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NeuroRehabilitation 19 (2004) 131–139 IOS Press

Return to work for persons with spinal cord injury: Designing work supports Pam Targett∗ , Paul Wehman and Cynthia Young Virginia Commonwealth University, Rehabilitation Research & Training Center on Workplace Supports, 1314 West Main Street, P.O. Box 842011, Richmond, VA 23284-2011, USA Tel.: +1 804 828 2325; Fax: +1 804 828 2193; E-mail: [email protected]

Abstract. Recent advances in medical practices have led to increased survival rates among persons with spinal cord injuries. Many of these individuals find themselves unemployed post injury and face a myriad of challenges, such as lack of transportation, limited accessibility, and health problems. This paper describes how a Supported Employment approach can be used to assist persons with SCI with return to work. A number of issues that may impede employment and how to circumvent each are offered, along with a case study that describes one individual’s return to work. Keywords: Return to work, Spinal Cord Injury (SCI), Supported Employment (SE)

1. Introduction Recent advances in medical technology have led to increased survival rates among persons with spinal cord injury (SCI). The number of individuals living with SCI is estimated to be between 183,000 and 230,000, with approximately 10,000 new cases reported each year [2]. Since many persons with SCI are expected to have longer life expectancies, return to work (RTW) becomes critical not only to secure a positive financial situation, but also impacts other aspects of life. Positive relationships have been found between life satisfaction, adjustment after SCI, and employment status [2,8–11,6,13,14]. Individuals who were employed were more active, had fewer medical treatments, completed more years of education, perceived themselves to have fewer problems, were more satisfied with their lives, and rated their overall adjustment higher than those who were unemployed [8,9]. These results indicated that employment is related to better outcomes after SCI [10]. Legislation such as the Americans with Disabilities Act of 1990 [1] and the advancement of assistive tech∗ Corresponding

author.

nology have played vital roles in enhancing RTW for persons with SCI [3,7,17,18,23,24]. However, many individuals still continue to face challenges that impede employment. These barriers may include difficulties related to social support, transportation, financial security, and mobility [17,18,23,15]. Other factors that limit RTW for individuals with SCI include poor health, lack of suitable jobs, and compensation entitlement [4]. While some persons who experience SCI will return to pre-injury employment or be able to locate a new job with limited assistance, others will not. The inability to secure and maintain employment may be related to a number of factors including: issues related to personal care, lack of mobility including transportation, inability to perform work without accommodation, need for on the job support and lack of knowledge about potential accommodations and workplace supports. Individuals who face these issues may be able to secure and maintain employment by utilizing Supported Employment services. This approach is used to assist persons with the most severe disabilities with gaining and maintaining work. Severity may be defined by the nature of the disability itself or relate to a person’s inability to find work or maintain employment for an extended period of time. The major components of the Supported Employment model: (1) analysis of the job

ISSN 1053-8135/04/$17.00  2004 – IOS Press and the authors. All rights reserved

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seeker’s strengths, abilities, and support needs to guide the job search, and job selection assistance based on a comparison of this analysis with potential work environments and job opportunities; (2) tailored on-thejob-site support and advocacy that may include additional job skills training, arranging or providing on the job supports, and ensuring work is completed while the new hire is getting up to speed at work; and (3) ongoing long term support throughout employment [20,21]. These services are provided by an employment specialist sometimes referred to as a job coach, who conducts the aforementioned and other activities to assist individuals with the most severe disabilities with overcoming the obstacles which have traditionally impeded them from gaining or maintaining work [22]. Employment specialists can help identify potential barriers to employment and develop or provide supports and accommodations to assist individuals with SCI succeed at work. Supported employment is distinct from other vocational and rehabilitation models in that it capitalizes on the person’s existing abilities (the person does not have to “get ready” to work) provides on-the-job vocational interventions (i.e. additional skills training, identification, facilitation and/or provision of accommodations etc . . . ) that do not supplant, but instead complement the employer’s existing practices and supports; and provides ongoing long term support and advocacy to help problem solve any future barriers to success at work. In addition, paramount to the concept of Supported Employment is the individualization of services to support persons with disabilities in their vocational pursuits. This tailored approach can be particularly useful when assisting persons who have sustained severe SCI with employment. Although each person is different and has a unique set of circumstances, there are still some common themes that emerge when serving individuals with SCI. This paper identifies some of the barriers that may be faced and offers some initial guidance on how employment specialist can assist the person with circumventing the presenting issues and become gainfully employed in the community.

