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Background Increased physical activity is a common feature of anorexia nervosa (AN). Although high activity levels are associated with greater risk of developing AN, particularly when combined with dieting, most individuals who diet and exercise maintain a healthy body weight. It is unclear why some individuals develop AN while most do not. A rodent model of resilience and vulnerability to AN would be valuable to research. Dopamine, which is believed to play a crucial role in AN, regulates both reward and activity and may modulate vulnerability. Methods Adolescent and young adult female C57BL/6N mice were tested in the activity-based anorexia (ABA) model, with an extended period of food restriction in adult mice. ABA was also tested in dopamine transporter knockdown mice and wild-type littermates. Mice that adapted to conditions and maintained a stable body weight were characterized as resilient. Results In adults, vulnerable and resilient phenotypes emerged in both the ABA and food-restricted mice without wheels. Vulnerable mice exhibited a pronounced increase in running throughout the light cycle, which dramatically peaked prior to requiring removal from the experiment. Resilient mice exhibited an adaptive decrease in total running, appropriate food anticipatory activity, and increased consumption, thereby achieving stable body weight. Hyperdopaminergia accelerated progression of the vulnerable phenotype. Conclusions Our demonstration of distinct resilient and vulnerable phenotypes in mouse ABA significantly advances the utility of the model for identifying genes and neural substrates mediating AN risk and resilience. Modulation of dopamine may play a central role in the underlying circuit.

Objective To assess the feasibility and potential benefits of clinical meditation and imagery (CMI) for people with chronic spinal cord injury (SCI) and chronic pain. Design Pilot randomized, controlled trial. Setting Outpatients with SCI in the United States. Participants 24 adults with chronic SCI (>1 year) and a >3 month history of pain rated ≥4/10 on average over the last week. Interventions 4-week program of once-weekly 2-hour group classes, offered in-person and online. CMI group participants were taught mindfulness, mantra meditation, and guided imagery practices. Control group participants received education on topics related to health and function after SCI. Outcome measures Pain interference (primary outcome), pain cognitions, pain intensity/unpleasantness, depressive symptomology, perceived stress. Results Pain interference decreased to a greater extent in the control group at both Day 42 and Day 70, with a large effect size (d > 1.0). Several secondary outcome measures showed changes consistent with more favorable outcomes in the CMI group at both Day 42 and Day 70, with a large effect size d > 0.80, including worst pain intensity over the last week, depressive symptomology, belief in pain as a sign of harm and perceived control over pain. Perceived stress improved to a greater extent in the control group (d = 1.16 at Day 42, d = .20 at Day 70). Conclusion CMI is feasible and acceptable to implement with people with SCI and chronic pain. Further study is warranted to assess potential benefits for pain-related outcomes.

The spinal cord injury (SCI) research community has experienced great advances in discovery research, technology development, and promising clinical interventions in the past decade. To build upon these advances and maximize the benefit to persons with SCI, the National Institutes of Health (NIH) hosted a conference February 12-13, 2019 titled "SCI 2020: Launching a Decade of Disruption in Spinal Cord Injury Research." The purpose of the conference was to bring together a broad range of stakeholders, including researchers, clinicians and healthcare professionals, persons with SCI, industry partners, regulators, and funding agency representatives to break down existing communication silos. Invited speakers were asked to summarize the state of the science, assess areas of technological and community readiness, and build collaborations that could change the trajectory of research and clinical options for people with SCI. In this report, we summarize the state of the science in each of five key domains and identify the gaps in the scientific literature that need to be addressed to move the field forward.

Current clinical literature and supporting animal literature have shown that repeated and profound early-life adversity, especially when experienced within the caregiver–infant dyad, disrupts the trajectory of brain development to induce later-life expression of maladaptive behavior and pathology. What is less well understood is the immediate impact of repeated adversity during early life with the caregiver, especially since attachment to the caregiver occurs regardless of the quality of care the infant received including experiences of trauma. The focus of the present manuscript is to review the current literature on infant trauma within attachment, with an emphasis on animal research to define mechanisms and translate developmental child research. Across species, the effects of repeated trauma with the attachment figure, are subtle in early life, but the presence of acute stress can uncover some pathology, as was highlighted by Bowlby and Ainsworth in the 1950s. Through rodent neurobehavioral literature we discuss the important role of repeated elevations in stress hormone corticosterone (CORT) in infancy, especially if paired with the mother (not when pups are alone) as targeting the amygdala and causal in infant pathology. We also show that following induced alterations, at baseline infants appear stable, although acute stress hormone elevation uncovers pathology in brain circuits important in emotion, social behavior, and fear. We suggest that a comprehensive understanding of the role of stress hormones during infant typical development and elevated CORT disruption of this typical development will provide insight into age-specific identification of trauma effects, as well as a better understanding of early markers of later-life pathology.

The complex process of regulating physiological functions and homeostasis during external and internal disruptions develops slowly in altricial species, with parental care functioning as a co-regulator of infant physiological and emotional homeostasis. Here, we review our current understanding of the infant’s use of parental behaviors for neurobehavioral regulation and its disruption with harsh parental care. Taking a cross-species view, we briefly review the human developmental literature that highlights the importance of the caregiver in scaffolding the child’s physiological and emotional regulation, especially under threat and stress. We then use emerging corresponding animal literature within the phylogenetically preserved attachment system to help define neural systems supporting caregiver regulation and its supporting causal mechanism to provide translational bridges to inform causation and mechanisms impossible to define in children. Next, we briefly review animal research highlighting the impact of specific sensory stimuli imbedded in parental care as important for infant physiological and emotion regulation. We then highlight the importance of parental sensory stimuli gaining hedonic value to go beyond simple sensory stimuli to further impact neurobehavioral regulation, with poor quality of care compromising the infant’s ability to use these cues for regulation. Clinically, parental regulation of the infant is correlated with later-life neurobehavioral outcome and quality of life. We suggest an understanding of this parental regulation of the infant’s immediate neurobehavioral functioning within the context of attachment quality, that may provide insights into the complex processes during early life, initiating the pathway to pathology.

