National Defence Committee on Dec. 10th, 2013

[The Chair, Conservative, Peter Kent]

Thank you very much, General.

Thank you, all, for your appearances here today. Although this mission still has the rest of the course to run, we'd appreciate it if you could convey the committee's congratulations and an interim “well done”. Thank you.

[MGen Michael Hood]

It would be a pleasure. Thank you.

[The Chair, Conservative, Peter Kent]

We will suspend now as our witnesses from the first hour depart and we seat the witnesses for our second hour.

Thank you.

[The Chair, Conservative, Peter Kent]

All right, colleagues, we will resume. Time is of the essence.

We have 45 minutes to hear two witnesses. We have before us from the Canadian Chiropractic Association, Eric Jackson, doctor of chiropractic, and Ken Brough, a doctor of chiropractic, and board member. From the Veterans Transition Network, we'll hear from Tim Laidler, executive director.

You have 10 minutes for opening remarks. You may wish to keep them to a minimum to allow for questioning. That could work to your advantage.

Mr. Jackson or Mr. Brough, go ahead, please, for 10 minutes.

[Ken Brough, Doctor of Chiropractic, Board Member, Canadian Chiropractic Association]

Thank you very much, Mr. Chairman, for the introduction and the invitation to present to this committee.

Good morning, honourable members.

On behalf of the Canadian Chiropractic Association, the profession and its patients, it is my pleasure to be here today along with my colleague, Dr. Eric Jackson. We are both in clinical practice here in Ottawa.

My name is Dr. Ken Brough, and I am a director of the Canadian Chiropractic Association. Dr. Jackson was the CCA representative on the recent Canadian Forces expert panel on low back pain.

The Canadian Chiropractic Association is a national association representing 8,400 highly trained and regulated doctors of chiropractic. Today is, in fact, the 60th anniversary of the founding of the Canadian Chiropractic Association.

Seven years of post-secondary education and training prepare chiropractors to assess, diagnose, and manage musculoskeletal, MSK, conditions that include conditions of the low back, neck, muscles, and joints of the extremities.

Thank you to the committee for the invitation to discuss the impact of MSK conditions on our men and women in uniform.

This morning we will suggest strategies to help keep injured soldiers on active duty at lower cost. We have provided a written submission that provides more details on the issues we have raised today, and a proposed strategy for addressing the tremendous impact of MSK conditions on the military.

MSK conditions are an occupational hazard for every military; in fact, the prevalence of low back pain in the Canadian military is double that of the Canadian population. Of all medical releases, 53% are for MSK conditions. Likewise, non-deployment is more likely due to MSK conditions than any other reason, including family, illness, or mental health.

Besides the obvious impact on the resources and operational readiness of the military, MSK conditions may also lead to a lifetime of chronic pain, complicating the return to civilian life. Half of the health claims of veterans are MSK related. It could even complicate mental health treatment for those soldiers and veterans relying on opiates for pain relief.

As a result, the cumulative impact of MSK conditions is significant and deserves more attention than it has received to date.

Being a soldier is one of the most physically demanding careers. Rarely do jobs have comparable risks as those of a soldier. Activities including jumping out of a plane with a fully loaded pack, a fighter pilot wearing heavy headgear being subjected to G-forces, or the demands of constant training place significant stress on the musculoskeletal system.

The stakes are high. For example, consider the training of an air fighter pilot, which takes years, at a cost of $2 million or more. Keeping these men and women operational is crucial.

Neck pain is a particular problem. To prevent and quickly address early symptoms, proper management is needed. The culture of being a soldier works against seeking early care. Soldiers are trained to be fighters and to ignore early signs of trouble. Evidence shows that delaying treatment often makes the problem worse and more expensive to treat. Even if they were interested in preventative care, it is often not available. Seeking treatment risks being put on sick parade.

It is reasonable to draw a parallel between soldiers and professional athletes. Olympic athletes and professional sports franchises employ a team of therapists and health professionals, including chiropractors, to promptly address impairments and prevent injuries. The integrated support team approach commonly used in athletics uses each member of the team, contributing their strongest skills and competence.

Now I'd like to turn our presentation over to Dr. Jackson.

[Eric Jackson, Doctor of Chiropractic, Canadian Chiropractic Association]

Thank you, Dr. Brough.

What can we do today? We can do better at less cost. That's why we're pleased to have this time with you. We're proposing to build on what works for other militaries. We commend the recent efforts of the CF to look at new approaches, as they've done with mental health.

