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Yilmaz E. Secondary fibromyalgia: An entity to be remembered-A case series with axial spondyloarthritis. Mod Rheumatol Case Rep 2023; 8:26-32. [PMID: 37249440 DOI: 10.1093/mrcr/rxad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/12/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023]
Abstract
Fibromyalgia (FM) is a clinical syndrome characterised by chronic widespread musculoskeletal pain, stiffness, and tenderness in addition to a variety of physical and mental symptoms such as fatigue, sleep disturbances, depression, anxiety, cognitive dysfunction, headaches, and digestive problems. FM can be associated with or coexist with other inflammatory rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and spondyloarthritis. This phenomenon is called secondary FM. Although FM cannot be considered an autoimmune disease, it may in some cases be an early sign of an autoimmune disease. Therefore, clinicians should be cautious in these situations. This case series presents three patients diagnosed with axial spondyloarthritis coexisted with FM symptoms.
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Affiliation(s)
- Ebru Yilmaz
- Department of Physical Medicine and Rehabilitation, Bezmialem Vakıf University, İstanbul, Turkey
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Byrne A, Jones K, Backhouse M, Rose F, Moatt E, van der Feltz-Cornelis C. Patient and primary care practitioners' perspectives on consultations for fibromyalgia: a qualitative evidence synthesis. Prim Health Care Res Dev 2023; 24:e58. [PMID: 37750736 PMCID: PMC10540196 DOI: 10.1017/s1463423623000506] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/29/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Fibromyalgia presents a challenge to both the patients experiencing symptoms and the staff aiming to treat them. This qualitative review aimed to synthesise how patients and practitioners experience primary care consultations, develop a rounded picture of how they perceive each other, the challenges to primary care consultation and how they might be tackled. METHODS CINAHL, Embase, CENTRAL and Medline were searched from inception to November 2021. Qualitative studies were included if they explored the perspectives and experiences of either fibromyalgia patients or primary care practitioners. Quantitative data, studies not published in English, not set in primary care or that did not distinguish the type of patient or clinician were excluded. Included studies were analysed using thematic synthesis and their quality assessed. RESULTS In total, 30 studies met the inclusion criteria. Thematic synthesis identified three overarching themes: (1) life turned upside down - exploring the chaos experienced by patients as they seek help; (2) negative cycle - highlighting how patient and practitioner factors can create a detrimental cycle; and (3) breaking the cycle - validating patient-doctor relationships underpinned by clear communication can help break the negative cycle. CONCLUSIONS Fibromyalgia patients experience uncertainty and chaos that can clash with the attitudes of GPs and the help they can feasibly provide. Difficult consultations in which neither the GP nor patient are satisfied can easily occur. Promoting supportive, reciprocal and open patient-doctor relationships is essential. Future research is required to further explore GP attitudes and to develop an intervention that could improve consultations, patient outcomes and GP satisfaction.
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Affiliation(s)
- Ailish Byrne
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, UK
| | - Katherine Jones
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Fiona Rose
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, UK
| | - Emma Moatt
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, UK
| | - Christina van der Feltz-Cornelis
- Mental Health and Addictions Research Group, Department of Health Sciences, Hull York Medical School, University of York, Heslington, York, UK
- Institute of Health Informatics, University College London, London, UK
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Abstract
Supplemental Digital Content is Available in the Text. Patients with chronic widespread pain may regularly consult in primary care for regional pain without being recognized as having a generalized condition. Chronic widespread pain (CWP) is common in the general population. It is unclear how people reporting this problem present in primary care; they may regularly consult for regional pains without being recognized as having a generalized condition. Our objectives were to determine the prevalence of people consulting in primary care for musculoskeletal conditions in different body regions on different occasions (recurrent regional pain consultation), the proportion with diagnosed generalized pain and survey-reported widespread pain, and if they have features characteristic of CWP. Phase 1 used electronic records from 12 general practices in North Staffordshire (Consultations in Primary Care Archive) from 2005 to 2009. Phase 2 used linked self-reported health and primary health care data from 8286 people aged >50 years in 8 general practices (North Staffordshire Osteoarthritis Project) between 2002 and 2005. In Phase 1, 11% of registered patients fulfilled criteria for recurrent regional pain consultation. Three-quarters had no recorded CWP-related generalized pain condition (eg, fibromyalgia). In Phase 2, 53% of recurrent regional pain consulters had survey-reported widespread pain and 88% had consulted for somatic symptoms. Self-reported general health was worse in recurrent regional pain consulters than in single-region consulters and poorest in those who also reported persistent widespread pain. Recurrent regional pain consulters are a heterogeneous group of frequent consulters sharing features with CWP (eg, somatic symptoms) but including those less severely affected. They lie on the spectrum of polysymptomatic distress characteristic of CWP and represent a group whose needs may be better met by earlier diagnosis of multisite pain.