OBJECTIVE: To inform clinicians’ equipment recommendations by characterizing the experiences, skin integrity, and interface pressures in a series of recently discharged individuals with spinal cord injury (SCI) who chose to use an alternative adjustable bed system at home rather than a standard of care hospital bed with mattress overlay. DESIGN: Mixed methods, observational case series. SETTING: Community based. METHODS: Four individuals with cervical SCIs and one partner of a participant with SCI completed interviews about their experiences using an alternative adjustable bed system and their skin health. Participants also underwent pressure mapping on their alternative adjustable bed system and on a standard of care hospital bed with mattress overlay. Interview themes were identified using a consensus qualitative approach. Pressure readings at the sacrum and ischial tuberosities in supine and at the greater trochanter in side lying were compared between surfaces. OUTCOME MEASURES: Semi-structured interview, questionnaire, and pressure mapping. RESULTS: All participants reported positive experiences utilizing an alternative adjustable bed system and no episodes of bed-related skin breakdown. Reasons for wanting an alternative adjustable bed included a greater sense of normalcy and larger size. Participants perceived their alternative beds to be comfortable, and to have features that aided their function and assisted their caregivers. Features used included head of bed elevation, height elevation, and bed rails. All participants had clinically acceptable pressure mapping patterns on the alternative adjustable bed system. CONCLUSION: An adjustable bed system, combined with other skin protection strategies, may be appropriate for certain individuals with spinal cord injury.

Objective To identify barriers and facilitators to achieving optimal inpatient rehabilitation outcome among individuals with spatial neglect (SN). Design Cross-sectional, semistructured focus group discussions. Setting Rehabilitation hospitals. Participants A total of 15 occupational therapists and 14 physical therapists treating patients with SN on 3 campuses of a rehabilitation hospital system (N=29). Six focus group sessions were conducted and audio-recorded for transcription. Interventions Not applicable. Main Outcome Measures Not applicable. Results Participants identified several patient-related characteristics that posed barriers to treatment, including the symptoms of SN itself, cognitive issues, physical weakness, comorbidities, and reduced therapy engagement. Supportive family members were considered a key facilitator, but lack of preparedness to assume caregiving roles, poor understanding of SN and rehabilitation goals, and inadequate levels of involvement were family-related barriers to successful treatment. Participants expressed that having resources and technologies available at their center to support SN treatment facilitated positive outcomes and perceived limited staff knowledge and skills and poor interclinician communication as barriers to treatment. At the health care system level, barriers included a lack of responsive measures of SN progress and insurer-related issues. Strong continuity of care between transitions was considered an important factor for enabling effective treatment. Conclusions Barriers and facilitators to the current practice of SN care were identified from occupational and physical therapists’ point of view. Opportunities exist to promote identified facilitators and minimize barriers to improve SN rehabilitation. The present study makes a unique contribution in identifying specific needs for innovative interventions that involve family support and training, promotion of interdisciplinary collaboration, development of interprofessional vocabulary, and continuous treatment and follow-up assessment for SN through care transitions.

Objective To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches. Design Online cross-sectional survey. Setting Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States. Participants Individuals with SCI (N=1076). Interventions Not applicable. Main Outcome Measures Qualities of Spasticity Questionnaire, modified Spinal Cord Injury–Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM). Results Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged 55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%). Conclusions The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.

Child development research highlights caregiver regulation of infant physiology and behavior as a key feature of early life attachment, although mechanisms for maternal control of infant neural circuits remain elusive. Here we explored the neurobiology of maternal regulation of infant fear using neural network and molecular levels of analysis in a rodent model. Previous research has shown maternal suppression of amygdala-dependent fear learning during a sensitive period. Here we characterize changes in neural networks engaged during maternal regulation and the transition to infant self-regulation. Metabolic mapping of 2-deoxyglucose uptake during odor-shock conditioning in postnatal day (PN)14 rat pups showed that maternal presence blocked fear learning, disengaged mesolimbic circuitry, basolateral amygdala (BLA), and plasticity-related AMPA receptor subunit trafficking. At PN18, when maternal presence only socially buffers threat learning (similar to social modulation in adults), maternal presence failed to disengage the mesolimbic dopaminergic system, and failed to disengage both the BLA and plasticity-related AMPA receptor subunit trafficking. Further, maternal presence failed to block threat learning at PN14 pups following abuse, and mesolimbic dopamine engagement and AMPA were not significantly altered by maternal presence-analogous to compromised maternal regulation of children in abusive relationships. Our results highlight three key features of maternal regulation: (1) maternal presence blocks fear learning and amygdala plasticity through age-dependent suppression of amygdala AMPA receptor subunit trafficking, (2) maternal presence suppresses engagement of brain regions within the mesolimbic dopamine circuit, and (3) early-life abuse compromises network and molecular biomarkers of maternal regulation, suggesting reduced social scaffolding of the brain.

