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Glob Adv Health Med. 2015 Nov; 4(6): 44–50.
Published online 2015 Nov 1. doi:10.7453/gahmj.2015.056
PMCID: PMC4653605
PMID: 26665022
Kimberly Firth, PhD, Katherine Smith, MPH, Bonnie R. Sakallaris, PhD, RN,
Dawn M. Bellanti, MSN, CRNP, Cindy Crawford, BA, and Kay C. Avant, PhD, RN, FNI, FAAN
Author information Copyright and License information PMC Disclaimer
INTRODUCTION
Healing is a commonly used term, and yet rigorous research on the definition and meaning of healing has been published infrequently, and understanding of the concept remains confusing and inexact.1 Clinicians and patients are overwhelmed with a healthcare system focused on disease over health creation, reductionist, fragmented, costly, and often ineffective. In response, there has been an increasing recognition that quality healthcare and the delivery of that care need to take a more holistic, patient-centric approach, an approach that emphasizes healing as important as curing. In 2004, Samueli Institute, Alexandria, Virginia, proposed a whole-system, healing-focused framework for delivering care and coined the term optimal healing environments (OHE). An OHE is comprised of people in relationships, their health-creating and healing behaviors, and the surrounding physical environment. An OHE supports and stimulates patient healing by addressing the social, psychological, physical, spiritual, and behavioral components of healthcare, enabling the person's innate capacity to heal.2 The OHE framework (Figure) is composed of 4 domains or integrated environments that reinforce each other by acting synergistically. Each environment is applicable on a personal level to the important relationships in our lives and to the organizations and physical environments where we work, play, and receive healthcare.3
Figure
Optimal Healing Environments framework.
Originally developed by consensus of experts, the OHE framework evolved over the past decade through insight gained at exemplar organizations and practices, and new information generated through research activities.3 The individual constructs as described lacked operational definitions to guide measurement. The research team wanted to create operational definitions for each of the concepts in the OHE framework to inform future research and facilitate measurement and evaluation of the concepts. Since healing is the desired outcome of an OHE and is central to all other constructs in the framework, the research team made the decision to subject healing to concept analysis methodology. The aim of this article is to describe the use of a rigorous methodology, concept analysis, to clarify the meaning of healing and propose an operational definition of healing in order to further the scientific understanding and translation of OHEs into practice.
Methodology
We used concept analysis methodology because of its stated purposes to examine the basic elements of a widely used concept to clarify meaning, develop operational definitions that help validate the construct, and facilitate instrument development in practice.4 The Walker and Avant method of concept analysis was employed as it is widely used and highly regarded in the field as a process for bringing about clarification, identification, and meaning of concepts.5 The methodology has critics, particularly regarding depth, rigor, and replicability of the findings as the methods used to analyze are influenced by the skill, knowledge, culture, and understanding of the analyst and the framework being used.6 The Walker and Avant method of concept analysis is criticized for lack of integration between the steps and limited applicability and clinical relevancy.7 We employed multiple actions to mitigate these criticisms throughout the process.
The Walker and Avant methodology includes 9 steps: (1) select the concept for analysis; (2) determine the aims of the analysis; (3) identify all uses of the concept; (4) determine defining attributes based on the literature review; (5) construct or identify a model case; (6) identify contrary, borderline, related, invented, and/or illegitimate cases; (7) identify antecedents and consequences related to the concept; (8) define empirical referents; and (9) create a final definition of the concept.4 The steps are not linear but are iterative in nature and may occur “out of order” as 1 step informs another throughout the philosophic inquiry.
We identified healing as the concept to study fulfilling the work of Step 1. Step 2 was to determine the aim of the study, which was “to develop an operational definition of healing in order to study the OHE framework.” We deliberately chose to use the OHE framework to focus the analysis despite the limitations that predetermined frameworks impose on the analysis.
Step 3 was to identify all uses of the concept. The use of the OHE framework limited the context of healing to humans, so descriptions and definitions of healing in relation to political relationships, conflict, the environment, and so forth were reviewed but not included in the analysis.
Early in the process of the analysis, we located 5 published concept analyses related to healing, 3 on healing, 1 on self-healing, and 1 on healing and chronic pain. The preexisting analyses provided insight into how others have conceptualized healing (Table 1) but did not provide the operational clarity that we sought to further our understanding of healing as it manifests in optimal healing environments.
