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Norweg A, Oh C, DiMango A, Hofferber B, Spinner M, Stavrolakes K, Pavol M, Lindenauer P, Murphy CG, Simon NM. Mind the Breath: Feasibility of Capnography-Assisted Learned Monitored (CALM) Breathing for Dyspnea Treatment. J Cardiopulm Rehabil Prev 2025; 45:118-131. [PMID: 39976559 PMCID: PMC11864056 DOI: 10.1097/hcr.0000000000000939] [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] [Indexed: 02/28/2025]
Abstract
PURPOSE To evaluate the feasibility and acceptability of Capnography-Assisted Learned Monitored (CALM) Breathing, a carbon dioxide (CO 2 ) biofeedback, and motivational interviewing intervention, to treat dyspnea and anxiety together. METHODS We randomized adults (n = 42) with chronic obstructive pulmonary disease (COPD) to a 4-week, 8-session intervention (CALM Breathing, n = 20) or usual care (n = 22). The CALM Breathing intervention consisted of tailored, slow nasal breathing exercises, capnography biofeedback, motivational interviewing, and a home breathing exercise program. The intervention targeted unlearning dysfunctional breathing behaviors. All participants were offered outpatient pulmonary rehabilitation (PR) in the second phase of the study. The primary outcomes were feasibility and acceptability of CALM Breathing. Exploratory secondary outcomes included respiratory and mood symptoms, physiological and exercise tolerance measures, quality of life, and PR uptake. RESULTS Attendance at CALM Breathing sessions was 84%, dropout was 5%, and home exercise completion was 90% and 73% based on paper and device logs, respectively. Satisfaction with CALM Breathing therapy was rated as "good" to "excellent" by 92% of participants. Significantly greater between-group improvements in secondary outcomes-respiratory symptoms, activity avoidance, oxygen saturation (SpO 2 ), end-tidal CO 2 , and breathing self-regulation (interoception)-were found post-intervention at 6 weeks in support of CALM Breathing compared with usual care. At 3 months (after PR initiation), statistically significant between-group differences in Borg dyspnea and SpO 2 post-6-minute walk test were identified also supporting CALM Breathing. CONCLUSIONS Patient-centered CALM Breathing was feasible and acceptable in adults with COPD and dyspnea anxiety. A CALM Breathing intervention may optimize dyspnea treatment and complement PR.
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Affiliation(s)
- Anna Norweg
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Cheongeun Oh
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Angela DiMango
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Brittany Hofferber
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Michael Spinner
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Kimberly Stavrolakes
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Marykay Pavol
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Peter Lindenauer
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Charles G. Murphy
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
| | - Naomi M. Simon
- Author Affiliations: Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA (Dr Norweg); Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Ms Hofferber and Mr Spinner); Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA; Department of Physical Therapy, Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, New York, USA (Dr Stavrolakes); Department of Neurology and Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, New York, USA (Dr Pavol); Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Springfield, MA, USA (Dr Lindenauer); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York, USA (Drs DiMango and Murphy); and Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, USA (Dr Simon)
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Wu DW, Yang PC, Lin IM. Effects of Heart Rate Variability (HRV) Biofeedback in Pulmonary Indicators and HRV Indices Among Patients with Chronic Obstructive Pulmonary Disease. Appl Psychophysiol Biofeedback 2024:10.1007/s10484-024-09664-z. [PMID: 39254863 DOI: 10.1007/s10484-024-09664-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2024] [Indexed: 09/11/2024]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) exhibit reduced cardiac autonomic activity, linked to poor prognosis and exercise intolerance. While heart rate variability biofeedback (HRVB) can enhance cardiac autonomic activity in various diseases, its use in patients with COPD is limited. This study explored the impact of the HRVB on cardiac autonomic activity and pulmonary indicators in patients with COPD. Fifty-three patients with COPD were assigned to either the HRVB (n = 26) or the control group (n = 27), with both groups receiving standard medical care. The HRVB group also underwent one-hour HRVB sessions weekly for six weeks. All participants had pre- and post-test measurements, including the Six-Minute Walking Test (6MWT), lead II electrocardiogram (ECG) recording, Modified Medical Research Council Dyspnea Scale (mMRC), body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index. ECG data were analyzed for heart rate variability (HRV) as an index of cardiac autonomic activity. A two-way mixed analysis of variances demonstrated significant interaction effects of Group × Time in pulmonary indicators and HRV indices. The HRVB group exhibited significant post-test improvements, with decreased mMRC and BODE scores and increased 6MWT distance and HRV indices, compared to pre-test results. The 6MWT distance significantly increased and mMRC significantly decreased at post-test in the HRVB group compared with the control group. This study confirmed the efficacy of HRVB as an adjunct therapy in patients with COPD, showing improvements in exercise capacity, breathing difficulties, and cardiac autonomic activity.
