National Defence Committee on Nov. 26th, 2013

[The Chair, Conservative, Peter Kent]

Colleagues, we have quorum. Today we will continue our study of the care of ill and injured Canadian Armed Forces members.

We have two groups with us today. Appearing as an individual we have Dr. Anne Germain, associate professor of psychiatry, from the University of Pittsburgh School of Medicine.

From the Ottawa Hospital Rehabilitation Centre we have Helen Zipes, clinical director of the rehabilitation centre and academic family health team, and Sean Gehring, the manager of the specialized care stream.

We will begin as usual with 10-minute presentations from each group.

Dr. Germain, could you take the table, please, and give us your 10-minute presentation. Thank you for travelling to be with us today.

[Dr. Anne Germain, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, As an Individual]

Thank you for inviting me. It's really an honour to be here today.

As you said, I am Anne Germain. I'm an associate professor in psychiatry and psychology at the University of Pittsburgh School of Medicine. I graduated in 2001 from the University of Montreal with a Ph.D. in clinical psychology and moved to Pittsburgh for a post-doctoral fellowship, where I joined the faculty in 2005.

Since then my research program there has focused on understanding how sleep disruption can compromise mental health and mental readiness in military populations, active duty service members and veterans, as well as on developing and testing sleep-focused treatments as a pathway to enhance psychological resilience and accelerate recovery from chronic maladaptive stress reactions in service members.

My research program has been continuously funded by the U.S. Department of Defense and the National Institutes of Health.

I want to take the opportunity today to demonstrate that sleep is a core component of mental health and mental readiness, especially for the armed forces.

Sleep is a fundamental brain function and biological process that is involved in sustaining mental and physical performance.

We all sleep, and we've all occasionally experienced the adverse effects of sleep disruption, but unless we have chronic sleep disturbances, we spend very little time thinking about sleep and its function, especially in a military context.

In 1981, Major-General Aubrey Newman wrote the following in his book:

In peace and war, the lack of sleep works like termites in a house: Below the surface, gnawing quietly and unseen to produce gradual weakening, which can lead to sudden and unexpected collapse.

This citation is a great illustration of how sleep disruption is really a threat to mental readiness and operational performance in military settings.

Sleep is essential for survival, and it's involved in different biological and mental functions, including emotion regulation, decision-making, learning and memory, as well as cardiovascular and immune functions.

Sleep can and will temporarily adapt to unusual and extreme demands and circumstances. However, we need to think about it as malnutrition. Chronic sleep deficiency will lead to organ damage and failure.

In the case of sleep, the primary organ is the brain. Failure and chronic damage means compromised mental health and readiness in our armed forces.

Sleep disturbances are the most common problems reported during and after military deployment. We have many studies now that show the likelihood of poor sleep quality and short sleep duration dramatically increases during deployment in service members. We also have quite a bit of evidence that post-deployment the sleep problems that occur during deployments do not return to pre-deployment levels. In other words, sleep does not just return to normal after people come home from different deployments.

That's true even when operational demands and stressors are terminated. In fact, in the U.S. among active duty service members and veterans we know that anywhere between 40% and 90% of those who have served in different theatres since 2001 report clinically significant sleep problems, including insomnia. It's true even in those who don't meet full-blown criteria for post-traumatic stress: depression, anxiety disorders, or mild traumatic brain injury, for example.

It's also important to remember that sleep problems are also prevalent in those who have not deployed. Luxton and colleagues recently showed that over 70% of non-deployed service members have a very short sleep duration, less than six hours a night, chronically. That number is about 30% in the general civilian population.

When we put that together, what we can realize is that our service members continuously operate and fulfill missions under conditions of marked sleep restriction, if not full-blown sleep disorders. This may very well be unavoidable during different military operations; however, it should and needs to be addressed when people come home so that the service members can return to their optimal levels of readiness and veterans can be best prepared to return to a healthy civilian life.

There's a very tight and robust relationship between sleep disturbances and poor psychiatric outcomes following exposure to stress or trauma exposure.