Rehabilitation clinicians strive to provide cost-effective, patient-centered care that optimizes outcomes. A barrier to this ideal is the lack of a universal system for describing, or specifying, rehabilitation interventions. Current methods of description vary across disciplines and settings, creating barriers to collaboration, and tend to focus mostly on functional deficits and anticipated outcomes, obscuring connections between clinician behaviors and changes in functioning. The Rehabilitation Treatment Specification System (RTSS) is the result of more than a decade of effort by a multidisciplinary group of rehabilitation clinicians and researchers to develop a theory-based framework to specify rehabilitation interventions. The RTSS describes interventions for treatment components, which consist of a target (functional change brought about as a direct result of treatment), ingredients (actions taken by clinicians to change the target), and a hypothesized mechanism of action, as stated in a treatment theory. The RTSS makes explicit the connections between functional change and clinician behavior, and recognizes the role of patient effort in treatment implementation. In so doing, the RTSS supports clinicians' efforts to work with their patients to set achievable goals, select appropriate treatments, adjust treatment plans as needed, encourage patient participation in the treatment process, communicate with team members, and translate research findings to clinical care. The RTSS may help both expert and novice clinicians articulate their clinical reasoning processes in ways that benefit treatment planning and clinical education, and may improve the design of clinical documentation systems, leading to more effective justification and reimbursement for services. Interested clinicians are invited to apply the RTSS in their local settings.

The field of rehabilitation remains captive to the black-box problem: our inability to characterize treatments in a systematic fashion across diagnoses, settings, and disciplines, so as to identify and disseminate the active ingredients of those treatments. In this article, we describe the Rehabilitation Treatment Specification System (RTSS), by which any treatment employed in rehabilitation may be characterized, and ultimately classified according to shared properties, via the 3 elements of treatment theory: targets, ingredients, and (hypothesized) mechanisms of action. We discuss important concepts in the RTSS such as the distinction between treatments and treatment components, which consist of 1 target and its associated ingredients; and the distinction between targets, which are the direct effects of treatment, and aims, which are downstream or distal effects. The RTSS includes 3 groups of mutually exclusive treatment components: Organ Functions, Skills and Habits, and Representations. The last of these comprises not only thoughts and feelings, but also internal representations underlying volitional action; the RTSS addresses the concept of volition (effort) as a critical element for many rehabilitation treatments. We have developed an algorithm for treatment specification which is illustrated and described in brief. The RTSS stands to benefit the field in numerous ways by supplying a coherent, theory-based framework encompassing all rehabilitation treatments. Using a common framework, researchers will be able to test systematically the effects of specific ingredients on specific targets; and their work will be more readily replicated and translated into clinical practice.

Although infants learn and remember, they rapidly forget, a phenomenon known as infantile amnesia. While myriad mechanisms impact this rapid forgetting, the molecular events supporting memory maintenance have yet to be explored. To explore memory mechanisms across development, we used amygdala-dependent odor-shock conditioning and focused on mechanisms important in adult memory, the AMPA receptor subunits GluA1/2 and upstream protein kinases important for trafficking AMPAR, protein kinase M zeta (PKMζ) and iota/lambda (PKCι/λ). We use odor-shock conditioning in infant rats because it is late-developing (postnatal day, PN10) and can be modulated by corticosterone during a sensitive period in early life. Our results show that memory-related molecules did not change in pups too young to learn threat (PN8) but were activated in pups old enough to learn (PN12), with increased PKMζ-PKCι/λ and GluA2 similar to that observed in adult memory, but with an uncharacteristic decrease in GluA1. This molecular signature and behavioral avoidance of the conditioned odor was recapitulated in PN8 pups injected with CORT before conditioning to precociously induce learning. Blocking learning via CORT inhibition in older pups (PN12) blocked the expression of these molecules. PN16 pups showed a more adult-like molecular cascade of increased PKMζ-PKCι/λ and GluA1–2. Finally, at all ages, zeta inhibitory peptide (ZIP) infusions into the amygdala 24 hr after conditioning blocked memory. Together, these results identify unique features of memory processes across early development: AMPAR subunits GluA1/2 and PKC isoform expression are differentially used, which may contribute to mechanisms of early life forgetting.

Hippocampal dendritic spine density rapidly increases following estradiol (E2) treatment, but the types of spines and trafficking of synaptic markers have received little investigation. We assessed rapid effects of E2 over time on the density of four spine types (stubby, filopodial, long thin and mushroom) and trafficking of AMPA receptor subunit GluA2 and PSD95 on tertiary, apical dendrites in CA1. Castrated male rats received 20 μg/kg of E2 or vehicle and were sacrificed 30 or 120 min later. Images of Golgi-Cox impregnated and PSD95/GluA2 stained dendrites were captured under the confocal microscope and quantified with IMARIS-XT. Stubby and filopodial spine densities did not change following treatment. Long-thin spines significantly decreased at 30 min while mushroom spines significantly increased at 120 min. GluA2, PSD95 and GluA2/PSD95 colocalization levels in stubby or long thin spines did not change, but filopodial spines had significantly reduced GluA2 levels at 30 min. Mushroom spines showed significantly increased levels for GluA2, PSD95 and GluA2/PSD95 colocalization at 120 min. Since GluA2 is important for memory consolidation, current results present novel data suggesting that trafficking of GluA2 to mushroom spines provides one mechanism contributing to estradiol's ability to enhance learning and memory by the PI3 signaling pathway. This article is protected by copyright. All rights reserved.