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Able SL, Robinson RL, Kroenke K, Mease P, Williams DA, Chen Y, Wohlreich M, McCarberg BH. Variations in the management of fibromyalgia by physician specialty: rheumatology versus primary care. Pragmat Obs Res 2016; 7:11-20. [PMID: 27799842 PMCID: PMC5085275 DOI: 10.2147/por.s79441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the effect of physician specialty regarding diagnosis and treatment of fibromyalgia (FM) and assess the clinical status of patients initiating new treatment for FM using data from Real-World Examination of Fibromyalgia: Longitudinal Evaluation of Costs and Treatments. Patients and methods Outpatients from 58 sites in the United States were enrolled. Data were collected via in-office surveys and telephone interviews. Pairwise comparisons by specialty were made using chi-square, Fisher’s exact tests, and Student’s t-tests. Results Physician specialist cohorts included rheumatologists (n=54), primary care physicians (n=25), and a heterogeneous group of physicians practicing pain or physical medicine, psychiatry, neurology, obstetrics and gynecology, osteopathy, or an unspecified specialty (n=12). The rheumatologists expressed higher confidence diagnosing FM (4.5 on a five-point scale) than primary care physicians (4.1) (P=0.037). All cohorts strongly agreed that recognizing FM is their responsibility. They agreed that psychological aspects of FM are important, but disagreed that symptoms are psychosomatic. All physician cohorts agreed with a multidisciplinary approach including nonpharmacological and pharmacological treatments, although physicians were more confident prescribing medications than alternative therapies. Most patients reported moderate to severe pain, multiple comorbidities, and treatment with several medications and nonpharmacologic therapies. Conclusion Physician practice characteristics, physician attitudes, and FM patient profiles were broadly similar across specialties. The small but significant differences reported by physicians and patients across physician cohorts suggest that despite published guidelines, treatment of FM still contains important variance across specialties.
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Affiliation(s)
- Stephen L Able
- US Health Outcomes and Technology Assessment, Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - Rebecca L Robinson
- Lilly Research Labs, Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - Kurt Kroenke
- Department of Medicine, Indiana University; VA Health Services Research and Development Center for Health Information and Communication, Regenstrief Institute, Indianapolis, IN, USA
| | - Philip Mease
- Rheumatology Associates, Division of Rheumatology Clinical Research, Swedish Medical Center; University of Washington School of Medicine, Seattle, WA, USA
| | - David A Williams
- Chronic Pain and Fatigue Research Center, Michigan Institute for Clinical and Health Research, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Yi Chen
- inVentiv Health Clinical, Indianapolis, IN, USA
| | - Madelaine Wohlreich
- USMD Neuroscience, Lilly USA LLC, Eli Lilly and Company, Indianapolis, IN, USA
| | - Bill H McCarberg
- Department of Family Medicine, University of California at San Diego School of Medicine, San Diego, CA, USA
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Spencer CH, Patwardhan A. Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease. Curr Probl Pediatr Adolesc Health Care 2015. [PMID: 26205101 DOI: 10.1016/j.cppeds.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.
