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De Lucia A, Perlini C, Chiarotto A, Pachera S, Pasini I, Del Piccolo L, Donisi V. eHealth-Integrated Psychosocial and Physical Interventions for Chronic Pain in Older Adults: Scoping Review. J Med Internet Res 2024; 26:e55366. [PMID: 39073865 PMCID: PMC11319891 DOI: 10.2196/55366] [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: 12/11/2023] [Revised: 03/11/2024] [Accepted: 04/30/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Chronic noncancer pain (CNCP) is highly present among older adults, affecting their physical, psychological, and social functioning. A biopsychosocial multimodal approach to CNCP management is currently extensively suggested by international clinical practice guidelines. Recently, the growing development and application of eHealth within pain management has yielded encouraging results in terms of effectiveness and feasibility; however, its use among the older population remains underexamined. OBJECTIVE The overall aim of this scoping review was to systematically map existing literature about eHealth multimodal interventions (including both physical and psychosocial components) targeting older adults with CNCP. METHODS This review adhered to the JBI methodology, a protocol was a priori registered as a preprint on the medRxiv platform, and the results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and PsycINFO) were systematically searched for relevant articles. Studies were included if they reported on multimodal interventions (including both physical and psychosocial components) delivered through any eHealth modality to an older population with any type of CNCP. Two reviewers selected the studies: first by screening titles and abstracts and second by screening full-text articles. The quality of the included studies was evaluated using the Quality Assessment Tool for Studies with Diverse Designs. The results of the studies were summarized narratively. RESULTS A total of 9 studies (n=6, 67% published between 2021 and 2023) with quality rated as medium to high were included, of which 7 (78%) were randomized controlled trials (n=5, 71% were pilot and feasibility studies). All the included studies evaluated self-management interventions, most of them (n=7, 78%) specifically designed for older adults. The participants were aged between 65 and 75 years on average (mean 68.5, SD 3.5 y) and had been diagnosed with different types of CNCP (eg, osteoarthritis and chronic low back pain). Most of the included studies (5/9, 56%) involved the use of multiple eHealth modalities, with a higher use of web-based programs and video consulting. Only 1 (11%) of the 9 studies involved a virtual reality-based intervention. The evaluated interventions showed signs of effectiveness in the targeted biopsychosocial outcomes, and the participants' engagement and ratings of satisfaction were generally positive. However, several research gaps were identified and discussed. CONCLUSIONS Overall, of late, there has been a growing interest in the potential that eHealth multimodal interventions offer in terms of improving pain, physical, and psychosocial outcomes in older adults with CNCP. However, existing literature on this topic still seems scarce and highly heterogeneous, with few proper randomized controlled trials, precluding robust conclusions. Several gaps emerged in terms of the older population considered and the lack of evaluation of comorbidities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1101/2023.07.27.23293235.
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Affiliation(s)
- Annalisa De Lucia
- Section of Clinical Psychology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Cinzia Perlini
- Section of Clinical Psychology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sara Pachera
- Fondazione Casa di Riposo S Giuseppe Nonprofit Organization of Social Utility, San Martino Buon Albergo (Verona), Italy
| | - Ilenia Pasini
- Section of Clinical Psychology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Lidia Del Piccolo
- Section of Clinical Psychology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Valeria Donisi
- Section of Clinical Psychology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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McKay MA, Cohn A, O'Connor M. The Symptom Experience of Older Adults with Mobility Difficulties: Qualitative Interviews. J Appl Gerontol 2024; 43:129-138. [PMID: 37994808 DOI: 10.1177/07334648231205420] [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] [Indexed: 11/24/2023] Open
Abstract
Eighteen million older adults have mobility limitations, defined as difficulty walking a quarter of a mile or climbing stairs unassisted. Little is known about how symptom burden impacts mobility difficulty in older adults. Understanding the burden of symptoms responsible for mobility difficulties may be an area for intervention to improve mobility and to prevent adverse outcomes. We conducted 31 semi-structured qualitative interviews (one interview per participant) regarding the symptom burden experience associated with a current mobility difficulty. Thematic analysis revealed symptoms were limiting, were barriers to participation in daily activities, and produced a psychological and emotional burden that negatively impacted quality of life. Older adults employed various strategies to overcome the symptom burden. Participants also believed symptoms were a non-modifiable part of the aging process and at times felt disregarded by healthcare professionals. Future interventions should focus on reducing the symptom burden experience for older adults to improve mobility and prevent adverse outcomes.