Social interaction deficits seen in psychiatric disorders emerge in early-life and are most closely linked to aberrant neural circuit organization and function. Due to technical limitations, we have had little understanding of the typical ontogeny of social behavior neural circuits or how early caregiving adversity impacts infant neurobiology to perturb lifelong social interaction. Using a suite of invasive procedures in awake, behaving young infant rats, including optogenetics, microdialysis and microinfusions, we charted the gradual increase in social behavior deficits following adversity-rearing and dissected circuits controlling this process. Persistently elevated dopamine in basolateral amygdala (BLA) was necessary and sufficient in initiating social behavior pathology, as demonstrated by manipulation of amygdala dopamine during adversity and during expression of social behavior deficits with the mother and peers. Taken together, these data highlight mesolimbic dopamine circuit organization and function as a potential therapeutic target in understanding behavioral deficits associated with psychiatric disorders.

Social stress, including bullying during adolescence, is a risk factor for common psychopathologies such as depression. To investigate the neural mechanisms associated with juvenile social stress-induced mood-related endophenotypes, we examined the behavioral, morphological, and biochemical effects of the social defeat stress model of depression on hippocampal dendritic spines within the CA1 stratum radiatum. Adolescent (postnatal day 35) male C57BL/6 mice were subjected to defeat episodes for 10 consecutive days. Twenty-four h later, separate groups of mice were tested on the social interaction and tail suspension tests.Hippocampi were then dissected and Western blots were conducted to quantify protein levels for various markers important for synaptic plasticity including protein kinase M zeta (PKMζ), protein kinase C zeta (PKCζ), the dopamine-1 (D1) receptor, tyrosine hydroxylase (TH), and the dopamine transporter (DAT). Furthermore, we examined the presence of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)-receptor subunit GluA2 as well as colocalization with the post-synaptic density 95 (PSD95) protein, within different spine subtypes (filopodia, stubby, long-thin, mushroom) using an immunohistochemistry and Golgi-Cox staining technique. The results revealed that social defeat induced a depression-like behavioral profile, as inferred from decreased social interaction levels, increased immobility on the tail suspension test, and decreases in body weight. Whole hippocampal immunoblots revealed decreases in GluA2, with a concomitant increase in DAT and TH levels in the stressed group. Spine morphology analyses further showed that defeated mice displayed a significant decrease in stubby spines, and an increase in long-thin spines within the CA1 stratum radiatum. Further evaluation of GluA2/PSD95 containing-spines demonstrated a decrease of these markers within long-thin and mushroom spine types. Together, these results indicate that juvenile social stress induces GluA2- and dopamine-associated dysregulation in the hippocampus – a neurobiological mechanism potentially underlying the development of mood-related syndromes as a consequence of adolescent bullying.

It is well known that young organisms do not maintain memories as long as adults, but the mechanisms for this ontogenetic difference are undetermined. Previous work has revealed that the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAr) subunits are trafficked into the synaptic membrane following memory retrieval in adults. Additionally, phosphorylated PSD-95-pS295 promotes AMPAr stabilization at the synapse. We investigated these plasticity related proteins as potential mediators in the differential contextual stress memory retrieval capabilities observed between adult and juvenile rats. Rats were assigned to either pedestal stress (1 h) or no stress control (home cage). Each animal was placed alone in an open field for 5 min at the base of a 6 × 6 sq inch pedestal (4ft high). Stress subjects were then placed on this pedestal for 1hr and control subjects were placed in their home cage following initial exploration. Each animal was returned to the open field for 5 min either 1d or 7d following initial exposure. Freezing postures were quantified during the memory retrieval test. The 1d test shows adult (P90) and juvenile (P26) stressed rats increase their freezing time compared to controls. However, the 7d memory retrieval test shows P90 stress rats but not P26 stress rats freeze while in the fear context. Twenty minutes after the memory retrieval test, hippocampi and amygdala were micro-dissected and prepared for western blot analysis. Our results show that 1d fear memory retrieval induced an upregulation of PSD-95 and pS295 in the adult amygdala but not in the juvenile. However, the juvenile animals upregulated PKMζ, PI3K and GluA2/3, GluA1-S845 in the dorsal hippocampus (DH), but the adults did not. Following the 7d memory retrieval test, adults upregulated GluA2 in the amygdala but not the juveniles. In the DH, adults increased PSD-95 and pS295 but not the juveniles. The adults appear to preferentially increase amygdala-driven processing at 1d and increase DH-driven context specific processing at 7d. These data identify molecular processes that may underlie the reduced fear-memory retrieval capability of juveniles. Together these data provide a potential molecular target that could be beneficial in treatment of anxiety disorders and PTSD. Keywords: Stress, Fear, Memory, Amygdala, Hippocampus, Plasticity, AMPA receptor, PSD-95, Development

Despite significant advances in measuring the outcomes of rehabilitation interventions, little progress has been made in specifying the therapeutic ingredients and processes that cause the measured changes in patient functioning. The general approach to better clarifying the process of treatment has been to develop reporting checklists and guidelines that increase the amount of detail reported. However, without a framework instructing researchers in how to describe their treatment protocols in a manner useful to or even interpretable by others, requests for more detail will fail to improve our understanding of the therapeutic process. In this paper, we describe how the Rehabilitation Treatment Specification System (RTSS) provides a theoretical framework that can improve research intervention reporting and enable testing and refinement of a protocol’s underlying treatment theories. The RTSS framework provides guidance for researchers to explicitly state their hypothesized active ingredients and targets of treatment; as well as how the individual ingredients in their doses directly affect the treatment targets. We explain how theory-based treatment specification has advantages over checklist approaches for intervention design, reporting, replication, and synthesis of evidence in rehabilitation research. A complex rehabilitation intervention is used as a concrete example of the differences between an RTSS-based specification and the Template for Intervention Description and Replication (TIDieR) checklist. The RTSS’s potential to advance the rehabilitation field can be empirically tested through efforts to use the framework with existing and newly developed treatment protocols.