Table 1
Definitions of Healing From Existing Concept Analysis Work
| Authors | Definition |
|---|---|
| JA Glaister | Healing is a natural active and multidimensional process that is individually expressed with common patterns. Healing is influenced by body-condition, personal attitudes, and relationships.1(p67) |
| D McElliott | Theoretical definition: Healing is a positive, subjective, unpredictable process involving transformation to a new sense of wholeness, spiritual transcendence, and reinterpretation of life. Operational definition: Healing is the personal experience of transcending suffering and transforming to wholeness.8(p251) |
| MC Wendler | Healing is an experiential, energy-requiring process in which space is created through a caring relationship in a process of expanding consciousness and results in a sense of wholeness, integration, balance, and transformation and which can never be fully known.9(p836) |
| WJW Robb | Self-healing is the active, personal process that, upon the use of an energetic catalyst, results in the rechanneling of innate, vital energy forces throughout the journey towards transcendence.10(p74) |
| AA Smith | No definition proposed. Three attributes of healing: Sense of transcending the immediate environment or situation Sense of timeless connection, unity, and interdependence with the self and others: Sense of inner knowing, strength, and peace11(p23) |
After reviewing the existing concept analyses, researchers launched an in-depth review that included journals, books on healing, and journal articles. A wide variety of dictionaries were searched: historical, abridged and unabridged, the Laffal Concept Dictionary of English,12 an etymological dictionary, complementary and/or alternative medicine dictionaries, and ancient medical dictionaries stored at the National Institutes of Health's National Library of Medicine (NLM). We conducted searches in PubMed/Medline, ProQuest, CINAHL, PsycInfo, and Google Scholar using the term healing as a keyword from database inception through July 2015. This search strategy yielded thousands of results, which were screened by the research team. The majority focused on specific curative procedures and medications in human and animal models. The OHE framework is a holistic approach to healing, so subsequent searches were limited to human research using the Title/Abstract delimiter where available and “defin*” or “meaning” as key words. The authors pulled literature from reference lists, bibliographies, and other sources in addition to the formal search strategy (eg, unpublished literature, book chapters, and non–peer-reviewed articles). The researchers reviewed all retrieved articles, books, and web pages looking for definitions and descriptions of healing. The information was compiled into a comprehensive list of 118 healing definitions and descriptions (Appendix A, available at www.gahmj.com). The team reviewed all data, noting words and phrases used repeatedly to define or describe the characteristics and consequences of healing. We used the team approach to data analysis to mitigate the impact of individual knowledge, skill, and culture on the analysis.
A total of 99 key terms and phrases were extracted from the data and recorded as well as the number of times each was mentioned (Appendix B, available at www.gahmj.com). The 99 key terms were the “first cut” and formed the foundation for determining the core attributes of healing. Next, we eliminated redundancies and collapsed the terms into higher order concepts. For example, the terms progression, journey, emergent process, shift, and evolving collapsed into the higher-order concept process. Fourteen higher order concepts evolved from 99 original key terms and phrases. These 14 higher-order concepts were the “second cut” of the analysis.
Steps 4 through 8 required multiple meetings where the team examined the higher-order concepts in order to group them into mutually exclusive categories: defining attributes (key characteristics of healing), antecedents (necessary for healing to occur), or consequences (result of healing). Consensus was not declared until all team members agreed that the defining attributes immediately called the concept of healing (and only healing) to mind. At times, we shifted higher-order concepts into different categories. For example, repair and recovery was first categorized as a consequence of healing. However, it became clear that without repair and recovery, the defining attributes did not bring the concept of healing immediately to mind, and thus we reclassified the process of repair and recovery as a defining attribute. After lengthy discussions and examinations, 4 final defining attributes, 2 antecedents and 3 consequences were agreed upon, from which evolved a working definition of healing (Table 2).
Table 2
Defining Attributes of Healing, Antecedents, and Consequences
| Antecedents | Defining Attributes | Consequences |
|---|---|---|
| Brokenness | Holistic transformative process | Positive change |
| Connection with self or others | Innate or naturally occurring process | Finding meaning |
| Multidimensional | Personal wholeness | |
| Involves repair and recovery of mind, body, and spirit |
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The team tested antecedents, attributes, and consequences with actual and composite cases to clarify, refine, and validate the defining attributes. A model case is a clear example of the concept that contains all defining characteristics. A borderline case almost exemplifies the concept but lacks one or more of the defining attributes. Contrary cases are clearly not representative of the concept being studied.4 Finally, we reviewed the literature for empirical referents. Empirical referents are the measurable ways to demonstrate healing.
