1
|
Day MA, Ciol MA, Mendoza ME, Borckardt J, Ehde DM, Newman AK, Chan JF, Drever SA, Friedly JL, Burns J, Thorn BE, Jensen MP. The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial. BMC Med 2024; 22:156. [PMID: 38609994 PMCID: PMC11015654 DOI: 10.1186/s12916-024-03383-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Chronic low back pain (CLBP) is a significant problem affecting millions of people worldwide. Three widely implemented psychological techniques used for CLBP management are cognitive therapy (CT), mindfulness meditation (MM), and behavioral activation (BA). This study aimed to evaluate the relative immediate (pre- to post-treatment) and longer term (pre-treatment to 3- and 6-month follow-ups) effects of group, videoconference-delivered CT, BA, and MM for CLBP. METHODS This is a secondary analysis of a three-arm, randomized clinical trial comparing the effects of three active treatments-CT, BA, and MM-with no inert control condition. Participants were N = 302 adults with CLBP, who were randomized to condition. The primary outcome was pain interference, and other secondary outcomes were also examined. The primary study end-point was post-treatment. Intent-to-treat analyses were undertaken for each time point, with the means of the changes in outcomes compared among the three groups using an analysis of variance (ANOVA). Effect sizes and confidence intervals are also reported. RESULTS Medium-to-large effect size reductions in pain interference were found within BA, CT, and MM (ds from - .71 to - 1.00), with gains maintained at both follow-up time points. Effect sizes were generally small to medium for secondary outcomes for all three conditions (ds from - .20 to - .71). No significant between-group differences in means or changes in outcomes were found at any time point, except for change in sleep disturbance from pre- to post-treatment, improving more in BA than MM (d = - .49). CONCLUSIONS The findings from this trial, one of the largest telehealth trials of psychological treatments to date, critically determined that group, videoconference-delivered CT, BA, and MM are effective for CLBP and can be implemented in clinical practice to improve treatment access. The pattern of results demonstrated similar improvements across treatments and outcome domains, with effect sizes consistent with those observed in prior research testing in-person delivered and multi-modal psychological pain treatments. Thus, internet treatment delivery represents a tool to scale up access to evidence-based chronic pain treatments and to overcome widespread disparities in healthcare. TRIAL REGISTRATION Clinicaltrials.gov, NCT03687762.
Collapse
Affiliation(s)
- Melissa A Day
- School of Psychology, University of Queensland, 330 McElwain Building, Brisbane, QLD, 4072, Australia.
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Marcia A Ciol
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - M Elena Mendoza
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jeffrey Borckardt
- Departments of Psychiatry, Anesthesia, and Stomatology, Medical University of South Carolina, Charleston, SC, USA
| | - Dawn M Ehde
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Andrea K Newman
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Joy F Chan
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Sydney A Drever
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - John Burns
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Beverly E Thorn
- Department of Psychology, University of Alabama, Tuscaloosa, AL, USA
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
2
|
Cook CE, O’Halloran B, McDevitt A, Keefe FJ. Specific and shared mechanisms associated with treatment for chronic neck pain: study protocol for the SS-MECH trial. J Man Manip Ther 2024; 32:85-95. [PMID: 37819161 PMCID: PMC10795632 DOI: 10.1080/10669817.2023.2267391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Treatment mechanisms involve the steps or processes through which an intervention unfolds and produces change in an outcome variable. Treatment mechanisms can be specific to the intervention provided (i.e. pain modulation) or shared with other treatments (i.e. reduced fear of movement). Whether specific and shared treatment mechanisms are different across interventions and whether they lead to the outcomes seen in trials is largely unknown. The management of individuals with chronic neck pain routinely include manual therapy (MT) and resistance exercise (RE), as both approaches are included in clinical practice guidelines and both yield similar outcomes. OBJECTIVES Our study plans to answer two research questions: 1) what are the specific mechanisms associated with MT versus interventions (and are these different), and 2) what are the shared mechanisms associated with these interventions, and do specific or shared mechanisms mediate clinical outcomes? METHODS This study will involve a 2-group parallel (1:1) single-blinded randomized trial to compare the specific and potential shared treatment mechanisms between these two approaches. We will enroll individuals with a history of chronic neck pain and evaluate whether specific or shared mechanisms mediate clinical outcomes. RESULTS We hypothesize that MT and RE approaches will both exhibit different specific treatment mechanisms, and that both approaches will exhibit shared treatment mechanisms, which will notably influence outcomes at both discharge and 6-months. CONCLUSIONS This study is important because it will help identify what specific or shared treatment mechanisms are associated with different interventions and, how different treatment mechanisms influence clinical outcomes.