We know that sleep disturbances that precede or occur shortly after exposure to stress or traumatic events are a very strong predictor of poor psychiatric outcomes, and those include post-traumatic stress disorder, depression, heightened suicidality and other anxiety disorders, alcohol abuse and other addictive disorders, as well as the cognitive problems that are oftentimes associated with mild traumatic brain injury. The same observations, however, suggest that the preservation of sleep during stressful conditions or the rapid restoration of consolidated sleep after stress exposure is a pathway not only to enhance psychological resilience but also to accelerate recovery from expected stress reactions.

Although sleep disturbances are prevalent in service members and they are associated with an increased risk with poor psychiatric outcomes, they are a treatable condition. In other words, they are a modifiable threat to mental readiness and psychological resilience in military service members. We, as well as others, have shown that evidence-based treatment not only improves sleep quality in service members and veterans but also that sleep improvements are consistently associated with improvements in daytime symptoms of post-traumatic stress, depression, anxiety, and even cognitive functioning in those with mild traumatic brain injury.

There are two types of stress strategies for the treatment of sleep disturbances. The more behavioural treatments involve initiating and maintaining different sleep-promoting habits and behaviours. Those have shown to be highly effective in improving sleep and daytime consequences of sleep disturbances or of co-morbid psychiatric disorders. Pharmacological treatments can also be helpful, and when sleep is improved, we consistently see improvements in daytime functioning.

Even though we have effective sleep treatments that are evidence based, there is still a lot of work to be done to test their true effectiveness in military health care settings and in military populations. For example, the behavioural treatment of insomnia typically requires six to eight weeks of individual therapy delivered by a specialist in behavioural sleep medicine. This is typically not widely available, and it's not practical for most military health care settings, or in most military populations, for that matter.

By the way, engaging service members for two months of therapy is not a small challenge either.

Effective treatments that we have must be re-evaluated and adapted for the reality of military health care settings and the kinds of challenges that are faced by our service members. For example, we have shown that we can effectively treat insomnia within four weeks of using evidence-based educational material and personalized treatments that are delivered over a single 45-minute session and a two-week follow-up by phone. In this pilot trial we have seen full insomnia remission within four weeks in over 50% of people who received the intervention.

We've also worked to develop intervention packages that can be deployed and used in theatre. You may have seen an example of the war fighter sleep kit. It's a little box that contains information about sleep, an eye mask, and earplugs. It's not perfect. It's a prototype. There's still a lot of work that can be done to improve the impact, but this just shows that this kind of effort is feasible. We have deployed over 5,000 of these to service members deploying previously to Iraq and now to Afghanistan.

The last argument I want to offer in support of the notion that sleep is a core component of mental health and mental readiness is that sleep is a non-stigmatizing entry into mental health care. Everybody's sleep is disrupted during military training and military operations. Sleep disturbances are the norm rather than the exception during military service. Everybody easily acknowledges having sleep problems which do not bear the stigma of mental illness, so if we promote sleep health, we can actually provide an acceptable entry into mental health care where other psychiatric problems can be identified and adequately treated.

In summary, what I wanted to convey to you today is, first, that sleep is a core component of mental health and mental readiness in military samples; second, sleep disturbances are a threat to mental health but they are a modifiable threat. We can treat sleep disturbances with evidence-based treatments and therefore modify the risk that is associated with poor sleep in terms of psychiatric outcomes.

It's true there is still a lot of work to be done before we can effectively package and disseminate the evidence-based sleep treatments that we have, but I strongly believe that targeting sleep health can have a significant and rapid impact on the life of our service members and veterans.

In conclusion, I would like to recommend that the committee recognize that sleep is a core component of mental and physical readiness and mental health, and that efforts aimed at understanding, evaluating, detecting, and treating sleep disturbances should be encouraged and supported.

Thank you very much.

[The Chair, Conservative, Peter Kent]

Thank you, Dr. Germain.

If you would, please stay at the table as we invite Ms. Zipes and Mr. Gehring to make their presentation.

Those who are sitting too close to the screen, like us at this end of the table, will move back in the room for the deck presentation.

Thank you.

