Confirming the Effects of Acupuncture Treatments to Relieve Symptoms of Gulf War Illness

Gulf War Illness (GWI), or chronic multisymptom illness (CMI), is a complex illness characterized by multiple symptoms, including fatigue, sleep and mood disturbances, cognitive dysfunction, and musculoskeletal pain, which are unexplained by physical and laboratory examinations. There is no standard of care treatment for this syndrome at this time. First defined by the Centers for Disease Control and Prevention (CDC) after the first Gulf War, it is commonly seen with a highly individualistic presentation, associated with clusters of symptoms and co-morbid medical diagnoses, including chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, arthralgia, digestive complaints, and mood-related psychiatric disorders, including depression, posttraumatic stress disorder (PTSD), and other anxiety disorders. It has been shown to be remarkably stable at 5- and 10- year follow-ups. Of the 700,000 service personnel deployed to the Persian Gulf, 100,000 veterans of the first Gulf War (Operation Desert Shield/Storm, years 1990-1991) have presented with medical complaints through clinical and registry programs. GWI is twice as prevalent in deployed veterans, and seen in 15% of non-deployed veterans.

CMI symptoms have been studied in cohorts of veterans in the United Kingdom, Canada, and Australia. The etiology of CMI is still unknown, and hypotheses involving exposures to vaccines, medications, pesticides, chemical munitions, and inhalation of depleted uranium dust and smoke from burning oil fields, have all been investigated inconclusively. Stress plays a likely role in the etiology of other multisymptom illnesses, such as irritable bowel syndrome (IBS), multiple chemical sensitivity and chronic headache. It is likely that veterans of the current war in Iraq and Afghanistan are exposed to similar deployment stressors and will benefit from an investigation of CMI and its treatment.

Acupuncture is an evidence-based, nonpharmacologic treatment commonly used for many symptoms affecting veterans and active military personnel, including pain. Acupuncture has shown efficacy for a variety of painful musculoskeletal disorders, as a treatment for both acute and chronic pain after amputation in military contexts, and in the treatment of related comorbidities such as fatigue, state, trait and situational anxiety, and depression. Acupuncture has shown effectiveness and is used in the Veterans Health Administration (VHA) and covered by Medicare for some conditions.

The L Conboy lab has completed multiple successful acupuncture trials in areas such as Irritable Bowel Syndrome, Carpel Tunnel Syndrome, and pelvic pain. Most recently the study team successfully completed a 3.5-year Congressionally Directed Medical Research Program (CDMRP) randomized controlled trial (RCT) "The Effectiveness of Acupuncture in the Treatment of Gulf War Illness". In that study, veterans chose a trained study acupuncturist in a location convenient to them. These community-based acupuncturists provided personalized acupuncture in a therapeutically informed dose. In the robust sample (n=104), investigators found a clinically and statistically significant improvement in pain after 2 months of treatment. After 6 months of treatment McGill Pain Scale values showed a 6-point improvement (p<=0.001), and the physical component of the SF-36 (SF-36P) showed a 9-point improvement (p<=0.003). Investigators also found statistically and clinically improvements in: the severity of veterans' self-reported main (p<0.01) and secondary (p<0.009) complaints as measured by the patient-centered Measure Your Medical Outcomes Profile (MYMOP) outcome measure, self-reported overall health from the SF-36P (p<0.007), and fatigue (p<0.05) based on the Multidimensional Assessment of Fatigue. Patient satisfaction with care and confidence in treatment was also very high (95% rated satisfied and confident). In addition, investigators found that the theoretically informed dose (2 sessions per week for 6 months) provided more relief for pain and poor function than did the comparison dose of one session per week, and that over 95% of symptom improvement for pain was maintained at 5-year follow up. Acupuncture at a sufficient dose is one of the only treatments found to be effective in improving pain and function in this hard-to-treat population while also addressing other symptoms in the patient's biopsychosocial presentation. Other high-quality science has shown that dosage is important for acupuncture treatment, and that treatment effects can persist long after acupuncture treatment has ended.

While this clinical data is very promising, equally important is furthering the understanding of the mechanisms of Gulf War Illness and successful treatments. Investigators conducted blood biomarker analyses using the collected blood samples from the parent trial, including collaborations with the Boston Biorepository, Recruitment and Integrative Network (BBRAIN) consortium at Boston University. Investigators found a number of interesting contrasts including significantly altered ether lipid metabolism in GWI, and that acyl-carnitine molecules are decreased in GWI, in agreement with previous reports. More recently, in collaboration with anti-aging researchers at Berkeley, investigators have found that acupuncture at the proper dose shifts the protein signature of GWI veteran to resemble a younger state (see below). In order to further elucidate the mechanisms underlying both GWI and successful treatments, the collection of blood biomarkers will be augmented by collection of physiological biomarkers potentially implicated in GWI symptoms.