Transforming modeling in neurorehabilitation: clinical insights for personalized rehabilitation.

Practicing clinicians in neurorehabilitation continue to lack a systematic evidence base to personalize rehabilitation therapies to individual patients and thereby maximize outcomes. Computational modeling- collecting, analyzing, and modeling neurorehabilitation data- holds great promise. A key question is how can computational modeling contribute to the evidence base for personalized rehabilitation? As representatives of the clinicians and clinician-scientists who attended the 2023 NSF DARE conference at USC, here we offer our perspectives and discussion on this topic. Our overarching thesis is that clinical insight should inform all steps of modeling, from construction to output, in neurorehabilitation and that this process requires close collaboration between researchers and the clinical community. We start with two clinical case examples focused on motor rehabilitation after stroke which provide context to the heterogeneity of neurologic injury, the complexity of post-acute neurologic care, the neuroscience of recovery, and the current state of outcome assessment in rehabilitation clinical care. Do we provide different therapies to these two different patients to maximize outcomes? Asking this question leads to a corollary: how do we build the evidence base to support the use of different therapies for individual patients? We discuss seven points critical to clinical translation of computational modeling research in neurorehabilitation- (i) clinical endpoints, (ii) hypothesis- versus data-driven models, (iii) biological processes, (iv) contextualizing outcome measures, (v) clinical collaboration for device translation, (vi) modeling in the real world and (vii) clinical touchpoints across all stages of research. We conclude with our views on key avenues for future investment (clinical-research collaboration, new educational pathways, interdisciplinary engagement) to enable maximal translational value of computational modeling research in neurorehabilitation.

Skeletal Muscle Dysfunction in People With Multiple Sclerosis: A Physiological Target for Improving Physical Function and Mobility.

Impaired mobility is amongst the most debilitating symptoms reported by people with multiple sclerosis (MS). Historically, it has been viewed that walking impairments in people with MS are directly caused by the physical damage to the neurons in the central nervous system (CNS) which results from the immunopathology of MS. However, research from over the past 4 decades has revealed that physical function in people with MS is also affected by skeletal muscle dysfunction characterized by a reduced capacity to produce, regulate, and sustain the force-generating muscle contractions that propel human movement. While the immediate CNS damage caused by MS can alter the neural activation of muscle by disrupting neuromotor transmission, chronic reductions in mobility and extreme fatigue can lead to physically inactive lifestyles that negatively affect skeletal muscle through mechanisms of deconditioning. Consequently, people with MS can experience alterations in activation patterns, muscle mass and tissue composition, contractility, metabolism, and perfusion that contribute to reductions in muscle function that ultimately impair key physical functions such as walking. This article provides an overview of the cellular mechanisms that contribute to skeletal muscle dysfunction in people with MS and a discussion of the current evidence suggesting that skeletal muscle may be a key physiological target for interventions aiming to improve mobility in this population. We specifically highlight recent evidence demonstrating the potential for rehabilitation and exercise interventions to induce muscle plasticity in people with MS who have moderate to severe levels of disability. In conclusion, we discuss future directions in basic science and clinical research that may advance our understanding of muscle dysfunction in MS and lead to the development of more precise and effective treatment strategies.

Job Retention Among Individuals With Multiple Sclerosis: Relationship With Prediagnostic Employment and Education; Demographic Characteristics; and Disease Course, Severity, and Complications.

OBJECTIVE: To identify how prediagnosis employment, education, demographic statuses, and disease factors relate to job retention among people with multiple sclerosis (MS). DESIGN: Cross-sectional logit model. SETTING: Data were collected at an academic Medical University and a specialty hospital, both in the Southeastern US. PARTICIPANTS: People with MS (N=1126) who were employed at the time of MS diagnosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Job retention was measured by employment status at the time of follow-up assessment. RESULTS: Prediagnostic educational attainment was predictive of job retention. Among several prediagnostic employment characteristics, only working in production, transportation, and material moving was significantly related to a lower odds of job retention compared with those working in professional/managerial occupations. Aging factors were strongly related to job retention, with declines in job retention observed with increasing age and years since diagnosis. Non-Hispanic Black and Hispanic participants reported lower odds of job retention than non-Hispanic White participants, although there were no observed effects of sex. A significantly lower job retention rate was observed among those with progressive MS, compared with relapsing-remitting. Job retention was also less likely among people with greater MS severity and fatigue. CONCLUSIONS: Job retention strategies and interventions should target people with greater MS complications and severity, as well as non-Hispanic Black and Hispanic persons, because these characteristics are more highly related to job retention than our prediagnostic employment and vocational history.

Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time.

OBJECTIVES: To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF). DESIGN: Cross-sectional study design. SETTING: University research laboratory. PARTICIPANTS: Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF. RESULTS: A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F2,82=4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F4,63=3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF. CONCLUSIONS: FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.