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Affiliation(s)
- Michelle A McKay
- Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Alexis Cohn
- Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Melissa O'Connor
- Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
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Fanning J, Brooks AK, Robison JT, Irby MB, Ford S, N’Dah K, Rejeski WJ. Associations between patterns of physical activity, pain intensity, and interference among older adults with chronic pain: a secondary analysis of two randomized controlled trials. FRONTIERS IN AGING 2023; 4:1216942. [PMID: 37564194 PMCID: PMC10411520 DOI: 10.3389/fragi.2023.1216942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023]
Abstract
Background: Clinical management of chronic pain often includes recommendations to engage in physical activity (PA), though there are little data on the interplay between pain symptoms and key aspects of PA participation (e.g., intensity and bout duration) among older adults. Herein we investigate the longitudinal relationships between changes in PA behavior and changes in pain intensity and interference among low-active older adults with obesity and chronic pain. Methods: Participants (N = 41) were enrolled in two randomized pilot trials wherein they were assigned to an intervention focused on participation in frequent PA across the day, or to a low-contact control. Participants completed the 3-item PROMIS pain intensity scale and 8-item PROMIS pain interference scale before and after the interventions. Participants also wore an ActivPAL accelerometer for 7 days before and during the final week of the interventions. Results: A series of linear regression analyses demonstrated that increased time spent stepping at a high-light intensity in very short bouts was associated with increased pain intensity scores. By contrast, increased time spent stepping at a high-light intensity in bouts of 5-20 min was associated with reductions in pain intensity and interference scores. Increased time spent stepping at a moderate intensity overall was associated with reduced pain intensity scores, and time spent stepping at a moderate intensity for 10-20 min associated with reduced pain interference. Conclusion: These findings suggest older adults with chronic pain may benefit by moving at high-light or moderate intensities in brief bouts of at least 5 min in duration.
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Affiliation(s)
- Jason Fanning
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
| | - Amber K. Brooks
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Justin T. Robison
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
| | - Megan B. Irby
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
| | - Sherri Ford
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
| | - Kindia N’Dah
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
| | - W. Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, United States
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Buis L, Moral-Munoz JA, Salazar A, Failde I. mHealth Intervention for Improving Pain, Quality of Life, and Functional Disability in Patients With Chronic Pain: Systematic Review. JMIR Mhealth Uhealth 2023; 11:e40844. [PMID: 36729570 PMCID: PMC9936365 DOI: 10.2196/40844] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/24/2022] [Accepted: 12/14/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Chronic pain (CP) is 1 of the leading causes of disability worldwide and represents a significant burden on individual, social, and economic aspects. Potential tools, such as mobile health (mHealth) systems, are emerging for the self-management of patients with CP. OBJECTIVE A systematic review was conducted to analyze the effects of mHealth interventions on CP management, based on pain intensity, quality of life (QoL), and functional disability assessment, compared to conventional treatment or nonintervention. METHODS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed to conduct a systematic review of randomized controlled trials (RCTs) published in PubMed, Web of Science, Scopus, and Physiotherapy Evidence Database (PEDro) databases from February to March 2022. No filters were used. The eligibility criteria were RCTs of adults (≥18 years old) with CP, intervened with mHealth systems based on mobile apps