National Defence Committee on Nov. 26th, 2013

[Sean Gehring]

In Canada there are only two sites, the Ottawa Hospital Rehabilitation Centre and Glenrose Rehabilitation Hospital, that have this particular version of this machine. There are universities that have the CAREN basic, which doesn't have the platform, and the pit, and the six degrees of freedom. It's basically standard treadmill force plates.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

In this, with your patients, do you have occasion to measure the brainwave activity concurrently as you're doing the—

[Helen Zipes]

No.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Would that be the subject of a science experiment then?

[Helen Zipes]

It would depend on what you wanted to measure.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Okay, it hasn't been used in conjunction or collaboration with your eye movement desensitization and reprocessing therapy at all.

[Helen Zipes]

Yes, actually with vestibular therapy, absolutely. You can cause the platform to perturb, to move in different directions, and depending upon what you're working on you can have the screen with different images. Definitely it could be used for people with vestibular problems.

We're learning as we use it as well.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Okay, how is the CAREN used to help patients with traumatic brain injuries?

[Helen Zipes]

It depends on what the symptoms are or what the deficits with the patients are. Someone with a mild injury may have memory problems. They may have visual field problems. They may have neglect. Some of our patients, depending on where the brain injury is, may forget about one side of their body, so the system forces will force them to do different things to remember that, yes, I do have a left arm and a left leg, or it will force them to try.

We're always trying to give people a way of overcoming their deficits. I can give you an example. We had a young man who had a fairly serious brain injury. He looked very normal. If you saw him walking you'd think he was quite normal, but he doesn't have short-term memory. It's very hard to live if you don't have short-term memory, so we use technology to help him. One of the things we do is program his BlackBerry or his iPhone and it will beep, and we train him that when it beeps to look at it, and it will say, “get up, get out of bed, brush your teeth, eat, get dressed”, or whatever is needed.

It's the same thing with this machine. For whatever is needed, our operator can write a program and insert things into it so that as you're walking and you meet someone.... What do you do when you meet someone? You stop, you say hello. There are things we can program to try to make it more normal for these patients.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Okay, what about the complex regional pain syndrome? How has this been used?

[Helen Zipes]

With complex regional pain, for instance, in the shoulder, you have probably heard that people have frozen shoulders. Because of the pain you're not using your arm, and the more you don't use it, the weaker it gets. With this program there is one program where there are balloons, and you have to reach up and pop a balloon as you're walking. When you're immersed in the program you forget about your pain and patients will absolutely reach higher, because we have the objective data. If you do things with them in the gym and you just say, “Okay, I want you to walk your fingers up the wall”, which is a common exercise, they don't get very far, but if you put them in this machine and they're walking and they sort of forget, and there is a balloon coming and they reach for it, then they go much farther. We have markers on their joint, so we can measure their shoulder and the range of motion moved.

[The Chair, Conservative, Peter Kent]

Thank you, the time has expired.

Madame Michaud.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Thank you very much.

First, I want to thank you for your presentations. They were very interesting.

My first few questions are for Dr. Germain.

I was going to ask you a question about this, and I am pleased you spoke about it. You said that timely screening of sleep problems was good for diagnosing and effectively and quickly treating other mental health disorders.

What is the success rate for overall treatment of operational stress injuries when a sleep problem is involved?

[Dr. Anne Germain]

I'm going to try to answer you in proper French.

Based on the data we have on treating post-traumatic stress, be it through cognitive behavioural approaches or medication, the best we can expect is a 40% to 60% success rate. I'm not talking about remission here, but really a response to treatment. The success rate with the placebo is between 30% and 40%. Right now, treatment strategies for post-traumatic stress syndrome can improve symptoms, but full remission is rare. The same thing is true for depression.