2. Address personal care issues While family members are often utilized to help with activities of daily living, many individuals with SCI enlist the services of personal care attendants. Personal care attendants are paid assistants who help individuals with SCI and other physical disabilities perform

their daily routines (e.g., bathing, grooming, toileting, dressing, eating, and housekeeping). Dependency on others for basic life activities may affect some individuals’ self esteem and lead to reservations about one’s ability to work outside of their home. The job seeker and employment specialist should discuss these legitimate concerns and how such matters may be managed at work. Examples of common concerns related to personal care and possible approaches to solving each follow. 2.1. Morning schedule/routine Some individuals with SCI require assistance getting out of bed and preparing for work in the morning. Whether a family member or friend volunteers to assist with morning routines, or a paid attendant is hired, the employment specialist should inquire about the reliability of the assistant. An aide that is not punctual or dependable directly influences the prospective employee’s ability to arrive to work on time. In some instances, the job seeker may need to locate a new service or need to make modifications to an existing schedule. Thus, the job seeker and job coach need to be in synch about the “best” times of day for the person to arrive to and depart from work. This information then becomes used during the job search process. 2.2. Toileting Some individuals with SCI will be able to use bathroom facilities independently if the restroom is accessible and/or equipped with assistive devices. Other individuals cannot toilet independently. Concerns may arise regarding how to explain the need of an aid or the presence of a device to a potential employer. The employment specialist can begin to help reduce this anxiety by reassuring the client that employers are generally accommodating. In order to further allay fears, the employment specialist can also work with the client to develop a plan for addressing toileting needs with potential employers. Additionally, role-playing on how to ask for necessary assistance (e.g., asking a coworker to operate a leg bag valve mechanism) can be used to build confidence and reduce this concern. In this instance, hiring a personal service attendant or a coworker to assist may be a viable option. The local state vocational rehabilitation agency may have funds available to help pay for this type of service, and/or if the person receives disability-related income and pays for the service, the expense may be “written

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off.” Whenever someone is hired or volunteers to assist, it is important for the individual with the disability to personally inform the assistant of preferences regarding how aid should be given. A backup plan that indicates viable alternatives in case the original plan cannot be followed should also be devised. Another cause of apprehension relates to potential toileting accidents while at work. Some individuals may lack full control over their bladder and/or bowel and may use catheters, leg bags, or other devices for elimination. Advanced planning on what to do if an “accident” were to occur should take place. Issues to be addressed include: where the person should go, if cleaning up or changing clothes is possible, how the person would get home and who would arrange the ride home, if needed, etc. The plan should be reviewed and modified as needed throughout employment. 2.3. Assistance with eating Many people will need or want to drink or eat while at work. Since many friendships and “natural supports” develop during informal interactions like those that take place in the employee’s lounge or cafeteria, an opportunity could arise where a co-worker will volunteer to assist. For example, a person may be able to drink from a cup attached to their chair using a straw, if a coworker pours the liquid into the cup and moves it to a suitable position [16]. In other instances, eating implements and drinking devices that are used at home can be successfully used in the workplace with little or no assistance. Hiring a personal service attendant is also an option.

3. Investigate mobility Due to severe physical impairments often experienced by individuals with SCI, mobility may be seriously restricted. Fortunately, the Americans with Disabilities Act clearly outlines transportation requirements that private and public transportation systems must meet to be in compliance with the law [23]. However, mobility issues still abound for individuals with physical disabilities. When making determinations regarding job placement, the employment specialist must consider potential barriers to mobility for individuals with SCI with regard to personal mobility and transportation as well as solutions for overcoming such obstacles.

