Impact scale symptoms including headache, falling asleep, and better emotional health. Improvements were generally similar between the 2 groups. PCL-M (PTSD) showed drops of 17.0% and 16.8% in the control and HBOT groups, respectively.
Comments Engaging in 30 chamber sessions appears to result in modest improvements in selected physical symptoms and emotional health, including modest reduction in symptoms of PTSD. These improvements appear to occur irrespective of the dose of oxygen, and therefore, cannot rule out the possibility of significant benefit attributed to expectation (placebo).
2 Cifu / 2014
Double blind randomized sham controlled RCT
Service members with combat-related mTBI
40 daily sessions
(1) 100% oxygen at 2.0 ATA (n=21)
Post-concussion Symptoms
PTSD Symptoms
(2) 75% oxygen at 2.0 ATA (n=18)(3) 10.5% oxygen at 2.0 ATA (n=21)
Main Results Nominal 12.5% reduction in PCS in 100% oxygen group. No reduction in PCS in 75% or 10.5% oxygen groups. Differences with 100% oxygen group not significant.Nominal 14.1% reduction in PCL score in 100% oxygen group. Minimal reduction in PCL in 75% or 10.5% oxygen groups. Differences with 100% oxygen group not significant.
Comments Minimal evidence of therapeutic effect of HBOT at 100% oxygen. No effect of HBOT at 75% oxygen or 10.5% oxygen (sham).Mean drop in PCL of 6.9 points in 100% oxygen group is of nominal clinical relevance.
3 Cifu / 2014
Double blind randomized sham controlled RCT
mTBI within past 3-months to 3 years, diagnosis of PCS, stable
40 daily sessions
(1) 100% oxygen at 2.0 ATA (n=19)
Post-concussion Symptoms
Depression, memory, cognition, life satisfaction(2) 75%
oxygen at 2.0 ATA (n=21)(3) 10.5% oxygen at 2.0 ATA (n=21)
Main Results No statistical difference in PCS between groups, including pre versus post and at 3-month follow-up.No statistical difference in any secondary outcome between groups, including pre versus post and at 3-month follow-up.
Comments Poor analysis that relies on statistical testing and does not report absolute or magnitude of treatment-related changes. Still, no evidence of efficacy of HBOT at 100% or 75% oxygen.
Page 16 of 36
4 Walker / 2014
Same as Cifu (ref 2)
Same as Cifu (ref 2)
Same as Cifu (ref 2)
(1) 100% oxygen at 2.0 ATA (n=21)
Psychomotor function (e.g. postural stability and balance)
Cognitive function (e.g. executive function, working memory)
(2) 75% oxygen at 2.0 ATA (n=18)(3) 10.5% oxygen at 2.0 ATA (n=21)
Main Results No immediate post-compression beneficial effect of HBOT on cognitive or psychomotor performance at 1.5 to 2.0 ATA O2 as compared to sham. Within group changes in all outcome measure were very small to small, with most noticeable differences in some measures of cognitive attention and executive function generally observed across all groups.
Comments Minimal evidence of therapeutic effect of HBOT at 100% oxygen in terms of psychomotor performance and cognitive function.
5 Miller / 2015
Double blind randomized sham controlled RCT
Symptoms of mTBI for at least 4 months
40 daily sessions
(1) 100% oxygen at 1.5 ATA (n=24)
Post-concussion Symptoms
PTSD checklist and Neurobehavioral Symptom Inventory
(2) 100% oxygen at 1.2 ATA (n=25)(3) No chamber (n=23)
Main Results HBOT (1.5 ATA) and sham (1.2 ATA) showed significant reduction in PCS total score of 16.4% and 23.2%, respectively. The No chamber group did not improve on Sx of PTSD or NSI. Significant reductions in PCL and NSI scores were almost twice as large in sham (1.2 ATA) group compared to HBOT (1.5 ATA) group.Sham group also showed substantial reductions in depression, anxiety, and pain whereas HBOT group (1.5 ATA) did not show meaningful improvements. Sham group also showed better results in terms of physical and emotional functioning.
Comments Unexpectedly, postulated sham condition of 1.2 ATA seemed to perform better than conventional 1.5 ATA regimen. This occurred across a range of outcome measures. Expectancy and daily routine effects of being in the chamber cannot be estimated with respect to comparison against the no chamber group.
References (Initial Literature Review)
1. Kip, K.E., et al., Evaluation of brief treatment of symptoms of psychological trauma among veterans residing in a homeless shelter by use of Accelerated Resolution Therapy (ART). Nursing Outlook, 2016. 64: p. 411-423.
2. Kip, K.E., et al., Brief treatment of symptoms of post-traumatic stress disorder (PTSD) by use of Accelerated Resolution Therapy (ART). Behavioral Sciences, 2012. 2(2): p. 115-134.
3. Kip, K.E., et al., Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD). Military Medicine, 2013. 178: p. 1298-1309.