Collapse
Affiliation(s)
- Chad E. Cook
- Department of Physical Therapy, School of Health Professions, Saint Joseph’s University, Philadelphia, PA, USA
- Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
- Duke Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Bryan O’Halloran
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Amy McDevitt
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Francis J. Keefe
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| |
Collapse
|
3
|
Torres ND, Newman AK, Day MA, Chan JF, Friedly JL, Jensen MP. The Moderating Effects of Cognitive Processes on Pain-related Outcomes. THE JOURNAL OF PAIN 2024:104483. [PMID: 38296008 DOI: 10.1016/j.jpain.2024.01.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/08/2024] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
Although evidence supports the importance of pain-related thoughts (ie, cognitive content, or what people think) as predictors of pain and pain-related function, evidence regarding the role of cognitive processes (ie, how people think about pain, eg, by accepting pain, not making judgments about pain, or being absorbed by the pain experience) in adjustment to chronic pain is in its early stages. Using baseline data from a clinical trial of individuals with chronic low back pain (N = 327), the study aimed to increase knowledge regarding the associations between cognitive processes, pain intensity, pain interference, and depression. The results indicate that a number of cognitive processes are significantly related to pain intensity when controlling for catastrophizing, although the pattern of associations found was opposite to those anticipated. One cognitive process (pain absorption) was found to be significantly associated with pain interference, and 9 of 10 cognitive processes were significantly associated with depression when controlling for catastrophizing. In each case, the processes thought to be adaptive were negatively associated with pain interference and depression, and processes thought to be maladaptive evidenced the opposite pattern. The findings are consistent with-but do not prove, given the cross-sectional nature of the data-the possibility that cognitive processes play an important role in adjustment to chronic pain. The potential role these variables play in depression was particularly noteworthy. Longitudinal and experimental studies to evaluate the causal nature of the associations identified are warranted. PERSPECTIVE: The study findings highlight the potential importance of cognitive process variables (ie, how people think) in adjustment to chronic pain. Research to evaluate cognitive processes as potential mechanism variables in pain treatment is warranted.
Collapse
Affiliation(s)
- Nikki D Torres
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Andrea K Newman
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Melissa A Day
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Joy F Chan
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
4
|
Wilson M, Skeiky L, Muck RA, Miller MA, Hansen DA, Williams RM, Jensen MP, Van Dongen HPA. Sleep and Pain in Veterans with Chronic Pain: Effects of Psychological Pain Treatment and Temporal Associations. Nat Sci Sleep 2023; 15:1061-1077. [PMID: 38144708 PMCID: PMC10748706 DOI: 10.2147/nss.s418532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/26/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Chronic pain is highly prevalent in US military Veterans. Non-opioid and non-pharmacologic treatments are recommended when clinically appropriate, but research on the mechanisms underlying benefits of these treatments is lacking. Here, we examined the role of sleep in the effects of three non-pharmacologic pain treatments in Veterans. Specifically, we investigated whether treatment effects on sleep predicted treatment effects on pain occurring later, or vice versa. Methods Veterans enrolled in a randomized controlled trial were invited to participate in this supplementary sleep study. A total of 174 Veterans were randomized to one of three 8-session, in-person, group-based pain treatments: hypnosis, mindfulness meditation, or education control. Measurements included self-reported sleep disturbance, pain intensity, and pain catastrophizing; sleep duration was assessed with actigraphy. Sleep and pain measurements were obtained at baseline, posttreatment, and 3-month posttreatment follow-up. Results At baseline, average pain intensity was moderate (mean ± SD: 5.7 ± 1.7 on the 0-10 Numeric Rating Scale), pain catastrophizing was just below the clinically relevant threshold (mean ± SD: 28.6 ± 12.2 on the Pain Catastrophizing Scale), and subjective sleep disturbance exceeded the US population average (mean ± SD: 58.5 ± 8.1 on the Patient Reported Outcomes Measurement Information System Sleep Disturbance - Short Form). By contrast, objective sleep duration was consistent with the recommended daily sleep amount of 7-8 h for adults (mean ± SD: 8.3 ± 1.4 h). Across treatment conditions, pain intensity, pain catastrophizing, and subjective sleep disturbance were significantly less at posttreatment and 3-month follow-up than at baseline (p < 0.001). Actigraphic sleep duration did not differ significantly as a function of time. There was a high degree of covariation among the measures of pain intensity, pain catastrophizing, and sleep disturbance (p < 0.05). However, self-reported sleep disturbance was not significantly correlated with actigraphic sleep duration (|r| <= 0.13, p > 0.05). Sleep and pain variables observed at prior assessments predicted these same variables at subsequent assessments. There was no significant evidence that changes in pain preceded changes in sleep or that changes in sleep preceded changes in pain (all p > 0.05). Discussion For this study's Veterans, treatment-related changes in sleep and pain appeared to occur in parallel. The concomitant changes in sleep and pain suggest that therapies improving pain in Veterans may yield attendant benefits for the treatment of sleep, and possibly vice versa.