Let's reflect on our role as chiropractors and the care we can provide to soldiers. Our primary therapeutic approach is spinal manipulation, which evidence shows is an important clinical tool in treating musculoskeletal conditions. Spinal manipulation is recommended by numerous clinical practice guidelines, including the U.S. Veterans Administration, the Bone and Joint Decade task force, the American College of Physicians, the American Pain Society, and Britain's National Institute for Health and Care Excellence.

Manipulation is often complemented by other therapies, including rehabilitation, and is readily available on base to soldiers in the U.S. While other professions can do manipulation, 94% of spinal manipulation in Canada is performed by chiropractors. Our proficiency and competence in spinal manipulative therapy and musculoskeletal care makes sense for soldiers who must bear the burden of these injuries. This is why chiropractic services are already recognized by both the Department of National Defence and Veterans Affairs Canada as part of an extended health care benefit.

However, access to chiropractic services for the Canadian military is limited. Physicians, nurses, and physiotherapists can refer a soldier to chiropractors based in the community, typically after an extended period has passed and when nothing else is working. The patient is now considered chronic and we know that intervening earlier in a team-based setting can greatly improve outcomes and prompt return to duty. In fact, most other Canadians, even the families of our military members, have better access to chiropractic care than the soldiers themselves in dealing with these service-related injuries.

Our role is to complement primary care providers such as medical doctors while they coordinate care. This role is well supported by evidence. I can provide an example.

A 38-year-old active duty instructor pilot was suffering from neck pain for two years with little relief. He managed primarily with the use of anti-inflammatories until being referred to a chiropractor. He received treatment over a four-week period, which included manipulation complemented by home exercise. At follow-up he reported no pain or stiffness, and he had a full range of active movement in the neck. He returned to full duty without symptoms. This is only one example of the role chiropractors play in coordination with primary care. However, the delays experienced continue to be a reality. Given the tremendous impact, an MSK strategy is needed to help more members of our military get the timely care they need.

Better care doesn't have to cost more. The evidence is clear. A U.S. military study published this year in Spine, by Dr. Goertz, found that the chiropractic care provided as part of a health care team decreases pain and improves function, which decreases overall costs. Similarly, another U.S. study by Heymans concluded that the addition of chiropractors resulted in faster recovery for injured soldiers.

Also, the Veterans Health Administration in the U.S. is considered to be a model to emulate. Veterans have an array of services available, including chiropractic care. This allows for significant improvement in pain, function, and overall savings. The model is collaborative and similar to the Olympic care model for athletes. The soldier and veteran are at the centre of the care model.

Canada has an obligation to provide the best care available to members of the Canadian Forces for their unlimited dedication and sacrifice. However, this requires some rethinking of the health delivery system in order to provide better care at better value. CCA has been encouraged by recent CF efforts to address the management of lower back pain through an expert panel by developing a care pathway. CCA would suggest that DND and the Canadian Forces build on recent efforts to develop a mental health strategy and invest in a broader and more systemic musculoskeletal strategy. We've included details in our written submission.

Back to you, Dr. Brough.

[Ken Brough]

Thank you, Dr. Jackson.

I'm pleased to inform you that the CCA is also making our own direct contribution to improving MSK care. As part of our role in the recent DND expert panel on spinal health, the CCA has offered significant funding for a research project on five CF bases, introducing chiropractic care as part of the health care team. Our offer is currently under review. We are encouraged by the interest shown by CF leadership.

The chiropractic profession in the U.S. celebrates the opportunity to use their clinical skills on 51 military bases to improve the lives of their soldiers. We're here today hoping, with your support, to do the same for Canada's chiropractors. The evidence shows the strong value of chiropractic care.

We believe that a comprehensive MSK strategy will identify the importance of improved access to spinal manipulation delivered by chiropractors. The MSK strategy we propose should be a coordinated effort between the Department of National Defence, Veterans Affairs Canada, and other stakeholders to ensure that active and retired soldiers are provided the best care possible. There are many successful team care models, showing that each profession making its full contribution delivers better care at better value. We welcome the opportunity to be part of this solution.

Thank you very much for your time and attention. We'll be happy to take any questions.

[The Chair, Conservative, Peter Kent]

Thank you very much.

We'll have opening remarks, please, from Mr. Laidler.

[Tim Laidler, Executive Director, Veterans Transition Network]

Thank you so much for having me here. My name is Tim Laidler. I'm the executive director of the Veterans Transition Network. It's a non-profit organization started by the University of British Columbia, which is based on a 15-year research project called the veterans transition program.

I came into this position because I served in the military. At 22 years old, I was deployed to Afghanistan. My job was to guard supply convoys driving through Kandahar City. As many of you know, that was the primary danger at the time, with the suicide bombers and the IEDs.