[Helen Zipes, Clinical Director, Rehabilitation Centre and Academic Family Health Team, Ottawa Hospital Rehabilitation Centre]

Good morning, everyone. Thank you very much for inviting us.

My name is Helen Zipes. I'm the clinical director of the Ottawa Hospital Rehabilitation Centre. With me today is my colleague, Sean Gehring, who is the manager of the specialized care stream.

Today I'm going to talk a little bit about the rehab virtual reality lab. I'll talk to you a little bit about some of the clinical results from the lab and a little bit about some of the research and innovative things we're doing here in Ottawa. I will end with a patient experience from one of the members of the Canadian Forces.

This piece of equipment, the CAREN, or computer assisted rehabilitation environment, was purchased for us by DND and was installed at the Ottawa Hospital Rehabilitation Centre. I'm very proud that we were the first in Canada to have this piece of equipment. DND purchased a second unit for Glenrose. Glenrose is the rehab hospital that tends to serve the military population in western Canada; we serve everything central and to the east.

This extended system is only found in four countries: the Netherlands from where it comes, the United States, Canada, and Israel.

We really have a wonderful working relationship with our military partners.

First of all, may I ask whether anyone knows where the rehabilitation centre is?

Most people don't know that we have this jewel here in Ottawa. It is in its own building, a two-storey building behind the General campus. We treat patients there who have had some sort of major illness or accident; something has happened to people to interfere with their functions, something very serious: either they have had a spinal cord accident, an amputation, or a brain injury. They come to us for rehabilitation.

We have an in-patient program. Usually we see about 400 in-patients a year. We also have a huge outpatient program. We see more than 60,000 outpatient visits a year.

Patients come to us to improve their function. Our aim in rehab is to get people back to the community, back home, if possible.

The wonderful thing about this lab is that it helps us speed up rehab. I'm going to show you a demonstration, but it puts people in a very realistic situation. As an example, take our amputee program. In the past, the physiotherapists and occupational therapists would work with the patients in the gym. We would go outside and work on uneven ground, but we waited a long time before we would take them outside, because we have to make sure that someone is not going to fall.

With this piece of equipment, we can progress the treatment much faster. It's a very safe way. There's a harness. We can work on different goals, be it balance, gait, cognition. We use it for a wide range of patients. Virtually all outpatients can qualify for the CAREN system.

We immerse the patient in this environment, and we're able to alter the screen and the program depending on what the goals of treatment are.

As you can see in the photo on the slide, there is a series of 12 motion cameras that circle the area. There is a platform in the centre that moves in six degrees of freedom, plus can also yaw. There are two treadmills, a dual-pace treadmill, in the centre of the platform. There is a sling system; we put the patient in a harness so that they can't fall and don't walk off the platform. There is a 180° screen that surrounds. It's like a giant Wii machine, but it's so much more immersive. We've added a few extra cameras as well on the bars on either side. You really get the sensation, when you're centred on the treadmill, that you're immersed in the environment.

The lab began operations in March 2011.

In the next slide is a breakdown of some of the conditions that we've treated.

I'm going to go to the next slide. I think this will be more interesting for you.

Of the patients we have had since 2008, we have had approximately 25 Canadian Forces patients at the Ottawa Hospital Rehabilitation Centre. We've also had two civilians who were injured in Afghanistan. We've had about 12 CF patients and have done about 61 patient sessions using this equipment. They have orthopaedic injuries, most of our patients with amputations, and then some other diagnosis.

CRPS is chronic regional pain syndrome; ABI is acquired brain injury; and we have also had a mild traumatic brain injury.

We've also used the CAREN system as an assessment tool. We assessed a group of 10 Canadian Forces soldiers who were participating in the Nijmegen march. We were able to put them on this treadmill. The Nijmegen march is really an endurance test. I don't remember the mileage they march, but I think it's 60 kilometres—it's huge—and it's four days in a row. These were all injured soldiers who wanted to make sure that they could participate in the march, so we put them through tests on this unit.