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3.1. Transportation A primary factor the employment specialist and job seeker should examine early in the job search is the person’s options for getting to and from work. Some individuals may drive or could drive if they had a vehicle and/or the proper adaptive equipment; others may use public transportation or para transit services. The employment specialist should note how the person’s daily routine and transportation options impact the job search, specifically the job seeker’s hours of availability, the area where he or she can travel to and the locality in which he or she lives (i.e., they live on the bus line or they live in a rural area difficult to travel from). It is equally important to investigate the person’s mobility in the community and at home. Often individuals with SCI will have to rely on others for transportation to and from work. Since services that are not timely or reliable can negatively impact a person’s job tenure, the employment specialist should review all possible modes of transportation with the job seeker to ensure that he or she is aware of all available options and taps into the most reliable source. Often, the client may not be accessing the most reliable mode of transportation due to a lack of knowledge, limited accessibility, or a lack of skills. The job coach can help by providing referral, advocacy, and/or transportation skills training. It is important to note, that if the person receives skills training that this is not a prerequisite to pursuing work. Instead, transportation training can be provided in the context of actually going to and from work. Even when existing personal care and transportation services seem adequate, it is important to put into place a backup plan just in case things go awry. The plan should outline what to do when a ride is late or does not show; including who should be contacted at work. 3.2. Personal mobility The technology of power wheelchairs has advanced independent mobility, both indoor and out, however, many individuals will not own this type of chair. It is important to understand the parameters of mobility. For example, if the person uses a self-propel wheelchair, under what circumstances do they find this easy or difficult to do (i.e., on gravel or carpeted surfaces, up hills, etc.)? [5] How does this effect accessibility in an office, restrooms, and other workplace locations? Although power wheelchairs have advanced mobility, they are usually larger in size and this must be taken

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into consideration; as it may be difficult to navigate in some workplaces. These factors should be considered by the employment specialist and job seeker when considering specific work opportunities. A quick tour of the workplace can provide insight into accessibility as well as the possible types of accommodations that may improve workplace mobility.

4. Explore accommodations When assessing the feasibility of a specific job, the job seeker and his or her employment specialist should explore the types of accommodations that may be needed. Job accommodation may take many forms, including: accessibility of workplace facilities, modifying work schedules, restructuring jobs, acquiring or modifying equipment or devices, and providing support services assistance. This information will help the jobseeker prepare for the job interview and help allay potential employer concerns related to ability to the individual’s ability to perform the work and possible cost of accommodation. 4.1. Accessibility It is important to analyze the entire work environment for accessibility, from parking paths into the building, to restrooms and doorknobs. When considering workplace accessibility, factors such as the width of the person’s wheelchair should be considered. This information will come in handy when rating the accessibility of a potential workplace. Other considerations should include: the availability of ramps, elevators, and other structural accommodations made to buildings for individuals with physical disability, and an assessment of potential difficulties individuals might face when navigating the interior structure once inside a building. 4.2. Assistive devices The job seeker and employment specialist should discuss the types of assistive aids the jobseeker currently uses and how these and/or other devices and modifications can be used in a work setting. Prior to the job interview a list of essential job functions should be examined, and as needed, strategies or technology that would allow the job seeker to perform this job should be identified. Input from experienced rehabilitation professionals, such as vocational rehabilitation counselors, rehabilitation engineers, occupational ther-

apists, may be helpful. It is also important, to solicit feedback from the individual with the disability and family members. Employers may also have creative solutions to maximize the employee’s potential. Some examples of assistive technology for the workplace are in Sections 5.2 and 5.3. 4.3. Costs and funding for accommodations The employment specialist and prospective employee must be prepared to convince the employer that most accommodations are easy and inexpensive. Once a job opportunity is identified and a job analysis has been performed, the job seeker and employment specialist should review the job functions and identify adaptive solutions which would enable the prospective employee to perform the job. When considering possible accommodations, attention should be given to cost effective strategies to which employers would more readily agree. For example, a portable ramp may be a viable alternative to remedy an inaccessible entrance. However, when a removable ramp is used, consideration needs to be given to its weight restrictions, ease of use, personnel required to manipulate it, and cost. Therefore, when contemplating alternatives, it is important to consider many factors beyond initial costs in each cost/benefit analysis and discuss with the employer. The job seeker and employment specialist must also consider how future job accommodations will be financed. Although by law most employers are required to provide accommodations, employer concerns regarding the cost of job accommodations may put the job candidate at a disadvantage. Therefore, it is useful to identify all available outside funding sources. Common funding sources include assistance available through state vocational rehabilitation services, IRS tax incentives, loans, and payment out of pocket [19]. 5. Arrange and/or provide on the job supports After the job seeker secures work, the employment specialist can then help the new employee develop and implement various adaptive solutions and accommodations. The employment specialist may also provide skills training at this stage. Skills training may include instruction on positioning, the use of assistive technology, and how to perform the job duties. Once these have been identified, the employment specialist collects data related to job performance in order to measure the effectiveness of the workplace supports and identify any additional support needs.