4. Kip, K.E., et al., Brief treatment of co-occurring post-traumatic stress and depressive symptoms by use of accelerated resolution therapy. Frontiers in Psychiatry, 2013. 4: p. 1-12.
Page 17 of 36
5. Kip, K.E., et al., The emergence of Accelerated Resolution Therapy (ART) for treatment of post-traumatic stress disorder (PTSD): A review and new subgroup analyses. Counselling and Psychotherapy Research, 2019. 19: p. 117–129.
6. Kip, K.E., et al., Case report and theoretical description of accelerated resolution therapy (ART) for military-related post-traumatic stress disorder. Military Medicine, 2014. 179: p. 31-37.
7. Purves, D., G.J. Augustine, and D. Fitzpatrick, Neuroscience. Second ed. 2001, Sunderland, MA: Sinauer Associates.
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11. Rossiter, A.G., et al., Accelerated resolution therapy for women veterans experiencing military sexual trauma related post-traumatic stress disorder. Annals of Psychiatry and Mental Health, 2017. 5: p. 1108.
12. Kip, K.E., et al., Accelerated resolution therapy (ART) for treatment of pain secondary to combat-related post-traumatic stress disorder (PTSD). European Journal of Psychotraumatology, 2014. 5: p. 24066.
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14. Schimmels, J. and W. Waits, A Tale of Two Compulsions - Two Case Studies Using Accelerated Resolution Therapy (ART) for Obsessive Compulsive Disorder (OCD). Mil Med, 2019. 184(5-6): p. e470-e474.
15. Earles, J.L., L.L. Vernon, and J.P. Yetz, Equine-assisted therapy for anxiety and posttraumatic stress symptoms. Journal of Traumatic Stress, 2015. 28: p. 149–152.
16. Shelef, A., et al., Equine assisted therapy for patients with post traumatic stress disorder: A case series study. Military Medicine, 2019.
17. O’Haire, M.E., N.A. Guérin, and A.C. Kirkham, Animal-assisted intervention for trauma: a systematic literature review. Frontiers in Psychology, 2015. 6: p. 1121.
18. Van Der Kolk, B., The Body Keeps the Score, Brain, Mind & Body in the Healing of Trauma. 2014, New York, NY: Viking.
19. Lanning, B.A., et al., Using Therapeutic Riding as an Intervention for Combat Veterans: An International Classification of Functioning, Disability, and Health (ICF) Approach. Occupational Therapy in Mental Health, 2017. 33(3): p. 259-278.
20. Johnson, R.A., et al., Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Mil Med Res, 2018. 5(1): p. 3.
21. Martz, K.C., An evidence-based protocol of equestrian therapy in veterans with posttraumatic stress disorder: A best practice approach, in Nursing. 2014, University of Arizona.
22. Kinney, A.R., et al., Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review. Military Medical Research, 2019. 6(1): p. 28.
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24. Kruger, K. and J. Serpell, Animal-assisted interventions in mental health: Definitions and theoretical foundations, in Handbook on animal-assisted therapy: Theoretical foundations and guidelines for practice, A.H. Fine, Editor. 2010, Academic Press: San Diego. p. 33-48.
25. Tedeschi, P., A. Fine, and J. Helgeson, Assistance animals: Their evolving role in psychiatric service applications, in Handbook on animal-assisted therapy: Theoretical foundations and guidelines for practice, A.H. Fine, Editor. 2010, Academic Press: San Diego. p. 421-438.
26. Taylor, M.F., M.E. Edwards, and J.A. Pooley, “Nudging them back to reality”: Toward a growing public acceptance of the role dogs fulfill in ameliorating contemporary veterans’ PTSD symptoms. Anthrozoös, 2013. 26(4): p. 593–611.
27. Yeager, A.F. and J. Irwin, Rehabilitative canine interactions at the Walter Reed National Military Medical Center. US Army Med Dep J, 2012: p. 57-60.
28. Yount, R., et al., The role of service dog training in the treatment of combat-related PTSD. Psychiatric Annals, 2013. 43(6): p. 292–295.
29. Crowe, T.K., et al., Veterans transitioning from isolation to integration: a look at veteran/service dog partnerships. Disabil Rehabil, 2018. 40(24): p. 2953-2961.
30. Thorne, K.L., E.J. Devlin, and K.M. Dingess, Service dogs for veterans with PTSD: Implications for workplace success. Career Planning & Adult Development Journal,, 2017. 33(2): p. 36-48.
31. Kloep, M.L., R.H. Hunter, and S.J. Kertz, Examining the effects of a novel training program and use of psychiatric service dogs for military-related PTSD and associated symptoms. Am J Orthopsychiatry, 2017. 87(4): p. 425-433.
32. Yarborough, B.J.H., et al., Benefits and challenges of using service dogs for veterans with posttraumatic stress disorder. Psychiatr Rehabil J, 2018. 41(2): p. 118-124.
33. Arehart-Treichel, J., Guide dogs for the mind ease path through mental illness. Psychiatric News, 2010. 45: p. 14-28.