for monitoring pain and health-related outcomes, for pain and behavioral self-management, and for performing therapeutic approaches, compared to conventional treatments (physical, occupational, and psychological therapies; usual medical care; and education) or nonintervention, reporting pain intensity, QoL, and functional disability. The methodological quality and risk of bias (RoB) were assessed using the Checklist for Measuring Quality, the Oxford Centre for Evidence-Based Medicine Levels of Evidence, and the Cochrane RoB 2.0 tool. RESULTS In total, 22 RCTs, involving 2641 patients with different CP conditions listed in the International Classification of Diseases 11th Revision (ICD-11), including chronic low back pain (CLBP), chronic musculoskeletal pain (CMSP), chronic neck pain (CNP), unspecified CP, chronic pelvic pain (CPP), fibromyalgia (FM), interstitial cystitis/bladder pain syndrome (IC/BPS), irritable bowel syndrome (IBS), and osteoarthritis (OA). A total of 23 mHealth systems were used to conduct a variety of CP self-management strategies, among which monitoring pain and symptoms and home-based exercise programs were the most used. Beneficial effects of the use of mHealth systems in reducing pain intensity (CNP, FM, IC/BPS, and OA), QoL (CLBP, CNP, IBS, and OA), and functional disability (CLBP, CMSP, CNP, and OA) were found. Most of the included studies (18/22, 82%) reported medium methodological quality and were considered as highly recommendable; in addition, 7/22 (32%) studies had a low RoB, 10/22 (45%) had some concerns, and 5/22 (23%) had a high RoB. CONCLUSIONS The use of mHealth systems indicated positive effects for pain intensity in CNP, FM, IC/BPS, and OA; for QoL in CLBP, CNP, IBS, and OA; and for functional disability in CLBP, CMSP, CNP, and OA. Thus, mHealth seems to be an alternative to improving pain-related outcomes and QoL and could be part of multimodal strategies for CP self-management. High-quality studies are needed to merge the evidence and recommendations of the use of mHealth systems for CP management. TRIAL REGISTRATION PROSPERO International Prospective Register of Systematic Reviews CRD42022315808; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315808.
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Affiliation(s)
| | - Jose A Moral-Munoz
- Observatory of Pain, University of Cádiz, Cádiz, Spain.,Department of Nursing and Physiotherapy, University of Cádiz, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of the Province of Cadiz (INiBICA), Cádiz, Spain
| | - Alejandro Salazar
- Observatory of Pain, University of Cádiz, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of the Province of Cadiz (INiBICA), Cádiz, Spain.,Department of Statistics and Operational Research, University of Cádiz, Cádiz, Spain
| | - Inmaculada Failde
- Preventive Medicine and Public Health Area, Department of Biomedicine, Biotechnology and Public Health, University of Cádiz, Cádiz, Spain.,Observatory of Pain, University of Cádiz, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of the Province of Cadiz (INiBICA), Cádiz, Spain
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Fanning J, Brooks AK, Ford S, Robison JT, Irby MB, Rejeski WJ. A remote group-mediated daylong physical activity intervention for older adults with chronic pain: Results of the MORPH-II randomized pilot trial. Front Digit Health 2022; 4:1040867. [PMID: 36405417 PMCID: PMC9666366 DOI: 10.3389/fdgth.2022.1040867] [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] [Received: 09/09/2022] [Accepted: 10/14/2022] [Indexed: 01/24/2023] Open
Abstract
Chronic pain is a debilitating condition that affects many older adults who often have limited access to non-pharmacological pain management strategies. One potentially effective and novel lifestyle medicine for chronic pain involves increasing physical activity through frequent movement across the day, thereby also decreasing the presence of extended sedentary bouts. The MORPH-II pilot randomized controlled refinement trial iterated on the MORPH trial, which was a first-of-its-kind group-mediated daylong physical activity (DPA) intervention for older adults with chronic pain rooted in social cognitive and self-determination theories and supported by an mHealth toolset designed to foster social connection and awareness of physical activity patterns. MORPH-II was