National Defence Committee on Nov. 26th, 2013

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

That's great.

Do some of the patients go back? Are most of the patients people who would be transitioning out of the armed forces or have just left, or have you treated patients who are serving members with certain disabilities and you're rehabilitating them to go back into some form of service in the forces?

[Helen Zipes]

That's a great question. All of the military patients we've had are active servicemen. While they're with us, that's considered their service and they are active members.

My understanding is there's quite a rigorous physical test that they have to pass in order to remain in the military, especially for some of them. We've had several patients who have stepped on IEDs, who are triple amputees, so they've lost both legs above the knee and an arm. Someone like that is not going to be able to pass the physical test to stay in the military. Someone like this sergeant is able to pass the test.

Part of the test is that they have to be able to walk a certain distance with a heavy pack, so we put the pack on them and they do training with it. There's another program with a rifle that they have to shoot at different things, and we can help train them and see how they do.

The reality is, though, that very few of our injured soldiers do remain in the military because of the difficulty in passing the exam. You have to remember that the rehab centre is a tertiary rehab centre, so we take people who have either been very severely injured in an accident or had a serious illness. We don't take people at the rehab centre who have just had a total hip or a total knee replacement. That's considered secondary rehab.

[The Chair, Conservative, Peter Kent]

Thank you, Ms. Zipes.

Go ahead, Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

Continuing on this conversation, Ms. Zipes, do you work with anyone with PTSD but without physical injuries?

[Helen Zipes]

The majority of our patients do have physical injuries. That's why they're at the rehab centre. Colonel Jetly, I believe is his name, is a psychiatrist with the military, and he has submitted a project to us to work with patients from the military with PTSD who don't necessarily have injuries.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

The reason I ask is there are some estimates that up to 3,000 of the armed forces members who served in Afghanistan may be presenting severe PTSD. If this is working as well as you're describing for normalizing some of the unexpected events and being able to do the physical tasks while doing mental tasks, there might be an application.

[Helen Zipes]

Absolutely. With our brain injury population, we have been working towards that, and Colonel Jetly's study will take it forward.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Yes, so severe PTSD is a brain injury.

[Helen Zipes]

Yes.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Is there any research that would take some of the principles of what this million-dollar machine does and develop more affordable Wii-type equipment that people could take home and continue to work, maybe not on a sophisticated level, but on some of the critical practices that they need for their rehabilitation?

[Helen Zipes]

Yes, one of the principles of rehab is that you want people to carry back to the community and to their homes what they've learned in rehab and to continue, absolutely.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Is that under development?

[Helen Zipes]

Yes, and where there's something that is commercially available, we use it, like the Wii.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

I'm interested, Dr. Germain, in what you see as a pathway between the research on sleep and practical on-the-ground use of that research in the Canadian Armed Forces. Is that occurring now and in what way is it occurring? What would you see as a next step if it's not occurring? Can you talk about life in the armed forces? Where would it reside? Would it be in the JPSUs? Would sleep be a prophylactic?

[Dr. Anne Germain]

I was talking to Dr. Jetly recently. I liked his approach to mental health from cradle to grave, basically from the moment people sign and join the military all the way to the time they retire and after. I think sleep can reside all along the continuum of military service.

The transition from research to practice is relatively straightforward in sleep, because most of us who do the research are also clinicians, or work very closely in clinical settings. I have been fortunate to be able to build and maintain collaborations with active duty, different leaders in the U.S. military to be able to take what we do in our research lab out in the field. The war fighter sleep kit is actually an example of this.

There are different ways of doing this. I think for us researchers and clinicians it is to be able to embrace and consider the military realities and take that information back to how we package our treatments, to make it as feasible and practical as possible. Again, it's all the way through, from the time people sign up all the way through to the time they retire, and beyond.

There are different kinds of efforts that are currently being made. Oftentimes in sleep intervention, there is this myth that sleep hygiene is sufficient to improve sleep, so have some warm milk before you go to bed and take a hot bath. That may all be good and fine, but in people who have clinically significant sleep disturbances, those techniques do not work. There aren't that many that work, and the strategies that do work are very straightforward. That's why I was saying with respect to disseminating, we still have a lot of work to do to disseminate what we know works, that it's biologically driven, for sleep into different clinical settings.

Clinicians are trained that sleep hygiene is the way to do behavioural treatments of sleep problems, where we do know that sleep hygiene, if anything, is a good control condition in clinical trials, because it doesn't work. What does work is very specific behavioural changes that people have to adhere to, such as getting up at the same time every day of the week, no matter how many hours of sleep they got the night before, and not to be in bed or stay in bed unless they're sleepy or sleeping. They sound simple, but they're pretty hard to do. If you want to try it at home, tell me how long you can stick with it.

We do know that if people stick with it for three or four days, the first thing that happens is they get tired and sleepy during the day. It's a sign that the treatment works. If they stick with it for two weeks, usually they don't have insomnia two weeks later. There are very rapid improvements in sleep.

We see it in research. We see it in different clinical settings with what we've developed and others have developed that have been implemented. As long as clinicians stick with it and encourage patients to really make those behavioural modifications, it can be very effective.

In terms of how we take it to the field, again it's challenging. The war fighter sleep kit, to my knowledge, is the only package that has been put together. It does include way too much language, too many things to read. That's one of the reasons I was saying there's quite a bit of work to be done on this prototype, but it is a marker of feasibility. We can do some things like this. We've conducted focus groups to get active duty service members' and veterans' feedback on what they would need, what they like, and how we can package it.

We're working on having an app, for example, where people can enter their information and get automatic feedback of what kind of behavioural changes would be recommended based on the kind of sleep problems and sleep patterns they report.

It can be linked to a clinician. We have one in development right now that is linked to a clinician—right now it's me—who can see how different people are progressing or adhering to recommendations that come from the app that are really based on the same kind of decision-making tree that I would use in the clinic or in the research setting, and follow how people are doing. With very minimal clinician intervention, I can encourage people to adhere more closely to the recommendations. We can track if their mood is changing, not for the better. We can have interventions. They can text us, call us, e-mail us. We can definitely use technology to make sure that those are packages that people are willing and interested in using and that we're also not over-burdening clinicians.

[The Chair, Conservative, Peter Kent]

Thank you, Dr. Germain.

The time is up.

We are moving into our second round of questioning, five-minute segments. Ms. Gallant, please.

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

Thank you, Mr. Chairman, and thank you to our clerk for arranging these fabulous witnesses.

My first questions have to do with the CAREN system. How long is the waiting list for soldiers as well as civilians?

[Sean Gehring, Manager, Specialized Care Stream, Ottawa Hospital Rehabilitation Centre]

Presently we don't have a wait list.

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

You don't have a wait list, but it's still used.

[Sean Gehring]

The way the arrangement was originally set up was that we dedicate time, 40% to the CF patients and then 60% of time to the patients of the rehab centre, and within that time is the maintenance of the machine itself. Presently we don't have a wait list, although we haven't utilized the machine for research as much as we initially thought we would, but the projects are lined up to come through, so maybe a year from now we might be in a different position.

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

Is this a unique machine or does it exist somewhere else?

[Helen Zipes]

There are other variations of this machine, but what's called the CAREN, the extended system, as I said, is only in four countries: Canada, the U.S., the Netherlands, and Israel.

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

Do we own this technology?

[Helen Zipes]

As far as owning this technology is concerned, the firm that sells it is Motek Medical from the Netherlands, but the components are outsourced from different areas across Canada and the United States. The cameras may come from the United States and the treadmill from other places.

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

It's not commercialized as a package and done across the country at—