34. Krause-Parello, C.A., S. Sarni, and E. Padden, Military veterans and canine assistance for post-traumatic stress disorder: A narrative review of the literature. Nurse Educ Today, 2016. 47: p. 43-50.
35. Whitworth, J.D., D. Scotland-Coogan, and T. Wharton, Service dog training programs for veterans with PTSD: results of a pilot controlled study. Soc Work Health Care, 2019. 58(4): p. 412-430.
36. O'Haire, M.E. and K.E. Rodriguez, Preliminary efficacy of service dogs as a complementary treatment for posttraumatic stress disorder in military members and veterans. J Consult Clin Psychol, 2018. 86(2): p. 179-188.
37. Rodriguez, K.E., et al., The effect of a service dog on salivary cortisol awakening response in a military population with posttraumatic stress disorder (PTSD). Psychoneuroendocrinology, 2018. 98: p. 202-210.
38. Hurt-Thaut, C., Clinical practices in music therapy, in The Oxford Handbook of Music Psychology, S.C. Hallam, I., Thaut, M., Editor. 2009, Oxford University Press: New York, NY.
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39. Bensimon M, Amir D, and W. Y., Drumming through trauma: Music therapy with post-traumatic soldiers. The Arts in Psychotherapy, 2008. 35: p. 34–48.
40. Vaillancourt, G., Music therapy: A community approach to social justice. The Arts in Psychotherapy, 2012. 39(3): p. 173-178.
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42. Bonde, L. and T. Wigram, A comprehensive guide to music therapy: Theory, clinical practice, research, and training. 2002, London, England: Jessica Kingsley Publishers.
43. Bradt, J., J. Biondo, and R. Vaudreuil, Songs created by military service members in music therapy: A retrospective analysis. Arts in Psychotherapy, 2019. 62: p. 19-27.
44. Bronson, H., R. Vaudreuil, and J. Bradt, Music Therapy Treatment of Active Duty Military: An Overview of Intensive Outpatient and Longitudinal Care Programs. Music Therapy Perspectives, 2018. 36(2): p. 195-206.
45. Carr, C., et al., Group music therapy for patients with persistent post-traumatic stress disorder--an exploratory randomized controlled trial with mixed methods evaluation. Psychol Psychother, 2012. 85(2): p. 179-202.
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47. S., V., Music therapy and the treatment of trauma-induced dissociative disorders. The Arts in Psychotherapy, 1993. 20(3): p. 243–251.
48. Chanda, M.L. and D.J. Levitin, The neurochemistry of music. Trends Cogn Sci, 2013. 17(4): p. 179-93.
49. Wise, R.A., Dopamine, learning and motivation. Nat Rev Neurosci, 2004. 5(6): p. 483-94.
50. Gesell, L.B., Hyperbaric Oxygen Therapy Indications: The Hyperbaric Oxygen Therapy Committee Report. 12th ed. 2008: Durham, NC.
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52. Whitaker, A.M., N.W. Gilpin, and S. Edwards, Animal models of post-traumatic stress disorder and recent neurobiological insights. Behav Pharmacol, 2014. 25(5-6): p. 398-409.
53. Ding, Z., et al., Hyperbaric oxygen therapy in acute ischemic stroke: a review. Interv Neurol, 2014. 2(4): p. 201-11.
54. Liu, W., et al., Application of medical gases in the field of neurobiology. Med Gas Res, 2011. 1(1): p. 13.
55. Golden, Z., C.J. Golden, and R.A. Neubauer, Improving neuropsychological function after chronic brain injury with hyperbaric oxygen. Disabil Rehabil, 2006. 28(22): p. 1379-86.
56. Golden, Z.L., et al., Improvement in cerebral metabolism in chronic brain injury after hyperbaric oxygen therapy. Int J Neurosci, 2002. 112(2): p. 119-31.
57. Hardy, P., et al., Pilot case study of the therapeutic potential of hyperbaric oxygen therapy on chronic brain injury. J Neurol Sci, 2007. 253: p. 94-105.
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59. Wright, J.K., et al., Case report: Treatment of mild traumatic brain injury with hyperbaric oxygen. Undersea Hyperb Med, 2009. 36(6): p. 391-9.
60. Harch, P.G., et al., A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma, 2012. 29(1): p. 168-85.
61. Cifu, D.X., et al., The effect of hyperbaric oxygen on persistent postconcussion symptoms. J Head Trauma Rehabil, 2014. 29(1): p. 11-20.
62. Cifu, D.X., et al., Hyperbaric oxygen for blast-related postconcussion syndrome: three-month outcomes. Ann Neurol, 2014. 75(2): p. 277-86.
63. Miller, R.S., et al., Effects of hyperbaric oxygen on symptoms and quality of life among service members with persistent postconcussion symptoms: a randomized clinical trial. JAMA Intern Med, 2015. 175(1): p. 43-52.
64. Walker, W.C., et al., Randomized, Sham-Controlled, Feasibility Trial of Hyperbaric Oxygen for Service Members With Postconcussion Syndrome: Cognitive and Psychomotor Outcomes 1 Week Postintervention. Neurorehabilitation and Neural Repair, 2014. 28: p. 420-432.