Barriers and Facilitators to Employment: A Comparison of Participants With Multiple Sclerosis and Spinal Cord Injury.

OBJECTIVE: To compare self-reported barriers and facilitators to employment among employed and unemployed participants with multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Cross-sectional study using self-report assessment obtained by mail or online. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants (N=2624) identified from either a specialty hospital or a state-based surveillance system in the southeastern United States, including 1234 with MS and 1390 with SCI. All participants were aged <65 years at the time of assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported barriers and facilitators to employment. RESULTS: Overall, the MS participants reported more barriers, particularly stress, cognition, and fatigue, whereas those with SCI were more likely to report not having the proper education and training, resources, transportation, and attendant care. Follow-up analyses broken down by employment status indicated that several barriers and facilitators were significantly related to diagnosis for either employed or unemployed participants, but not both. Among those employed, participants with SCI were more likely to report they could not do the same types of jobs as they could pre-SCI and those with MS were more likely to state that they did not know much about jobs for people with disabilities (no differences were noted for these variables among unemployed participants). Unemployed individuals with SCI were more likely to report that the jobs for which they were trained were not accessible. CONCLUSIONS: The primary barriers for individuals with MS revolve around the condition itself, whereas the barriers for SCI appear to be more related to modifiable factors. Vocational rehabilitation specialists need to identify diagnostic-specific barriers to promote employment outcomes.

Endurance neuromuscular electrical stimulation training improves skeletal muscle oxidative capacity in individuals with motor-complete spinal cord injury.

INTRODUCTION: Spinal cord injury (SCI) results in skeletal muscle atrophy, increases in intramuscular fat, and reductions in skeletal muscle oxidative capacity. Endurance training elicited with neuromuscular electrical stimulation (NMES) may reverse these changes and lead to improvement in muscle metabolic health. METHODS: Fourteen participants with complete SCI performed 16 weeks of home-based endurance NMES training of knee extensor muscles. Skeletal muscle oxidative capacity, muscle composition, and blood metabolic and lipid profiles were assessed pre- and post-training. RESULTS: There was an increase in number of contractions performed throughout the duration of training. The average improvement in skeletal muscle oxidative capacity was 119%, ranging from -14% to 387% (P = 0.019). There were no changes in muscle composition or blood metabolic and lipid profiles. CONCLUSION: Endurance training improved skeletal muscle oxidative capacity, but endurance NMES of knee extensor muscles did not change blood metabolic and lipid profiles. Muscle Nerve 55: 669-675, 2017.

Determinants of On-Road Driving in Multiple Sclerosis.

OBJECTIVE: To investigate the cognitive, visual, and motor deficits underlying poor performance on different dimensions of on-road driving in individuals with multiple sclerosis (MS). DESIGN: Prospective cross-sectional study. SETTING: MS clinic and driving simulator lab. PARTICIPANTS: Active drivers (N=102) with various types of MS. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Off-road cognitive, visual, and motor functions, as well as 13 specific driving skills. These skills were categorized into hierarchic clusters of operational, tactical, visuo-integrative, and mixed driving. Stepwise regression analysis was used to determine the off-road functions influencing performance on the on-road test and each cluster. RESULTS: Visuospatial function (P=.002), inhibition (P=.008), binocular acuity (P=.04), vertical visual field (P=.02), and stereopsis (P=.03) best determined variance in total on-road score (unadjusted R2=.37). Attentional shift (P=.0004), stereopsis (P=.007), glare recovery (P=.047), and use of assistive devices (P=.03) best predicted the operational cluster (unadjusted R2=.28). Visuospatial function (P=.002), inhibition (P=.002), reasoning (P=.003), binocular acuity (P=.04), and stereopsis (P=.005) best determined the tactical cluster (unadjusted R2=.41). The visuo-integrative model (unadjusted R2=.12) comprised binocular acuity (P=.007) and stereopsis (P=.045). Inhibition (P=.0001) and binocular acuity (P=.001) provided the best model of the mixed cluster (unadjusted R2=.25). CONCLUSIONS: Our results provide more insights into the specific impairments that influence different dimensions of on-road driving and may be used as a framework for targeted driving intervention programs in MS.

Knowledge Translation in Rehabilitation: A Shared Vision.

PURPOSE: Advances in rehabilitation provide the infrastructure for research and clinical data to improve care and patient outcomes. However, gaps between research and practice are prevalent. Knowledge translation (KT) aims to decrease the gap between research and its clinical use. This special communication summarizes KT-related proceedings from the 2016 IV STEP conference, describes current KT in rehabilitation science, and provides suggestions for its application in clinical care. SUMMARY OF KEY POINTS: We propose a vision for rehabilitation clinical practice and research that includes the development, adaptation, and implementation of evidence-based practice recommendations, which will contribute to a learning health care system. A clinical research culture that supports this vision and methods to engage key stakeholders to innovate rehabilitation science and practice are described. CONCLUSIONS: Through implementation of this vision, we can lead an evolution in rehabilitation practice to ultimately prevent disabilities, predict better outcomes, exploit plasticity, and promote participation.

