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--> A Data Collection and Analysis In an effort to be comprehensive in addressing the committee's overarching task of assessing the current status of rehabilitation science and engineering and developing recommendations for future needs in the field, the committee pursued several avenues of data collection and analysis. In addition to what might be the obvious, that is, reviewing federally funded research in the field, the committee also explored many other sources in a concerted attempt to cast a broad net for the collection and assessment of information. These sources included discussions with federal agency representatives, a variety of presentations at committee meetings, focus groups with consumers and professional associations, surveys of private and public organizations, and commissioned papers. A summary description of these follows. Review of Rehabilitation Research Abstracts As part of the charge to this committee to assess and evaluate federal rehabilitation research programs and make recommendations for future research, the committee collected, reviewed, and analyzed research abstracts from the major agency programs in rehabilitation research. The general purposes were to (1) assess the current status of research, (2) identify research needs and gaps, and (3) provide an objective basis for the committee's consideration in the development of recommendations for future research. More specifically, the committee was interested in the following questions (among others):
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--> How much research is clearly related to rehabilitation according to the committee's definition of rehabilitation as the ''process" of movement in the enabling/disabling process? How much rehabilitation-related research is being done in the various categories of pathology, impairment, functional limitation, and disability? What are the common study designs and experimental subjects? What are the major areas of research emphasis for each federal agency? Do the areas of research emphasis complement each other? How much rehabilitation-related research focuses on factors such as: environmental factors, policy issues, developing assistive technology, secondary conditions, quality of life, and health outcomes. The remainder of this section describes the process that the committee used in collecting, reviewing, and analyzing the abstracts, a summary of the results of the analysis, and a discussion of some of the problems encountered as part of the process. Sources and Numbers of Abstracts Abstracts of rehabilitation-related research activities were obtained for fiscal year 1995 from the following agencies for review (numbers in parentheses indicate how many abstracts were received): Centers for Disease Control and Prevention (CDC) (17) National Institutes of Health (NIH) (1,480) Agency on Health Care Policy and Research (AHCPR) (12) National Science Foundation (NSF) (124) National Institute for Disability and Rehabilitation Research (NIDRR) (288) U.S. Department of Veterans Affairs (VA) (176) Of the 17 abstracts provided by CDC, 12 were from the Disability Prevention Program 2 were from National Center for Injury Prevention and Control, and 3 were from the National Institute on Occupational Safety and Health. The 124 abstracts from NSF were from its Bioengineering and Environmental Systems Division. The 288 NIDRR abstracts were obtained from its Annual Program Directory for fiscal year 1995. All of the VA abstracts were from the Rehabilitation Research and Development Program—although other rehabilitation-related research is apparently conducted by VA, abstracts were not obtainable for review. The 1,894 NIH abstracts were obtained from two different sources. The first set (973 abstracts) was provided in response to a committee request to the director
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--> FIGURE A-1 PHS research in rehabilitation: process for identifying, retrieving, and reviewing rehabilitation related abstracts. of NIH.1 The second set (764 abstracts, 257 of which corresponded with abstracts identified by the Institutes) was retrieved from the Computer Retrieval of Information on Scientific Projects (CRISP) database on CD ROM for fiscal year 1995. The CRISP database is an online computer-based system that contains information on funded extramural and intramural research in the Public Health Service. CRISP was also the source for the abstracts from AHCPR that were reviewed. Finally, the committee received one abstract from the Health Resources and Services Administration and three abstracts from the Office of Disability, Aging, and Long Term Care within the Office of the Assistant Secretary for Planning and Evaluation. Figure A-1 describes the process that the committee followed in identifying and retrieving abstracts from CRISP. 1 NIH was asked to provide the committee with abstracts from each of the institutes at NIH, along with their respective definitions of rehabilitation-related research.