DEFINITIONS OF HEALING
The word healing comes from the old-English term haelen, meaning “wholeness”13 and often refers to the process of moving toward a desired wholeness or achievement of cohesion.14 Healing is an intervention, an outcome, and a process, and at times, all three.15 It also describes an ability or power,10 energy,16 and cleansing of grief, trouble, or evil.17 The concept is relevant in a wide range of disciplines, including medicine, nursing, psychology, public health, education, religion, and spirituality. Healing occurs in multiple dimensions—physical, mental, emotional, spiritual, familial, social, communal, and environmental. Healing occurs at multiple levels from the micro level, as in cellular wound healing, to the macro level, as in national and global healing. Healing originates from within the individual and from external sources (eg, human healers and God) or substances (eg, herbs and medicines). Perspectives on healing come from health-care practitioners, patients, priests, rabbis, energy practitioners, spiritual healers, people close to death, people living with pain and other chronic illnesses, people who have suffered abuse and neglect, and those who have suffered hardship such as divorce, miscarriage, or death of a child.18-21
DEFINING ATTRIBUTES OF HEALING
Defining attributes are the characteristics of a concept that differentiate that concept from other similar or related concepts.4 Four defining attributes emerged in this concept analysis. Healing is a holistic transformative process; it is personal; it is innate or naturally occurring; it is multidimensional; and it involves repair and recovery of mind, body, and spirit.
The positive, transformative process, progression, or journey does not occur in a single instant but evolves over time.22 Studies support healing as a process of moving away from an undesired state to a state of renewal.22-24 The process is dynamic, emergent, and experiential. It is a journey and an experience. Multiple healthcare providers and patients describe it as “an evolving process that may require changes in direction and final destination.”18(p310) Healing involves the whole person—mind, body, and spirit. Holistic processes integrate multiple dimensions synergistically, creating a new dimension that is more than the sum of the original dimensions; “Healing requires understanding the patient as a whole person, not just addressing a discrete physical problem.”18(p310) Though cure usually occurs solely on the physical or mental level, healing does not; it occurs holistically in the mind, body, and spirit.
The process of healing is transformative; it changes the individual in expected and unexpected ways, creating a new entity. The individual transcends distress, suffering, and the disease state and becomes a different person. People are transformed from the old to the new. Some describe both the healer and healee transforming in a positive direction.25
Healing involves repair and recovery in multiple dimensions—mind, body, and spirit. We are all broken in some way and in need of healing. The healing process engages the individual's innate ability to repair damage and recover function. Repair means to fix or mend and to recover is to return to a previous state.26 In healing, repair and recovery may occur at the micro level of cells and tissue, the orderly series of cellular processes that restore tissue integrity.27 Healing also involves repair and recovery at the emotional, psychological, social, and spiritual levels, such as when an assault victim overcomes intense anxiety and moral distress.28 Spiritual repair is described by Kubler-Ross as when “the spiritual quadrant opens and matures”23 and can be seen in the amputee who overcomes anger and blame by making a commitment to use the negative experience to help other amputees.29 Repair and recovery of mind, body, and spirit are what differentiates healing from cure. When people are cured, their disease or disease symptoms are physically eradicated, but they may or may not repair or recover in other areas.24 Healing, on the other hand, involves repair and recovery in all aspects of the physical, psychic and spiritual person: in other words, healing is concerned with wholeness for the total person.30
ANTECEDENTS OF HEALING
The antecedents of healing are conditions or actions necessary for healing and usually precede the experience of healing. They include a brokenness and relationships with others and/or oneself.
Activation of the repair or recovery process occurs in response to a defect, disruption, disharmony, or malfunctioning. Living beings are complex physical, mental, spiritual, and energy systems, and disruption can occur in any of the systems. For example, physiological healing is a response to a biological injury or imbalance, but the injury may lead to mental disruption expressed by swift mood changes, difficulty concentrating, and anxiety as seen in the transition from acute pain associated with injury to chronic pain.11 As previously mentioned, the human condition is one of brokenness and healing occurs naturally all of the time: “By becoming aware that our lives are a continual process of healing, we can learn to come to peace with any illness or injury that may manifest.”30(p187) In the context of significant hurt, healing may need to be facilitated by healers and healing practices. Medical intervention may provide relief of suffering and cure but may not be sufficient to facilitate healing. Stories of healing suggest that healing is more complex than “fixing the broken part.”24
Healing occurs in the context of a relationship: “At the heart of nearly every healing story are one or more critical relationships.”31 The relationships critical for the healing process to occur may involve friends, family, community, a higher being, or oneself19; for some, it is even achieved through relationship and connection with a pet.32 Anthropological research highlights the therapeutic impact of the relationship between healers and healees.33,34 Healing is an innate capability, a natural process; therefore, the healing relationship is facilitative.