65. Wolf, G., et al., The effect of hyperbaric oxygen on symptoms after mild traumatic brain injury. J Neurotrauma, 2012. 29(17): p. 2606-12.
66. Peterson, K., et al., Evidence Brief: Hyperbaric Oxygen Therapy (HBOT) for Traumatic Brain Injury and/or Post-traumatic Stress Disorder. 2018: Portland, OR.
67. Mozayeni, B.R., et al., The National Brain Injury Rescue and Rehabilitation Study - a multicenter observational study of hyperbaric oxygen for mild traumatic brain injury with post-concussive symptoms. Med Gas Res, 2019. 9(1): p. 1-12.
68. Hoge, C.W. and W.B. Jonas, The ritual of hyperbaric oxygen and lessons for the treatment of persistent postconcussion symptoms in military personnel. JAMA Intern Med, 2015. 175(1): p. 53-4.
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70. Hoge, C.W., Interventions for war-related posttraumatic stress disorder: meeting veterans where they are. JAMA, 2011. 306(5): p. 549-51.
2.3 Interim Analyses of Participating Organizations and Program Evaluation Data Collected to
Date
As seen in the table that follows, a large cadre of services organizations have expressed interest
and agreed to participate in the project. Of these, the 3 highlighted organizations have collected
and submitted program evaluation data to date, as included in this report. They include:
Veterans Alternative, Quantum Leap Farm, and Guardian Angels Medical Services Dogs,
Inc. In addition, K9 Partners for Patriots have provided data under a separate effort that will be
included in future reports.
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Alternative Treatment Modality Provider Name Description of Services Street City & State Zip Primary Contact
Accelerated Resolution Therapy
Organization/Site (1) Veterans Alternative (Holiday)
Accelerated Wellness Program and Individualized ART sessions
1750 Arcadia Road Holiday, FL 34690 Patricia Fried, COO
Organization/Site (2) Veterans Alternative (Tampa) Individualized ART sessions 1905 N. Florida
Avenue Tampa, FL 33602 Patricia Fried, COO
Organization/Site (3) Camaraderie Foundation Individualized ART Sessions 2488 East Michigan
Street Orlando, FL 32806 Anna Tanzilla, Program Manager
Equine Therapy
Organization/Site (1) Quantum Leap Farm
At E.A.S.E.- Facilitates learning through experiences with horses in specifically designed activities for emotional and relational growth
10401 Woodstock Rd Odessa, FL 33556 Edie Dopking, Ph.D.
Organization/Site (2) Inspire Equine Therapy Program
Offers Freedom Heroes and Equines Carriage Driving program for disabled veterans and first responders.
1743 Doncaster Road Clearwater, FL 33764 Melissa Yarbrough,
ED
Organization/Site (3) S.A.D.L.E.S Ranch
CODE H.O.R.S.E. program- This unique program developed by its founder is based on the outcomes from a two and one half year pilot research study designed and co-facilitated by Cher Myers, Founder of S.A.D.L.E.S. Ranch, Inc.
41025 Thomas Boat Landing Rd Umatilla, FL 32784 Cher Meyers, LCSW
Organization/Site (4)Emerald M. Theraputic Riding Center
P.E.A.C.E. Program for Veterans 4022 Goldsmith Rd Brooksville, FL 34602 Lisa Michaelangelo,
MPT
Service Animal
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Training Therapy
Organization/Site (1) Rescue 22
Pairs rescued working breeds with veterans of our United States Armed Forces and in some cases with those currently serving.
7006 229th Street East Bradenton, FL 34211 Angela Connor, VP
Organization/Site (2) K9 Partners for Patriots
Teaches qualifying veterans to train selected dogs and provides them based on their specific needs. The dog and the veteran work together from the onset through a 19-week training program. Evaluated by James Whitworth, PhD, LCSW
15322 Aviation Loop Dr Brooksville, FL 34604 Mary Peter, CEO
Organization/Site (3) K9 Partners for Warriors
Provides service canines to warriors suffering from PTSD, TBI Traumatic Brain Injury, and/or MST.
114 Camp K9 Road Ponte Vedra Beach, FL 32801 Patty Dodson
Organization/Site (4)Guardian Angels Medical Service Dogs, Inc.
Rescues, raises, trains and then donates individually trained medical service dogs to veterans and others struggling with a myriad of disabilities.
3251 NE 180 Ave. Williston, FL 32696
Music Therapy
Organization/Site (1) Tampa Bay Institute for Music Therapy
Works to provide Music Therapy to individuals experiencing TBI & psychological trauma, including PTSD.
311 E Bullard Pkwy, Suite A
Temple Terrace, FL 33617 Sharon Graham, Exc.
Director
Organization/Site (2) Creative Forces: NEA Military Healing Arts
Provides art, music, and dance therapies, for military patients and veterans with TBI & psychological trauma.