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Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD. Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int 2011; 31:1409-17. [PMID: 21800117 DOI: 10.1007/s00296-011-1999-3] [Citation(s) in RCA: 436] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 07/10/2011] [Indexed: 12/20/2022]
Abstract
Review articles comprehensively covering a specific topic are crucial for successful research and academic projects. Most editors consider review articles for special and regular issues of journals. Writing a review requires deep knowledge and understanding of a field. The aim of this review is to analyze the main steps in writing a narrative biomedical review and to consider points that may increase the chances of success. We performed a comprehensive search through MEDLINE, EMBASE, Scopus, and Web of Science using the following keywords: review of the literature, narrative review, title, abstract, authorship, ethics, peer review, research methods, medical writing, scientific writing, and writing standards. Opinions expressed in the review are also based on personal experience as authors, peer reviewers, and editors.
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Affiliation(s)
- Armen Yuri Gasparyan
- Department of Rheumatology, Clinical Research Unit, Dudley Group of Hospitals NHS Foundation Trust (Teaching Trust of University of Birmingham, UK), Russell's Hall Hospital, North Block, Dudley, West Midlands, DY1 2HQ, United Kingdom.
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McNett M, Goldenberg D, Schaefer C, Hufstader M, Baik R, Chandran A, Zlateva G. Treatment patterns among physician specialties in the management of fibromyalgia: results of a cross-sectional study in the United States. Curr Med Res Opin 2011; 27:673-83. [PMID: 21294700 DOI: 10.1185/03007995.2011.553214] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fibromyalgia (FM) is characterized by persistent and widespread pain and often associated with other symptoms and comorbidities. Thus, FM patients seek care from multiple physician specialties. This study compared prescribing patterns, patient-reported outcomes (PROs), healthcare resource use (HRU), and direct costs related to FM in routine clinical practice across physician specialties. METHODS This cross-sectional, observational study recruited 203 FM subjects from 20 community-based physician offices (eight primary care, six rheumatology, three neurology, three psychiatry). Subjects completed questions about pain, other symptoms, quality of life, productivity, treatment effectiveness and satisfaction, and out-of-pocket expenses related to FM; site staff recorded subjects' treatment and HRU based on medical chart review. Results were compared across specialties. Statistical significance was evaluated at the 0.05 level. Annual direct costs associated with FM were calculated in 2009 US dollars. RESULTS Subject demographic and clinical characteristics were not significantly different across physician specialties, except psychiatry subjects had the highest mean number of co-morbid conditions; p < 0.001. PROs were similar across physician specialties except fatigue; neurology subjects reported the highest levels. There were no significant differences in subject-reported outcomes of medication effectiveness (p = 0.782) and medication satisfaction (p = 0.338) for FM. Psychiatry subjects had more FM-related physician visits compared to other specialties (p = 0.013) and a higher proportion received diagnostic tests related to FM (p = 0.013). The mean (SD) number of FM prescription medications prescribed per subject was highest in the primary care and lowest in the neurology group; p = 0.024. The proportion of hypnotic (p = 0.001), muscle relaxant (p = 0.005), anxiolytic (p = 0.005), anti-epileptic (p = 0.007), and other medications (p = 0.044) prescribed for FM were significantly different across specialties. Overall direct medical costs did not differ significantly (p = 0.284) across specialties. CONCLUSIONS Patient characteristics were similar across specialties, except with regards to comorbidity burden. This study noted significant differences among physician specialties in HRU and treatment patterns among medications, diagnostics, and outpatient visits. Consistent with other studies, this study did not identify a dominant strategy for FM management across physician specialties as overall per patient medical costs and subject-reported treatment satisfaction were similar. Future research to better characterize differences among physician specialties in FM management, as well as the reasons for these differences, would be useful.