Most rehabilitation treatments are volitional in nature, meaning that they require the patient's active engagement and effort. Volitional treatments are particularly challenging to define in a standardized fashion, because the clinician is not in complete control of the patient's role in enacting these treatments. Current recommendations for describing treatments in research reports fail to distinguish between 2 fundamentally different aspects of treatment design: the selection of treatment ingredients to produce the desired functional change and the selection of ingredients that will ensure the patient's volitional performance. The Rehabilitation Treatment Specification System (RTSS) is a conceptual scheme for standardizing the way that rehabilitation treatments are defined by all disciplines across all areas of rehabilitation. The RTSS highlights the importance of volitional behavior in many treatment areas and provides specific guidance for how volitional treatments should be specified. In doing so, it suggests important crosscutting research questions about the nature of volitional behavior, factors that make it more or less likely to occur, and ingredients that are most effective in ensuring that patients perform desired treatment activities.

Objective To describe group therapy utilization in spinal cord injury (SCI) inpatient rehabilitation. Design Prospective observational study. Setting Six inpatient rehabilitation facilities. Participants Patients (N=1376) receiving initial rehabilitation after traumatic SCI. Interventions Not applicable. Main Outcome Measure Time spent in group versus individual therapy for physical therapy (PT), occupational therapy (OT), therapeutic recreation (TR), and psychology (PSY) therapies. Results The majority (98%) of patients participated in at least 1 group therapy session, with 83%, 81%, 80%, and 54% of patients receiving group PT, OT, TR, and PSY, respectively. On average, 24% of treatment sessions and 27% of treatment time was provided in group sessions, with TR providing the greatest percent of its time in groups. Group therapy time and time spent in specific activities varied among patient subgroups with different injury characteristics. Group therapy time also varied widely among centers (range, 1.2–6.6h/wk). Across all injury subgroups, individual and group therapy hours per week were negatively correlated for OT and positively correlated for TR. Patient characteristics, clinician experience, and treatment center predicted 32% of variance in group hours per week. PT and OT strengthening/endurance interventions and TR outings were the most common group activities overall. Conclusions While the majority of inpatient SCI rehabilitation consists of individual sessions, most patients participate in group therapy, which contributes significantly to total therapy time. Patterns of group utilization fit with functional expectations and clinical goals. A trade-off between group and individual therapy may occur in some disciplines. Utilization of group therapy varies widely among centers, and further study is needed to identify optimal patterns of group therapy utilization.

Jette AM, Tulsky DS, Ni P, Kisala PA, Slavin MD, Dijkers MP, Heinemann AW, Tate DG, Whiteneck G, Charlifue S, Houlihan B, Williams S, Kirshblum S, Dyson-Hudson T, Zanca J, Fyffe D. Development and initial evaluation of the Spinal Cord Injury-Functional Index. Objectives To describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain. Design Cross-sectional survey followed by calibration data simulations. Setting Inpatient and community settings. Participants A sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury. Interventions None. Main Outcome Measure SCI-FI instrument. Results Item response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks. Conclusions Initial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI.

Resume Le debit de filtration glomerulaire (DFG) est un parametre fondamental dans l’evaluation de la fonction renale. La mesure du DFG en routine clinique represente la methode de reference pour l’etude d’un dysfonctionnement renal. Les etudes utilisant les sequences d’IRM dynamique apres injection de produit de contraste pour l’estimation du DFG se sont particulierement developpees au cours des dix dernieres annees. Cette technique est fondee sur la visualisation du passage d’un produit de contraste (chelates de gadolinium) dans les reins. L’IRM y apparait comme une technique prometteuse mais encore relativement difficile a mettre en place dans l’evaluation du DFG. On constate, a l’analyse de la litterature, une grande heterogeneite de protocoles utilises, autant sur le mode d’acquisition que sur la dose de produit de contraste ou les techniques de post-traitement, ce qui reflete le nombre de defis techniques qui restent a resoudre avant de parvenir a un accord sur la methode. De plus, la precision et la reproductibilite signalees dans la litterature apparaissent encore insuffisantes pour motiver l’utilisation routiniere de l’IRM du Gd dans l’evaluation du DFG. Cette mise au point presente et discute les differentes etapes permettant une quantification par IRM du DFG.

Multi-center, prospective, cohort study. To assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III) in measuring functional ability in persons with spinal cord injury (SCI). Inpatient rehabilitation hospitals in the United States (US). Functional ability was measured with the SCIM III during the first week of admittance into inpatient acute rehabilitation and within one week of discharge from the same rehabilitation program. Motor and sensory neurologic impairment was measured with the American Spinal Injury Association Impairment Scale. The Functional Independence Measure (FIM), the default functional measure currently used in most US hospitals, was used as a comparison standard for the SCIM III. Statistical analyses were used to test the validity and reliability of the SCIM III. Total agreement between raters was above 70% on most SCIM III tasks and all κ-coefficients were statistically significant (P

Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, Backus D, Charlifue S, Ballard PH, Zanca JM. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab study. Objective To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI). Design Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview. Setting Inpatient and postdischarge rehabilitation programs. Participants Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study. Interventions Not applicable. Main Outcome Measures Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews. Results Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services. Conclusions SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes.