delivered fully remotely via videoconference software and supported by a technology kit comprising an iPad, activity monitor, and wireless weight scale. It was also implemented a refined coaching model designed to help participants better understand their own patterns of activity. A total of 44 participants were randomized to receive the 12-week group-mediated DPA intervention or to a low-contact control. Qualitative interviews suggest the program was well-received by participants and that participants developed an understanding of how patterns of physical activity related to their pain symptoms. Participants also highlighted several additional areas for refinement related to the coaching model and feedback provided within the mHealth app. Analyses of covariance, controlling for baseline values, revealed a small effect (η 2 = 0.01) on pain intensity favoring the intervention condition, though both groups improved during the study period. There was a large effect favoring the intervention condition on ActivPAL-assessed average daily steps (η 2 = 0.23) and postural shifts (η 2 = 0.24). Control participants spent less time in short sedentary bouts (η 2 = 0.09), and there was a small effect (η 2 = 0.02) indicating intervention participants spent less time in extended sedentary bouts. Finally, relative to control, intervention participants demonstrated a moderate improvement in autonomy satisfaction (η 2 = 0.05), relatedness frustration (η 2 = 0.05), and competence frustration (η 2 = 0.06), and a large magnitude improvement in competence satisfaction (η 2 = 0.22). These findings indicate that the MORPH-II intervention was feasible and acceptable, and may positively impact steps, postural breaks, and several key domains of basic psychological needs detailed in self-determination theory.
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Affiliation(s)
- Jason Fanning
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, United States
| | - Amber K. Brooks
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Sherri Ford
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, United States
| | - Justin T. Robison
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, United States
| | - Megan B. Irby
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, United States
| | - W. Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, United States
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Self-reported symptom causes of mobility difficulty contributing to fear of falling in older adults. Aging Clin Exp Res 2022; 34:3089-3095. [PMID: 36121639 DOI: 10.1007/s40520-022-02253-2] [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: 05/19/2022] [Accepted: 09/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Self-reported symptom causes of mobility difficulty that contribute to fear of falling (FOF) in older adults has not been fully explored as an area for intervention. AIMS Identify the prevalence of self-reported symptoms causing mobility difficulties and to examine the difference in FOF by symptom category. METHODS Conduct a secondary data analysis of a population-based cohort of community-dwelling older adults, ≥ 70 years, enrolled in the MOBILIZE Boston study. The analysis included 242 older adults reported difficulty walking ¼ mile (0.4 km) and/or climbing one flight of stairs. Participants identified the main symptom cause of the mobility difficulty from a list of 32 symptoms, grouped into five categories. FOF was measured using the Tinetti Falls Efficacy Scale. RESULTS Pain was the primary symptom causing mobility difficulty (38%), followed by endurance (21%), weakness (13%), balance (9%), and other (3%). Although a greater proportion of participants who identified balance as the primary symptom category had significantly higher FOF compared to others, there was a greater number overall who reported pain as their main symptom who also had FOF. Therefore, pain contributed to a higher relative burden of FOF in the population than did balance symptoms. DISCUSSION Various symptoms affect mobility and are associated with FOF, a known fall risk factor. Many older adults identify pain as the main cause of their mobility difficulty and report FOF. CONCLUSIONS Improving pain symptoms for older adults may improve mobility and reduce fear of falling, potentially averting further decline in mobility and independence.