400 7th Street, SW Washington, DC 20506 Mary Anne Carter,
Chairman
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Hyperbaric Oxygen Therapy
Organization/Site (1) National Hyperbaric Treatment Center
Provides HBOT for numerous medical conditions, including PTSD and TBI.
31608 US Highway 19 North
Palm Harbor, FL 34684 Dr. Allan Spiegel
Organization/Site (2) Oxygen Rescue Care Centers of America
Specializes in the use of HBOT for "off-label" conditions in addition to TBI, PTSD, etc.
525 NE 3rd Ave, Suite 107
Delray Beach, FL 33444 Ray H. Cralle, RRT
Organization/Site (3) Tallahassee Memorial Healthcare
Provides HBOT for PTSD and TBI.
1300 Miccosukee Road Tallahassee, FL 32308 Dean Watson
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Initial results for the 3 organizations that have contributed data to the project to date are
summarized in the pages that follow. This includes initial results for the modalities Accelerated
Resolution Therapy (ART), Equine Therapy, and Service Animal Assisted Therapy.
Accelerated Resolution Therapy (ART)
To date, 16 veterans have provided data for enrollment of services with Accelerated
Resolution Therapy (ART). All 16 of these veterans were enrolled at the Veterans Alternative
site in Tampa. Of these 16 veterans, 5 have both pre-assessment and post-assessment data.
As seen in Table 1a, most veteran participants were of non-Hispanic white race with
primary service in the Army. Previous trauma history was significant, with 69% witnessing death
or execution and 44% being exposed to an IED blast or combat explosion. The prevalence of
possible TBI/concussion-related symptoms was high, especially for headaches (56%), memory
problems (69%), ringing in ears (69%), and sleep problems (69%). Medication use for pain,
depression, anxiety, and sleep problems was also common.
Table 1a. Presenting Characteristics of Veterans Enrolled (Accelerated Resolution Therapy - ART) (n=16)
Characteristic PrevalenceProgram (n, %) Accelerated Resolution Therapy 15 (93.7) Accelerated Resolution Therapy + Equine Therapy 1 (6.3)Age in years (n, %) 18 to 29 2 (12.5) 30 to 39 7 (43.7) 40 to 49 1 (6.2) 50 to 59 4 (25.0) 60 to 69 2 (12.5)Female gender (n, %) 2 (12.5)Race (n, %) White 10 (62.5) Black/African American 5 (31.2) Native Hawaiian/Pacific Islander 1 (6.2)Hispanic Ethnicity (n, %) 1 (6.2)Primary military service (n, %) Army 12 (75.0) Marine Corps 2 (12.5) Marine Corps Reserves 1 (6.2) Air Force 1 (6.2)Number of deployments (n, %) None 6 (37.5)
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One 6 (37.5) Two 2 (12.5) Three 1 (6.2) Four or more 1 (6.2)Previous trauma history Witness death or execution (n, %) 11 (68.7) IED blast or combat explosion (n, %) 7 (43.7) Witness major injuries (non-lethal) (n, %) 10 (62.5) Physical assault (n, %) 5 (31.2) Sexual assault (n, %) 5 (31.2)Current possible TBI/concussion-related symptoms Headaches (n, %) 9 (56.2) Dizziness (n, %) 6 (37.5) Memory problems (n, %) 11 (68.7) Balance problems (n, %) 7 (43.7) Ringing in ears (n, %) 11 (68.7) Irritability (n, %) 8 (50.0) Sleep problems (n, %) 11 (68.7)Current medications Pain (n, %) 7 (43.7) Depression (n, %) 9 (56.2) Anxiety (n, %) 8 (50.0) Seizures (n, %) 1 (6.2) Sleep (n, %) 8 (50.0)
Table 2a provides results for symptoms of PTSD, depression, anxiety, and somatization at the
start and end of the ART program (typically 1 to 2-week time period). As seen, PTSD scores
from the 20-item PCL-5 instrument dropped from a mean of 44.6 to 18.4 after completion of the
ART program. This represents a 59% reduction in self-reported symptoms of PTSD (see figure
2a as well). In addition, by use of these established cutpoint score of >33 on the 20-item PCL-5
(PTSD) checklist as probable diagnosis of PTSD, 80% of veterans met this criteria at the start of
the program compared to 0% at the end of the program.