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--> In general, the keywords "rehabilitation" and "disability" were used and the keywords "mental health'' and "substance abuse" were excluded Through the Medical Rehabilitation Coordinating Committee, the various NIH institutes submitted their definitions of rehabilitation research and a listing of all the rehabilitation or rehabilitation-related research that was funded in fiscal year 1995 Review and Analysis of Abstracts The committee performed a pilot examination of the abstracts using a form that it created to assess whether certain types of information would be available for review and analysis The form included six major sections (see Box A-1), each with a subset of several variables for evaluation. The results of the pilot study indicated that the varied quality and limited amount of information in the abstracts were inadequate to address many of the committee's questions and the review needed to be reduced in scope Following the pilot review and in accord with the limited amount of information available in the abstracts, the abstract review process was scaled back to address only the first three sections (see Box A-1) All abstracts from the federal agencies were then reviewed by a subcommittee and staff, and classified according to rehabilitation relevance, rehabilitation state addressed, and experimental subject. The intent of these three categories is to provide a succinct summary of the rehabilitation science and engineering research that is funded by the federal government, the extent to which the research projects identified by the agencies fulfill this committee's definition of rehabilitation science, and whether the work involved human subjects, animals, tissue culture, synthetic materials, or computer models In this way, the committee could assess the current range, trends, and general priorities in the field of federally funded research in rehabilitation science and engineering The operational definitions for the different categorizations are described below BOX A-1 Major Sections of the Abstract Review Form Relevance to rehabilitation science and engineering Rehabilitation states 3 Experimental subjects 4 Targeted population and condition Study design 6 Other descriptors
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--> TABLE A-1 Rehabilitation Relevance Classification Category Description of Research Rehabilitation science Research that addresses the transition between states of the enabling-disabling process (i.e., pathology, impairment, functional limitation, and disability) Rehabilitation engineering Research that emphasizes the development of devices or other technology applicable to the enabling-disabling model states Drug or alcohol abuse and mental health Research that addresses rehabilitation of drug and alcohol abuse; mental health studies were also classified here Rehabilitation related (single state) Research that is related to rehabilitation but not emphasizing transition among rehabilitative states and that can include studies of materials, tissues, or subjects with no disabling conditions Not related Research that is not clearly relevant to rehabilitation Rehabilitation Relevance This classification had five mutually exclusive categories (see Table A-1). "Rehabilitation science" includes research projects that address two or more rehabilitative states (defined in the following section), and in some cases can span all of the rehabilitative states from pathology to disability. Because these are exclusive categories, any project that cut across rehabilitation states, and therefore met the definition of rehabilitation science, but that was predominantly an engineering modality, was categorized as "rehabilitation engineering." The "rehabilitation-related/ single state" category includes projects that are relevant to rehabilitation but that focus on only one state in the enabling-disabling process (not transitions among the states). Research involving drug or alcohol abuse and mental health research were specifically excluded from this committee's charge. Finally, the category "not related" described projects that did not have a research component or that were not clearly relevant to rehabilitation research. Among such abstracts were grants to purchase equipment for research, training with no research component, and seminars that did not produce a report. Rehabilitative States Under this classification the project abstracts were categorized ac-
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--> TABLE A-2 Rehabilitative States Classification Category Description of Research No disabling conditions Research that addresses the state of function or use of subjects with no disabling conditions to investigate mechanisms that are potentially relevant to assessing and treating disabling conditions Pathology Research that examines changes of molecules, cells, and tissues that may lead to impairment, functional limitation, or disability, distinguished from pathology by manifestation at organ or organ system level Impairment Research that analyzes changes in particular organs, systems, or parts of the body; impairment is distinguished from functional limitation due to emphasis on organ and body components instead of the whole body Functional limitation Research that examines functional changes involving the entire subject, manifested by task performance Disability Research that focuses on the interaction of the subject with and in the larger context of the physical and social environments cording to the states described in the enabling-disabling process developed by this committee (see Table A-2; for more detailed