The Journal of Rehabilitation Research and Development

Online ISSN: 1938-1352
Print ISSN: 0748-7711
Publications
Linear polarized near-infrared light created with linear polarized near-infrared light therapy equipment (Super Lizer HA-550, Tokyo Iken Co, Ltd, Tokyo, Japan) has been used for the treatment of various painful disorders in Japan. Irradiation near the stellate ganglion with a Super Lizer (ISGL) is an especially notable therapeutic method used with stellate ganglion block (SGB) or substitutes for SGB. ISGL is a safe, simple, well-tolerated, and effective treatment. We examined the effects of irradiation with a Super Lizer applied to an area near the lumbar sympathetic ganglia on the ligated side in a chronic constriction injury (CCI) model, which is believed to be an animal model of complex regional pain syndrome (CRPS). Rats showing thermal hyperalgesia in a radiant heat test 1 wk postoperatively were used in Experiments 1 and 2: (1) Thermal hyperalgesia of irradiation group (n = 11) was less than that of the control or nonirradiation (n = 11) group at 1, 3, and 8 h after irradiation; however, the effect disappeared 12 h after irradiation. (2) Daily irradiation (n = 16) and 1 wk (n = 14) from 7 days after nerve ligation significantly shortened the interval from thermal hyperalgesia until recovery. Rats showing mechanical hyperalgesia in the von Frey hair test 1 wk postoperatively were used in Experiment 3: 1 wk irradiation beginning 7 days after nerve ligation (n = 9) did not promote the recovery from mechanical hyperalgesia. We speculate that repeated ISGL may be more effective than a single ISGL in alleviating pain in CRPS patients. We cannot explain the discrepancy between the results obtained in Experiments 2 and 3. We believe the results of this study are relevant to the effect of ISGL for patients with upper-limb CRPS: irradiation near the lumbar sympathetic ganglia of the rat is effective for thermal but not mechanical pain in CCI.
 
This study investigated long-term use of custom-made orthopedic shoes (OS) at 1.5 years follow-up. In addition, the association between short-term outcomes and long-term use was studied. Patients from a previously published study who did use their first-ever pair of OS 3 months after delivery received another questionnaire after 1.5 years. Patients with different pathologies were included in the study (n = 269, response = 86%). Mean age was 63 ± 14 years, and 38% were male. After 1.5 years, 87% of the patients still used their OS (78% frequently [4-7 days/week] and 90% occasionally [1-3 days/week]) and 13% of the patients had ceased using their OS. Patients who were using their OS frequently after 1.5 years had significantly higher scores for 8 of 10 short-term usability outcomes (p-values ranged from <0.001 to 0.046). The largest differences between users and nonusers were found for scores on the short-term outcomes of OS fit and communication with the medical specialist and shoe technician (effect size range = 0.16 to 0.46). We conclude that patients with worse short-term usability outcomes for their OS are more likely to use their OS only occasionally or not at all at long-term follow-up.
 
Metabolic data. 
Maximal arm power output .* 
The hips and lower extremities of four complete paraplegic male subjects (T-6, T-7, T-8, and T-11) were stimulated with functional neuromuscular stimulation (FNS) via transcutaneous intramuscular electrodes (20 mA, 0-150 pulse width, and 20 Hz). Cardiopulmonary (CP) and/or cardiovascular (CV) responses were measured during maximal (seated) arm ergometry (AE), FNS, and FNS + AE. Subjects' lower extremities were stimulated with a 2 s walking cycle via a microprocessor computer. Data were collected with a SensorMedic MMC Horizon (VO2 and VCO2 at STPD and VE at BPTS). The mean MET level (1 MET = 3.5 ml O2/kg/min) during FNS was 4.8. Mean METS during FNS + AE was 10.3 and mean METS for AE was 7.2. Mean lactic acid (LA) after FNS, AE, and FNS + AE was 73 mg percent, 77 mg percent and 115 mg percent respectively. Respiratory exchange ratio (RER) (VCO2/VO2) was greater than 1.2 during the first 2 to 5 min of FNS but decreased to less than 1.0 during the second 5 min of FNS. Steady state VO2 and RER less than 1.0 indicated a FNS transition from anaerobic to aerobic metabolism. Subject T-11 had CV limitations during FNS and FNS + AE due to excessive LA from FNS (115 mg percent). Ventilatory (VE) responses during AE, FNS, and FNS + AE were consistent with VO2; and mean maximal VE and VO2 for subjects T-6, T-7, and T-8 during FNS + AE was greater than 90 percent of that observed in sedentary normals. The aerobic and anaerobic capacities of paraplegic subjects is primarily limited by available muscle mass rather than impaired CV or CP function.
 