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Table 2a - ATOV Program Evaluation ReportComparison of Pre and Post Retreat Symptoms
Accelerated Resolution Therapy (ART) Programs
Characteristic Total (N=10)
a. Pre-program
assessment(N=5)
b. Post-program
assessment(N=5)
p-value
PCL5 (PTSD) score (total), mean, SD 31.5, 20.6 44.6, 19.4 18.4, 12.3 0.07
PCL5 Intrusion subscale score, mean, SD 6.7, 5.8 10.6, 5.8 2.8, 2.2 0.06
PCL5 Avoidance subscale score, mean, SD 2.9, 2.2 4.2, 2.3 1.6, 1.1 0.13
PCL5 Mood-Cognition subscale score, mean, SD 13.5, 7.6 18.2, 5.4 8.8, 6.8 0.06
PCL5 Arousal subscale score, mean, SD 8.4, 6.2 11.6, 7.1 5.2, 3.2 0.13
Provisional PTSD diagnosis based on PCL-5, % 30.0 60.0 0.0 ---
PTSD cutpoint diagnosis (PLC5 score >=33), % 40.0 80.0 0.0 ---
Brief Symptom Inventory (BSI) score (total), mean, SD
21.2, 12.6 27.6, 11.5 14.8, 11.0 0.03
BSI Somatization subscale score, mean, SD 5.7, 4.3 7.6, 4.0 3.8, 4.1 0.005
BSI Depression subscale score, mean, SD 7.6, 4.6 10.0, 3.5 5.2, 4.4 0.04
BSI Anxiety subscale score, mean, SD 7.9, 5.2 10.0, 6.0 5.8, 3.7 0.18
Figure 2a. PTSD (PCL-5) scores for veterans treated with ART before (pre-program) and after (post-program) receipt of services.
Page 27 of 36
The de-identified listing of veterans who received services with ART follows:
Veterans Served with ART: November 1 – December 31, 2019
01F79
01K66
01M06
01M86
01R47
02K29
02K68
05D05
06C88
07F41
07M31
09B95
09S72
10M19
11W22
12P47
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Equine Therapy
To date, 7 veterans have provided data for enrollment of services with Equine Therapy.
All 7 of these veterans were enrolled at Quantum Leap Farm in Odessa, FL. All 7 of these
veterans provided pre-assessment and post-assessment data.
As seen in Table 1b, most veteran participants were age 40 to 49 years, all were female,
and with equal representation of service (42.9%) in the Army and Navy. In terms of trauma
history, the prevalence of physical assault (57%) and sexual assault (86%) was high. The
prevalence of possible TBI/concussion-related symptoms was also high, especially for memory
problems (71%), ringing in ears (71%), irritability (71%), and sleep problems (71%). Medication
use for pain, depression, anxiety, and sleep problems was also common (71% for all).
Table 1b. Presenting Characteristics of Veterans Enrolled (Equine Therapy) (n=7)
Characteristic PrevalenceProgram (n, %) Equine Therapy 5 (71.4) Equine Therapy + Accelerated Resolution Therapy 2 (28.6)Age in years (n, %) 40 to 49 4 (57.1) 50 to 59 2 (28.6) 60 to 69 1 (14.3)Female gender (n, %) 7 (100.0)Race (n, %) White 4 (57.1) Black/African American 3 (42.9)Hispanic Ethnicity (n, %) 1 (14.3)Primary military service (n, %) Army 3 (42.9) Navy 3 (42.9) Marine Corps 1 (14.3)Number of deployments (n, %) None 2 (28.6) Two 2 (28.6) Three 2 (28.6) Four or more 1 (14.3)Previous trauma history Witness death or execution (n, %) 2 (28.6) IED blast or combat explosion (n, %) 1 (14.3) Witness major injuries (non-lethal) (n, %) 2 (28.6) Physical assault (n, %) 4 (57.1) Sexual assault (n, %) 6 (85.7)Current possible TBI/concussion-related symptoms Headaches (n, %) 4 (57.1)
Page 29 of 36
Dizziness (n, %) 3 (42.9) Memory problems (n, %) 5 (71.4) Balance problems (n, %) 3 (42.9) Ringing in ears (n, %) 5 (71.4) Irritability (n, %) 5 (71.4) Sleep problems (n, %) 5 (71.4)Current medications Pain (n, %) 5 (71.4) Depression (n, %) 5 (71.4) Anxiety (n, %) 5 (71.4) Seizures (n, %) 0 (0.0) Sleep (n, %) 5 (71.4)
Table 2b provides results for symptoms of PTSD, depression, anxiety, and somatization at the
start and end of the Equine Therapy program. As seen, PTSD scores from the 20-item PCL-5
instrument dropped from a mean of 50.0 to 28.0 after completion of the Equine Therapy
program. This represents a 44% reduction in self-reported symptoms of PTSD (see figure 2b). In
addition, by use of these established cutpoint score of >33 on the 20-item PCL-5 (PTSD)
checklist as probable diagnosis of PTSD, 86% of veterans met this criteria at the start of the
program compared to 29% at the end of the program.