Collapse
Affiliation(s)
- Marian Wilson
- College of Nursing, Washington State University, Spokane, WA, USA
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
| | - Lillian Skeiky
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Rachael A Muck
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Megan A Miller
- Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Devon A Hansen
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| | - Rhonda M Williams
- Rehabilitation Care Service, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Hans P A Van Dongen
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA
- Department of Translational Medicine and Physiology, Washington State University, Spokane, WA, USA
| |
Collapse
|
5
|
Ferreira-Valente A, Sharma S, Chan J, Bernardes SF, Pais-Ribeiro J, Jensen MP. Pain-Related Beliefs, Coping, and Function: An Observational Study on the Moderating Influence of Country of Origin. THE JOURNAL OF PAIN 2023; 24:1645-1663. [PMID: 37146671 DOI: 10.1016/j.jpain.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/07/2023]
Abstract
Chronic pain is a multidimensional experience and pain treatments targeting psychosocial factors reduce pain and improve function. These treatments often overlook the sociocultural factors that influence pain and the psychological factors associated with function in people with chronic pain. Although preliminary findings suggest that cultural background may influence pain and function via their effects on beliefs and coping, no previous study has directly tested if the country of origin moderates the associations between these psychological factors and pain and function. This study sought to address this knowledge gap. Five hundred sixty-one adults with chronic pain, born and living in the USA (n = 273) or Portugal (n = 288), completed measures of pain, function, pain-related beliefs, and coping. Between-country similarities were found in the endorsement of beliefs related to disability, pain control, and emotion, and in asking for assistance, task persistence, and coping self-statement responses. Portuguese participants reported greater endorsement of harm, medication, solicitude, and medical cure beliefs, more frequent use of relaxation and support seeking, and less frequent use of guarding, resting, and exercising/stretching. In both countries, disability and harm beliefs and guarding responses were associated with worse outcomes; pain control and task persistence were associated with better outcomes. Six country-related small effect-size moderation effects emerged, such that task persistence and guarding are stronger predictors of pain and function in adults from the USA, but pain control, disability, emotion, and medication beliefs are more important in adults from Portugal. Some modifications may be needed when adapting multidisciplinary treatments from one country to another. PERSPECTIVE: This article examines the similarities and differences in beliefs and coping endorsed by adults with chronic pain from 2 countries, and the potential moderation effects of country on the associations between these variables and pain and function. The findings suggest that some modifications may be needed when culturally customizing psychological pain treatments.
Collapse
Affiliation(s)
- Alexandra Ferreira-Valente
- William James Center for Research, Ispa - University Institute, Lisbon, Portugal; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Research Center for Human Development, Faculty of Education and Psychology, Universidade Católica Portuguesa, Porto, Portugal
| | - Saurab Sharma
- Department of Exercise Physiology, School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia; Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Joy Chan
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Sónia F Bernardes
- Centre for Social Research and Intervention (CIS-IUL), ISCTE-Lisbon University Institute, Lisbon, Portugal
| | - José Pais-Ribeiro
- William James Center for Research, Ispa - University Institute, Lisbon, Portugal; Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
6
|
McDevitt AW, O'Halloran B, Cook CE. Cracking the code: unveiling the specific and shared mechanisms behind musculoskeletal interventions. Arch Physiother 2023; 13:14. [PMID: 37415258 DOI: 10.1186/s40945-023-00168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Mechanisms reflect the steps or processes through which an intervention unfolds and produces change in a specified outcome variable. Mechanisms are responsible for determining "how treatments work" which has emerged as a critical question for both developing theory and enhancing treatment efficacy. Studies that evaluate "how" treatments work, not just "if" treatments work are of considerable importance. DISCUSSION Specific and shared mechanisms research is a promising approach which aims to improve patient outcomes by tailoring treatments to the specific needs of each patient. Mechanisms research is an underexplored area of research requiring a unique research design. CONCLUSION Although mechanisms research is still in its infancy, prioritizing the study of the mechanisms behind manual therapy interventions can provide valuable insight into optimizing patient outcomes.