discussion, see Chapter 3). The four basic states of pathology, impairment, functional limitation, and disability are those that were initially described by Nagi and more recently elaborated by the Institute of Medicine (1991). A category called "no disabling conditions" was added to accommodate research that dealt with nonpathological materials. Note that this category is intended for studies that focus exclusively on materials or subjects with no disabling conditions (excluding those that only have control subjects with no disabling conditions). This category includes research that addresses technology or mechanisms contributing to disability without directly studying pathology, impairment, functional limitation, or disability. Experimental Subjects A third categorization of the projects is summarized in Table A-3. Note that this categorization distinguishes between "human" and nonhu-
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--> TABLE A-3 Subject Classification Category Description of Research Human Clinical studies involving human subjects, including noncultured human tissues such as brain slices, tissues, and blood samples, and cadaver materials Animal In vivo studies involving nonhuman animal subjects, including noncultured animal tissues such as brain slices Cultures In vitro studies involving animal tissue cultures; this includes cell lines, as well as primary cell cultures Synthetic Studies of synthetic materials, both organic and inorganic; this includes electrodes, plastics, biopolymers, and inorganic materials Computer Computer and other models, including mathematical models man "animal" preparations and that these two categories include both cadaver and living tissues from these two sources. "Cultures" are different in that they involve living cells that are cultured from either human or animal sources. The "synthetic" category includes both organic and inorganic materials that are used, particularly for prostheses and other devices. Finally, a category of "computer" and other modeling is included. These are not exclusive categories; many studies involve studies of multiple subjects, ranging from human to computer modeling. Results As mentioned previously, the committee was limited in their efforts to assess the current status of research by the quality of the abstracts. The abstracts often did not contain enough detail to ascertain study designs, for example, or whether the projects adequately addressed environment, policy, secondary conditions, quality of life, or outcomes measures, among other concerns. Furthermore, because the data were culled from the abstracts, some of which were quite brief, it is likely that our results do not reflect every experiment that was supported by the larger grants. Additionally, the abstract analysis was dependent on the efforts of a small subcommittee and IOM staff. No formal evaluation of internal validity was performed, e.g., inter-rater reliability evaluation. The committee does have confidence, however, these results provide a reasonable indication of the general trends that currently exist in rehabilitation-related research in the federal government. The committee's specific results which describe each program and its research priorities can be found in Chapter 10.
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--> General Conclusions Table A-4 summarizes the federal spending on rehabilitation-related research, according to the committee's findings. The committee segregated the programs into two groups. Those with budgets greater than $5,000,000 were analyzed individually and are listed first; those with budgets less than $5,000,000 were not examined and are listed on the bottom of the table. The first column enumerates the funding levels reported by the programs themselves. The second column then lists the amount of the funding associated with the total number of research abstracts that were reviewed for each program. NIDRR, for example, has a budget of $70,000,000, but much of this supports such items as centers and training—activities that were assessed separately from the examination of research activities. The third column lists the amount of funding that the committee classified as not related to rehabilitation-related research. The following three columns then delineate the amounts of the programs' budgets that support rehabilitation-related research, through individual research projects, center grants, and other spending, respectively. The final column provides the committee's best approximation of the amount of each program's budget that supports rehabilitation-related research. The evaluation process itself led to several important conclusions. First, the task of identifying and collecting the abstracts illuminated the need for centralized administrative control of rehabilitation research. Agencies seemed unsure of their own rehabilitation efforts, much less those of other agencies. NIH's lack of a unified definition for rehabilitation research (see Box A-2), for example, and the lack of correlation between NIH and the CRISP system of projects identified as being rehabilitation related indicates a discordant effort inside NIH and reflects the lack of true coordination throughout the federal government. The committee also drew conclusions from the size of the research effort. The relatively small size of the research funding pool suggests that there are several gaps in the overall research efforts, but this is not meant to fault any particular agency for ignoring a specific issue. The fiscal limitation on rehabilitation research limits investigation to a narrow level of effort in each field. Of the rehabilitation states described above, pathology and impairment receive the most attention, primarily because it is within the mission of NIH to address these and NIH has the largest budget. NIDRR, among others, does focus on functional limitation and disability, but it only has approximately $12 million to support field-initiated or other investigative research efforts, as opposed to center grants or State Technology Assistance, for example. Rehabilitation has yet to become a high priority for NIH and other agencies for which rehabilitation is not the primary goal. The current