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5.1. Positioning The employment specialist should be familiar with common positioning problems experienced by individuals with SCI, and ways to achieve the best working posture within the workplace. Some problems may be due to the person’s wheelchair seating system; others may be related to weak muscles or postural habits. In some cases, a seating specialist may be needed to help correct any problems; in other cases, the guidance of a trained professional (i.e. occupational/physical therapist) will be needed for recommendations on equipment purchases or changes in the workstation. Individuals who are in jobs that require limited movement may be at risk for multiple problems, including skin breakdown, and wrist, neck, or shoulder pain. In addition to corrective positioning, potential problems may be reduced if the employee takes adequate breaks to stretch or exercise. The employment specialist may help the new employee devise a way to remind him or her to take these “unscheduled” breaks. Weight shifts are also very important in order to promote good circulation and prevent skin breakdown that can lead to pressure sores. In some instances, a customized weight shift program may be designed by an appropriate health professional. Afterwards, the employment specialist can help reinforce this at work; until it becomes part of the individual’s daily routine. 5.2. Adaptations and modifications As mentioned in Section 4.2, there are other professionals who can help identify potential accommodations. In addition, the employment specialist should become familiar with various accommodations and workplace supports and help arrange for or provide these as needed. In some instances, a difficulty on the job may require a no tech solution. For instance, the way the job is executed may simply need to be modified or the work environment rearranged for optimal access. Before, using any technology the employee should always be given the opportunity to try and perform tasks without adaptations [16]. Again, the employment specialist should collect data to verify that with or without accommodation the employee is improving his or her ability to perform the necessary job functions. The employee with SCI should customize his or her workstation, just as any other employee. However, the employment specialist may need to make sure that the station is indeed organized for maximum efficiency. This may require activities like: identifying a place for

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everything that is used frequently, finding a way to keep items well stocked, and making sure the employee has easy access to them. In addition to providing easy access to materials, the employee and employment specialist might make adjustments to the workstation in order to improve working conditions. For example, a common problem for individuals using wheelchairs is a lack of knee room at their workstations. To correct this problem, the work area can often be raised or lowered with little difficulty.

5.3. Assistive devices Computers are being used more and more frequently in the workplace. Most individuals with SCI should be able to learn to use a computer with the right adaptive aids and skills training. Therefore, the employment specialist needs to be familiar with low and high tech assistive devices that can enhance computer access. Examples of low tech aids include mouth sticks and docking stations, typing aids, trackballs, keyboards; productivity software (e.g., work prediction), High tech systems, include voice dictation and scanning systems [16]. If the person is not able to access equipment independently, an environmental control unit (ECU) may be needed. An ECU allows the person to access and manipulate office equipment (e.g., overhead lights, computers, telephones) that could not be controlled otherwise. In some instances, wireless remote control devices may suffice. These devices may need to be installed by professional rehabilitation engineers or another professional.

5.4. Safety The employer’s safety evacuation plan should be reviewed and a procedure on how the new hire would get out of the building should be devised. In some instances, an evacuation chair may need to be purchased. The help of coworkers or other individuals may need to be enlisted to ensure that the employee can evacuate the building in a timely manner. If coworkers will be assisting, the employment specialist can arrange or if knowledgeable, provide skills training on how to assist the person during an evacuation.