CONSEQUENCES OF HEALING
Healing results in positive change, finding meaning, and the realization of wholeness. These consequences differentiate healing from cure in that cure may occur without the patient finding meaning or realizing wholeness of mind-body-spirit. Healing results in positive changes at many levels, including but not limited to physical health. Improvements in mental, emotional, social, or spiritual harmony are examples of healing outcomes.1 The positive change that occurs in healing is not limited to the event at hand but continues as the person progresses through life.35
A common outcome of healing is a reinterpretation of the event or situation that provides meaning and transcends the situation. It may include understanding and reinterpreting one's condition such that a new sense of purpose is found. For some, meaning is found in their actual illness. Others find it through helping others. As Victor Frankl so eloquently described in Man's Search for Meaning, “suffering ceases to be suffering in some way, in the moment it finds a meaning.”36 Moreover, according to Smith11, “In order to say that healing is occurring there must be a sense of inner knowing … The person has a sense of meaning and purpose in life.”11(p23)
The realization of wholeness is the integration of physical, emotional, intellectual, energy, and spiritual systems into a balanced and harmonious total being, the sum of which is greater than its individual parts.37 Wholeness is harmony of body, mind, and spirit and may involve social and environmental elements.38,39
Healing and the resulting wholeness are individual processes and personal experiences unique to the individual40 and occurring within the life narrative of the person experiencing the phenomenon.23 While a healthcare provider can evaluate objective data in order to determine if a person is “cured,” only the individual can determine that healing has occurred. Hence, a consequence of healing is a uniquely subjective and personal realization and perception of wholeness.
TEST CASES
The defining attributes of healing were exposed to actual and constructed cases. Cases are useful to test the defining attributes and to refine them using comparative reflection.
A Model Case of Healing
A search of the literature, both published and lay literature (eg, newspaper articles, personal communications) resulted in the adoption of the following model case of healing:
Jorge Morales settled in a rapidly growing urban Mexican immigrant community in the United States when he was in his teens. Jorge took great pride in learning English and advancing his education, believing that independence was important for assimilating into American society. As a gay male, Jorge was well aware of his risks for contracting HIV, but was devastated when he discovered his partner had the disease and was dying. Feeling betrayed and depressed by his partner's infidelity, Jorge ignored his own symptoms until he needed hospitalization; he could no longer deny his own HIV status. As he lay desperately ill and alone in his hospital bed, a group of doctors came to his bedside, informed him that he had “full-blown AIDS” and walked away.
Although his body responded to the HIV medicines, his spirit did not. Dejected, Jorge returned home to live with his mother, but there was little solace there. She understood neither his sexual orientation nor his disease. She was terrified of catching AIDS and refused to touch him, even insisting that he eat on his own dinnerware and wash his clothes and linens separately. Disconnected and empty of hope, he planned a return to the United States to die. Before leaving, however, his 11-year-old sister tearfully pleaded with him to live for her. “I want you to give me away at my wedding,” she said. Clinging to this lifeline of hope, he returned to the United States.
With a reason to live, Jorge sought help in a small inner-city family medicine office near his apartment. Unlike the physicians at the hospital, this doctor treated him as if he, Jorge, distinctly mattered. Over time, Jorge grew to trust his doctor. He felt this doctor was able to get into his head, particularly when he would say, “Don't you want to see your sister get married?” In return, Jorge worked hard to adhere to his medical regimen.
Meanwhile, Jorge began to take care of his home, giving him a sense of pride and control. His work provided a place of support and gave him needed self-respect. Over time, and with the persistent intercession of his sister, Jorge's mother gained a better understanding of his life with AIDS, and Jorge was able to arrange for her to move from Mexico into an apartment in his building. While he may never be “cured” from his disease, Jorge has experienced healing.31(ppS41-S42)
Jorge's case embodies the defining attributes of healing; he experienced a holistic transformative process integrating his physical, emotional, and social systems resulting in positive movement toward higher physical, emotional, social, and relational health and wellbeing. Jorge's case demonstrated repair and recovery within the context of his incurable disease.