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--> level of research activity for NIDRR and other agencies is not sufficient to address the many pressing issues in rehabilitation today. A coordinating body equipped with the tools required to organize the federal agencies would not only bring much needed attention to the field would, but also increase the quality and efficiency of the present research efforts. The current status of research in the field of rehabilitation science and engineering is that it is small and could benefit greatly from additional funds, greater attention, and better overall administrative control. A majority of the grants regarded by federal agencies to be for rehabilitation research involved studies of humans or human materials. Many studied both animals and human subjects. Rehabilitation research that involve human subjects and studies of functional limitation and disability were substantially more costly than grants that dealt with animals, tissue cultures, or subjects with no disabling conditions. For example, although only 58 percent of the grants at NIH involved human subjects, those grants took up a lion's share of the funds (80 percent). Within rehabilitation science research specifically, human studies dominated and outnumbered studies involving animal, tissue culture, synthetic, and computer models by a 2:1 ratio. A small minority of studies used tissue cultures. Use of computer models was relatively rare. Finally, the committee analyzed the research projects of each agency in terms of the agency's mission. (The committee used a series of interviews and questionnaires to investigate the agencies' missions, the method for which is described below, and a more detailed discussion of the mission and research analysis is available in Chapter 10.) In summary, each of the primary agencies involved in funding research in rehabilitation science and engineering has a unique mission and identity, and they do fund projects whose topics are related to the mission of the agency. The committee found no programs that need to be eliminated or consolidated, but it did feel that the efforts could be better coordinated. In all, the committee reviewed many promising projects and quality research which have the potential to influence the lives of people with potentially disabling conditions. There is still a pressing need for more research, and a better coordinated federal effort. Agency Questionnaires and Interviews In order to obtain a better understanding of the federal agencies involved in funding research related to Rehabilitation science and engineering, the committee developed two questionnaires: one designed to characterize the general mission and composition of each agency (see Box A-3, the second to characterize training activities (see Box A-4). The committee also interviewed federal agency representatives in person.
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--> gitudinal studies that determine the impact of conditions over time, and studies that bridge the levels of pathophysiology to disability. These studies should also focus on the time in life at which disability occurs, as it impacts outcome. This could also involve aging with a disability, specifically the simultaneous declines in cognitive, auditory, and visual functioning which may accompany aging. Rehabilitation also needs research into the environment. The effects of different kinds of family support and health care delivery patterns were identified as worthy subjects of research. Scientists should also investigate how capacities can be developed instead of restored, making progress toward higher levels of functioning that may not have existed prior to impairment. Finally, one of the largest unmet research needs is how to measure unmet needs of individuals with disabilities, especially the "unserved" population. The fourth question dealt with problems that could interfere with developing and improving rehabilitation science. The lack of training and experience of rehabilitation researchers to compete successfully for NIH funding and the increasing burden of clinical care responsibilities faced by physicians who care for people with disabilities severely limit advances to the field were both mentioned as impediments to the development of rehabilitation science. Another major obstacle is the perceived lack of value for the applied sciences. In academe, rehabilitation is "applied" science and often has "second class citizen" status. This perception about rehabilitation needs to be changed. In addition, a poorly understood taxonomy for rehabilitation and poor communication among disciplines and the disability community contribute to the slow development within rehabilitation. Dissemination of rehabilitation-related information was also cited as a major deterrent to better rehabilitation. First of all, general dissemination is not adequate to reach the grass roots level. Compounding this is the fact that critical information comes too quickly to the individual and the family at the initial onset of the disabling condition; they simply cannot retain and therefore utilize the material. "Survivors' Councils" may be one solution to this, but frequently, the information needed to identify patients and their families is not available, which is another barrier to community development and education. Another solution is to disseminate information better via a variety of sources, for example, the Internet. Independent Living Centers (ILCs) could also serve as a valuable tool for informing consumers, but they are largely isolated from other resources. Frequently, contacts in housing accessibility associations are not known, and often ILCs, Community Wellness Centers, and Rehabilitation Centers need a go-between. Whether the problem is a lack of services or a lack of coordination and dissemination, it was felt that