Table 2b - ATOV Program Evaluation ReportComparison of Pre and Post Retreat Symptoms
Equine Therapy Programs
Characteristic Total (N=14)
a. Pre-program
assessment(N=7)
b. Post-program
assessment(N=7)
p-value
PCL5 (PTSD) score (total), mean, SD 39.0, 20.1 50.0, 12.4 28.0, 21.0 0.02
PCL5 Intrusion subscale score, mean, SD 7.7, 5.1 10.0, 4.4 5.4, 5.1 0.03
PCL5 Avoidance subscale score, mean, SD 4.7, 2.6 6.0, 2.1 3.4, 2.6 0.02
PCL5 Mood-Cognition subscale score, mn, SD 14.4, 7.7 18.4, 4.9 10.3, 8.1 0.01
PCL5 Arousal subscale score, mean, SD 12.2, 6.4 15.6, 4.2 8.9, 6.6 0.04
Provisional PTSD diagnosis based on PCL-5, % 57.1 85.7 28.6 0.046
PTSD cutpoint diagnosis (PLC5 score >=33), % 57.1 85.7 28.6 0.046
Brief Symptom Inventory (BSI) score (total), mean, SD
28.1, 16.3 40.7, 6.3 15.6, 13.0 0.001
BSI Somatization subscale score, mean, SD 8.9, 5.0 12.9, 2.4 4.9, 3.4 0.003
Page 30 of 36
Characteristic Total (N=14)
a. Pre-program
assessment(N=7)
b. Post-program
assessment(N=7)
p-value
BSI Depression subscale score, mean, SD 10.1, 7.0 14.3, 4.3 6.0, 7.0 0.005
BSI Anxiety subscale score, mean, SD 9.1, 5.8 13.6, 3.6 4.7, 3.8 0.002
Figure 2b. PTSD (PCL-5) scores for veterans treated with Equine Therapy before (pre-program) and after (post-program) receipt of services.
De-identified listing of veterans who received services with Equine Therapy is provided below:
Veterans Served with Equine Therapy -- November 1 – December 31, 2019
08W64
05C46
08F72
11M18
09H41
04W65
06H59
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Service Animal Assisted Therapy
To date, 6 veterans have provided data for enrollment of services with Service Animal
Assisted Therapy (i.e. service dog). Of these 6 veterans, one completion both the pre-approval
application phase and then was approved for receipt of a service dog (hence 2 assessments). In
future analyses, results will be presented by each phase of the approval process for a service dog.
All of the veterans were enrolled at Guardian Angels Medical Service Dogs, Inc. in Williston,
FL. Given the early stage of the process, only pre-assessment data is available for the current
report.
As seen in Table 1c, most veteran participants were age 30 to 39 years, only one was
female, and nearly all (85.7%) were of White race. In terms of trauma history, most (71.4%) had
witnessed death or execution, 43% had experienced IED blast or combat explosion, and 86% had
witnessed non-lethal major injuries. The prevalence of possible TBI/concussion-related symptoms
was very high, especially for headaches, irritability, and sleep problems (all 86%).
Table 1c. Presenting Characteristics of Veterans Enrolled (Service Animal Therapy) (n=7)
Characteristic PrevalenceProgram (n, %) Service Animal (Dog) Therapy 5 (71.4) Service Animal (Dog) Therapy + Hyperbaric Oxygen Therapy 1 (14.3) Service Animal (Dog) Therapy + Music Therapy 1 (14.3)Current status of placement with service dog (n, %) In the pre-approval application phase 6 (85.7) Approved for receipt of a service dog 1 (14.3)Age in years (n, %) 18 to 29 1 (14.3)) 30 to 39 3 (42.9) 40 to 49 2 (28.6) 60 to 69 1 (14.3)Female gender (n, %) 1 (14.3)Race (n, %) White 6 (85.7) Black/African American 3 (14.3)Hispanic Ethnicity (n, %) 0 (0.0)Primary military service (n, %) Army 4 (57.1) Navy 1 (14.3) Air Force 2 (28.6)Number of deployments (n, %) None 3 (42.9) One 3 (42.9)
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Four or more 1 (14.3)Previous trauma history Witness death or execution (n, %) 5 (71.4) IED blast or combat explosion (n, %) 3 (42.9) Witness major injuries (non-lethal) (n, %) 6 (85.7) Physical assault (n, %) 3 (42.9) Sexual assault (n, %) 1 (14.3)Current possible TBI/concussion-related symptoms Headaches (n, %) 6 (85.7) Dizziness (n, %) 4 (57.1) Memory problems (n, %) 5 (71.4) Balance problems (n, %) 4 (57.1) Ringing in ears (n, %) 5 (71.4) Irritability (n, %) 6 (85.7) Sleep problems (n, %) 6 (85.7)Current medications Pain (n, %) 3 (42.9) Depression (n, %) 3 (42.9) Anxiety (n, %) 4 (57.1) Seizures (n, %) 0 (0.0) Sleep (n, %) 2 (28.6)
The de-identified listing of veterans who began to receive services with Service Animal Assisted
Therapy (service dogs) is provided below:
Veterans Served with Initial Service Dog Services: November 1 – December 31, 2019
02V84 Pre-approval phase and Approval phase
03M56 Pre-approval phase
05M02 Pre-approval phase
09M06 Pre-approval phase
11X11 Pre-approval phase
12W31 Pre-approval phase
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2.4 Estimated Return on Investment (ROI)
For the 5 veterans who received services with ART and 7 veterans who received services
with Equine Therapy, and who provided pre-program and post-program assessment data, initial
estimates of return on investment (ROI) can be calculated.