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Seidel MF, Müller W. Differential pharmacotherapy for subgroups of fibromyalgia patients with specific consideration of 5-HT3 receptor antagonists. Expert Opin Pharmacother 2011; 12:1381-91. [PMID: 21323622 DOI: 10.1517/14656566.2011.557362] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The fibromyalgia syndrome (FMS) has a prevalence of about 2% and is characterized by generalized musculoskeletal pain, reduced pain threshold and autonomic and functional symptoms. It is a multifactorial syndrome with four different subgroups exhibiting pathophysiological and psychiatric findings. No precise treatment strategy is currently available for the different FMS subgroups. AREAS COVERED This article reviews the evidence for treatment options for the different FMS subgroups. EXPERT OPINION Therapy for the first subgroup of primary FMS, with high levels of pain but no psychopathological alterations, is targeted at nociceptors expressing serotonin (5-hydroxytryptamine-3; 5-HT3) receptors with 5-HT3 receptor antagonists. The second and third subgroups are characterized by depressive syndromes with a major indication for antidepressants. The fourth subgroup with psychosomatic syndromes requires psychotherapeutic treatment. Secondary FMS is similar to the primary syndromes but is triggered by a variety of other diseases and frequently responds to 5-HT3 receptor antagonist treatment. Different classes of drug, such as pregabalin, must be tested for efficacy and tolerance. FMS treatment strategies should be tailored after the identification of individual FMS subgroups. Although several groups of drug have been studied extensively, 5-HT3 receptor antagonists are most effective in patients without psychopathological alterations.
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Affiliation(s)
- Matthias F Seidel
- Medizinische Klinik und Poliklinik I, Rheumatology Unit, Wilhelmstrasse, Bonn, Germany.
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Toda K. Comparison of Symptoms Among Fibromyalgia Syndrome, Chronic Widespread Pain, and an Incomplete Form of Chronic Widespread Pain. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/10582452.2010.502614] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Validierung der deutschen Version der regionalen Schmerzskala zur Diagnose des Fibromyalgiesyndroms. Schmerz 2010; 24:226-35. [DOI: 10.1007/s00482-010-0931-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Holman AJ. Pragmatic consideration of recent randomized, placebo-controlled clinical trials for treatment of fibromyalgia. Curr Pain Headache Rep 2009; 12:393-8. [PMID: 18973730 DOI: 10.1007/s11916-008-0067-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A flurry of recent randomized, placebo-controlled trials assessing dissimilar pharmacotherapeutic treatment options for fibromyalgia (FM) have been presented in the past few years. This review evaluates these trials in light of recent pathophysiological concepts germane to FM, including mood disorders, autonomic dysregulation, altered sleep stage architecture, and the diagnostic tender point controversy. Studies with gabapentin, pregabalin, duloxetine, milnacipran, sodium oxybate, and pramipexole for treatment of FM are discussed.
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Clasificación de la fibromialgia. Revisión sistemática de la literatura. ACTA ACUST UNITED AC 2009; 5:55-62. [DOI: 10.1016/j.reuma.2008.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 07/30/2008] [Indexed: 12/23/2022]
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Mathieu N. Comorbidités somatiques dans le Syndrome de l’Intestin Irritable : fibromyalgie, syndrome de fatigue chronique et cystite interstitielle/syndrome de la vessie douloureuse. ACTA ACUST UNITED AC 2009; 33 Suppl 1:S17-25. [DOI: 10.1016/s0399-8320(09)71521-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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van Wilgen CP, van Ittersum MW, Kaptein AA, van Wijhe M. Illness perceptions in patients with fibromyalgia and their relationship to quality of life and catastrophizing. ACTA ACUST UNITED AC 2009; 58:3618-26. [PMID: 18975315 DOI: 10.1002/art.23959] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In the last decade, illness perceptions have been identified as important in the treatment of fibromyalgia (FM). The aim of the present study was to examine illness perceptions and use of the revised Illness Perception Questionnaire in patients with FM (IPQ-R-FM) and their relationship to quality of life and catastrophizing. METHODS A domain with specific causal attributions related to FM was added to the IPQ-R-FM. The psychometric properties of the IPQ-R-FM dimensions and attribution scales were examined. The causal domain, in which patients describe the most important perceived causes for their FM, was analyzed. To analyze the relationship with quality of life and catastrophizing, the Fibromyalgia Impact Questionnaire and the Pain Catastrophizing Scale were used. RESULTS Fifty-one outpatients completed the questionnaires on 2 occasions, 3 weeks apart. FM was considered to be chronic and to have serious consequences; patients perceived little personal control and did not expect medical treatment to be effective. The psychometric properties of the IPQ-R-FM were found to be adequate. Patients most frequently attributed the causes of FM to an external somatic source (58%). Quality of life was related to experiencing more consequences attributable to FM. Catastrophizing was related to a limited understanding of the symptoms of FM, the more cyclical nature of FM, and an emotional representation. CONCLUSION The IPQ-R-FM is a useful tool to assess illness perceptions in patients with FM. Illness perceptions are related to quality of life and catastrophizing; therefore, it seems important to assess and integrate illness perceptions into the management of patients with FM.