The purpose of this study was to determine the relationship between selected anthropometric and physiological variables and 10K time. Eleven male wheelchair athletes with spinal cord injuries in training for national competition performed continuous progressive exercise tests on a wheelchair ergometer to determine maximal metabolic and cardiorespiratory values. Anthropometric data were also collected. The laboratory data were analyzed for correlation with the best 10K time of each subject during the test period. The subjects averaged 27 min 30 sec for their 10K races, 2.49 L.min-1 for VO2max and 35 percent for maximal gross mechanical efficiency during submaximal exercise. Speed at peak oxygen consumption (r = -0.66), gross mechanical efficiency (r = -0.56), and body density (r = -0.57) was found to be significantly (p less than 0.10) correlated with 10K time. The results show very little correlation between VO2max and 10K time (r = 0.02). Further study is indicated for the relationship between gross mechanical efficiency, speed at maximal oxygen consumption, body density, and 10K time; these variables may be useful in evaluating training programs for improving race performance.
 
The Case Western Reserve University/Department of Veterans Affairs 8-channel lower-limb neuroprosthesis can restore standing to selected individuals with paraplegia by application of functional electrical stimulation. The second generation of this system will include 16 channels of stimulation and a closed-loop control scheme to provide automatic postural corrections. This study used a musculoskeletal model of the legs and trunk to determine which muscles to target with the new system in order to maximize the range of postures that can be statically maintained, which should increase the system's ability to provide adequate support to maintain standing when the user's posture moves away from a neutral stance, either by an external disturbance or a volitional change in posture by the user. The results show that the prime muscle targets should be the medial gastrocnemius, tibialis anterior, vastus lateralis, semimembranosus, gluteus maximus, gluteus medius, adductor magnus, and erector spinae. This set of 16 muscles supports 42% of the standing postures that are attainable by the nondisabled model. Coactivation of the lateral gastrocnemius and peroneus longus with the medial gastrocnemius and of the peroneus tertius with the tibialis anterior increased the percentage of feasible postures to 71%.
 
Future progress in neuromuscular prostheses will depend on developing techniques for stimulating paralyzed muscle, especially utilizing neuromuscular stimulation. We have found nonlinear force versus stimulus amplitude characteristic (recruitment) curves in the gastrocnemius-soleus-plantaris muscle group of the cat in response to stimulation of the tibial nerve near the muscle entry point. Such response characteristics are undesirable in neuromuscular control systems. Nonlinear recruitment curves usually consisted of two regions in which force increased linearly with stimulus amplitude, separated by a "plateau" region in which force was relatively constant. The two linear regions were associated with activation of separate neuromuscular compartments (lateral or medial gastrocnemius, plantaris, soleus, or subdivisions of those muscles). When the stimulated myoelectric responses from these compartments were plotted versus stimulus amplitude, the region of recruitment between threshold and saturation often did not appreciably overlap for different compartments, suggesting that the axons innervating those compartments were physically segregated within the nerve from axons innervating other compartments. Correlation coefficients between force and stimulated myoelectric response were very high (up to R2 = 0.99) when using a composite curve produced by averaging myoelectric response curves recorded from each of the active compartments. By dividing the tibial nerve into its component bundles or fascicles and stimulating each in turn, it was possible to show that individual bundles innervate non-overlapping groups of muscle compartments, and that recruitment of the nerve bundles over different threshold ranges could account for the nonlinear force/stimulus response curves initially observed. The presence of separate innervation of muscles or compartments by fascicles should be an important factor in designing functional neuromuscular stimulation (FNS) systems.
 