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6. Roberto: A case study The following case study is provided to illustrate the supported employment approach as outlined in Sections 1–5. Roberto is a 31 year-old male who sustained a C-5 level spinal cord injury resulting in complete tetraplegia, secondary to an automobile accident at age 19. He is unable to ambulate without the use of a power wheelchair and cannot use his upper extremities. He resides in an institution for adults with disabilities and is dependent upon others for activities of daily living. Nine years after his injury, Roberto was referred to a supported employment program by the state vocational rehabilitation agency. During initial meetings with the employment specialist, Roberto indicated that prior to his injury; he had dropped out of high school after completing the tenth grade. Since leaving high school, he held several construction jobs for brief periods of time. He stated that his past use of illegal drugs had impacted his ability to maintain steady employment. Roberto appeared depressed and told the employment specialist that it would be hard enough to get a job with a poor work history, and his disability would make it even more difficult. The employment specialist reassured Roberto that employment was possible and shared with him stories of how other individuals with similar disabilities had succeeded. Roberto agreed he would give supported employment a “shot,” as long as the “right” job was found for him. The employment specialist explained that it was her job to assist him with not only locating work that used his strengths and abilities, but to also find options that were meaningful and of interest to him. Roberto and the employment specialist also discussed his personal care needs, transportation, and potential accommodation needs related to work. A month later, a parking lot attendant position was identified that met Roberto’s preferences. Roberto wanted a job where he could move around, did not commit to “sell” anything, and would have opportunities to interact with co-workers. The employment specialist felt this job may be a good match for Roberto. Prior to Roberto’s interview, the employment specialist met with the employer and explained the supports provided with Supported Employment. She also determined that the job was located close enough to his residence that he could transport himself there and not have to rely on an unreliable paratransit service, which was also one of Roberto’s preferences. In addition, the coworkers were friendly, the job required good verbal communication skills, which

is one of Roberto’s strengths, and all parties felt that the necessary accommodations could be made. Although initially reluctant, with encouragement, Roberto agreed to an interview. The employment specialist set up the interview with the employer for the next day. During the interview, Roberto was offered a part-time job as a lot attendant and was asked to start work the following day. His job duties included: greeting customers, selling parking tickets, directing customers to parking areas within the lot and answering customer questions. The pay was $7.50 per hour to start, with the possibility of a raise after 60 days. The employment specialist and Roberto had previously discussed employment and related support needs, and refined the plan to address personal care, mobility, and on-the-job accommodations and supports specific to his new job as illustrated below in Table 1. The employment specialist assisted Roberto with creating and implementing his jobsite support plan and after a few weeks, she was able to begin fading from the job site, and eventually she reduced her time to two job site visits a month. During follow-up visits, the employer, Roberto, and the employment specialist problem solved several disability related issues. Roberto had been employed for six months when a coworker told him about a job opening as a dispatcher at a local bus company. Roberto thought it sounded interesting and contacted his state vocational rehabilitation counselor and employment specialist about applying for the job. The vocational rehabilitation counselor agreed to reopen Roberto’s case, since this was a solid career move. The employment specialist and Roberto contacted this employer. The employment specialist met with the employer to analyze the worksite and discuss the job position with the employer. Roberto was interviewed and was offered the job. He gave his two weeks notice to the parking lot employer and started working at the bus company as a dispatcher/receptionist. Today, he works 25 hours a week for $7.00 an hour. Once again, the employment specialist and Roberto created a job support plan and accommodations were put into place. Table 2 below describes some of the presenting issues and the accommodation/supports used at the bus company. 7. Conclusion Roberto has been employed for over one year. This employer has mentioned that Roberto excels in his job

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Table 1 Job site support plan Transportation to and from Work: Transportation question: What is the best method for Roberto to travel to and from work? Current Situation: Roberto and his social worker confirm that Roberto often takes long rides alone during the day for relaxation. For example, he recently wheeled his chair to and from the baseball field that is located near the parking lot that he will be working at. – Roberto will use his wheelchair for transportation from his residence to the scheduled parking lot area. The route is accessible and the ride will take about 30 minutes. Roberto works the day shift with the possibility of sometimes working until 6:30 p.m. (it is still daylight). Reflectors and a headlight will be secured to Roberto’s wheelchair. – Although it is unlikely he will encounter working late, Roberto’s residence locks the doors at 9:30 p.m. In the case that Roberto will be arriving home after 9:30 p.m., it is prearranged that he will call the head nurse who will have someone let him in. If she is not in, he will contact the floor nurse. Transportation for an Extended Work Schedule or Extreme Weather Conditions, etc. – – – –

Use of paratransit is available should Roberto choose to use it, or Roberto will request a ride in the residence van provided by his nursing home, or Roberto will call his mother (who has an accessible van) to see if she can transport him. The employer provides a cellular phone for employee use during all shifts. Roberto will ask either his coworker or the on duty police officer to place a telephone call for him if needed.