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Affiliation(s)
- C Paul van Wilgen
- University Medical Center Groningen, University of Groningen, and Hanze University of Applied Sciences Groningen, Groningen, The Netherlands.
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Comparing fibromyalgia patients from primary care and rheumatology settings: clinical and psychosocial features. Rheumatol Int 2008; 29:1151-60. [PMID: 19096850 DOI: 10.1007/s00296-008-0818-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 11/27/2008] [Indexed: 10/21/2022]
Abstract
The aim of this study was to compare clinical symptoms, perceived health status, health resource use and psychosocial features in fibromyalgia (FM) patients at different health care levels. A total of 315 participants were recruited from primary care (PC) (n=101) and rheumatology settings (RS) (n=214). Subjects completed a protocol of clinical features and health resource use, hospital anxiety and depression scale, sickness impact profile, chronic pain self-efficacy scale, multidimensional pain locus of control scale, perceived health competence scale and chronic pain coping inventory. Student's t test, effect size, and contrast and power test were performed to examine differences between samples. FM patients treated in PC and RS were similar in most variables assessed and only differed significantly in tender points, sleep disturbance, wellness-focused coping strategies and in self-efficacy beliefs. The similarities do not support patient selection through care levels and thus, in the Spanish health care system at least, endorse PC as a reference unit for treatment and questioning the benefits of referring patients to RS.
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Katz JD, Seaman R, Diamond S. Exposing Gender Bias in Medical Taxonomy: Toward Embracing a Gender Difference Without Disenfranchising Women. Womens Health Issues 2008; 18:151-4. [DOI: 10.1016/j.whi.2008.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 03/11/2008] [Indexed: 11/28/2022]
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Bakal D, Coll P, Schaefer J. Somatic awareness in the clinical care of patients with body distress symptoms. Biopsychosoc Med 2008; 2:6. [PMID: 18291028 PMCID: PMC2288613 DOI: 10.1186/1751-0759-2-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 02/21/2008] [Indexed: 12/28/2022] Open
Abstract
The purpose of this paper is to provide primary care physicians and medical specialists with an experiential psychosomatic framework for understanding patients with body distress symptoms. The framework relies on somatic awareness, a normal part of consciousness, to resolve the dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which acknowledges the validity of the patient's physical symptoms and uses body sensations to identify the psychological, physiological, and social factors needed for symptom self-regulation. The experiential approach is based on psychobiologic concepts which include bodily distress disorder, central sensitization, dysfunctional breathing, and contextual nature of mood.
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Affiliation(s)
- Donald Bakal
- Department of Medicine, University of Calgary, Calgary, Canada
- Clinic for Mind/Body Medicine, Calgary Health Region, Calgary, Canada
| | - Patrick Coll
- Clinic for Mind/Body Medicine, Calgary Health Region, Calgary, Canada
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Jeffrey Schaefer
- Department of Medicine, University of Calgary, Calgary, Canada
- Clinic for Mind/Body Medicine, Calgary Health Region, Calgary, Canada
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