Management of Chronic Subdural Hematoma With Adjunctive Embolization of Middle Meningeal Artery: The EMMA-Can Randomized Clinical Trial

# Management of Chronic Subdural Hematoma With Adjunctive Embolization of Middle Meningeal Artery: The EMMA-Can Randomized Clinical Trial *Published: 2026 May 26* The Veterans Affairs' Whole Health Approach for Chronic Pain Management: The wHOPE Randomized Clinical Trial. Seal KH(1)(2)(3)(4), Morasco BJ(5), Martin AM(6)(7), Reddy KP(8)(9), Van Iseghem TM(8)(10), Bolton RE(11), Bokhour BG(11)(12), Murphy J(6), Denneson LM(5)(13), Esserman D(14), Buta E(14), Purcell N(1)(2), Bertenthal D(1), Painter JT(15)(16), Abadjian LR(1), Moore LC(1), Chan AC(1), McCamish N(1), Maguen S(1)(4), Neylan TC(1)(4), Gibson CJ(1)(4), Becker WC(17)(18); wHOPE Study Group. Collaborators: Adams M, Allen R, Ankawi B, Bailey D, Bay W, Beglane M, Berry-Hyatt T, Bess C, Blankenship A, Blankenship E, Borsari B, Burgo L, Burton C, Cagnina M, Chadwell R, Chun V, Cline B, Collins D, Cristoferi K, Dante G, Dayton-Keyhoe A, DeBar L, DeRonne BM, Dougherty J, Edmond SN, Eichelsdoerfer E, Etzel B, Fabian E, Feinberg T, Frank JW, Gagnon TC, Garvey C, George K, Greaves DW, Greene C, Gregg ES, Guo LR, Hagedorn HJ, Hardaway A, Haywood CL, Hildebrand C, Hill L, Hillgren K, Hixson JD, Hokazano A, Horn J, Hubbard A, Hudson T, Huffer M, Ibarra JV, Jacobson C, Jeffries J, Jenkins D, Jones M, Joseph J, Khanna M, Klayman J, Krebs E, Krishnaswamy A, Kuhn A, Lederer V, Lee T, Lisi A, Lucas L, Mack J, Majoris N, Makonnen R, Mathias M, Mazzone KE, Miller E, Morgan C, Munusami M, Nguyen YH, Nieves Y, Noack A, Noonan K, Palyo S, Parker JP, Parrilla D, Pierce W, Pitts SE, Prasad LN, Pyne JM, Raciborski R, Ramirez T, Rankin S, Richards L, Roca H, Rodenkirch IKT, Rodriguez Y, Rudroff K, Saeed A, Seidel I, Sewell K, Shah R, Sivilich H, Suitter J, Torres R, Valenti A, Vannier R, Vassilieva S, Wells M, Wentross J, Wesolowicz D, Woodruff N, Yap EB, Yeung CS, Ying A, Zuniga S. Author information: (1)San Francisco VA Health Care System, San Francisco, California. (2)Center for Data to Discovery and Delivery Innovation, San Francisco VA Health Care System, San Francisco, California. (3)Department of Medicine, University of California, San Francisco. (4)Department of Psychiatry and Behavioral Sciences, University of California, San Francisco. (5)VA Portland Health Care System, Portland, Oregon. (6)Mental Health and Behavioral Sciences Service, James A. Haley VA Healthcare System, Tampa, Florida. (7)Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa. (8)VA St Louis Health Care System, St Louis, Missouri. (9)Washington University School of Medicine, St Louis, Missouri. (10)Department of Family and Community Medicine, St Louis University School of Medicine, St Louis, Missouri. (11)Center for Health Optimization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts. (12)Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester. (13)Department of Psychiatry, Oregon Health & Science University, Portland. (14)Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut. (15)Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Health Care System, Little Rock. (16)Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. (17)VA Connecticut Healthcare System, West Haven. (18)Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut. Comment in doi: 10.1001/jama.2026.5038. doi: 10.1001/jama.2025.11178. doi: 10.1001/jamanetworkopen.2024.15842. ## IMPORTANCE The US Department of Veterans Affairs (VA) Whole Health approach was congressionally mandated in 2016 for patients with chronic pain receiving care in VA hospitals, but no randomized clinical trials have tested its benefits. ## OBJECTIVE To evaluate the effectiveness of a whole health team intervention in VA patients with chronic pain compared with cognitive behavioral therapy and with usual care, and to evaluate the effectiveness of cognitive behavioral therapy compared with usual care in reducing long-term pain interference. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial involving 6 VA health systems in the US enrolled participants between September 18, 2020, and January 19, 2024. Final follow-up occurred on January 27, 2025. Analyses took place between April 1, 2025, and February 3, 2026. Participants were patients with chronic pain receiving VA primary care. ## INTERVENTIONS Patients with chronic pain were randomized (11:11:2) to receive a whole health team intervention (n = 343), cognitive behavioral therapy for chronic pain delivered in group sessions (n = 339), or usual care (n = 82) for 12 months. The whole health team included a primary physician or nurse practitioner, a second clinician providing nonpharmacological or integrative pain care, and a coach. The team provided interdisciplinary, individualized care consistent with the VA Whole Health model to attain personal health goals aligned with patients' personal values and life goals. MAIN OUTCOMES AND MEASURES The primary outcome was the Brief Pain Inventory interference (BPI-I) subscale score (range, 0-10 points; higher scores indicate worse interference from pain; minimal clinically important difference, 1.0) at 12 months. ## RESULTS Of 764 randomized patients (mean [SD] age, 60.5 [12.3] years; 66.5% were men), 632 (82.7%) completed 12-month follow-up. At 12 months, the whole health group had significantly improved pain interference scores (from 6.6 to 4.9) compared with the cognitive behavioral therapy (from 6.4 to 5.5) (mean difference, -0.58 [97% CI, -1.11 to -0.05]; P = .02) and usual care (from 6.4 to 5.7) (mean difference, -0.77 [99% CI, -1.40 to -0.15]; P = .002) groups. At 12 months, cognitive behavioral therapy did not improve pain interference scores significantly more than usual care (mean difference, -0.19 [99% CI, -0.89 to 0.50]; P = .46). The most common adverse event was suicidal ideation, which occurred in 15.9% of patients in the cognitive behavioral therapy group, 13.7% in the whole health team group, and 13.4% in the usual care group. CONCLUSIONS AND RELEVANCE These results support use of the whole health team approach to attain a statistically significant but small improvement in pain interference in VA patients with chronic pain. ## TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04330365. DOI: 10.1001/jama.2026.5006 PMCID: PMC13130068 DOI: 10.1001/jama.2026.4910