With funding from a cooperative agreement from the National Institute on Disability and Rehabilitation Research, we have worked for the past 5 years on the development of a rehabilitation treatment taxonomy, a system of classifying all treatments delivered by all rehabilitation disciplines for all diagnostic groups of patients, whatever the setting in which these services are delivered. To date, we have focused on developing a conceptual framework for such a taxonomy, specifying the scope of the taxonomy and the basis for classifying treatments. A recent supplement of the Archives of Physical Medicine and Rehabilitation contained a series of articles setting forth the background for the project, our approach to conceptual issues, and the need to classify treatments based on a theory of how active ingredients bring about change in a clinical target of treatment (some aspect of patient functioning) through a specific mechanism of action.1 It also contains papers on how therapists view classification and lessons learned during a previous effort at classifying learning interventions, as well as commentaries by various scholars who had an opportunity to review these papers. Here we summarize the key points. The field of rehabilitation has made substantial advances in defining and measuring the functional outcomes of the rehabilitation process and the patient characteristics that are associated with those outcomes. However, we lack a rigorous and shared approach to defining, classifying, and measuring the rehabilitation treatments that are hypothesized to moderate the relationships between patient factors and outcomes. At present, rehabilitation treatments may be described as number …

OBJECTIVES: To determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home population. DESIGN: Clinical trial with participants assigned at random to a skin protection or segmented foam cushion. Two hundred thirty-two participants were recruited between June 2004 and May 2008 and followed for 6 months or until pressure ulcer incidence. SETTING: Twelve nursing homes. PARTICIPANTS: Nursing home residents aged 65 and older who were using wheelchairs for 6 or more hours per day and had a Braden score of 18 or less and a combined Braden activity and mobility score of 5 or less. Participants were recruited from a referred sample. INTERVENTION: All participants were provided with a fitted wheelchair and randomized into skin protection (SPC, n=113) or segmented foam (SFC, n=119) cushion groups. The SPC group received an air, viscous fluid and foam, or gel and foam cushion. The SFC group received a 7.6-cm crosscut foam cushion. MEASUREMENTS: Pressure ulcer incidence over 6 months for wounds near the ischial tuberosities (IT ulcers) were measured. Secondary analysis was performed on combined IT ulcers and ulcers over the sacrum and coccyx (sacral ulcers). RESULTS: One hundred eighty participants reached a study end point, and 42 were lost to follow-up. Ten did not receive the intervention. There were eight (6.7%) IT ulcers in the SFC group and one (0.9%) in the SPC group (P=.04). There were 21 (17.6%) combined IT and sacral ulcers in the SFC group and 12 (10.6%) in the SPC group (P=.14). CONCLUSION: Skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence for elderly nursing home residents and should be used to help prevent pressure ulcers.

Ragweed is an allergenic weed of public health concern in several European countries. In Italy ragweed occurs prevalently in north-north-eastern regions, where sensitization is increasing. Because of the small diameter of pollen grains, ragweed pollen is often involved in episodes of long-range transport, as already shown in central Italy. The objective of this study was to evaluate the extent of such transport by comparing pollen and meteorological data for two northern Italian cities (Parma and Mantova) with data from Pistoia and Florence in central Italy. In 2002 and 2004 peaks in ragweed pollen levels were detected in these four cities on the same day, and concentrations of the grains were above clinical thresholds. Weather-map analysis and computation of back-trajectories showed that air masses from eastern Europe might carry ragweed pollen to a wide area of central and northern Italy. These findings suggest that episodes of long-range transport of ragweed pollen could be clinically relevant, resulting in sensitization of a large number of people. The results might provide a basis for monitoring and forecasting periods of long-distance transport with the objective of reducing their effects on allergic patients. © 2007 Springer Science+Business Media B.V.

Environmental enrichment (EE) housing paradigms have long been shown beneficial for brain function involving neural growth and activity, learning and memory capacity, and for developing stress resiliency. The expression of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor subunit GluA2, which is important for synaptic plasticity and memory, is increased with corticosterone (CORT), undermining synaptic plasticity and memory. Thus, we determined the effect of EE and stress on modulating GluA2 expression in Sprague-Dawley male rats. Several markers were evaluated which include: plasma CORT, the glucocorticoid receptor (GR), GluA2, and the atypical protein kinase M zeta (PKMz). For one week standard- (ST) or EE-housed animals were treated with one of the following four conditions: (1) no stress; (2) acute stress (forced swim test [FST] on day 7); (3) chronic restraint stress (6 h/day for 7 days); (4) chronic + acute stress (restraint stress 6 h/day for 7 days + FST on day 7). Hippocampi were collected on day 7. Our results show that EE animals had reduced time immobile on the FST across all conditions. After chronic + acute stress EE animals showed increased GR levels with no change in synaptic GluA2/PKMz. ST-housed animals showed the reverse pattern with decreased GR levels and a significant increase in synaptic GluA2/PKM. These results suggest that EE produces an adaptive response to chronic stress allowing for increased GR levels, which lowers neuronal excitability reducing GluA2/PKMz trafficking. We discuss this EE adaptive response to stress as a potential underlying mechanism that is protective for retaining synaptic plasticity and memory function.

Objective To identify pressure ulcer research funding sources. Design A systematic review of the acknowledgment sections of pressure ulcer literature published between 2000 and 2002. Results Sixty-four papers were identified that acknowledged funding sources. Governmental funding sources were acknowledged in 53% (n = 34) of these papers, followed by manufacturers (30%, n = 19), consumer/professional organizations (17%, n = 11), provider organizations (11%, n = 7), philanthropic organizations (11%, n = 7), and academic institutions (9%, n = 6). Conclusion Although various governmental organizations fund most pressure ulcer-related projects, this systematic review found that many other sources of funding are available. Researchers are encouraged to explore multiple sources for funding clinical research.