Before I talk more about my story, I want to bring everyone up to date on what we've learned at the Veterans Transition Network, and hopefully give some information and share some of the learning points we've had in our organization.

The first one I want to talk about is post-traumatic stress disorder. PTSD is probably the most well-publicized mental health condition associated with the military around the world right now. However, what we've found in the Veterans Transition Network is that this is not the only issue confronting veterans in their transition. In fact, PTSD on its own is probably the easiest thing for our clinicians to treat. The more complex issue is the psychological identity transition that takes place when they leave the military.

The post-traumatic stress symptoms on their own are often managed by one-on-one therapy, and they have lots of evidence proving their effectiveness. The complication comes when someone has to reinvent themselves moving from a military career to civilian life and has to deal with some of these post-traumatic stress disorder symptoms, and potential depression symptoms and other mental health issues. This transition piece is where the real problems are.

If I can leave this committee with one message, it's not to just invest in the mental health area; it's to invest in the transition areas as well.

The statistics for post-traumatic stress rates in the Canadian Forces are often a bit disputed. The numbers across the forces are quite a bit lower than many people would expect. We see this as being for a number of reasons. There are good programs available to veterans and military personnel within the forces, but there is also the stigma to come forward for help. There are all sorts of confounding variables that lead to people not wanting to be put on a medical category, to not admitting to their peers and their cohorts that they have sustained an injury and risk losing their careers.

When we're looking at the PTSD statistics, we don't want to have it contained to reducing the statistical number of PTSD cases and somehow the issue is over. In fact, I think it's going to be quite the opposite. What we've learned at the Veterans Transition Network is that it is this other piece that gets quite complicated, though it is quite fixable, as I hope to share with my story at the end of this presentation.

The next thing is to give everyone a little more background on the actual program that we deliver. The Veterans Transition Network delivers 10-day programs across the country. We fly our clinicians into small towns, into the communities where veterans are in need, and deliver a program over two months. It's 10 days altogether, and it's residential. It's broken up, though. It's four days in the retreat and two to three weeks back in the veteran's home community where they practise their skills. They start to integrate with their families and back into their employment. They come back to us for another four days, and then again there's a two to three day break. Then in the final two days, they do their check-in and completion of the group.

The power of this program, and what makes it very unique, is that we are using a strength that most military people come to us with, and that's how to operate in groups and support one another. The peer-to-peer recruitment model is another key aspect. Veterans go back into the communities once they leave our program, grab their friends out of their basements, and say, “You have to take this program. This is something for you.” We find that this peer-to-peer element really helps overcome that stigma.

That sort of shifts towards my story. That's how I got into the program.

When I came back from Afghanistan, I was finishing my fourth year at the University of British Columbia. I was 23. I was hard, and I didn't need any sort of therapy. It wasn't until a friend of mine who was working for a professor at UBC, Dr. Marv Westwood, strongly encouraged me to take a look at this program. I said, “I don't have that PTSD stuff. I've talked to a psychiatrist. I have a couple of the symptoms, but I don't have PTSD.” He said to come and take the program and that maybe I could help out some of the other people there. I did, and it was exactly what I needed at the time.

The program put me into this group context where I saw other veterans who were hard men, with tattoos up and down their arms. They were the first ones to show me that it's okay to talk about the impacts some of the hard things overseas can have. It was not only showing me it was okay to talk about it, but when I did that, it could actually bring some of those things to rest. It could conclude some of those hard distressing images that can go through your mind over and over.

One of the things that did come home with me occurred on one of our convoys. It was just another day in Afghanistan. There was a suicide bomber that detonated on the convoy in front of us, and we pulled up on the scene to the chaos that was going on in the middle of Kandahar City that day.

The vehicles we were in, the RG31s, were excellent. They protected all the Canadians involved in the incident. I think the lead gunner had an injury to his arm.

We pulled up. We were very thankful that all of our people were okay, but what we weren't prepared for was the toll it was going to take on the civilians. That suicide bomber killed 17 Afghan civilians that day right in the middle of their shopping district; men, women, children, it didn't matter. Obviously the scene was quite horrific.

That's something that stuck with me, the image of those people and what remained of them. When I came back to Canada, again, I didn't have PTSD, but I had this loop over in my mind: What if we had just got there a little bit sooner? What if I could have got out of the vehicle and helped the one person I saw who wasn't quite dead yet? What if? What if? What if?

This takes a real emotional and mental toll on you, playing it over and over and over. Nothing helped until I told that story to this group with the Veterans Transition Network, and then got the feedback from my colleagues who had also seen similar experiences. They said, “You know, it sounds like you were a good soldier. It sounds like you really did all you could do.”