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Wong AKC, Wong FKY, Bayuo J, Chow KKS, Wong SM, Lee AYL. A randomized controlled trial of an mHealth application with nursing interaction to promote quality of life among community-dwelling older adults. Front Psychiatry 2022; 13:978416. [PMID: 36329920 PMCID: PMC9623156 DOI: 10.3389/fpsyt.2022.978416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
SIGNIFICANCE Using mHealth apps alone at home without the support of healthcare experts could mean that older adults might not fully utilize the functions of the apps, recognize their benefits, and sustain their use. Incorporating an integrated health-social partnership model to support the app usage when further help is needed by the older adults might maximize the apps' benefits in the long term. OBJECTIVES This study aimed to examine the benefits of adding nursing interaction supported by a health-social partnership model in the use of mHealth, and the sustained beneficial effects on psychological outcomes, including quality of life, self-efficacy, and depression, among older adults after the completion of the program. METHODS A three-arm, randomized controlled trial design was adopted. Community-dwelling older adults with chronic pain, hypertension, or diabetes, were randomly assigned to either the mHealth, mHealth with interactivity, or control group. Subjects in both the mHealth and the mHealth with interactivity groups received the mHealth application. In addition, the mHealth with interactivity group received support from a nurse case manager, who was supported by a health-social partnership team. mHealth apps and services from a nurse case manager were not provided to the control group. The primary outcome measure was quality of life, and secondary outcomes were self-efficacy and depression. Data were collected at pre-intervention (T1), post-intervention (T2), and at 3 months post-intervention to measure the sustained effect of the program. RESULTS There were 74 mHealth+I, 71 mHealth, and 76 control group subjects enrolled in the program. No statistically significant between-group, within-group, and interaction effects between group and time in both physical component summary (PCS) and mental component summary (MCS) scores were found among the three groups. The mHealth group showed an improvement in PCS and depression scores from T1 to T2, sustained at T3; while the mHealth+I group demonstrated improved self-efficacy from T1 to T2, with a decrease at T3. CONCLUSION Adding nurse-directed telephone calls may be of little to no benefit at all in the long term. Future studies may consider a longer intervention period to build and sustain quality of life and self-efficacy levels among community-dwelling older adults. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier: NCT03878212.
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Affiliation(s)
| | - Frances Kam Yuet Wong
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | | | - Siu Man Wong
- The Hong Kong Lutheran Social Service, Ho Man Tin, Hong Kong SAR, China
| | - Athena Yin Lam Lee
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
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Fanning J, Rejeski WJ, Leng I, Barnett C, Lovato JF, Lyles MF, Nicklas BJ. Intervening on exercise and daylong movement for weight loss maintenance in older adults: A randomized, clinical trial. Obesity (Silver Spring) 2022; 30:85-95. [PMID: 34932885 PMCID: PMC8711609 DOI: 10.1002/oby.23318] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study aimed to determine the impact of dietary weight loss (WL) plus aerobic exercise (EX) and a "move more, more often" approach to activity promotion (SitLess; SL) on WL and maintenance. METHODS Low-active older adults (age 65-86 years) with obesity were randomized to WL+EX, WL+SL, or WL+EX+SL. Participants received a social-cognitive group-mediated behavioral WL program for 6 months, followed by a 12-month maintenance period. EX participants received guided walking exercise with the goal of walking 150 min/wk. SL attempted to achieve a step goal by moving frequently during the day. The primary outcome was body weight at 18 months, with secondary outcomes including weight regain from 6 to 18 months and objectively assessed physical activity and sedentary behavior at each time point. RESULTS All groups demonstrated significant WL over 6 months (p < 0.001), with no group differences. Groups that received SL improved total activity time (p ≤ 0.05), and those who received EX improved moderate-to-vigorous activity time (p = 0.003). Over the 12-month follow-up period, those who received WL+EX demonstrated greater weight regain (5.2 kg; 95% CI: 3.5-6.9) relative to WL+SL (2.4 kg; 95% CI: 0.8-4.0). CONCLUSIONS Pairing dietary WL with a recommendation to accumulate physical activity contributed to similar WL and less weight regain compared with traditional aerobic exercise.
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Affiliation(s)
- Jason Fanning
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina, USA
| | - W Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Iris Leng
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Cheyenne Barnett
- Department of Internal Medicine, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - James F Lovato
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Mary F Lyles
- Department of Internal Medicine, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Barbara J Nicklas
- Department of Internal Medicine, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
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