Methamphetamine (MA) is an addictive drug with neurotoxic effects on the brain producing cognitive impairment and increasing the risk for neurodegenerative disease. Research has focused largely on examining the neurochemical and behavioral deficits induced by injecting relatively high doses of MA [30 mg/kg of body weight (bw)] identifying the upper limits of MA-induced neurotoxicity. Accordingly, we have developed an appetitive mouse model of voluntary oral MA administration (VOMA) based on the consumption of a palatable sweetened oatmeal mash containing a known amount of MA. This VOMA model is useful for determining the lower limits necessary to produce neurotoxicity in the short-term and long-term as it progresses over time. We show that mice consumed on average 1.743 mg/kg bw/hour during 3 hours, and an average of 5.23 mg/kg bw/day over 28 consecutive days on a VOMA schedule. Since this consumption rate is much lower than the neurotoxic doses typically injected, we assessed the effects of long-term chronic VOMA on both spatial memory performance and on the levels of neurotoxicity in the hippocampus. Following 28 days of VOMA, mice exhibited a significant deficit in short-term spatial working memory and spatial reference learning on the radial 8-arm maze (RAM) compared to controls. This was accompanied by a significant decrease in memory markers protein kinase Mzeta (PKMζ), calcium impermeable AMPA receptor subunit GluA2, and the post-synaptic density 95 (PSD-95) protein in the hippocampus. Compared to controls, the VOMA paradigm also induced decreases in hippocampal levels of dopamine transporter (DAT) and tyrosine hydroxylase (TH), as well as increases in dopamine 1 receptor (D1R), glial fibrillary acidic protein (GFAP) and cyclooxygenase-2 (COX-2), with a decrease in prostaglandins E2 (PGE2) and D2 (PGD2). These results demonstrate that chronic VOMA reaching 146 mg/kg bw/28d induces significant hippocampal neurotoxicity. Future studies will evaluate the progression of this neurotoxic state.

The objective of the proposed study is to create an assessment tool for use by clinicians during inpatient rehabilitation to systematically evaluate and describe competence in self-direction of care and caregiving skills. Key findings derived from rehabilitation chart reviews include the following: The persons who receive caregiver education during the inpatient rehabilitation stay are varied, including spouses, children, parents, and friends of the person with tetraplegia, as well as hired attendants. Instructional methods include discussion and verbal presentation of information, provision of written materials, demonstration of skills, and opportunities to practice skills with feedback from clinicians. A wide variety of topics related to self-care, activities of daily living, equipment use, secondary complications, emergency preparedness, and medical issues appeared in clinical documentation of patient and caregiver training. Clinicians use several techniques to assess the ability of persons with tetraplegia and their caregivers to direct care or perform care tasks. A variety of descriptors are used to characterize the ability of persons with tetraplegia and/or their caregivers to direct or perform care tasks. These include the level of independence with which a task is performed or directed, quality (good, fair, poor), accuracy (correctness), frequency (compared with what is ideal), completeness, and extent to which further training is needed.

In relation to the conceptual framework for a rehabilitation treatment taxonomy (RTT), which has been proposed in other articles in this supplement, this article discusses a number of issues relevant to its further development, including creating distinctions within the major target classes; the nature and quantity of allowable targets of treatment; and bracketing as a way of specifying (1) the skill or knowledge taught; (2) the nature of compensation afforded by changes in the environment, assistive technology, and orthotics/prosthetics; and (3) the ingredients in homework a clinician assigns. Clarification is provided regarding the role of the International Classification of Functioning, Disability and Health, focusing a taxonomy on ingredients versus other observable aspects of treatment, and regarding our lack of knowledge and its impact on taxonomy development. Finally, this article discusses the immediate implications of the work to date and presents the need for rehabilitation stakeholders of all disciplines to be involved in further RTT development.

Objective To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization. Design Prospective observational cohort study. Setting Six geographically dispersed rehabilitation centers in the U.S. Participants Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey. Interventions Not applicable. Main Outcome Measures Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations. Results More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034–2.279), having Medicaid as the main payer (95% CI, 1.303–2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960–.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized—from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered. Conclusions Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Objective To describe pain during inpatient rehabilitation and its impact on delivery of inpatient rehabilitation services for persons with spinal cord injury (SCI). Design Prospective observational study and retrospective chart review. Setting Six inpatient rehabilitation facilities participating in the SCIRehab Study. Participants Patients (N=1357) receiving initial rehabilitation after traumatic SCI, for whom pain data were available. Interventions Not applicable. Main Outcome Measures Self-reported rating of pain intensity (0–10), pain locations, and treatment time by various rehabilitation disciplines. Results The vast majority of patients (97%) reported pain at least once during the rehabilitation stay, with an average pain intensity ± SD of 4.9±2.4. Average pain intensity over the stay was severe (rated 7–10) for 30% of patients, moderate (4–6) for 42%, and mild (1–3) for 25%. Pain prevalence at admission was greater than at discharge (87% vs 74%), as was pain intensity (6.0 vs 4.6). Most (79%) of the 177 participants who did not have pain at admission reported pain at least once later in the rehabilitation stay, but their average high pain intensity over the stay was lower than that of the full sample (1.9 vs 4.9). Nearly half (47%) of patients reported pain at ≥3 locations during the stay, with the back, neck, and shoulder commonly reported. Patients with severe pain spent fewer days in rehabilitation, received less rehabilitation treatment time (hours per week and total hours), and had more treatment sessions altered in objective or content because of pain than those with lower pain levels. Conclusions Pain is a common problem for persons receiving inpatient rehabilitation for traumatic SCI and adversely impacts delivery of therapy services.