Increasing Physical Activity and Participation in People With Multiple Sclerosis: A Review.

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system (CNS) affecting >2.5 million people worldwide. Damage to neurons in the CNS causes various sensorimotor and cognitive symptoms, such as fatigue, pain, spasticity, memory deficits, and impairment of mobility. Until the late 1990s, it was believed that symptoms of MS would be worsened with physical exertion and people with MS were encouraged to limit physical activity and exertion. Not only has emerging evidence suggested that physical activity, including exercise, is safe for people with MS, there is also evidence that at least some of the disability that occurs after MS is due to secondary deconditioning from the sedentary lifestyle adopted because of the symptoms of MS, not just CNS damage alone. Therefore, not only is physical activity safe, it is also required for maintaining function and health in people with MS. The purpose of this article is to review the unique physical and social barriers to physical activity in people with MS, including those with moderate to severe disability who use a wheelchair or scooter for mobility. We will discuss how existing guidelines for physical activity may not meet the needs of people with MS and present evidence-based considerations for promoting physical activity in people with MS. Ultimately, the goal is to overcome the barriers to physical activity and improve health, participation, and quality of life in people with MS.

Pilot study: evaluation of the effect of functional electrical stimulation cycling on muscle metabolism in nonambulatory people with multiple sclerosis.

OBJECTIVE: To investigate the changes in muscle oxygen consumption (mV˙O2) using near-infrared spectroscopy (NIRS) after 4 weeks of training with functional electrical stimulation (FES) cycling in nonambulatory people with multiple sclerosis (MS). DESIGN: Four-week before-after trial to assess changes in mV˙O2 after an FES cycling intervention. SETTING: Rehabilitation hospital. PARTICIPANTS: People (N=8; 7 men, 1 women) from a volunteer/referred sample with moderate to severe MS (Expanded Disability Status Scale score>6.0). INTERVENTION: Participants cycled 30 minutes per session, 3d/wk for 4 weeks or a total of 12 sessions. MAIN OUTCOME MEASURES: mV˙O2 of the right vastus lateralis muscle was measured with NIRS before and within 1 week after the intervention. Six bouts of 15-second electrical stimulation increasing from 2 to 7Hz were used to activate the muscle. mV˙O2 was assessed by analyzing the slope of the NIRS oxygen signal during a 10-second arterial occlusion after each electrical stimulation bout. RESULTS: Significant FES training by electrical stimulation frequency level interaction was observed (P=.031), with an average increase in mV˙O2 of 47% across frequencies with a main effect of training (P=.047). CONCLUSIONS: FES cycling for 4 weeks improved mV˙O2, suggesting that FES cycling is a potential therapy for improving muscle health in people with MS who are nonambulatory.

Assisted movement with proprioceptive stimulation reduces impairment and restores function in incomplete spinal cord injury.

OBJECTIVE: To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia. DESIGN: Prospective, pre-post study. SETTING: Laboratory and rehabilitation hospital. PARTICIPANTS: We recruited 15 arms from 10 individuals (8 men; mean age, 40.5 y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia. INTERVENTION: Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle. MAIN OUTCOME MEASURES: Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE). RESULTS: The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session. CONCLUSIONS: People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial.

OBJECTIVE: To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation. DESIGN: Randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). RESULTS: Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002). CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Activity-based therapy for recovery of walking in chronic spinal cord injury: results from a secondary analysis to determine responsiveness to therapy.

OBJECTIVE: To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial. DESIGN: Secondary analysis of results from a randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). RESULTS: This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program. CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Adverse events in cardiovascular-related training programs in people with spinal cord injury: a systematic review.

CONTEXT: There are anecdotal reports of adverse events (AEs) associated with exercise in people with spinal cord injury (SCI) and consequent concern by people with SCI and their providers about potential risks of exercise. Enumeration of specific events has never been performed and the extent of risk of exercise to people with SCI is not understood. OBJECTIVE: To systematically review published evidence to identify and enumerate reports of adverse events or AEs associated with training in persons with SCI. METHODS: Review was limited to peer-reviewed studies published in English from 1970 to 2011: (1) in adults with SCI, (2) evaluating training protocols consisting of repeated sessions over at least 4 weeks to maintain or improve cardiovascular health, (3) including volitional exercise modalities and functional electrical stimulation (FES)-enhanced exercise modalities, and (4) including a specific statement about AEs. Trained reviewers initially identified a total of 145 studies. After further screening, 38 studies were included in the review. Quality of evidence was evaluated using established procedures. RESULTS: There were no serious AEs reported. There were no common AEs reported across most types of interventions, except for musculoskeletal AEs related to FES walking. There were few AEs in volitional exercise studies. CONCLUSION: There is no evidence to suggest that cardiovascular exercise done according to guidelines and established safety precautions is harmful. To improve the strength of these conclusions, future publications should include definition of AEs, information about pre-intervention screening, and statements of the nature and extent of AEs.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities.

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

Validation of scores from a telephone administered multiple sclerosis walking scale-12 in persons with multiple sclerosis.

BACKGROUND: The Multiple Sclerosis Walking Scale-12 (MSWS-12) has typically been delivered through paper-and-pencil or computer-based administration. PURPOSE: This study examined the validity of inferences from scores derived via a telephone administration of the MSWS-12 applied as part of screening of participants with walking dysfunction into a clinical trial of exercise training in MS. METHOD: The MSWS-12 was administered on two occasions separated by approximately 2 weeks through the telephone and then in-person (i.e., computer-based administration). Participants further completed the Patient Determined Disease Steps (PDDS) scale, timed 25-foot walk (T25FW), six-minute walk (6MW), Modified Fatigue Impact Scale (MFIS), and Multiple Sclerosis Impact Scale-29 (MSIS-29), and underwent a neurological exam for generating an expanded disability status scale (EDSS) score. The primary set of data (Full Sample) for analyses included all persons who passed the telephone screening for inclusion with MSWS-12 scores between 25 and 75 (N = 374). The secondary set of data (Truncated Sample) included only persons with MSWS-12 scores between 25 and 75 for both the telephone and computer administrations of the MSWS-12 (N = 248). RESULTS: The results in the Full Sample indicated a difference in overall and item levels scores between the telephone and computer data collections, and the computer version had higher internal consistency and stronger unidimensionality. Nevertheless, MSWS-12 scores from both modes of administration had comparable correlations with the T25FW, 6MW, EDSS, PDDS, MFIS, and MSIS-29, but the correlation between the two MSWS-12 administrations did not approach unity. There was a systematic difference in scores between telephone and computer administrations across levels of walking dysfunction based on a Bland-Altman plot, and the difference was predicted by MFIS physical, 6MW, and EDSS scores. The comparison of results between the Full and Truncated Samples suggested that the primary analysis might have been influenced by the larger range of scores on the computer than telephone administrations of the MSWS-12. CONCLUSION: The telephone administration of the MSWS-12 provides an efficient and cost-effective measure of walking dysfunction in persons with MS.

Home-based circuit resistance training to overcome barriers to exercise for people with spinal cord injury: a case study.

BACKGROUND AND PURPOSE: People with spinal cord injury (SCI) have limited options for aerobic exercise. Existing options are often difficult to access, or they result in muscle imbalances that can eventually contribute to joint dysfunction. These difficulties can cause individuals to live a more sedentary lifestyle, putting them at greater risk for developing obesity and other cardiovascular disease risk factors. Therefore, a mode of exercise that allows people with SCI an affordable, accessible, and effective way to engage in cardiovascular exercise is needed. CASE DESCRIPTION: The participant was a 44-year-old man with chronic, complete T12 SCI resulting from a motor vehicle accident 28 years ago. He participated in a case study evaluating the effectiveness of a home-based aerobic and strengthening exercise program. INTERVENTION: Outcome measures were assessed before and after completing a 12-week home-based circuit resistance training (CRT) program. The intervention was a modified version of a previously studied CRT program performed in a traditional gym that was designed to improve strength and aerobic fitness and to elicit healthy cholesterol levels in people with paraplegia. OUTCOMES: After performing the CRT program, the participant demonstrated improvements in cardiovascular fitness and upper extremity strength. Cholesterol levels were unchanged. He also lost weight and his shoulder pain improved. DISCUSSION: The findings demonstrate the potential for some individuals with SCI to safely and effectively engage in aerobic and strengthening exercise in their home to improve or prevent cardiovascular-related risk factors.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A44) for more insights from the authors.

Maximizing research relevance to enhance knowledge translation.

This supplement focuses on an important issue in rehabilitation medicine: how to maximize research relevance in order to enhance knowledge translation into clinical practice. Authors provide insights into issues and barriers impacting effective translation of evidence into practice and provide useful guidance for rehabilitation researchers and practitioners on how to structure lines of inquiry to enhance clinical relevance. While this supplement will provide meaningful information to rehabilitation researchers, the content will also be of interest to clinicians, consumers of rehabilitation services, and reviewers for journals featuring rehabilitation research.