This study proposes an optimal set of lower-limb muscles to be stimulated electrically with a 16-channel neuroprosthesis that will allow persons with paraplegia caused by spinal cord injury to stand and shift postures smoothly, thus minimizing muscle fatigue and facilitating performance of activities of daily living. We used a three-dimensional (3-D) 15 degree-of-freedom musculoskeletal model of the human lower limbs to assess different muscle combinations that would maintain specific standing postures while minimizing the overall metabolic energy consumed. We initially selected the postures by discretizing the joint-angle space over the ranges of the knee, hip, and ankle angles and then refined the postures by relating the lower-limb joint angles to the center of mass (COM) of the musculoskeletal model to generate smooth transitions between desired postures. We found a set of four 3-D second-order polynomials adequate for obtaining the best fit between the joint angles and the COM components. The results showed that adding the gluteus medius and the adductor magnus to balance nonsagittal movements at the hip and adding several different combinations of ankle muscles should allow users to shift postures over 75% of the forward-backward range that nondisabled individuals use during typical activities. The simplest complete ankle-muscle set only requires the soleus and the tibialis anterior, and the medial and lateral gastrocnemii could be added for additional plantar flexion. Alternatively, if the ankle is consistently being inverted, the peroneus muscles could be added.
 
Medications taken by subjects. 
The purpose of this study was to determine and compare acute hemodynamic responses of spinal cord injured (SCI) quadriplegics (quads), and paraplegics (paras) during a graded-intensity knee extension (KE) exercise test utilizing functional neuromuscular stimulation (FNS) of paralyzed quadriceps muscles. Seven quads and seven paras (N = 14) performed a series of 4-minute stages of bilateral alternating FNS-KE exercise (approximately zero to 70 degree range of motion at the knee and 6 KE/min/leg) at ankle loads of 0, 5, 10, and 15 kg/leg. Physiologic responses were determined with open-circuit spirometry, impedance cardiography, and auscultation. Comparing rest with peak FNS-KE for both groups combined, FNS-KE exercise elicited significant (p less than 0.05) increases in oxygen uptake (130 percent), pulmonary ventilation (120 percent), respiratory exchange ratio (37 percent), arteriovenous oxygen difference (57 percent), cardiac output (32 percent), stroke volume (41 percent), mean arterial pressure (18 percent), and rate-pressure product (23 percent). Heart rate increased significantly by 11 percent from the 5- to the 15-kg/leg stages. Physiologic responses of quads and paras were very similar, except for lower (p less than 0.05) arterial pressures, rate-pressure product, and peripheral vascular resistance in quads. This graded FNS-KE exercise up to the 15-kg/leg load induced relatively small but appropriate increases in aerobic metabolism and cardiopulmonary responses that appear to be safe and easily tolerated by quads and paras. Arterial pressure needs to be monitored carefully in quads to prevent excessive hypertension or hypotension. Although FNS-KE exercise has been shown to elicit peripheral adaptations to improve muscle strength and endurance, it is probably not an effective central cardiovascular training tool for all but the least fit SCI individuals. This information is important for understanding the effects of FNS use during more complex activities such as cycling and ambulation.
 
Four paraplegic patients with traumatic upper motor neuron lesions at the spinal levels between D5 and D12 were activated by functional electrical stimulation (FES) and evaluated biomechanically and physiologically. After a training program aimed at strengthening the muscles of the lower legs, the patients were able to stand up, maintain the standing position, and walk for short distances while being supported. Biomechanical evaluation included weight bearing on the patients' own legs during standing as measured on a force platform and analysis of the time-distance parameters of the stride during walking as measured on a walkway. Physiological evaluation included heart rate and oxygen consumption at rest, when activated by FES in the sitting position, during standing, and during walking. The results obtained indicate that while significant standing and walking performances are achieved, the corresponding physical effort can reach relatively high levels requiring the support of anaerobic energy sources. The practical implications of these results are discussed.
 
Dear Editor:This letter addresses the following sentence in the "Mobility redux: Post-World War II prosthetics and functional aids for veterans, 1945 to 2010" editorial that appeared in JRRD, Volume 48, Number 2. The sentence on page xv, second column: "Early testing and rigorous subject feedback clearly showed that DEKA II's first active socket design was not what patients wanted or needed." is not accurate. There is evidence in the historical literature on problematic prosthetic sockets. However, user response to the interface design introduced as part of the DEKA Arm System in collaboration with prosthetists at biodesigns, Inc (Santa Monica, California) and Next Step Orthotics and Prosthetics, Inc (Manchester, New Hampshire) has been quite favorable.It would be accurate to say "Early testing and rigorous subject feedback clearly showed that the active socket design used as part of the DEKA Arm System offers significant benefits and was positively received by research subjects."
 