Objective To describe therapist-reported factors affecting therapy sessions in spinal cord injury (SCI) inpatient rehabilitation and explore their impact on the patient's rehabilitation program. Design Prospective observational longitudinal cohort design. Data were obtained from systematic recordings of interventions by clinicians and from medical record abstraction. Setting Six inpatient rehabilitation programs. Participants Patients (N=1376) with traumatic SCI admitted for initial rehabilitation. Interventions Not applicable. Main Outcome Measures Factors recorded as impacting the objective or content of treatment sessions by physical therapy, occupational therapy, speech therapy, and therapeutic recreation, patients' participation in treatment as rated using a modified Pittsburgh Rehabilitation Participation Scale (PRPS), length of stay (LOS), medical morbidity measured using the Comprehensive Severity Index, hours of therapy per week, and missed therapy minutes. Results Patients received 151,172 treatment sessions from 483 therapists. Pain, fatigue, and spasticity were commonly reported factors; other medical, behavioral, and logistical factors were also frequent, with 30% of sessions being affected by at least 1 factor. The number of factors was correlated with missed therapy minutes and with the PRPS score. Patients with more reported factors, overall or per average session, had a longer LOS and fewer hours of treatment per week. Conclusions Medical and other factors complicating therapy are common. Those who need a longer stay because of their injury level or for other reasons have more opportunity to have sessions affected, but having many treatment sessions impacted by 1 or more factors also is likely to increase LOS. The nature of these factors and their impact on rehabilitation processes and outcomes deserve further study.

Tulsky DS, Jette AM, Kisala PA, Kalpakjian C, Dijkers MP, Whiteneck G, Ni P, Kirshblum S, Charlifue S, Heinemann AW, Forchheimer M, Slavin MD, Houlihan B, Tate DG, Dyson-Hudson T, Fyffe D, Williams S, Zanca J. Spinal Cord Injury-Functional Index: item banks to measure physical functioning in individuals with spinal cord injury. Objectives To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning. Design Cross-sectional. Setting Inpatient and community. Participants Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury. Interventions None. Main Outcome Measure Spinal Cord Injury-Functional Index (SCI-FI) measurement system. Results Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models. Conclusions Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Background Inpatient rehabilitation for spinal cord injury (SCI) includes the use of both individual and group physical therapy sessions. A greater understanding of group physical therapy use will help in the evaluation of the appropriateness of its use and contribute to the development of standards of practice. Objective This report describes the extent to which group physical therapy is being used in inpatient rehabilitation for SCI, identifies group physical therapy interventions being delivered, and examines patterns in the types of activities being used for people with different levels and completeness of injury (ie, injury groups). Design The SCIRehab Study is a 5-year, multicenter investigation that uses practice-based evidence research methodology. Methods Data on characteristics of participants and treatments provided were collected through detailed chart review and customized research documentation completed by clinicians at the point of care. The analyses described here included data from 600 participants enrolled during the first year of the project. Results Most of the participants (549/600) spent time in group physical therapy, and 23% of all documented physical therapy time was spent in group sessions. The most common group physical therapy activities were strengthening, manual wheelchair mobility, gait training, endurance activities, and range of motion/stretching. Time spent in group physical therapy and the nature of activities performed varied among the injury groups. Limitations Physical therapy use patterns observed in the 6 participating centers may not represent all facilities providing inpatient rehabilitation for SCI. Research documentation did not include all factors that may affect group physical therapy use, and some sessions were not documented. Conclusions The majority of physical therapy was provided in individual sessions, but group physical therapy contributed significantly to total physical therapy time. Group physical therapy time and activities differed among the injury groups in patterns consistent with clinical goals.

To describe the nature and distribution of activities during physical therapy (PT) delivered in inpatient spinal cord injury (SCI) rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities.Six hundred patients from six inpatient SCI centers were enrolled in the SCIRehab study. Physical therapists documented details, including time spent, of treatment provided during 37 306 PT sessions that occurred during inpatient SCI rehabilitation. Ordinary least squares regression models associated patient and injury characteristics with time spent in specific PT activities.SCIRehab patients received a mean total of 55.3 hours of PT over the course of their rehabilitation stay. Significant differences among four neurologic groups were seen in the amount of time spent on most activities, including the most common PT activities of strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training. Most PT work (77%) was provided in individual therapy sessions; the remaining 23% was done in group settings. Patient and injury characteristics explained only some of the variations seen in time spent on wheelchair mobility, transfer and bed mobility training, and range of motion/ stretching.Analysis yielded both expected and unexpected trends in SCI rehabilitation. Significant variation was seen in time spent on PT activities within and among injury groups. Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings. Details about services provided, including time spent, will serve as a starting point in detailing the optimal treatment delivery for maximal outcomes.

Glomerular Filtration Rate (GFR) is one of the cardinal indices of renal function and is used clinically as the gold standard of renal dysfunction. In the past decade, many studies using dynamic contrast-enhanced MRI (DCE MRI) to measure GFR have been published. The MRI evaluation of GFR centers on visualizing the passage of contrast material (Gadolinium chelates) through the kidney. MRI appears as a promising tool but still relatively difficult to implement in the assessment of GFR. A high heterogeneity of protocols (e.g., in acquisition mode, dose of contrast, postprocessing techniques) is noted in the literature, reflecting the number of technical challenges that should first be solved in order to reach a consensus, and the reported accuracy and reproducibility are insufficient for justifying their use in clinical practice now. This paper presents and discusses the different steps that can be used to quantify the GFR by MRI.