Weather: Current Situation: Roberto and the Social Worker report changes in temperature do not present problems for Roberto. Hot Temperatures – A canopy is set up at the worksite to provide shade; when not assisting customers, Roberto and all employees may sit there. – Roberto will wear a hat. – Roberto has purchased suntan lotion and will ask for it to be put on by his personal assistant before he leaves for work. Heavy Rain – Roberto has a waterproof poncho in his book bag that is attached to his chair. Coworkers have agreed to help Roberto put the poncho on in case of rain. – The Manager has given Roberto permission to stay under the canopy during periods of heavy rain. The other workers will attend to the customers at this time. Cold Temperatures – Roberto will wear several layers of clothing, a coat, hat, and even a blanket if necessary. Financial: Current Situation: Roberto has met with an SSA representative and understands how his benefits will be affected and what information needs to be reported. – Roberto has an appointment with his social worker and a residence fiscal management employee to discuss how to manage these requirements. Drinking and Eating: Current Situation: Roberto has a water pouch attached to the back of his chair and can drink through a straw that is positioned near his mouth. Roberto carries an extra water bottle in his book bag. – Coworkers have agreed to fill the pouch with water when asked. – Roberto will eat lunch before he goes to work and will wait until he gets home to eat dinner. The cook will save his dinner and a nurse will assist him once home. Restroom Use: Current Situation: Roberto uses a catheter with manual leg bag emptier and must have assistance with eliminating the bag contents. Roberto: * Limits liquid intake * Eliminate bag prior to work. – An electronic leg bag emptier was later ordered to allow him to independently dump the contents of his bag using a lever that will be attached to the arm of his chair. Personal Safety on the Job: Current Situation: Roberto’s family has expressed concerns about his safety at this job site. Roberto will contact those concerned and explain the following: – No employee is ever at the job site alone. At all times, per company contract, two employees must be on the job site. – At least one, but usually two police officers are also on duty until the last car is off of the lot at the end of the day.

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P. Targett et al. / Return to work for persons with spinal cord injury: Designing work supports Table 1, continued

Selling Tickets and Taking Money: – Two people must be present at the close of business to count money. Roberto will confirm count by use of a pen held in his mouth and “x-ing” the information sheet. – The other employee(s) will handle the tickets while Roberto will handle the incoming traffic, answer customer questions, and gives directions.

Table 2 Dispatcher position Presenting Issue Roberto’s wheelchair was too wide to enter the only accessible entrance located in the back of the building.

Accommodation/Support The employer agreed to allow Roberto to use the front entrance with a portable ramp.

A portable ramp was purchased, but would not arrive for six weeks.

Roberto borrowed a portable ramp from a friend.

The portable ramp needed to be set out and taken down daily.

Specific coworkers agreed to set up and take down the ramp. Roberto and the employment specialist provided training on how to do it.

Roberto experienced difficulty answering the telephone due to no use of his hands.

Rehabilitation engineer created a raised and slanted work table. Roberto uses a headset that coworkers put on for him. Roberto uses a monitor stand to access phone keys and toggle switch.

Roberto experienced difficulty taking written messages due to no use of his hands.

Roberto uses a voice recorder to tape messages.

Specialized transportation service was late picking up Roberto after work and other personnel were ready to leave the building.

After Roberto was unsuccessful at improving the situation, he and the job coach contacted the president of the specialized transportation company. The president personally dealt with the scheduling issues and oversaw improvements. The employer assigned an employee each day to wait for Roberto until situation was resolved with paratransit company.

and is interested in having him do additional and new tasks. From an overall life adjustment prospective, Roberto and those who know him best will tell you that he does not appear depressed and his overall “attitude about life” has improved. In addition to going to work, Roberto obtained his General Equivalency Diploma. He is currently looking into community living options (renting/buying his own home) and is pursuing a license to sell automobiles. As mentioned earlier in this article, Roberto is an example of how Return to Work can facilitate higher overall adjustment rates to SCI and improve a person’s overall quality of life. This article provides an overview of some of the common issues faced by individuals with SCI who are attempting to return to work. As illustrated in Roberto’s case study, when using a supported employment approach, the employment specialist plays multiple roles in assisting individuals with disabilities with securing and maintaining employment. The employment specialist should always remember the individual with the disability is the expert and should always be encouraged and supported to take the lead in these activities.

Acknowledgements This paper was partially supported by Grant # H133N000015, funded by the United States Department of Education, and Grant # H133B980036, funded by the United States Department of Education National Institute on Disability and Rehabilitation Research.

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