An interesting thing that the operator of this unit did—our operator is an aeronautical engineer and a kinesiologist, so she's ideally placed to work this unit—was to alter the program a little bit. She had the crowd throwing flowers at the soldiers in the unit, because apparently that's what happens in real life. I understand that some of the soldiers find it quite shocking to have things thrown at them; many of our soldiers have PTSD. This was a way of preparing them, to see how they would react if things were thrown at them. That was a really interesting application. This isn't just a Wii machine; it is really a therapeutic tool.

The really wonderful thing about this unit—which was very expensive, a little over $1 million—is, as I said before, that it's very safe. We can try things on this unit that would be very difficult to try in a gym or outside. It's a controlled environment. We can control the pitch of the platform and the speed; we can control the environment; we can add tasks to the environment.

There is one program in which people are walking down a road, and the road goes up and down. We have birds flying. We can add math problems, because as you walk you have to be able to look at things and recognize things. We can make the program harder or easier, depending on the needs of the patient.

We can really push the patient in this unit, and it really improves their confidence. We had a young woman who had lost a lower leg in Afghanistan. She was very tiny. She did very well with her prosthetic device, but she was quite frightened. She said she wasn't sure that she could keep standing, if she took the bus and got jostled about. We put her in this unit and we were able to simulate a stumble by moving the treadmill at different speeds. She did very well and she realized that she could go on the bus. It's been wonderful that way.

It really has shortened the rehab time. We want to rehabilitate patients as fast as possible and get them back to the community. This unit is helping us do that.

As I said, we work on specific goals, be it weight-shifting, on feet or balance.... I have included “fun” on the clinical results slide. It is fun. Walking back and forth in a gym on parallel bars is not fun, and people don't stay at it that long. When you get them into an environment like this, especially our military members, who are athletes, very well-conditioned men and women, you have to push them a little bit more. This unit has been wonderful for that.

The unit is also for research. Some of the studies we have started and that we have planned on are ambulation and walking, psychology, post-traumatic stress, driving, and using a wheelchair.

In the next slide, these are things that some of our scientists, our engineer operator, and the team—when I say the team, this is really a team—the patients, the operator, the physiotherapist, the OT.... We haven't yet used it for speech therapy, but I understand there are some applications, and that's something we may consider. This really is a team.

These are things that have come from the patients who have told us, “We need help. What do we do if we trip? What do we do if we slip?” These are some of the projects that we're in the midst of right now. At the centre we have both upper and lower limb amputees...treadmill, slope adjustment, navigation.

I'd like to tell you about one of the gentlemen, a sergeant, who has used our unit. He unfortunately stepped on an IED in Afghanistan and lost his leg above the knee. He also had severe trauma to his arm. There was some worry at one point that he was going to lose his arm, but we've managed to save his arm. He doesn't have an elbow joint. His elbow is quite flail, but he's quite functional. He was admitted to the centre in April 2011. Originally when we asked him what his goals were, he said,“I want to be able to walk on the grass with my prosthetic.” His grandfather owns a farm and he wanted to be able to walk on the grass.

He had some further complications from his arm, as a matter of fact, and he had to have further surgery to debride the wound. Then he came back to us in May, and his initial cast for his prosthetic limb was made in June, and two weeks later he took his first steps with his prosthetic limb. On June 20, he had his first CAREN session.

This is a photo of the sergeant, and you can see it's his left leg, so he's missing his knee and his ankle. He has an above-knee prosthetic.

This is a program that was developed. It's like a maze. There are force plates under the treadmills, and there are markers put on the patient so that we can get objective data as well from this unit. This program, the maze, helps him with weight shifting, weight bearing, balance, and he has to be able to navigate the maze.

This is an example of one of our programs. It's a boat. You can see how he's moving back and forth. You see him in his harness so he can't fall. He has to navigate weight shift. There's a lot of muscles that come into play when you're with static stability, weight shifting. The waves are an added obstacle.

I'm going to go on to the next slide now. Here we have him walking down a slope, which is very difficult to do with a prosthetic limb. Don't forget, he doesn't have his knee or his ankle. I don't know if you can see, but in here it's quite a steep angle, and with this program we can either self-pace it or the operator can set the parameters for the unit, but we get objective data and we're able to progress the patient.

