Study protocol for a randomized controlled trial of the Parent-Child Assistance Program: a case management and home visiting program for people using substances during pregnancy.

BACKGROUND: Perinatal substance use can have significant adverse effects on maternal and child health and family stability. Few interventions are specifically designed to address this significant public health problem. The Parent-Child Assistance Program (PCAP) is a 3-year case management and home-visiting intervention that seeks to help birthing persons with at-risk substance use during pregnancy to achieve and maintain substance use disorder recovery and avoid exposing future children to substances prenatally. At-risk refers to a level of substance use that creates problems in the individuals' lives or puts them or their children at risk of harm either prenatally or postnatally. Although the program has consistently shown substantial pre- to post-intervention improvements in its participants, PCAP remains to be tested with a rigorous randomized controlled trial (RCT). This study protocol describes a randomized controlled trial that aims to examine the effectiveness of the intervention compared to services as usual in affecting primary outcomes related to substance use and family planning. Secondary outcomes will concern connection to recovery support services and family preservation. METHODS: Using an intent-to-treat design, the study will recruit from two metro areas in Oklahoma and enroll 200 birthing individuals who are pregnant or up to 24 months postpartum with at-risk substance use during their current or most recent pregnancy. Participants will be randomly assigned, stratified by location, to receive either PCAP or services as usual for 3 years. Participants in the PCAP condition will meet with their case manager approximately biweekly over the course of the intervention period, in their local communities or in their own homes whenever possible. Case managers will assist with goal setting and provide practical assistance in support of participants' goals. Primary and secondary outcomes will be assessed at baseline and 12, 24, and 36 months post-baseline using the Addiction Severity Index interview and a self-administered survey. DISCUSSION: Results from this trial will help to gauge the effectiveness of PCAP in improving parent and child well-being. Results will be reviewed by federal clearinghouses on home-visiting and foster care prevention to determine the strength of evidence of effectiveness with implications for federal financing of this program model at the state level. TRIAL REGISTRATION: ClinicalTrials.gov NCT05534568. Registered on 6/8/2022.

Oxycodone withdrawal is associated with increased cocaine self-administration and aberrant accumbens glutamate plasticity in rats.

Individuals with opioid use disorder (OUD) frequently use other substances, including cocaine. Opioid withdrawal is associated with increased likelihood of cocaine use, which may represent an attempt to ameliorate opioid withdrawal effects. Clinically, 30% of co-using individuals take opioids and cocaine exclusively in a sequential manner. Preclinical studies evaluating mechanisms of drug use typically study drugs in isolation. However, polysubstance use is a highly prevalent clinical issue and thus, we established a novel preclinical model of sequential oxycodone and cocaine self-administration (SA) whereby rats acquired oxycodone and cocaine SA in an A-B-A-B design. Somatic signs of withdrawal were evaluated at 0, 22, and 24h following oxycodone SA, with the 24h timepoint representing somatic signs immediately following cocaine SA. Preclinically, aberrant glutamate signaling within the nucleus accumbens core (NAcore) occurs following use of cocaine or opioids, whereby medium spiny neurons (MSNs) rest in a potentiated or depotentiated state, respectively. Further, NAcore glial glutamate transport via GLT-1 is downregulated following SA of either drug alone. However, it is not clear if cocaine can exacerbate opioid-induced changes in glutamate signaling. In this study, NAcore GLT-1 protein and glutamate plasticity were measured (via AMPA/NMDA ratio) following SA. Rats acquired SA of both oxycodone and cocaine regardless of sex, and the acute oxycodone-induced increase in somatic signs at 22h was positively correlated with cocaine consumption during the cocaine testing phase. Cocaine use following oxycodone SA downregulated GLT-1 and reduced AMPA/NMDA ratios compared to cocaine use following food SA. Further, oxycodone SA alone was associated with reduced AMPA/NMDA ratio. Together, behavioral signs of oxycodone withdrawal may drive cocaine use and further dysregulate NAcore glutamate signaling.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management.

BACKGROUND AND OBJECTIVES: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS: Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS: TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS: Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Synthetic contraceptive hormones occlude the ability of nicotine to reduce ethanol consumption in ovary-intact female rats.