A pressure sore is an ulceration of the skin and/or deeper tissues due to unrelieved pressure, shear force(s), and/or frictional force(s). This paper reviews the literature from 1977-1987 on the etiology and pathophysiology of pressure sores, factors contributing to their formation, diagnostic and pressure-measuring devices, and cushions and devices designed to prevent sores. The authors hope this review will show that many current assumptions may be invalid and should be re-examined.
 
To assess trends in peripheral vascular procedures performed in Veterans Health Administration (VHA) facilities. All discharges with peripheral vascular procedures recorded for 1989-1998 were analyzed. The VHA user population was used to calculate age-specific rates. Trends were evaluated using frequency tables and Poisson regression. The VHA had 55,916 discharges with peripheral vascular procedures performed almost exclusively in men. Indications included peripheral vascular disease (53.7%), gangrene (19.3%), surgical complications (13.3%), and ulcers and infection (9.6%). The VHA age-specific rates were higher than US population rates for persons 45 to 64 years, similar for those 65 to 74 years, and lower for those 75 years and older. The age-specific rates declined slightly over the 10 years of observation, with the greatest decline noted in men age 45 to 65. The VHA provides almost 8% of all US peripheral vascular procedures in males. The VHA age-specific rates differ from the US rates with a shift to younger patients. The rates decreased for all age groups between 1989-1998.
 
To assess trends in lower limb amputation performed in Veterans Health Administration (VHA) facilities. All lower limb amputations recorded in the Patient Treatment File for 1989-1998 were analyzed using the hospital discharge as the unit of analysis. Age-specific rates were calculated using the VHA user-population as the denominator. Frequency tables and linear, logistic, and Poisson regression were used respectively to assess trends in amputation numbers, reoperation rates, and age-specific amputation rates. Between 1989-1998, there were 60,324 discharges with amputation in VHA facilities. Over 99.9% of these were in men and constitute 10 percent of all US male amputations. The major indications were diabetes (62.9%) and peripheral vascular disease alone (23.6%). The age-specific rates of major amputation in the VHA are higher than US rates of major amputation. VHA rates of major and minor amputation declined an average of 5% each year, while the number of diabetes-associated amputations remained the same. The number and age-specific rates of amputations decreased over 10 years despite an increase in the number of veterans using VHA care.
 
The Housing and Urban Development-Department of Veterans Affairs Supportive Housing (HUD-VASH) program is the largest supported housing program in the country for homeless veterans who are seeking rapid entry into permanent independent housing. This study examined factors related to how rapidly clients were housed in the early years of the program and how long they stayed in the program. Mental health, substance abuse, work/income, criminal history, and site were examined as predictors of process times. Regression analyses based on 627 HUD-VASH clients who entered the program between 1992 and 2003 showed that client characteristics were not rate-limiting factors for obtaining HUD-VASH housing; i.e., clients who had greater substance abuse problems or more extensive criminal histories did not take longer to obtain housing. The large differences associated with site of entry partly reflected a curvilinear relationship between the duration of operation of the HUD-VASH program and process times; i.e., at relatively younger and older programs, clients entered housing slightly faster than at programs in the middle range. Lastly, HUD-VASH clients whose case managers reported good therapeutic alliances stayed in the program longer. These findings have implications for the continued expansion of the HUD-VASH program.
 
Hearing loss and tinnitus are the two most prevalent service-connected disabilities among U.S. veterans. The number of veterans receiving compensation and services from the Department of Veterans Affairs (VA) for these conditions continues to increase annually. However, the majority of veterans in the United States do not use VA medical centers or clinics for healthcare and do not receive VA compensation payments. Therefore, the prevalence of hearing loss and tinnitus among U.S. veterans is unknown. This study used National Health and Nutrition Examination Survey data to estimate the prevalence of these auditory conditions among male veterans. Between 1999 and 2006, pure tone audiometric data collected from 845 male veterans were compared with pure tone thresholds collected from 2,086 male nonveterans. We used questionnaire data collected between 1999 and 2004 to calculate and compare the prevalence of tinnitus for 2,174 veterans and 4,995 nonveterans. In general, pure tone thresholds did not differ significantly between veterans and nonveterans for most frequencies tested (500-8,000 Hz). The overall prevalence of tinnitus was greater for veterans than that for nonveterans (p < 0.001), with statistically significant differences in the 50 to 59 and 60 to 69 age groups.
 