Collapse
Affiliation(s)
- Amy W McDevitt
- Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, CO, Aurora, USA.
| | - Bryan O'Halloran
- Department of Physical Therapy, School of Health Sciences, Saint Joseph's University, PA, Philadelphia, USA
| | - Chad E Cook
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| |
Collapse
|
7
|
Day MA, Matthews N, Davies JN, Walker C, Bray N, Kim J, Jensen MP. Outcome Expectancies, Effects, and Mechanisms of Brief Training in Mindfulness Meditation vs. Loving-Kindness Meditation vs a Control Condition for Pain Management: A Randomized Pilot Study. J Pain Palliat Care Pharmacother 2023:1-11. [PMID: 36622873 DOI: 10.1080/15360288.2022.2141944] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/22/2022] [Accepted: 10/24/2022] [Indexed: 01/10/2023]
Abstract
This study investigated the analgesic effects of a single session of mindfulness meditation (MM) and loving-kindness meditation (LKM) relative to a control. A total of 100 adults with chronic or current problematic pain completed a survey and were randomized to a 20-minute MM, LKM, or audiobook control. Co-primary outcomes of pain intensity and unpleasantness and mediators of mindfulness and self-compassion were assessed pre- and posttraining. Expectancies were assessed pretraining. Pain type (chronic vs current problematic) was a covariate. Relative to the control, higher expectancies were reported for MM and LKM (P < .001). MM (d = 0.41, P = .032) and LKM (d = 0.38, P = .027) had medium effects on pain intensity, with greater decreases than control (d = 0.05, P = .768). All conditions had small effects on unpleasantness. Mindful observing increased more within MM (d = 0.52, P = .022) and the control (d = 0.50, P = .011) than LKM (d = 0.12, P = .50); self-compassion increased more in LKM (d = 0.36, P = .042) than MM (d = 0.27, P = .201) and the control (d = 0.22, P = .249). The mediation models were nonsignificant. Pain type was a nonsignificant covariate. Overall, MM and LKM were associated with positive expectancies and small-medium pain intensity reductions, which did not differ by pain type. Although MM and LKM were associated with changes in theorized mediators, these changes did not underlie improvement.
Collapse
Affiliation(s)
- Melissa A Day
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Natasha Matthews
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Jonathan N Davies
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Claire Walker
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Bray
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Kim
- School of Psychology, University of Queensland, Brisbane, Queensland, Australia
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
8
|
Williams RM, Day MA, Ehde DM, Turner AP, Ciol MA, Gertz KJ, Patterson D, Hakimian S, Suri P, Jensen MP. Effects of hypnosis vs mindfulness meditation vs education on chronic pain intensity and secondary outcomes in veterans: a randomized clinical trial. Pain 2022; 163:1905-1918. [PMID: 35082248 PMCID: PMC11089905 DOI: 10.1097/j.pain.0000000000002586] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Effective, rigorously evaluated nonpharmacological treatments for chronic pain are needed. This study compared the effectiveness of training in hypnosis (HYP) and mindfulness meditation (MM) with an active education control (ED). Veterans (N = 328) were randomly assigned to 8 manualized, group-based, in-person sessions of HYP (n = 110), MM (n = 108), or ED (n = 110). Primary (average pain intensity [API]) and secondary outcomes were assessed at pretreatment, posttreatment, and 3 and 6 months posttreatment. Treatment effects were evaluated using linear regression, a generalized estimating equation approach, or a Fisher exact test, depending on the variable. There were no significant omnibus between-group differences in pretreatment to posttreatment change in API; however, pretreatment to posttreatment improvements in API and several secondary variables were seen for participants in all 3 conditions. Participation in MM resulted in greater decreases in API and pain interference at 6 months posttreatment relative to ED. Participation in HYP resulted in greater decreases in API, pain interference, and depressive symptoms at 3 and 6 months posttreatment compared with ED. No significant differences on outcomes between HYP and MM were detected at any time point. This study suggests that all 3 interventions provide posttreatment benefits on a range of outcomes, but the benefits of HYP and MM continue beyond the end of treatment, while the improvements associated with ED dissipate over time. Future research is needed to determine whether the between-group differences that emerged posttreatment are reliable, whether there are benefits of combining treatments, and to explore moderating and mediating factors.
Collapse
Affiliation(s)
- Rhonda M. Williams
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Melissa A. Day
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Queensland, School of Psychology, Australia
| | - Dawn M. Ehde
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Aaron P. Turner
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Marcia A. Ciol
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Kevin J. Gertz
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - David Patterson
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| | - Shahin Hakimian
- Department of Neurology, University of Washington, Seattle, Washington
| | - Pradeep Suri
- VA Puget Sound Health Care System, Seattle, Washington
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
- University of Washington Clinical Learning, Evidence and Research (CLEAR) Center, Seattle, Washington
| | - Mark P. Jensen
- University of Washington School of Medicine, Department of Rehabilitation Medicine Seattle, Washington
| |
Collapse
|