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Affiliation(s)
- Da-Wei Wu
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, 812, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
- Doctoral Degree Program, Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
- Research Center for Precision Environmental Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Po-Chou Yang
- Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, No.100, Chih-Chuan 1st road, Kaohsiung, 807, Taiwan
| | - I-Mei Lin
- Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, No.100, Chih-Chuan 1st road, Kaohsiung, 807, Taiwan.
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
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Norweg A, Hofferber B, Oh C, Spinner M, Stavrolakes K, Pavol M, DiMango A, Raveis VH, Murphy CG, Allegrante JP, Buchholz D, Zarate A, Simon N. Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation. Contemp Clin Trials 2023; 134:107340. [PMID: 37730198 DOI: 10.1016/j.cct.2023.107340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/20/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes. METHODS We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group. RESULTS Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement. CONCLUSION By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.
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Affiliation(s)
- Anna Norweg
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Brittany Hofferber
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Cheongeun Oh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Michael Spinner
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kimberly Stavrolakes
- Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, NY, USA
| | - Marykay Pavol
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA; Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Angela DiMango
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Victoria H Raveis
- Department of Cariology and Comprehensive Care, College of Dentistry, New York University, New York, NY, USA
| | - Charles G Murphy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - John P Allegrante
- Department of Health and Behavior Studies, Teachers College, Columbia University, New York, NY, USA; Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David Buchholz
- Department of Primary Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Alejandro Zarate
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Naomi Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
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Norweg AM, Wu Y, Troxel A, Whiteson JH, Collins E, Haas F, Skamai A, Goldring R, Jean-Louis G, Reibman J, Ehrlich-Jones L, Simon N. Mind-Body Intervention for Dysfunctional Breathing in Chronic Obstructive Pulmonary Disease: Feasibility Study and Lessons Learned. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:156-168. [PMID: 36800224 PMCID: PMC10024272 DOI: 10.1089/jicm.2022.0552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Purpose: Dysfunctional breathing behaviors are prevalent in chronic obstructive pulmonary disease (COPD). Although these behaviors contribute to dyspnea, abnormal carbon dioxide (CO2) levels, and COPD exacerbations, they are modifiable. Current dyspnea treatments for COPD are suboptimal, because they do not adequately address dysfunctional breathing behaviors and anxiety together. We developed a complementary mind-body breathlessness therapy, called capnography-assisted respiratory therapy (CART), that uses real-time CO2 biofeedback at the end of exhalation (end-tidal CO2 or ETCO2), to target dysfunctional breathing habits and improve dyspnea treatment and pulmonary rehabilitation (PR) adherence in COPD. The study aim was to test the feasibility of integrating CART with a traditional, clinic-based PR program in an urban setting. Methods: We used a feasibility pre- and post-test design, with 2:1 randomization to CART+PR or control (PR-alone) groups, to test and refine CART. Multi-component CART consisted of six, 1-h weekly sessions of slow breathing and mindfulness exercises, ETCO2 biofeedback, motivational counseling, and a home program. All participants were offered twice weekly, 1-h sessions of PR over 10 weeks (up to 20 sessions). Results: Thirty-one participants with COPD were enrolled in the study. Approximately a third of participants had symptoms of psychological distress. Results showed that CART was feasible and acceptable based on 74% session completion and 91.7% homework exercise completion (n = 22). Within-group effect sizes for CART+PR were moderate to large (Cohen's d = 0.51-1.22) for reduction in resting Borg dyspnea (anticipatory anxiety) and respiratory rate, St. George's Respiratory Questionnaire (SGRQ) respiratory symptoms; and increase in Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and physical activity; all p < 0.05. Conclusions: CART is a new mind-body breathing therapy that targets eucapnic breathing, interoceptive function, and self-regulated breathing to relieve dyspnea and anxiety symptoms in COPD. Study findings supported the feasibility of CART and showed preliminary signals that CART may improve exercise tolerance, reduce dyspnea, and enhance PR completion by targeting reduced dysfunctional breathing patterns (CTR No. NCT03457103).
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Affiliation(s)
- Anna Migliore Norweg
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Yinxiang Wu
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Andrea Troxel
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Jonathan H. Whiteson
- Department of Rehabilitation, and New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Eileen Collins
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Francois Haas
- Department of Rehabilitation, and New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Anne Skamai
- Department of Family and Community Medicine, Downstate Medical Center, State University of New York, New York, NY, USA
| | - Roberta Goldring
- Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Girardin Jean-Louis
- Department of Population Health, New York University (NYU) Grossman School of Medicine, New York, NY, USA
- Department of Psychiatry, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | - Joan Reibman
- Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, NY, USA
| | | | - Naomi Simon
- Department of Psychiatry, New York University (NYU) Grossman School of Medicine, New York, NY, USA
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