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--> most settings can only currently offer fragmented resources to uninformed consumers. Community development should be a major goal of rehabilitation science so that the community itself becomes a tool for each individual's long-term rehabilitation. The final question asked participants to identify the best strategies for achieving the necessary level of research and professional expertise. Some mentioned infusions of federal research dollars: A large investment in rehabilitation research would change the academic and clinical institutions according to need. In education and training, long-term care and prevention should be the focal points of a new paradigm. Also, a decrease in the teaching loads of rehabilitation faculty would allow more time for research. The teaching loads are too high and need to be decreased if research productivity is to increase. This could occur if more grant funding was available. Dissemination was also identified as a means of developing research. Fostering the sharing of research results in interdisciplinary journals and scientific conferences, rather than limiting publication to strictly professional publications, would aid communication. A rehabilitation world wide web site that links scientists from different disciplines to the issues, questions, resources, and needs of persons and communities for knowledge to guide practice and design to limit disability, and that facilitates career mentorship for faculty, researchers, and scientists. Some felt that the promotion of community awareness and building community networks of services and education is key to establishing a coordinated system of care for the people with disabilities. Independent Learning Centers need to make themselves available to Vocational Rehabilitation Counseling students of all disciplines, because ILCs do what VR should be doing: faster, better, cheaper, and from a consumer-driven perspective. Finally, some called for a "War on Disability" similar to the "War on Cancer" in the 1960s, establishing a National Institute for Rehabilitation Research with appropriate accompanying study sections. Private Organizations The committee felt that it was important to get as much feedback as possible from individual consumers and small consumer groups. Because focus groups could not be held with each constituency, the committee designed a questionnaire to send to identifiable organizations that might have interest in rehabilitation science and engineering.
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--> Method Questionnaires were mailed to approximately 500 private organizations. The National Rehabilitation Information Center provided a list of disability-related organizations with a national constituency. The questionnaires were sent along with a one-page description of the study, the committee roster, and a cover letter explaining the committee's purpose for the information. The questionnaire consisted of 33 questions designed by the committee on issues raised in the initial focus group sessions (see Box A-6). The form identified unique issues or aspects of rehabilitation and asked the individual to rate the importance of each as a research, educational, or governmental priority in the current state of rehabilitation as a whole. The scale ranged from 1 to 7, with 7 being the most important or the most pressing need. Finally, the questionnaire contained several lines for the respondents to identify issues not addressed by the questionnaire. Response and Analysis The response rate was low: a total of 43 of 488 (less than 10 percent) of the questionnaires sent. Twenty-seven additional questionnaires were returned due to invalid addresses. Of those that did respond, there was little deviation from an average score of 5, with the maximum and minimum average scores very seldom fluctuating beyond ±0.7. To enhance the minor differences, the staff created a relative scale from 0 to 10 in which the lowest average score rated a 0 and the highest average score rated a 10. The other scores were then given proportional scores within this new scale. Figure A-2 illustrates this in a graph displaying the relative scores as a bar chart. Highest and Lowest Priorities Acknowledging some overanalysis and enhancement of the findings, the following is a list of the highest and lowest priorities identified in the survey of private organizations. Highest Priority Concerns or Needs Determine what quality means to people who have and who are restricted in social participation (Question 5; Score: 5.85) Involve consumers in advisory committees to understand the needs and potential contribution of science to improving social participation of people with disabling conditions (Question 23; Score: 5.76)