Again, I thank you very much for this opportunity. Our partnership with DND has been a wonderful one. This unit is available for our military patients, but also for our civilian patients, and we do use it very heavily. It has been a wonderful addition to our centre.

[The Chair, Conservative, Peter Kent]

Thank you very much.

We'll proceed now with our first round of questioning, seven minutes for question and answers, beginning with Mr. Opitz.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Thank you, Mr. Chair.

Thank you all for appearing today. Both presentations were quite enlightening. I understand the use of this machine is brilliant. Because most of these guys use video games and all kinds of things, they're adept at that. We actually used a video for a shooting-package program that we have.

We do all of that, and that's why they're so adaptable to this. In fact, I had a friend who joined the Canadian Forces with a prosthetic leg, way back in the day. He's just about to retire soon, so he's been around. He walks on grass just fine. In fact, he did his sergeant's training with a prosthetic leg.

You were saying this costs about a million dollars?

Would an occupational therapist be able to use this?

[Helen Zipes]

Yes. We've trained our physiotherapists and our occupational therapists. As I said, we're hoping that some of our speech therapists.... I understand there are some programs where you get instant feedback on how your mouth is moving and working.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

I'll leave that. Mr. Norlock is interested in technology, and I think he's going to talk to you about that.

I am interested in the brain injuries. Dr. Germain, have you worked with DRDC, Dr. Harvey Moldofsky?

[Dr. Anne Germain]

No.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

He's done some very similar research. They're working on brain injuries and sleep as well.

Having formerly served, I'll tell you that you don't get a lot of sleep on exercises or other things. Your sleep patterns are disrupted. Having observed veterans not only of my generation, but older ones, my parents and people like that, I know these things tend to be lifelong if they're not treated. I applaud the research you're doing.

Is this something you could also develop for pre-treatment, before soldiers deploy, to try to identify people who may be susceptible to sleep disorders, brain disorders, PTSD, and start treating that ahead of time? You have the war fighter kit, which is something I suspect you'd use while you're deployed. It has earphones and calming music, or...?

[Dr. Anne Germain]

There are different elements. On the CD there are actually different tracks of white noise to help people sleep or relax in a different environments. There's a self-administered treatment that is also included on this that guides people step-by-step on how to get rid of bad dreams or how to facilitate sleep onset, for example. It's basically material that we use in the clinic that we made more interactive and streamlined even further, so that people could use it.

Yes, we can detect sleep disturbances or vulnerability to sleep disturbances before people deploy. Because sleep is a modifiable behaviour, we can also train people ahead of time to get more consolidated sleep or get more bang for their buck, basically, so that when they can sleep, when the opportunity presents itself, they can get the most out of it, get the most sleep that they can. The use of scheduled naps is an example. There are different strategies that are applicable well before deployment, during training, to enhance not just sleep health, but also mental readiness.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Most soldiers are actually quite good at finding those catnaps.

[Dr. Anne Germain]

They're so sleep deprived they can fall asleep very quickly.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

You learn to do it, and it becomes a skill, quite frankly.

Do you use any chemical markers? I saw in your presentation somewhere that you talked about serotonin. Do you experiment with melatonin levels and that kind of thing?

[Dr. Anne Germain]

What we've used in the clinic is prazosin. It's an alpha-1 antagonist that has been very useful. Actually, it's the medication that had the most evidence for treating nightmares related to post-traumatic stress, sleep disturbances, and insomnia as well.

There are two issues we have with pharmacological agents. One is what can we use in theatre that is safe, because people need to wake up quickly oftentimes and be ready to perform, and you don't want to have any of the residual hypnotic or sedative effects.

With people with post-traumatic stress, our typical sleep medications perform very poorly, except for prazosin. There are plenty of different agents that have been used with mitigated success. I think for pharmacological intervention, generally speaking, it's really an art combined with science to personalize what is the exact agent or combination of agents that will help people most in terms of sleep, and have the least residual side effects.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

I also like the fact that it is a non-stigmatizing thing. It's a sleep disorder and people can accept that a lot better than other labels that are put on it. I think that's a very useful way of dealing with it, because there are the body rhythms and things like that and people deploy to different places, different times, and their body rhythms are not going to be regulated.