Data collection system. EMG = electromyography, PC = personal computer. 
Placement of one-dimensional sonomyography (1-D SMG) transducer, surface electromyography (SEMG) electrodes, and electronic goniometer on forearm. Ultrasound coupling gel was applied between transducer and skin. 
Relationship between smoothed electromyography (EMG) root mean square (rms) and wrist extension angle of typical trial for subject 1. Linear regression was used to represent relationship between smoothed surface EMG rms and wrist extension angle. 
We introduce a method, known as one-dimensional sonomyography (1-D SMG), that uses A-mode ultrasound signals to detect dynamic thickness changes in skeletal muscle during contraction. We custom-designed a 1-D SMG system to collect synchronized A-mode ultrasound, joint angle, and surface electromyography (EMG) signals of forearm muscles during wrist extension. We extracted the 1-D SMG signal from the ultrasound signal by automatically tracking the corresponding echoes, which we then used to calculate muscle thickness changes. We tested the right forearm muscles of nine nondisabled young subjects while they performed wrist extensions at 15.0, 22.5, and 30.0 cycles/min and their largest wrist extension angle ranged from 80 degrees to 90 degrees . We found that the muscle deformation and EMG root mean square signals correlated linearly with wrist extension angle. The ratio of deformation to wrist angle was significantly different among the subjects (p < 0.001) but not among the trials of different extension rates for each subject (p = 0.9). The results demonstrate that 1-D SMG can be reliably performed and that it has the potential for skeletal muscle assessment and prosthesis control.
 
Swallowing problems (dysphagia) can occur at any age but are most prevalent in elderly individuals and are a growing healthcare concern as the geriatric population expands. Without effective diagnosis and treatment, dysphagia may lead to serious medical conditions such as pneumonia, dehydration, and malnutrition. Experts in the field of dysphagia met on August 21, 2001, in Rockville, Maryland, to respond to this heightened healthcare need and to determine the course of dysphagia research. Presentations at the meeting included epidemiological data, geriatric-specific issues, diagnostic techniques, risk factors for pneumonia, and recent relevant trials. The experts identified outstanding issues in dysphagia research, such as study design, population selection, and the standardization of diagnostic and treatment protocols. They designed a clinical trial that represents what they deem is one of the greatest needs in dysphagia research, providing a critical springboard for research endeavors with far-reaching implications.
 
The purpose of this study was to estimate healthcare costs associated with diabetes-related lower-limb amputations (LLAs) within the Veterans Health Administration (VHA). We performed a cross-sectional comparative analysis of 3,381 VHA clinic users in fiscal year (FY) 2004 and 3,403 clinic users in FY2010 identified as having type 2 diabetes mellitus and nontraumatic LLA. LLA expenditures related to inpatient medical, inpatient surgical, and outpatient care were estimated using VHA Health Economics Resource Center average cost files. LLA-related pharmaceutical costs were obtained from VHA Decision Support System national extract files. From the Department of Veterans Affairs (VA) perspective, the mean cost associated with care for diabetes-related LLA per patient in the VA healthcare system in FY2004 was $50,351 (95% confidence interval [CI] = 48,939-51,803) in U.S. dollars; the total cost for all 3,381 patients was $170,236,037. In FY2010, cost per patient rose to $60,647 (95% CI = 59,143-62,188), with a total cost of $206,380,331 for 3,403 patients. In the VHA healthcare system, the economic burden associated with LLAs in patients with diabetes exceeded $200,000,000 in FY2010. This suggests that further improvements in care of patients with diabetes could be associated with significant cost savings.
 
Improvements in protective body armor technology in the past decade, combined with advances in emergency and intensive care medicine, have saved countless lives from battlefield injury [1–4]. Survivors of military conflicts often present with a constellation of injuries, recently described as “polytrauma” by the Veterans Health Administration (VHA) [5]. While traumatic brain injury (TBI) has been coined as the “signature injury” in this generation of combat returnees, other concomitant physical and psychological impairments also require long-term follow-up and care [6–8].
 