It wasn't until I got that from my peer group that I started to really accept that I had tried to do everything I could in that situation. It led me to start to close that loop that was going over and over and burning up all that mental energy. I was able to then refocus myself and continue to do well in my studies. I went back to the University of British Columbia to do a master's in counselling psychology and helped to grow the Veterans Transition Network.

In closing, I hope that by presenting here in front of you today I can leave you with the message about focusing on the transition, as well as the mental health issues for military leaving the forces, but also to say with a small investment.... This 10-day program really helped turn it around for me. Since then, as I have said, I've gone back to complete my master's in counselling psychology and I've helped raise over $2.5 million to grow this to a national organization.

Thank you very much.

[The Chair, Conservative, Peter Kent]

Thank you very much, Mr. Laidler.

Ms. Gallant, would you begin the round of questions, please.

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

Thank you, Mr. Chair.

What are your organization's sources of income, Mr. Laidler?

[Tim Laidler]

The primary source has been the Royal Canadian Legion. They've funded this project for the last 15 years in B.C. as a research project. Within the last year, we've received support from the True Patriot Love Foundation, Wounded Warriors, and the Dominion Command of the Royal Canadian Legion to expand it nationally. We're also excited to say that last year Veterans Affairs accepted us as a registered service provider, meaning that they'll pay for their clients to come through our program.

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

What is the cost to the veteran who participates in this program?

[Tim Laidler]

There is zero cost to the veteran. We pay for all their travel, all their accommodations, and everything to take the program.

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

How does your organization decide to which communities it will offer the program?

[Tim Laidler]

Currently, we are doing it on a needs basis. We have focused on the east coast because we've seen that there's a higher proportion of veterans out there. From here, we're building it out to where we get the most traction. Often they'll be one of our graduates who'll go back to the community and tell us that they have five people who are sort of interested, and we curtail it to where we're able to get that traction. Even though it is a really great program, it's still difficult for us to get veterans to come forward and take it, so we do require that peer-to-peer recruitment assistance.

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

Are you coordinating at all with OSISS?

[Tim Laidler]

Yes. Some of our graduates are actually OSISS operators. It is a good source for our recruitment.

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

When you're selecting the areas to go to, are you focusing on where there are a number of veterans from some conflict, or are you focusing on areas where there's a military base associated, or are you going to the places that would not necessarily have the resources of a JPSU available to them?

[Tim Laidler]

We've been going to the smaller communities, especially in areas where there's a large reservist population and perhaps not a major regular force base presence. That being said, we still do see a need in those areas, too. Then, ideally, we'll have programs running to support all the different generations.

Again, this started in 1997. This was before Afghanistan, so most of the people coming through the program before that were Bosnia-era veterans. Currently, we have mostly Afghanistan veterans, but there is often one of the peacekeeping-era veterans in the program. There's no age restriction or anything like that.

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

Have you found that there is a time span wherein your program offers the greatest chance of success, for instance, if it's given to a group of veterans six months, a year, or more after their deployment?

[Tim Laidler]

I don't think we've come up with any sort of data to show a best time for it. I took it earlier on. It was the first exposure I had to anything therapeutic, and I found that extremely helpful. We do find that we're catching people further upstream. We know if they're able to make a successful transition, if they're able to find a place for themselves emotionally and vocationally in the civilian sector, that is hugely beneficial to reducing the chance of their developing post-traumatic stress or some other sort of disorder or landing in jail and having ongoing transition problems. We think the earlier the better to generally answer.

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

On your website it indicates that 90% of program graduates are on a new career and education path.

What specific skills do CF members have that you build upon to help transition them to specific interests or careers?

[Tim Laidler]

The biggest one is the peer group work. Often what will happen if they come out and unsuccessfully transition is they'll end up on their own, isolated, trying to withdraw to the wilderness and not be around busy sounds and places like cities. This is hugely difficult when they're trying to make a career transition.

It's about having them come back to the community, come back to talking about their story, and being able to go back to military friends, family members, and then eventually employers and say, “Yes, I had this experience. Here's the impact it had on me, and here's what I learned from it.”

We find that having that confidence and understanding really helps them make that career transition, get back into networking, and find those job opportunities that would be lost to them in their isolation.

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

Okay.

The life after service study was a groundbreaking study completed jointly for VAC and National Defence in 2011. It offered the first in-depth look at re-establishment outcomes. Through the study's findings, the department has a greater understanding of how to design, implement, and deliver the policies, programs, and business processes that meet the needs of ill and injured personnel, including reservists.

Are you aware of this study, and if so, what are your thoughts on it?