You talked about post-deployment and bringing people back and a treatment that you had that could work effectively in potentially as little as four weeks. If this helps our soldiers get back and mitigate a lot of these issues as they return, it will help mitigate some of the long-term effects.

Can you talk a little bit more about that, please?

[Dr. Anne Germain]

It's delivered over four weeks, but what really is involved is a single in-person session—and we have done it by phone or by Skype as needed—where we provide people with basic education about sleep physiology: what the mechanisms are that control sleep, and how we can change some behaviours while we're awake to facilitate alignment of these mechanisms that control sleep to improve sleep quality. Those are very simple, straightforward treatments. They are called stimulus control and sleep restriction. They do need to be personalized to work well, but we can provide the education and personalize the strategies in less than an hour with an in-person session.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

All right. I just have about half a minute left here.

What have been your findings? What are your results from working with American soldiers with this treatment?

[Dr. Anne Germain]

Because of the fact that military people have extreme discipline, we can actually leverage that, provide them with information and basic guidance on what are healthy sleep behaviours. This includes: get up at the same time every day of the week no matter how many hours of sleep you got the night before; don't go to bed unless you're sleepy or sleeping; and don't stay in bed unless you're sleeping.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Do you have stats on its effectiveness right now?

[Dr. Anne Germain]

In just telling people—we actually give them a pamphlet with the information—we found that 50% no longer had insomnia within four weeks. They were good sleepers.

For those who spent 45 minutes with us in personalizing these sleep habits based on their own sleep patterns, 80% of the people were actually fully remitted from insomnia after four weeks. Four weeks from the initial in-person session, 80% no longer had insomnia. They fell asleep quickly, they stayed asleep, and they woke up rested in the morning.

[The Chair, Conservative, Peter Kent]

Thank you.

Mr. Harris.

[Jack Harris, NDP, St. John's East, NL]

Thank you, Chair.

This is a fascinating presentation from both of you.

Dr. Germain, first of all, could I get one of those kits? I say that because, although it's obviously designed for extreme stress situations, it seems to me it may well have application quite generally in the population.

A newspaper article a couple of days ago reported on sleep as a therapy for depression and I was absolutely astounded at the findings. I studied psychology in my early days, and did a lot of work in the 1990s with people with post-traumatic stress disorder, and with those who had a lot of depression, etc., resulting from sexual abuse. The rate of recovery from depression being reported is astonishing; the best discovery since Prozac, I think the article said. I don't know if it was about your work or not. It's better than Prozac. How come it has taken so long to find this out?

Are there any lessons to be learned for the military in terms of how you operate? Maybe you don't need to get people up at 4 a.m. to run three miles unless it happens to be a war zone and you have to do it because it's part of the defence. Are there lessons to be learned as to how you treat soldiers in general as well as how you treat them after the fact?

[Dr. Anne Germain]

Absolutely. That work was by Colleen Carney at Ryerson University in Toronto. She's done an outstanding study.

It also shows that when you focus on sleep, you show dramatic improvements in depression.

The thing about sleep is it is transdiagnostic. It's not just true for post-traumatic stress or depression, it's true for anything that relates to mental health. When we target sleep we can have a direct impact on daytime symptoms, whether it's anxiety or mood disorders.

It is true for military populations. It's also true for civilians. I think it's a little bit different for the military because of the different sleep demands related to training and operations. That's why I was saying we need to adapt what we're doing so it does fit the reality of the military context, but it is definitely feasible. Treatments are adaptable and should be adapted to fit that reality.

[Jack Harris, NDP, St. John's East, NL]

I think we all know about the sad but unfortunately too often occurring instance of the soldier in the basement, the post-deployed soldier who can't get out of the basement, or can't do anything because he is clearly depressed as well as frightened about going outside.

It strikes me that this therapy may actually hold some promise for that as well.