Probably no fashion has gripped first medicine; then the rest of health care; and finally social services, vocational rehabilitation, education, and other professional fields as quickly and deeply as evidence-based practice (EBP). There have been claims that there is nothing new here, that professionals have always been required to base treatment of their patients/clients on evidence as to what are effective, efficient, and reliable methods of diagnosing/assessing, treating, or offering prognosis, and have done so. However, the core message of EBP has been a worthwhile one whatever one thinks of that claim: not any odd piece of evidence will do. To provide patients/clients with optimal service, one needs to base it on a systematic study of the most recent and most appropriate evidence, carefully evaluated for potential biases and errors. Probably as a result of the prominence of the originators of EBP in medicine, as well as the appealing and easy quantitative and mathematical approaches to evidence evaluation, EBP is now a bandwagon few people dare to disdain publicly. In fact, adding the label "evidence-based" to about anything and everything done professionally is seen as a way of giving it a modern, up-to-date, scientific cachet that will appeal to other professionals, if not patents/clients. EBP has become a holy cow to whom tribute is due.
 
The continued wars in Iraq and Afghanistan have brought an increased focus on posttraumatic stress disorder (PTSD) and have made PTSD a part of a national conversation. Since the first edition of the Department of Veterans Affairs (VA)/Department of Defense (DOD) Clinical Practice Guideline (CPG) for PTSD was issued in 2004 at the beginning of these conflicts, more than 750,000 returning new Veterans have sought mental health care in the VA. It is anticipated that this number will climb dramatically as more than 1 million Veterans will leave the military in the next 5 years. This makes it all the more important that VA and DOD healthcare providers have clear guidance on best management practices for PTSD and an understanding of how they can best use the revised VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress issued in the fall of 2010. As coeditors, our goal with the production of this special issue of JRRD is to publish a series of articles that go beyond the recommendations in the new CPG by providing, in addition to a comprehensive overview of the latest scientific evidence, practical guidance for busy clinicians who wish to adopt the CPG recommendations within their various clinical settings.
 
The Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) are recommendations that are made to VA/DOD healthcare providers regarding their approaches to treatment of a variety of medical conditions. They are based on the best available clinical evidence and are designed to achieve the most desirable outcomes based on a variety of clinical situations. In general, CPGs have been defined as “systematically developed statements to assist practitioner and patient in making decisions about appropriate healthcare for specific clinical circumstances” [1]. CPGs are being used throughout healthcare systems as a means of enhancing quality, reducing costs, and optimizing performance. Good CPGs can change the process of healthcare and improve outcomes by providing recommendations for the management of patients and supporting the development of standards to assess outcomes. A CPG should also assist in healthcare providers’ education and training, likewise educating the patients; help in making informed decisions; and improve communication between the patient and provider. A CPG, when implemented, will influence practice patterns.
 
This year’s Research Week (May 2–6, 2011) continues a long-standing annual tradition of both celebrating the achievements of exceptional Department of Veterans Affairs (VA) researchers and paying tribute to Veterans who generously volunteer to participate in VA studies.
 
Looking at the evidence at present, the hypothesis of Ickmans et al. that activity level is a mediator of the relationship between the exercise capacity (e.g., VO2max) and cognitive functioning does not seem very likely. It seems more plausible that the low exercise capacity reflects the clinical status of a patient and that the negative effect of (moderate) exercise on the oxygen uptake and the anaerobic threshold puts the patient in a "catch-22" position, including characteristic low exercise capacity and cognitive deficits. ... http://www.rehab.research.va.gov/jour/2013/509/pdf/letterstotheeditor509.pdf
 
In this editorial, we report on the development of a smart-home-based cognitive prosthetic that will deliver 24/7 rehabilitation at the James A. Haley Veterans' Hospital Polytrauma Transitional Rehabilitation Program (PTRP) facility in Tampa, Florida. The Tampa Smart Home was designed to address two weaknesses identified by PTRP clinicians in the rehabilitation process for patients with traumatic brain injury (TBI): (1) patient safety and (2) inadequate timing and repetition of prompts used to overcome TBI-related cognitive and memory deficits.
 
Top-cited authors
Henry L Lew
  • University of Hawai'i System
Hermie J Hermens
  • Roessingh Research and Development
Douglas Smith
  • University of Washington Seattle
Peter S Lum
  • The Catholic University of America
Rich Simpson
  • Duquesne University