Rates of tobacco and alcohol use in women are rising, and women are more vulnerable than men to escalating tobacco and alcohol use. Many women use hormonal birth control, with the oral contraceptive pill being the most prevalent. Oral contraceptives contain both a progestin (synthetic progesterone) and a synthetic estrogen (ethinyl estradiol; EE) and are contraindicated for women over 35 years who smoke. Despite this, no studies have examined how synthetic contraceptive hormones impact this pattern of polysubstance use in females. To address this critical gap in the field, we treated ovary-intact female rats with either sesame oil (vehicle), the progestin levonorgestrel (LEVO; contained in formulations such as Alesse®), or the combination of EE+LEVO in addition to either undergoing single (nicotine or saline) or polydrug (nicotine and ethanol; EtOH) self-administration (SA) in a sequential use model. Rats preferred EtOH over water following extended EtOH drinking experience as well as after nicotine or saline SA experience, and rats undergoing only nicotine SA (water controls) consumed more nicotine as compared to rats co-using EtOH and nicotine. Importantly, this effect was occluded in groups treated with contraceptive hormones. In the sequential use group, both LEVO alone and the EE+LEVO combination occluded the ability of nicotine to decrease EtOH consumption. Interestingly, demand experiments suggest an economic substitute effect between nicotine and EtOH. Together, we show that chronic synthetic hormone exposure impacts nicotine and EtOH sequential use, demonstrating the crucial need to understand how chronic use of different contraceptive formulations alter patterns of polydrug use in women.

3D electron microscopy and volume-based bouton sorting reveal the selectivity of inputs onto geniculate relay cell and interneuron dendrite segments.

Introduction: The visual signals evoked at the retinal ganglion cells are modified and modulated by various synaptic inputs that impinge on lateral geniculate nucleus cells before they are sent to the cortex. The selectivity of geniculate inputs for clustering or forming microcircuits on discrete dendritic segments of geniculate cell types may provide the structural basis for network properties of the geniculate circuitry and differential signal processing through the parallel pathways of vision. In our study, we aimed to reveal the patterns of input selectivity on morphologically discernable relay cell types and interneurons in the mouse lateral geniculate nucleus. Methods: We used two sets of Scanning Blockface Electron Microscopy (SBEM) image stacks and Reconstruct software to manually reconstruct of terminal boutons and dendrite segments. First, using an unbiased terminal sampling (UTS) approach and statistical modeling, we identified the criteria for volume-based sorting of geniculate boutons into their putative origins. Geniculate terminal boutons that were sorted in retinal and non-retinal categories based on previously described mitochondrial morphology, could further be sorted into multiple subpopulations based on their bouton volume distributions. Terminals deemed non-retinal based on the morphological criteria consisted of five distinct subpopulations, including small-sized putative corticothalamic and cholinergic boutons, two medium-sized putative GABAergic inputs, and a large-sized bouton type that contains dark mitochondria. Retinal terminals also consisted of four distinct subpopulations. The cutoff criteria for these subpopulations were then applied to datasets of terminals that synapse on reconstructed dendrite segments of relay cells or interneurons. Results: Using a network analysis approach, we found an almost complete segregation of retinal and cortical terminals on putative X-type cell dendrite segments characterized by grape-like appendages and triads. On these cells, interneuron appendages intermingle with retinal and other medium size terminals to form triads within glomeruli. In contrast, a second, presumed Y-type cell displayed dendrodendritic puncta adherentia and received all terminal types without a selectivity for synapse location; these were not engaged in triads. Furthermore, the contribution of retinal and cortical synapses received by X-, Y- and interneuron dendrites differed such that over 60% of inputs to interneuron dendrites were from the retina, as opposed to 20% and 7% to X- and Y-type cells, respectively. Conclusion: The results underlie differences in network properties of synaptic inputs from distinct origins on geniculate cell types.

The importance of translationally evaluating steroid hormone contributions to substance use.