The antecedent criteria were met. Jorge was broken in body, mind, and spirit, and it was in the context of the relationships with his sister and doctor that he began to heal. The consequences of healing were demonstrated as Jorge found meaning in a variety of areas, moved toward wholeness in mind and spirit and made many positive changes in his life. In this particular example, healing occurred even though Jorge has an incurable disease.
A Borderline Case of Healing
The following is a constructed case while providing an example of a process toward repair and recovery that does not exemplify healing.
Jimmy, a 50-year-old banker diagnosed with multiple sclerosis (MS), grew up with an absentee, alcoholic father. He placed a high value on achievement and hard work and referred to himself as a “workaholic.” Jimmy had difficulty expressing his emotions, often raging at his wife and three children.
Jimmy managed to continue working despite his decreasing mobility. Tensions at home increased as work left him exhausted, edgy, and anxious. His doctor suggested reducing his work hours, incorporating gentle exercise to keep up his strength, and medication to address his anxiety and edginess. Jimmy utilized the antidepressants but did not follow through on alterations in life style to reduce stress.
Two years after his diagnosis, Jimmy had an exacerbation of his MS symptoms necessitating hospitalization. Frightened and frustrated, he lashed out at his wife and the hospital staff. His physician checked in on him each day during rounds and called his room each evening. It touched Jimmy that someone who was so busy would consistently check on him. One evening, after a very difficult day physically, Jimmy asked to see his physician. He was told that his doctor was in surgery that was expected to last into the evening and that the doctor would not be able to see him until the next day. However, that night after 10 PM the physician walked into Jimmy's room. The physician pulled up a chair and made it clear that he was there for as long as Jimmy needed. Jimmy and the physician talked for over an hour, during which Jimmy shared his anxieties about his inability to perform at work and provide for his family. The physician listened with care and validated Jimmy's concerns and struggles. That night, Jimmy slept better than he had in weeks.
See AlsoThe Three Stages of InflamationOver the next few months, Jimmy began incorporating many of the doctor's suggestions. His physical symptoms began to subside and his relationships with his wife and children have taken a greater priority in his life. While much improved, he continued to struggle emotionally and described his daily life as “just getting out of bed, when I can, and making it through the best I know how.”
This constructed case demonstrated progress towards improved physical repair and recovery of functioning, as seen by the considerable diminishment of physical symptoms and better sleep, as well as improved social/relational functioning, manifested by his improved relationships with his wife and children. There is also evidence of the consequences of finding meaning and positive change as he incorporates his doctor's suggestion to reduce work hours and his family becomes more of a priority in his life. However, Jimmy still had a significant amount of emotional brokenness and gave no indication that he considered himself to be healing or healed. Thus, his situation lacked the defining attribute of holism and the consequence of a self-realized perception of wholeness or healing.
A Contrary Case of Healing
Our constructed contrary case shows a nearly complete failure of healing.
From the age of 10, Ron always wanted to be a soldier in the US Army. Immediately following high school graduation, Ron enlisted in the army. A year after basic training, Ron received his first deployment to Iraq. He felt gratitude and honor about being called to do what was in his heart and what he was prepared for—fighting for his country.
Two years later, during his second deployment, Ron was seriously injured by an improvised explosive device while driving a Humvee on a mission. He sustained serious physical injuries and witnessed the death of a fellow soldier. Ron was immediately attended to and sent to the nearest medical facility. Once he was stabilized, Ron was flown back to the United States where he was treated by an expert team of specialists. Despite the injuries, Ron's prognosis was very good.
Over the next several months, Ron's progress toward full physical recovery failed to materialize, however, as Ron's disappointment in himself and in his self-professed “inability to save my friend” overwhelmed him. Ron seldom attends physical therapy, and his physical functioning is declining. He was diagnosed with posttraumatic stress disorder and urged to continue with his medication regimen and to seek therapy, either individually or via a support group. Ron rejected the suggestion of therapy, preferring to be left alone.
Ron's example lacks any of the defining attributes of healing. His physical abilities continue to decline, and he has mental, cognitive, and emotional disruptions, with no evidence that there will be repair and recovery in those areas or that he is undergoing or will undergo any sort of holistic transformation. Ron also has isolated himself, rejecting any sort of relationship, which is an antecedent to the healing process. Clearly, Ron's story does not embody a holistic, transformative process of repair and recovery in mind, body, or spirit.