According to the Congressional Budget Office (CBO) report (February 2012) entitled “The
Veterans Health Administration’s Treatment of PTSD and Traumatic Brain Injury Among
Recent Combat Veterans”( http://www.cbo.gov/sites/default/files/cbofiles/attachments/02-09-
PTSD.pdf), average annual health care costs of veterans treated within the Veterans Health
Administration (VHA) are $8,300 for veterans with post-traumatic stress disorder (PTSD),
versus $2,400 in the absence of PTSD. Of note, annual treatment costs are higher in the presence
of comorbidities associated with PTSD which are common and may include traumatic brain
injury (mTBI). Moreover, it should not be assumed that all annual healthcare costs for a given
veteran are represented within the VHA system. Nonetheless, these data are used to formulate
conservative estimates of return on investment (ROI) associated with the different alternative
treatment options for veterans being evaluated.
From the above, the net difference in annual health care costs in the presence versus absence
of PTSD are $8,300 - $2,400 = $5,900 per veteran.
In the Alternative Treatment Options for Veterans (ATOV) program evaluation, not all
veterans who receive services are required to present with a high level of PTSD or TBI
symptomatology. However, the inclusion criteria for the project require that all veterans have a
prior history of service-connected diagnosis of PTSD and/or TBI, and that all had previously
sought treatment. Therefore, it is expected that the majority of veterans served and evaluated in
the ATOV program will generally present with high levels of PTSD and/or TBI
symptomatology.
ROI – Accelerated Resolution Therapy (ART)
The estimate of ROI for veterans provided services with ART is based on veterans with pre-
and post-program data. For these 5 veterans served with complete data, mean pre- and post-
retreat scores on the 20-item PCL-5, a validated measure of PTSD symptom severity, were 44.6
and 18.4, respectively. This represents a 58.7% reduction in PTSD symptom level severity
associated with the services provided. Applying this symptom reduction level to the net annual
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treatment costs associated with PTSD within the VHA system equates to an estimated annual
savings of $3,463 per veteran (i.e. $5,900 x 0.587).
The benefits received from treatment with ART are believed to have sustained health benefits
well beyond the period in which services were provided. Therefore, to be conservative, we
estimate total ROI based on 10 years of benefits obtained from receipt of services, recognizing
that many veterans may experience benefits long beyond 10 years.
Therefore, the estimated ROI for each veteran who received services through an ART
program is:
$3,463 x 10 years = $34,630 per veteran.
With 5 veterans served and with complete pre- and post-assessment data, 10-year cumulative
savings are estimated at:
$34,630 x 5 veterans = $173,150 total savings.
Again, the above estimates do not consider alternative sources of cost benefits realized,
such as those among family members associated with veterans served, reductions in interactions
with the criminal justice system, and many other societal benefits.
ROI – Equine Therapy
The estimate of ROI for veterans provided services with Equine Therapy is based on veterans
with pre- and post-program data. For these 7 veterans served with complete data, mean pre- and
post-retreat scores on the 20-item PCL-5, a validated measure of PTSD symptom severity, were
50.0 and 28.0, respectively. This represents a 44.0% reduction in PTSD symptom level severity
associated with the services provided. Applying this symptom reduction level to the net annual
treatment costs associated with PTSD within the VHA system equates to an estimated annual
savings of $2,596 per veteran (i.e. $5,900 x 0.44).
The benefits received from treatment with Equine Therapy are believed to have sustained
health benefits well beyond the period in which services were provided. Therefore, to be
conservative, we estimate total ROI based on 10 years of benefits obtained from receipt of
services, recognizing that many veterans may experience benefits long beyond 10 years.
Therefore, the estimated ROI for each veteran who received services through an Equine
Therapy program is:
$2,596 x 10 years = $25,960 per veteran.
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With 7 veterans served and with complete pre- and post-assessment data, 10-year cumulative
savings are estimated at:
$25,960 x 7 veterans = $181,720 total savings.
Again, the above estimates do not consider alternative sources of cost benefits realized,
such as those among family members associated with veterans served, reductions in interactions
with the criminal justice system, and many other societal benefits.
ROI – Service Animal Assisted Therapy
An estimate of ROI for veterans provided services with Service Animal Assisted Therapy
(service dog) cannot be made at this time as no data are available for veterans after receipt of a
service dog.
ROI – Music Therapy
An estimate of ROI for veterans provided services with Music Therapy cannot be made at this
time as no data are available before and after receipt of services.
ROI – Hyperbaric Oxygen Therapy (HBOT)
An estimate of ROI for veterans provided services with Hyperbaric Oxygen Therapy (HBOT)
cannot be made at this time as no data are available before and after receipt of services.
Summary of ROI
From initial available data, the total estimated ROI for veteran who received services
through the Alternative Treatment Options for Veterans participating organizations is as follows:
Accelerated Resolution Therapy: $173,150
Equine Therapy: $181,720
Total Estimated Savings: $354,870
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