According to a study published recently by Colleen Carney, when treatment for a sleep problem is combined with treatment for post-traumatic stress, considerable improvement is seen in the response rate and remission. Studies to date are too small for us to draw definitive conclusions. However, based on studies conducted so far, there is one area that has some potential, and it involves knowing whether the combination of treatment for a sleep problem and treatment of other symptoms, such as symptoms of post-traumatic stress, would result in a better success rate, not just for the response but for complete remission, as well.

Post-traumatic stress syndrome is not simply having anxiety in response to various stimuli while you are awake. It really is a sleeping and wakefulness problem. We should test treatments that manage to treat symptoms experienced at night and during the day. I would expect that the success rates will be much higher than they are currently.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

In another part of your presentation, you spoke about certain challenges related to pharmacologic treatments of problems like that. Could you also tell us about challenges related to overmedicating, and the abuse and misuse of prescription medication?

[Dr. Anne Germain]

That often happens with sleeping pills. Clinical practitioners are often reluctant to prescribe benzodiazepines to treat sleep problems because of the potential for abuse and dependency. Based on what we know, in any event, this type of medication is not really effective for military personnel, probably because they have a hypervigilance that the civilian population doesn't have, including those people who have chronic insomnia that isn't linked to post-traumatic stress syndrome.

I forgot the start of your question.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

You still answered it well. My question was about the challenges related to the risk of overmedicating, and the abuse and misuse of medication.

[Dr. Anne Germain]

There's also the issue of interactions between various medications. Someone may consult a clinical practitioner who prescribes a certain medication, and then that person consults a different clinical practitioner who prescribes another medication for something else. Communication between clinical practitioners must be very open and very clear to ensure that there are no negative interactions.

There's something else. Side effects are one of the main reasons why people don't take prescribed medications. For young male military personnel who are given an anti-depressant for post-traumatic stress, depression or a sleep disorder, the sexual side effects of such a drug will be the primary reason they don't want to take it. If they do take it, they do so very irregularly, when it won't interfere with the activities they have planned.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Ideally, a combination of behavioural therapy and medication is used. Unless I'm mistaken, medication alone is generally somewhat effective.

[Dr. Anne Germain]

Yes, that's true.

[Élaine Michaud, NDP, Portneuf—Jacques-Cartier, QC]

Thank you very much.

[The Chair, Conservative, Peter Kent]

Thank you.

Mr. Allen.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Thank you very much, Mr. Chair, and thank you to our witnesses for being here. I apologize for being late. We have too many meetings around here.

I want to follow up on something. Dr. Germain, you were nodding vigorously when Ms. Gallant asked her question about scanning brain activity.

I'd like to get you to finish the thought.

[Dr. Anne Germain]

I'm a sleep researcher, so I started doing EEG research and looking at brain activity and how we use neuroimaging to address some related questions on sleep and on post-traumatic stress disorder.

I was nodding for a different reason.

If you can have objective markers for rehabilitation efforts or for post-traumatic stress disorder or for sleep that identify clinically significant improvement, or that can predict whether or not a patient is maximally benefiting from any kind of intervention to guide the clinical decision-making process that is going on.... For example, if we had any biological marker to indicate that a person is not likely to respond to medication, we wouldn't necessarily add another medication or keep them on the same treatment for an extended period of time. Knowing early on that they're unlikely to respond, we could intervene very quickly and adapt and re-evaluate the treatment plan to get to success and treatment much faster.

I was nodding because EEG is kind of dear to my heart, but also because it broadly and more globally touches on the questions of identifying objective markers of the recovery process and likelihood of response to treatments.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Okay, thank you.

I subscribe to a Twitter post from a fitness place. One of the comments this morning was that the best bridge between despair and hope is a good night's sleep. It is interesting that we're hearing that this morning as well.

Referring to your slides, in one you talk about sleep across the deployment cycle and match that to the next slide, which is the non-deployed service members. As I said, I wasn't here at the start, but for the non-deployed, it says that the odds of trouble sleeping are less, but then the other one says that non-deployed service members sleep less.