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--> BOX A-6 Questionnaire for Private Organizations How important is it to 1 Attract basic and social scientists to rehabilitation? 2 Describe etiology, implications, and history of secondary conditions and their impact on the quality of life of people with disabling conditions? 3 Determine the effectiveness of models that coordinate resources and use a community health orientation to support the health and functional needs identified by the person requesting services? 4 Determine the impact of rehabilitation science on the health of communities? 5 Determine what quality means to people who have and was restricted in social participation? 6 Develop a system for career mentorship to build rehabilitation scientists? 7 Develop and test a rehabilitation model to guide research across a continuum from acute care to community and independent living? 8 Develop methods to determine the needs of people who are underserved? 9. Establish center grants to foster interdisciplinary studies? 10. Evaluate the effectiveness of rehabilitation models that focus on prevention of secondary conditions? 11 Expand focus on studies of the environment and social participation? 12 Expand training moneys to prepare rehabilitation scientists? 13 Explore long-term outcomes in programs that are medically focused compared to those that are client focused and give people with disabling conditions the right to make their own decisions? 14 Explore the use of community networks as integral components of rehabilitation? 15 Facilitate the use of telecommunication for dissemination from findings of rehabilitation science? 16 Facilitate the community as a tool for individuals to help in the restorative process and achieving their goals for independence? 17 Facilitate coordination and communication among federal agencies that support rehabilitation science? 18 Identify and classify barriers to services with the goal of building better systems of services? 19 Increase communication among the rehabilitation scientists and disability community? 20 Increase funding for rehabilitation research? 21. Include independent living centers in studies to be a link to community resources and a mechanism to empower consumers? 22. Integrate behavioral medicine (and rehabilitation science) into medical and allied health education? 23 Involve consumers in advisory committees to understand the needs and potential contribution of science to improving social participation of people with disabling conditions? 24 Increase the funding for qualitative and single case study designs? 25. Provide vehicles for interdisciplinary communications among rehabilitation scientists and consumers?
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--> How important is it to: 26. Put more emphasis on transfer of information? 27 Establish means of supporting measurement studies across the continuum of rehabilitative services, including those provided in the community? 28. Conduct longitudinal studies to determine implications of conditions over time? 29 Conduct clinical trials of applied technology? 30 Establish grant review committees that are oriented to the continuum of science, from pathology to disability? 31 Develop mechanisms to fund studies that address questions at the functional limitation, disability, and environmental levels? 32 Study issues of care givers to determine the needs and issues that relate to their quality of life as well as to the quality of life of the care recipient? 33. Support collaborative grants and initiatives of individual investigators? *Responses were marked on a scale of 1-7 FIGURE A-2 Responses to the survey of private rehabilitation organizations: scores on relative scale.
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--> Identify and classify barriers to services with the goal of building better systems of services (Question 18; Score: 5.66) Increase communication among the rehabilitation scientists and disability community (Question 19; Score: 5.63) Determine the effectiveness of models that coordinate resources and use a community health orientation to support the health and functional needs identified by the person requesting services (Question 3; Score: 5.63) Lowest Priority Concerns or Needs Establish center grants to foster interdisciplinary studies (Question 9; Score: 4.56) Support collaborative grants and initiatives of individual investigators (Question 33; Score: 4.57) Increase the funding for qualitative and single case study designs (Question 24; Score: 4.62) Determine the impact of rehabilitation science on the health of communities (Question 4; Score: 4.63) Expand focus on studies of the environment and social participation (Question 11; Score: 4.76) Miscellaneous Activities The committee and staff also engaged in other activities to collect the pertinent information needed for this report. These activities ranged from obtaining necessary texts to conducting interviews with related agencies and programs. The Administration on Aging, for example, was contacted to discuss its methods and means for carrying out its charge. Former directors from pertinent agencies or programs were also contacted to collect other knowledgeable perspectives from people other than current government employees. Staff of committee members attended formal meetings conducted by such groups as the Subcommittee on Disability Statistics of the Interagency Committee on Disability Research and the NCMRR Advisory Panel. Finally, committee members or staff attended or made presentations to academic meetings and consumer groups, such as the Amputee Coalition. These activities put committee members and staff into contact with many different perspectives and ideas, all of which contributed to the whole of the report.