Clinically, women appear to be more susceptible to certain aspects of substance use disorders (SUDs). The steroid hormones 17ß-estradiol (E2) and progesterone (Pg) have been linked to women-specific drug behaviors. Here, we review clinical and preclinical studies investigating how cycling ovarian hormones affect nicotine-, cocaine-, and opioid-related behaviors. We also highlight gaps in the literature regarding how synthetic steroid hormone use may influence drug-related behaviors. In addition, we explore how E2 and Pg are known to interact in brain reward pathways and provide evidence of how these interactions may influence drug-related behaviors. The synthesis of this review demonstrates the critical need to study women-specific factors that may influence aspects of SUDs, which may play important roles in addiction processes in a sex-specific fashion. It is important to understand factors that impact women's health and may be key to moving the field forward toward more efficacious and individualized treatment strategies.

Intensive care management of a complex Medicaid population: a randomized evaluation.

OBJECTIVES: Care management programs are employed by providers and payers to support high-risk patients and affect cost and utilization, with varied implementation. This study sought to evaluate the impact of an intensive care management program on utilization and cost among those with highest cost (top 5%) and highest utilization in a Medicaid accountable care organization (ACO) population. STUDY DESIGN: Randomized controlled quality improvement trial of intensive care management, provided by a nonprofit care management vendor, for Medicaid ACO patients at 2 academic centers. METHODS: Patients were identified using claims, chart review, and primary care validation, then randomly assigned 2:1 to intervention and control groups. Among 131 patients included in intent-to-treat analysis, 87 and 44 were randomly assigned to the intervention and control groups, respectively. Patients in the intervention group were eligible to receive intensive care management in the community/home setting and, in some cases, home-based primary care. Patients in the control group received standard of care, including practice-based care management. Prespecified primary outcome measures included total medical expense (TME), emergency department (ED) visits, and inpatient utilization. RESULTS: Relative to controls, patients randomly assigned to receive intensive care management had a $1933 smaller increase per member per month in TME (P = .04) and directionally consistent but nonsignificant reductions in ED visits (17% fewer; P = .40) and inpatient admissions (34% fewer; P = .29) in the 12 months post randomization compared with the 12 months prerandomization. CONCLUSIONS: Our study results support that targeted, intensive care management can favorably affect TME in a health system-based high-cost, high-risk Medicaid population. Further research is needed to evaluate the impact on additional clinical outcomes.

Ovarian Hormones Regulate Nicotine Consumption and Accumbens Glutamatergic Plasticity in Female Rats.

Women report greater cigarette cravings during the menstrual cycle phase with higher circulating levels of 17ß-estradiol (E2), which is metabolized to estrone (E1). Both E2 and E1 bind to estrogen receptors (ERs), which have been highly studied in the breast, uterus, and ovary. Recent studies have found that ERs are also located on GABAergic medium spiny neurons (MSNs) within the nucleus accumbens core (NAcore). Glutamatergic plasticity in NAcore MSNs is altered following nicotine use; however, it is unknown whether estrogens impact this neurobiological consequence. To test the effect of estrogen on nicotine use, we ovariectomized (OVX) female rats that then underwent nicotine self-administration acquisition and compared them to ovary-intact (sham) rats. The OVX animals then received either sesame oil (vehicle), E2, or E1+E2 supplementation for 4 or 20 d before nicotine sessions. While both ovary-intact and OVX females readily discriminated levers, OVX females consumed less nicotine than sham females. Further, neither E2 nor E1+E2 increased nicotine consumption back to sham levels following OVX, regardless of the duration of the treatment. OVX also rendered NAcore MSNs in a potentiated state following nicotine self-administration, which was reversed by 4 d of systemic E2 treatment. Finally, we found that E2 and E1+E2 increased ERα mRNA in the NAcore, but nicotine suppressed this regardless of hormone treatment. Together, these results show that estrogens regulate nicotine neurobiology, but additional factors may be required to restore nicotine consumption to ovary-intact levels.

Natural and synthetic estrogens specifically alter nicotine demand and cue-induced nicotine seeking in female rats.

Women have more difficulty maintaining smoking cessation than men, and experience greater withdrawal symptomatology as well as higher prevalence of relapse. Further, currently available treatments for smoking cessation, such as the nicotine patch and varenicline, have been shown to be less effective in women. Fluctuations in ovarian hormones across the menstrual cycle can affect craving and smoking relapse propensity. In addition, many women who smoke use some form of oral contraceptives, which most often contain ethinyl estradiol (EE), a synthetic, orally bio-available estrogen that is currently prescribed to women chronically and has been shown to alter smoking reward in women. The current study examined the impact of 17ß-estradiol (E2), the prominent endogenous form of the steroid hormone estrogen, as well as EE, on nicotine self-administration, demand, and reinstatement following ovariectomy (OVX) or sham surgery. OVX vehicle-treated female rats consumed less nicotine, had lower intensity of demand, and reinstated less compared to sham vehicle-treated female rats. OVX-E2 and OVX-EE treatment groups showed a rebound of nicotine intake later in training, and Q0 levels of consumption were partially rescued in both groups. Further, E2 but not EE reversed the abolishment of reinstated nicotine seeking induced by OVX. Taken together, these results demonstrate that natural and synthetic estrogens play a critical role in mediating the neurobehavioral effects of nicotine, and future studies are essential for our understanding of how synthetic hormones contained within oral contraceptives interact with smoking.

Interactions of neuroimmune signaling and glutamate plasticity in addiction.

Chronic use of drugs of abuse affects neuroimmune signaling; however, there are still many open questions regarding the interactions between neuroimmune mechanisms and substance use disorders (SUDs). Further, chronic use of drugs of abuse can induce glutamatergic changes in the brain, but the relationship between the glutamate system and neuroimmune signaling in addiction is not well understood. Therefore, the purpose of this review is to bring into focus the role of neuroimmune signaling and its interactions with the glutamate system following chronic drug use, and how this may guide pharmacotherapeutic treatment strategies for SUDs. In this review, we first describe neuroimmune mechanisms that may be linked to aberrant glutamate signaling in addiction. We focus specifically on the nuclear factor-kappa B (NF-κB) pathway, a potentially important neuroimmune mechanism that may be a key player in driving drug-seeking behavior. We highlight the importance of astroglial-microglial crosstalk, and how this interacts with known glutamatergic dysregulations in addiction. Then, we describe the importance of studying non-neuronal cells with unprecedented precision because understanding structure-function relationships in these cells is critical in understanding their role in addiction neurobiology. Here we propose a working model of neuroimmune-glutamate interactions that underlie drug use motivation, which we argue may aid strategies for small molecule drug development to treat substance use disorders. Together, the synthesis of this review shows that interactions between glutamate and neuroimmune signaling may play an important and understudied role in addiction processes and may be critical in developing more efficacious pharmacotherapies to treat SUDs.

Immunocytochemical and ultrastructural organization of the taste thalamus of the tree shrew (Tupaia belangeri).

Ventroposterior medialis parvocellularis (VPMP) nucleus of the primate thalamus receives direct input from the nucleus of the solitary tract, whereas the homologous thalamic structure in the rodent does not. To reveal whether the synaptic circuitries in these nuclei lend evidence for conservation of design principles in the taste thalamus across species or across sensory thalamus in general, we characterized the ultrastructural and molecular properties of the VPMP in a close relative of primates, the tree shrew (Tupaia belangeri), and compared these to known properties of the taste thalamus in rodent, and the visual thalamus in mammals. Electron microscopy analysis to categorize the synaptic inputs in the VPMP revealed that the largest-size terminals contained many vesicles and formed large synaptic zones with thick postsynaptic density on multiple, medium-caliber dendrite segments. Some formed triads within glomerular arrangements. Smaller-sized terminals contained dark mitochondria; most formed a single asymmetric or symmetric synapse on small-diameter dendrites. Immuno-EM experiments revealed that the large-size terminals contained VGLUT2, whereas the small-size terminal populations contained VGLUT1 or ChAT. These findings provide evidence that the morphological and molecular characteristics of synaptic circuitry in the tree shrew VPMP are similar to that in nonchemical sensory thalamic nuclei. Furthermore, the results indicate that all primary sensory nuclei of the thalamus in higher mammals share a structural template for processing thalamocortical sensory information. In contrast, substantial morphological and molecular differences in rodent versus tree shrew taste nuclei suggest a fundamental divergence in cellular processing mechanisms of taste input in these two species.

Experience-Dependent Synaptic Plasticity in V1 Occurs without Microglial CX3CR1.

Brief monocular deprivation (MD) shifts ocular dominance and reduces the density of thalamic synapses in layer 4 of the mouse primary visual cortex (V1). We found that microglial lysosome content is also increased as a result of MD. Previous studies have shown that the microglial fractalkine receptor CX3CR1 is involved in synaptic development and hippocampal plasticity. We therefore tested the hypothesis that neuron-to-microglial communication via CX3CR1 is an essential component of visual cortical development and plasticity in male mice. Our data show that CX3CR1 is not required for normal development of V1 responses to visual stimulation, multiple forms of experience-dependent plasticity, or the synapse loss that accompanies MD in layer 4. By ruling out an essential role for fractalkine signaling, our study narrows the search for understanding how microglia respond to active synapse modification in the visual cortex.SIGNIFICANCE STATEMENT Microglia in the visual cortex respond to monocular deprivation with increased lysosome content, but signaling through the fractalkine receptor CX3CR1 is not an essential component in the mechanisms of visual cortical development or experience-dependent synaptic plasticity.

Effectiveness of family group conferencing in preventing repeat referrals to child protective services and out-of-home placements.

Rigorous research on the efficacy of family group conferencing is rare. This randomized control trial study used an intent-to-treat approach to examine whether a referral to a family group conference (FGC) was associated with re-referrals, substantiated re-referrals, or out-of-home placements among child welfare-involved families receiving in-home services. We found no significant associations between treatment and control group assignment and the three outcomes for the sample as a whole. However, families with more children had higher odds of a re-referral and a substantiated re-referral, families with more than one parent had higher odds of re-referral, and families where a substance abuse services referral was noted had higher odds of out-of-home placement. In interaction models with race, we found that families with African American mothers who were referred for an FGC were more likely to be re-referred compared to other families, but no differences were identified with respect to their rates of substantiated re-referrals or out-of-home placements. Implications are discussed.

All in the family: variations in the use of family meetings in child welfare.

The current state of family meeting practice within and across child welfare jurisdictions in the United States is widespread and varies greatly, presenting challenges for rigorous research and evaluation. Three illustrative jurisdiction-level case studies are provided, which demonstrate not only commonalities and differences in practice across agencies but the underlying reasons for this variation. The associated challenges for evaluation of this practice are also discussed.

Is a structured, manualized, evidence-based treatment protocol culturally competent and equivalently effective among American Indian parents in child welfare?

In a statewide implementation, the manualized SafeCare home-based model was effective in reducing child welfare recidivism and producing high client satisfaction. Concerns about the effectiveness and acceptability of structured, manualized models with American Indians have been raised in the literature, but have rarely been directly tested. This study tests recidivism reduction equivalency and acceptability among American Indian parents. A subpopulation of 354 American Indian parents was drawn from a larger trial that compared services with versus without modules of the SafeCare model. Outcomes were 6-year recidivism, pre/post/follow-up measures of depression and child abuse potential, and posttreatment consumer ratings of working alliance, service satisfaction, and cultural competency. Recidivism reduction among American Indian parents was found to be equivalent for cases falling within customary SafeCare inclusion criteria. When extended to cases outside customary inclusion boundaries, there was no apparent recidivism advantage or disadvantage. Contrary to concerns, SafeCare had higher consumer ratings of cultural competency, working alliance, service quality, and service benefit. Findings support using SafeCare with American Indians parents who meet customary SafeCare inclusion criteria. Findings do not support concerns in the literature that a manualized, structured, evidence-based model might be less effective or culturally unacceptable for American Indians.

Toolkit for Adapting Cognitive Behavioral Intervention for Trauma in Schools (CBITS) or Supporting Students Exposed to Trauma (SSET) for Implementation with Youth in Foster Care.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was developed for use by school-based mental health professionals for any student with symptoms of distress following exposure to trauma. Supporting Students Exposed to Trauma (SSET) was adapted from CBITS for use by any school personnel with the time and interest to work with students affected by trauma. The purpose of this toolkit is to assist school-based mental health professionals, school personnel, and child welfare social workers in adapting these interventions for use with youth aged 10-15 who are in foster care. The authors note that delivering a school-based mental health program to youth in foster care has many challenges, including collaboration between the child welfare and education systems, confidentiality and information sharing policies regarding youth in foster care, and identification of these youth. The toolkit was designed to help understand these challenges and provide strategies for addressing them.

Context matters: real-world and utilization-focused evaluation strategies to support change and improvement in child welfare.

This article examines the importance of context in evaluative inquiry. Following guidelines from real-world and utilization-focused evaluation frameworks, four projects are described to illustrate one foundation's pragmatic approach to evaluation that values collaboration, methodological appropriateness, and utilization. The authors contend that such an approach helps to ensure meaningful and actionable results in child welfare because it is responsive to local agency information and capacity needs while simultaneously contributing to the knowledge base of the field.

Preschool child care participation and obesity at the start of kindergarten.

OBJECTIVE: We examined the association between type of child care, participation in different types of child care in the year before kindergarten and the likelihood of obesity at the start of kindergarten. METHODS: Using a nationally representative sample of 15 691 first-time kindergartners from the Early Childhood Longitudinal Study-Kindergarten Cohort, we used logistic regression to estimate the relationship between type of primary child care arrangement and children's likelihood of being obese at the start of kindergarten. Our models controlled for family and child characteristics associated with obesity and choice of child care. To examine differential effects of child care participation for groups at high risk for obesity, we tested interactions between children's ethnicity and income with primary type of child care. RESULTS: At the start of kindergarten, 12% of the children were obese. Without controlling for other characteristics of children and families, children not in child care were significantly less likely and children in family, friend, and neighbor care were significantly more likely to be obese than children in other primary child care arrangements. White children were significantly less likely and Latino children more likely to be obese than children of other ethnic groups. After controlling for relevant child and family characteristics, children in family, friend, and neighbor care and non-Latino children in Head Start were more likely to be obese than children not in child care. For Latino children, however, participation in some types of nonparental child care had protective effects on their likelihood of being obese. CONCLUSIONS: Primary type of child care is associated with children's obesity. For Latino children, who are at a greater risk of being obese, participation in nonparental child care seems to have a protective effect. These results suggest that child care settings may be an important site for policy intervention during a crucial developmental period. Efforts to help family, friend, and neighbor caregivers support children's physical health may be warranted.

Social status determinants of control in individuals' accounts of their mental illness.

We examine the determinants of patients' accounts of their own mental illness. In particular, we examine the factors that affect the likelihood of attributing one's own mental illness to controllable factors rather than non-controllable factors. Our quantitative measure of attributional control is derived from the coding of in-depth interviews with people with severe mental illness seeking treatment for the first time (N = 144). We find that those who occupy positions of social disadvantage (particularly African-American males and those who receive public assistance) are less likely to attribute their illness to controllable sources, suggesting that personal mental illness attributions are systematically related to a person's social location. We outline the significance of these findings for research on the psychological consequences of mental illness attributions.

Physical functional performance in persons using a manual wheelchair.

STUDY DESIGN: Descriptive study. OBJECTIVES: To develop a performance-based physical functional measure for people using a manual wheelchair, and to evaluate the feasibility and reliability of the administration of the new procedure. BACKGROUND: Most performance-based measures of physical function focus on balance and ambulation impairments. Recent developments of performance measures fail to produce a valid and reliable performance-based measure to quantify physical function in people who must rely on upper-body function to mobilize. METHODS: Eighteen adults (ages 18 to 67 years) who used a nonmotorized wheelchair participated in this study. Volunteers performed selected tasks from the Continuous Scale Physical Functional Performance (CS-PFP) test, modified for persons using a wheelchair. Outcome measures included scores on the Wheelchair Physical Functional Performance (WC-PFP) test and the Sickness Impact Profile (SIP) questionnaire. RESULTS: Participants had substantial disability (mean total SIP > 20). Total and domain scores of the WC-PFP had no ceiling or floor effects and were reproducible with intraclass correlation coefficients ranging from 0.87 to 0.96. Poorer self-rated health was correlated with poorer performance in the upper-body domain of the WC-PFP (r = -0.45). Those reporting disability in bathing and dressing using the SIP had significantly lower WC-PFP scores, indicating that the WC-PFP had construct validity. A significant correlation was not found between WC-PFP and the ambulation and mobility domains of the SIP. CONCLUSION: The WC-PFP provides a reliable and quantifiable measure of mobility in persons who use a manual wheelchair.