OPERATIONAL DEFINITION OF HEALING
The operational definition that emerged from the concept analysis: Healing is a holistic, transformative process of repair and recovery in mind, body, and spirit resulting in positive change, finding meaning, and movement toward self-realization of wholeness, regardless of the presence or absence of disease.
EMPIRICAL REFERENTS
Empirical referents are vital because they support the concept's validity by providing ways to measure the existence of the concept. The research team anticipated the emergence of quantitative measures of healing through the concept analysis process. We concluded that given the highly subjective and personal nature of healing, a mixed-methods approach to measurement is most appropriate. This approach engenders a more robust understanding of the healing construct via interview probes expressly geared to the understanding of the holistic, transformative processes of the healing experience, as well as the quantitative measures of physiological change, symptom resolution, improved sense of wellbeing, sense of coherence, and enhanced relationships. Categories of qualitative data may include (1) changes in sensations and feelings; (2) changes in self-concepts and values; (3) changes in medical symptoms and complaints; and (4) construction of meaning or cognitive reframing.41 Miller et al recommend a composite measure of healing that incorporates physiological parameters, symptom relief scales, biomarkers, health status and functional status scales, wholeness scales. and measures of functional relationships.42 Healing has different empirical referents in different contexts, situations, and cultures. Measurement is possible using established biometrics for repair and recovery in concert with qualitative information on transformative change, personal wholeness, and meaning.
DISCUSSION
The aim of this study was to extract the defining attributes of healing in order to provide a clear and comprehensive definition of healing, a definition that could be used to operationalize the concept and measure it. The predominant clinical use of the concept is to convey full recovery from illness or repair of injury as in wound healing, disease management, and cure. The team acknowledged the biomedical use of the concept and included repair and recovery as a defining attribute. This decision was the result of significant debate and return to the literature with the conclusion that healing involves repair and recovery in the multiple dimensions of our humanity; mind, body, and spirit. Our use of the OHE framework to guide the concept analysis led us to focus on literature that examined healing as a holistic concept over the prevailing biomedical focus on repair and recovery.
As early as 400 BC, Hippocrates described healing as a natural process leading to restoration of wholeness, creating harmony between body and soul.8 Twenty-first century work added the dimension of the mind. Our search for definitions and descriptions of healing led to a set of defining attributes that support the conclusions of previous concept analyses. This congruence of attributes described across centuries validated our understanding of healing as an innate transformative process. The existing literature on the subject also provided an understanding that healing requires a brokenness or disruption of health and that the facilitation of healing, although personal in nature, does not occur in isolation but in relationship with one's self or another, frequently between healer and healee but also between the person and an important other. The literature also revealed that outcomes of healing include positive change, finding meaning, and the realization of personal wholeness.
CONCLUSION
An operational definition of healing with antecedents, defining attributes, and consequences emerged through the process of concept analysis. We tested the findings using multiple cases, ultimately resulting in a model case, a borderline case, and a contrary case.
The definition provided here and supported by the literature contends that healing is a holistic, transformative process of repair and recovery in mind, body, and spirit resulting in positive change, finding meaning, and movement towards self-realization of wholeness, regardless of the presence or absence of disease. Healing may or may not include cure, defined as the eradication of physical symptoms of illness or disease.
This definition of healing, as well as its antecedents, consequences, and empirical referents, provides a solid, evidence-based foundation for understanding and describing the seminal construct of the OHE framework.
Acknowledgments
The authors wish to acknowledge Courtney Boyd and Charmagne Paat, both of the Samueli Institute, for their assistance in the literature search and Kelly Gourdin for her assistance with the development of the contrary case.
Notes
Disclosures The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and had no conflicts to disclose.
Funding This work is supported by the US Army Medical Research and Materiel Command under Award No. W81XWH-10-1-0938. The views, opinions and/or findings are those of the authors and should not be construed as an official Department of the Army position, policy, or decision unless so designated by other documentation.
Contributor Information
Kimberly Firth, National Institute on Aging, Bethesda, Maryland (Dr Firth), United States.
Katherine Smith, Samueli Institute, Alexandria, Virginia (Ms Smith), United States.
Bonnie R. Sakallaris, Samueli Institute, Alexandria, Virginia (Dr Sakallaris), United States.
Dawn M. Bellanti, Samueli Institute, Alexandria, Virginia (Ms Bellanti), United States.
Cindy Crawford, Samueli Institute, Alexandria, Virginia (Ms Crawford), United States.
Kay C. Avant, University of Texas Health Science Center, San Antonio, Texas (Dr Avant), United States.
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