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--> Acknowledgments Commissioned Papers and Other Written Contributions "Participatory Action Research," "Demographics of Disability," and ''Summary of Information Sources on Disability and Rehabilitation Research," contributions from Christine Domzal Conwal Inc. "Technology Transfer," contributions from Betsy Phillips Tewey Conwal, Inc. "Federal Administration of Rehabilitation Research: An Overview and Outline," contributions from Jane West National Council on Disability "The Role of Environment in Supporting Performance" contributions from Mary Corcoran, Ph.D., OTR, and Laura Gitling, Ph.D. Thomas Jefferson University "Quality of Life" contributions from Dorothy Edwards, Ph.D. Washington University "Models of Service for People with Disabilities" contributions from Mary Ann McColl, Ph.D., OTR/C Queen's University "The Relationship of Vision and Impairment" contributions from Linda Hunt, M.S., OTR/C Washington University "The Relationship of Hearing and Impairment" contributions from Gerald R. Popelka, Ph.D. Washington University Invited Participants and Guests Judy Auerbach, Ph.D. National Institutes of Health Laura Baird, M.S. Institute of Medicine
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--> Praxedes Belandres, M.D. Walter Reed Army Medical Center Betty Jo Berland, Ph.D. National Institute on Disability and Rehabilitation Research David Beukelman, Ph.D. University of Nebraska, Lincoln John Bode Sandia National Laboratories Floyd Brown, Ph.D. U.S. Department of Health and Human Services Larry Burt Centers for Disease Control and Prevention Laura Cooper, J.D. Attorney Rory Cooper Paralyzed Veterans of America Francis V. Corrigan, EdD National Institute on Disability and Rehabilitation Research Dennis Chamot, Ph.D. National Research Council Gerben DeJong, Ph.D. Medlantic Research Institute Christine Domzal, Ph.D. Conwal Incorporated Pamela Duncan, Ph.D. University of Kansas Stephen Fawcett, Ph.D. University of Kansas Robert Felton University of California at Los Angeles
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--> Janie Fouke, Ph.D. National Science Foundation Marcus Fuhrer, Ph.D. National Center for Medical Rehabilitation Research Bruce Gans, M.D. Wayne State University School of Medicine Lynn Gerber, M.D. National Institutes of Health John Goldschmidt, M.D. Department of Veterans Affairs Dorothy Gordon, D.N.Sc., R.N., F.A.A.N. The Johns Hopkins University School of Nursing Margaret Gray Personal Assistant Mary Harahan U.S. Department of Health and Human Services Karen Hein, M.D. Institute of Medicine Jim Jenson National Research Council Petra Johnson Interpreter Bob Knouss, M.D. U.S. Department of Health and Human Services Philip Lee, M.D. U.S. Department of Health and Human Services James Lieberman, M.D. College of Physicians and Surgeons of Columbia University Phillip Marion, M.D. Robert Wood Johnson Fellow
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--> Maria Martino U.S. Department of Health and Human Services John Mather, M.D. Social Security Administration Lauren Meader Institute of Medicine John Melvin, M.D. Mossrehab Hospital Brian Millin National Institute on Disability and Rehabilitation Research Frank Morrone Paralyzed Veterans of America Larry Morton National Institutes of Health Jacques Normand, Ph.D. National Research Council James Reswick, Sc.D. (retired) National Institute on Disability and Rehabilitation Research Mark Rosenberg, M.D., M.P.P. National Center for Injury Prevention and Control Debbie Rothstein, Ph.D. National Institute on Child Health and Human Development Katherine Seelman, Ph.D. National Institute on Disability and Rehabilitation Research Valerie Setlow, Ph.D. Institute of Medicine Cynthia Shewan, Ph.D. American Physical Therapy Association
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--> Kenneth I. Shine, M.D. Institute of Medicine Joseph Sniezek, M.D., M.P.H. National Center for Injury Prevention and Control Suzanne Stoiber, Ph.D. U.S. Department of Health and Human Services R. Alexander Vachon, Ph.D. U.S. Senate Committee on Finance Richard Verville, Esq. representing AAPM&R, AAP, ACRM Richard Waxweiler, Ph.D. National Center for Injury Prevention and Control Alexandra Wigdor, Ph.D. National Research Council Dorrett Worrell National Institutes of Health Other Contributors Jeanette Bair American Occupational Therapy Association Carol Kochhar George Washington University Keith Miller Sandia National Laboratories Don Wesenberg Sandia National Laboratories George Zitnay, Ph.D. Brain Injury Association
Representative terms from entire chapter: