Cover Art Gallery

December 2014

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Person with stroke in powered wheelchair ascending a 5-degree incline in the powered wheelchair used for this study. The emergency-stop switch can be seen near the spotter’s right hand.

November 2014

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Congenital calf agenesis is a rare condition. A girl showed posture abnormality mimic talipes calcaneovalgus since birth and calcaneal gait during growing. Magnetic resonance imaging confirmed agenesis of the posterior superficial
compartment of the calf. The asterisk indicates the tibialis posterior, the white arrow indicates the soleus, and the black arrow indicates the gastrocnemius. Because the
patient had the normal long bone formation and intact peripheral nervous system, myogenetic defect in the early developmental period may have been compromised.

October 2014

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On the Front Cover: The transducer was applied over the tibialis anterior lateral to the
tibia, with the leg internally rotated for the anterior approach and applied to the medial
calf area with the leg externally rotated for the posterior approach. Safety window width
was defined as the distance between the neurovascular bundle and the tibial edge, as
indicated by the black arrows. Safety window depth was defined as the distance between
the skin and the tibialis posterior muscle, as indicated by the white arrow. Considering
the safety window width, the authors suggest needle placement at the upper third point
of the tibia for the anterior approach and at the midpoint for the posterior approach.
* 2014 Lippincott Williams & Wilkins

September 2014

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On the Front Cover: Examples of the traditional (left) and ballistic (right) versions of the
leg press (top) and leg sled (bottom) exercises. * 2014 Lippincott Williams & Wilkins

August 2014

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Two-week diffusion tensor tractography reveals that the left
corticospinal tract is discontinued below the midbrain level. However, 4-month diffusion
tensor tractography shows a new neural pathway originating from the left (affected) primary
motor cortex, descending to the corpus callosum level, and crossing to the right (unaffected)
hemisphere through transcallosal fibers (green arrow). After descending to the pons level in
the right hemisphere, the corticospinal tract crosses again to the left hemisphere via the
transpontine fibers (sky blue arrow). * 2014 Lippincott Williams & Wilkins

July 2014

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The drawing illustrates a contralaterally controlled functional
electrical stimulation system (CCFES), a new method to improve simultaneous reaching and
hand opening after stroke. Volitional elbow extension and hand opening of the unimpaired
side produces a proportional

June 2014

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The drawing illustrates a contralaterally controlled functional
electrical stimulation system (CCFES), a new method to improve simultaneous reaching and
hand opening after stroke. Volitional elbow extension and hand opening of the unimpaired
side produces a proportional intensity of stimulation to the paretic triceps and hand
extensors, respectively. The related research article in this issue by Knutson et al. reports on
the effects of the new treatment on upper-limb movement and function.

May 2014

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Subacute progressive ascending myelopathy (SPAM) is a rarely
reported neurologic complication after spinal cord injury. It typically presents as ascending
neurologic deficit with MRI demonstrating increased cord signal intensity at least four
vertebral levels above the site of insult. Similarly, cement leakage into the spinal canal is a rare
complication of percutaneous vertebroplasty. The image illustrates MRI findings suggestive
of SPAM with cord signal changes noted up to the C3 level, following vertebroplasty and
cement leakage for management of osteoporotic fracture at the T12 level. This Case Report
covers the existing literature with regards to the diagnosis and possible causes of SPAM. It also
includes the diagnostic and therapeutic challenges faced during the rehabilitation of this
patient. The report concludes with suggestions for clinical management and scope of future
research with regard to SPAM
.

April 2014

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A picture drawn to represent a scene from the combat of Hector
and Achilles. Hector is being injured from his supraclavicular area and suprasternal notch with a spear. Immediately after this injury, Achilles stabs his sword into Hector’s heart.

March 2014

• Table of ContentsA, A photograph of the patient’s hands, demonstrating right wrist
erythema and swelling. B, Chondrocalcinosis over right radiocarpal joint (arrow) and triangular fibrocartilage (arrowhead) in plain film. C and D, Ultrasonography demonstrating increased vascularity and multiple hyperechoic deposits with punctate and amorphous patterns within the right triangular fibrocartilage (arrowheads; Tr = triquetrum; U = ulna). E, Positively birefringent CPPD crystals under compensated polarized light microscopy
.

February 2014

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The photo shows a patient receiving dental care using a nasal interface
for ventilatory support. Many patients with no ventilator-free breathing ability require dental interventions that are prevented by themouthpiece used for noninvasive intermittent positive pressure ventilation (NIPPV). Other than for nasal interfaces that permit full access to the oral cavity, all other noninvasive positive pressure interfaces obstruct oral access for dental procedures. Switching patients from mouthpiece continuous NIPPV to nasal NIPPV may present some challenges. However, the nasal interface is generally a viable, comfortable, and highly desirable alternative to intubation or tracheostomy to permit continuous NIPPV during dental procedures for ventilator-dependent patients. Please see the case series described in this issue by Tran, Bach, and Gonc¸alves.

January 2014

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Doves in the Temple, a graphic design created by Gregory Gans, has been featured in the Art Ability program at Bryn Mawr Rehab Hospital in Malvern, PEnnsylvania. Gans' artwork includes landscapes, portraits, and collages of photos, texture, and light. This unique style known as Photographic Digital Art was selected for the Journal's series of covers highlighting artwork created by people with disabilities and individuals who are part of successful rehabilitation programs.

December 2013

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The photo demonstrates the VSail-Access sailing simulator for people
with disabilities. In this issue, Recio et al. report on a 12-week pilot therapeutic sailing program using the VSail-Access sailing simulation system, followed by on-water experience. The simulator is steered by a joystick (in the right hand of the subject), and the sail is trimmed (with respect to wind direction) with the mainsheet (rope) in the subject’s left hand. The simulated boat is shown sailing on the monitor, and screen icons indicate wind direction and boat speed.

November 2013

• Table of ContentsThe Hand Exoskeleton Rehabilitation Robot (HEXORR) was developed to retrain hand control and function. The pilot study in this issue by Godfrey et al. investigates the HEXORR, which allows free movement with optional robotic assistance to aid finger flexion and extension and can blockmovement to enable isometric exercises. The cover photo shows the HEXORR user interface side view with the hand fully extended.

October 2013

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Mechanical insufflation-exsufflation (MI-E) applies positive and negative airway pressure to assist cough and eliminate airway secretions in patients with neuromuscular weakness. The laryngeal response patterns to MI-E have not been established. The extent and manner MI-E interferes with normal cough responses are basically unknown. The research article in this issue by Andersen et al. investigates the feasibility of transnasal fiberoptic laryngoscopy during MI-E and describes normal laryngeal response pattern(s) to MI-E in healthy subjects. The cover photo shows a video-recorded transnasal fiber-optic laryngoscope extending through a modified interface and attaching to a custom-made headset.

 

September 2013

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Consecutive still images of ‘‘popping-up’’ performed by an experienced surfer. These images were extracted from the video posted at the Journal’s Video Gallery at www.AJPMR.com. The photos and video show the surfer moving from a ‘‘paddling’’ posture with hyperextended spinal column, pushing up the torso by extending both arms. In this movement, the lumber spine is intensively hyperextended, followed by crouching and dragging legs under the torso. In a moment’s time, the thoracolumbar spine is deeply flexed from hyperextended posture before the surfer finally stands to a half rising ‘‘riding’’ position. These maneuvers have been associated with myelopathy and paraplegia in surfers. Please see the patient cases described in reports by Takakura et al and Aoki et al inthis issue. © 2013 Lippincott Williams & Wilkins

August 2013

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The drawing illustrates a contralaterally controlled neuromuscular
electrical stimulation (CCNMES ) system for ankle dorsiflexion. CCNMES is a newmethod of delivering neuromuscular electrical stimulation (NMES) to pareticmuscles for the purpose of promoting motor relearning after stroke. Volitional dorsiflexion of the unimpaired ankle produces a proportional intensity of stimulation to the paretic ankle dorsiflexors. The related research article in this issue by Knutson et al. reports on the effects of CCNMES vs. cyclic NMES on lower limb impairment, functional ambulation, and gait characteristics.

July 2013

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The photo illustrates a device-assisted ultrasound-guided injection technique for treating plantar fasciitis. The syringe rests on the groove of the inclined plane, and the transducer fits into the hollow cuboid. In this issue, Chen et al. investigate the effectiveness of this assistive device to guide a steroid injection. Also in this issue, a metaanalysis by Dizon et al. evaluates the effectiveness of extracorporeal shock wave therapy (ESWT) to treat chronic plantar fasciitis. ©2013 Lippincott Williams & Wilkins

June 2013

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This image from a videofluoroscopic swallowing study (VFSS) shows tracheal aspiration with residue accumulating in the vallecula and pyriform sinuses in a patient with Ramsay-Hunt syndrome. Dysphagia has been reported in patients with Ramsay-Hunt syndrome, but the details of swallowing difficulty, including abnormalities in VFSS, have not been described.  The Video Gallery by Kim et al. in this issue describes dysphagia in Ramsay-Hunt syndrome with unique VFSS images in the print edition and informative video posted at www.AJPMR.com.

May 2013

• Table of ContentsFour scenes from a virtual walking training video are shown, including a sunny walking track, a rainy walking track, and a walking track with obstacles. The CME Article in this issue by Cho et al. investigates the effectiveness of a virtual walking training program, using real-world video, on walking balance and spatiotemporal gait parameters in patients with chronic stroke. ©2013 Lippincott Williams & Wilkins

April 2013

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Robin Duo, a photograph by Darlene Thompson of Rochester, Minnesota, was featured in the 2011 Mayo Clinic Art & Ability exhibit in celebration of National Rehabilitation Awareness Week. The art exhibit is cosponsored by the Mayo Clinic Department of Physical Medicine and Rehabilitation and the Southeastern Minnesota Center for Independent Living, Inc. This photo was selected for the Journal’s series of covers highlighting artwork created by people with disabilities and individuals who are part of successful rehabilitation programs.

March 2013

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Continuous noninvasive intermittent positive pressure ventilator support (CNVS) is being used to prolong life while avoiding invasive interfaces. The review and analysis in this issue by Bach et al. reports that respiratory management of patients with end-stage respiratory muscle failure of neuromuscular disease has evolved from no treatment and inevitable respiratory failure to the use of up to CNVS to avert respiratory failure and to permit the extubation of patients without tracheostomy who cannot be weaned. The front cover photo shows brothers aged, 17 and 15 years, with spinal muscular atrophy type 1, continuously dependent on noninvasive ventilatory support since the age of 4 mos. Dr. Bach reports that despite these positive outcomes associated with CNVS, 95% of children with SMA 1 die before 18 months of age, with a mean age of death at 25 weeks, and none of those cases reported using CNVS.

February 2013

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Turnout is a dance position with known contributions from the hip, knee, and foot. A standardized method measuring total turnout has been established. The research study by L.C. Khoo-Summers et al., in this issue, assessed the relationships between first position and measures of hip and tibiofemoral external rotation.

January 2013

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This Leather pincers is a hand tool used to pinch a sheet of leather to stretch and dry it. Two-finger pressures are involved: the thumb and second finger push the grip tip, placing radial deviation stress on the distal interphalangeal joint. The Visual Vignette by Jang et al. reports on the radial deviation of the distal interphalangeal joint becuase of overuse of the hand pincers tool.

December 2012

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This colorful abstract was selected for the front cover as part of the Journal's continuing are ability series featuring artwork submitted from the art therapy programs at rehabilitation centers. The contemporary design was created by Deborah Gallardo in the art therapy program at the Rancho Los Amigos National Rehabilitation Center in Downey, California. Deborah was born with cerebral palsy and is unable to walk independently or use her hands. She paints with a brush, marker, or crayon screwed into a head-pointing device.

 

November 2012

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The ReWalk powered exoskeleton allows thoracic or lower-level motor-complete indivuduals with SCI to walk independently. The composite photo illustration shows a patient demonstrating the ReWalk powered exoskeleton in various stages from sitting to walking at the MossRehab Gait & Motion Analysis Laboratory in Elkins Park, Pennsylvania. The related article by Esquenazi et al., in this issue, explores the safety and performance of ReWalk in enabling people with paraplegia resulting from spinal cord injury to perform routine ambulatory functions. See also a video demonstration of the ReWalk powered exoskeleton at www.AJPMR.com

October 2012

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The photo shows three positions of body weight bearing and adding loads to study prosthetic suspension systems in a bilateral transtibial amputee. The report in this issue by Gholizadeh et al. compares two suspension systems to study pistoning effect and patient satisfaction. The study involved a 51-yr-old female volunteer whose limbs had been amputated because of periperal vascular disease.

September 2012

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A patient with lymphedema exercises using a rubber device that measures squeezing pressure during compression therapy. The research study in this issue by Kang et al. measures the resting and working sub-bandage pressures in compression therapy for lymphedema patients to determine whether applying additional padding has an additional effect in volume reduction of the limb. In a related research article, Cantarero-Villanueva et al. examine muscular strength as measured by handgrip strength in breast cancer survivors.

 

August 2012

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Illustration of a stroke patient set up for mirror therapy on the upper limb. The research study by Lee et al., in this issue, investigated the effects of mirror therapy on upper-limb motor recovery and motor function in patiends with acute stroke. Mirror therapy was first introduced to treat phantom limb pain after amputation. In a related Literature Review in this issue, Moura et al. discuss the potential usefulness of specific mind-body therapies and the relevance of their mechanisms of action for treatment of conditions such as phantom limb pain.

July 2012

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 Illustration of a braced foot reprint, with permission, from the cover of chapter 4 "Rehabilitation" from 2011 World Report on Disability (http://www.who.int/disabilities/en/.) One of the most important findings of the report is the observation that at least 15% of the population of the world lives with disability, including an estimated 110 million with severe disability.

June 2012

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Wheelchair frame failure occurring during ANSI/RESNA wheelchair testing in this photo by Benjamin Gebrosky, testing engineer at the Human Engineering Research Laboratories at the University of Pittsburgh. See related research article in this month's issue by Worobey et al, which investigates the increases in wheelchair breakdowns, repairs, and adverse consequences for people with traumatic spinal cord injury. Also, a related research article by Moreno et al, discusses the positive influence of wheelchair sports on respiratory muscle strength and thoracic mobility in subjects with quadriplegia. In addition, a related brief report by Hoenig et al, studies the accuracy of new wheelchair users’ predictions about their future wheelchair use.

May 2012

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The Visual Vignette in this issue by Chang-Zern Hong, MD, describes the development of a specialized motorcycle for persons with disabilities, modified from a regular motor scooter with two additional rear wheels to increase stability, wide seating, and expansion of the foot support. The photo shows the capacity of the vehicle to carry a wheelchair, cane, or crutches. Operation and steering are accomplished by all hand controls. The motorcycle is intended for people who experience weakness or paralysis in the bilateral lower limbs.

April 2012

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 This computer-generated artwork, titled Euphoria, was selected for the front cover as part of the Journal's continuing art ability series featuring artwork from art therapy programs at rehabilitation centers. The red swirl design was created by Carlos Benavides in the art therapy program at the Rancho Los Amingos National Rehabilitation Center in Downey, California.  In 2002, Carlos experienced a spinal cord injury resulting in incomplete quadriplegia. Carlos is now an outpatient at Rancho and explains that the way he uses a camera and computer has been adapted to his ability as an artist. "Being in a wheelchair and in constant pain made me more aware of my surroundings and the challenges of everyday life...when someone has a life-altering injury, they have to find a way to express who they are. My designs, pictures, and music express who I am," he said. "I would like to say thank you to Rancho for supporting the Arts. I now have a more positive and passionate outlook on life. Rancho has helped many people find special meaning in their lives. I feel I can do almost anything any able-bodied person can do, because of the passion and love I have for life.

March 2012
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Anteroposterior view of a 64-multislice computed tomographic scan with three-dimensional reconstruction and bone density threshold indicated a developmental abnormality of both acetabular cavities with ventrolateral dislocation of the femoral heads of a 60-yr-old woman. Neoarticulation, as well as severe secondary osteoarthritis, was seen in both iliac blades. The defect caused coxa vara with proximal femoral anteversion, valgus deformity, and greater trochanter displacement. These findings were consistent with congenital hip dysplasia in an adult woman. The patient did improve, showing a significant decrease in hip pain after 30 sessions of physical therapy. The natural outcome of unreduced congenital hip dislocation has not been frequently described in the scientific literature.

February 2012
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Plantar fasciitis is the most common cause of inferior heel pain in adults. Although palpation-guided corticosteroid injection is convenient to perform, its accuracy is debated. Therefore, ultrasound-guided corticosteroid injections are used to improve accuracy and therapeutic efficacy. Positioning for the ultrasound examination of the plantar fascia: the patient is prone, with feet hanging over the edge of the examination table, and the probe is applied to the plantar aspect of the heel. To view the video of this ultrasound examination and injection technique for plantar fasciitis, see the related Video Gallery by Chen et al., published in this issue. In addition, a new ultrasound-based technique, sonoelastography, allows noninvasive estimation of tissue stiffness useful for further evaluation of the plantar fascia. See the related Visual Vignette by Wu et al., published in this issue of the Journal.

January 2012
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The photo shows an early front cover of Occupation Therapy and Rehabilitation, dated February 1925, Volume IV, Number 1, published by the Williams & Wilkins Company at Mt. Royal and Guilford Aves., in Baltimore, Maryland, as the official organ of the American Occupational Therapy Association. Founded in 1922, this bimonthly journal was a predecessor of the present day American Journal of Physical Medicine & Rehabilitation, the official scholarly journal of the Association of Academic Physiatrists. See the related editorial in this issue by Editor-in-Chief Walter R. Frontera, MD, PhD. As part of the 90th anniversary celebration of the AJPMR, various materials related to the Journal's history will be published in selected print issues and on the Journal's website. This month's cover photo is courtesy of the Library of the Harvard Medical School. Readers are welcome to submit photography or written information related to the Journal's history for consideration for publication.

December 2011
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This month’s front cover artwork is part of the Journal’s continuing Art Ability series featuring artistic work produced from art therapy programs at rehabilitation centers. The winter landscape was painted by Diana Luscombe in the art therapy program at Magee Rehabilitation in Philadelphia. Diana participated in art therapy following a car accident, which left her with a C5-C6 spinal cord injury. This watercolor was Diana’s first painting in art therapy. The program provided Diana with an opportunity to express herself while developing her hand strength and coordination.

November 2011
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Sonoelastographic image shows red coloring of meniscus, green
coloring of meniscal tear (arrowheads), and purple coloring of meniscal cyst (arrows). Real-time sonoelastography (RTS) is a recently developed ultrasound-based technique that evaluates tissue elasticity. Tissue elasticity varies among different tissues and seems to reflect disease-induced alterations in tissue properties. RTS was applied recently to the normal and pathologic tissues in muscle and tendon disorders, and is expected to be a useful modality for providing novel diagnostic information in the clinical setting. RTS also can be used as a research tool to provide insight into the biomechanics and pathophysiology of tissue abnormality. The focused Invited Review by Park and Kwon in this issue introduces RTS to physiatrists and summarizes some of the current clinical applications for musculoskeletal diseases related to physical medicine and rehabilitation.

October 2011
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Jeff Gray (1963Y2011), a 47.9-year-old man with Duchenne muscular dystrophy, is shown using a 15-mm angled mouthpiece for daytime noninvasive ventilatory support in a regimen of continuous noninvasive support for 27 years. Jeff developed a Web site in 1998 to spread his knowledge of what it means to avoid respiratory failure and invasive tubes. In February 2011, 1 month before his death, Jeff completed a book entitled I’m Not Dead Yet to deliver his message for prepublication editing. Jeff was visited by more than 100 physicians and therapists through the years, mostly from Europe and Canada, wanting to learn how to help their patients. See the related commentary by Bach and DeCicco in this issue, written and published as a tribute to Jeff’s life and message.

September 2011
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Haitian earthquake survivor Irese Dossa is shown with a mirror reflecting her intact limb. The mirrors were provided to amputees in Haiti by physicians from the New Jersey Medical School during their humanitarian visit in 2010. The physicians also provided education on indications and uses of mirror therapy to a team of local therapy and prosthetic trainees. The principle behind mirror therapy is that when a patient watches the reflection of the remaining limb, vision of the reflection of the intact limb, which looks like the amputated limb, is able to substitute for absent proprioception from the amputated limb and helps the patient to move the phantom. See related Letter to the Editor by Altschuler and Scott in this issue of the Journal. News photo by photojournalist Sarah Ryley.

August 2011
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Ice hockey is a collision sport in which speed, hard ice, boards, sticks, pucks, body checks, and aggressive behavior contribute to the prevalence of concussion. The front cover illustration depicts the concussive effects that can occur during collision sports, such as ice hockey. The Ice Hockey Summit: Action on Concussion, held at the Mayo Clinic in 2010, was derived from research on concussion and focused on recognition, assessment, management, and return-to-play guidelines integrated with ice hockey-specific research. The goal of the summit was to identify appropriate strategies to decrease concussion in hockey. See the related Consensus Statement by Smith et al. published in this issue of the Journal.

July 2011
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The tropical theme of this month’s Journal cover coincides with the ISPRM 2011 World Congress in San Juan, Puerto Rico. The cover artwork is part of the Journal’s continuing Art Ability series featuring artistic work produced from art therapy programs at rehabilitation centers. The fish watercolor was painted by Terrie Neff Atkins in the art therapy program at Magee Rehabilitation in Philadelphia. Terrie experienced congestive heart failure in 1998 and received an emergency heart transplant in 2007. Although she was initially unable to move independently, her participation in the art therapy program at Magee Rehabilitation provided additional confidence. Terrie experienced hand tremors when she began creating her watercolor painting, but the tremors decreased during the art therapy process. The broad topic of cardiac rehabilitation is an important focus of the content in this month’s Journal. See the related original research article on exercise in heart transplant recipients by Nytroen et al., the original research article on inpatient rehabilitation after acute coronary syndrome by Deskur-Smielecka et al., and the Invited Review on contemporary issues in cardiac rehabilitation by Debra L. Braverman.

June 2011
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Spondyloepiphyseal dysplasia tarda with progressive arthropathy is characterized by short stature resulting from platyspondylia and progressive arthropathy. This disorder may cause a predisposition to disk herniations, which may rarely lead to spastic paraplegia. See the report by Yoleri et al. in this issue concerning the case of a 21-yr-old male patient with spondyloepiphyseal dysplasia tarda with progressive arthropathy who developed spastic paraplegia because of spinal stenosis caused by thoracic disk herniations.

May 2011
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Breast cancer is the most common cancer among women. Survivors often experience muscular impairments after treatment, including problems with range of motion and shoulder disability, which may play an important role in the development of shoulder pain. The electromyographic study by Galiano-Castillo et al. in this issue shows that breast cancer survivors exhibit greater activation of both upper trapezius and sternocleidomastoidmuscles during an upper limb task compared with controls, which may contribute to the development of neck and shoulder impairments in this patient population. In addition, rehabilitation of cancer patients is the focus of the special supplement accompanying this issue of the Journal. The supplement editors, Ralph M. Buschbacher,MD, and Kelly Paul,MD, have coordinated this publication of several current reviews on the topic of cancer rehabilitation. Mammogram of breast cancer reprinted with permission from Mitchell GW. The Female Breast and Its Disorders. 1st ed. Baltimore, MD.

April 2011
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This issue of the Journal features a section of ‘‘Winter Pines’’ (from a larger original 10’’ x 10’’ acrylic on canvas). The artist, Michael O’Neill, was born in Oak Park, Illinois, in 1973 and spent several years living in Ireland. A spinal cord injury resulting in quadriplegia brought him to the Rehabilitation Institute of Chicago (RIC), where he rediscovered his passion for painting during art therapy sessions. Michael uses a universal cuff to hold a brush and finds the painting process very relaxing. Painting has become Michael’s new hobby. The art therapy program at RIC provides individual and group sessions to assist patients in exploring emotions accompanying the rehabilitation process. The program is intended to encourage self-expression, reduce stress and anxiety, and promote healing and self-awareness.

March 2011
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A medical student learns how to maneuver a wheelchair around obstacles normally found at the grocery store. An educational workshop about wheelchairs conducted in the community setting improves medical students’ wheelchairrelated knowledge, skills, and attitudes. See related research article by Kirby et al. in this issue.

February 2011
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Postpolio survivors in iron lungs were ventilated via a dome around their heads instead of by simple mouthpiece when receiving nursing care with the lung open. Revisiting the development of respiratory physical medicine, John R. Bach, MD, in his commentary in this issue, suggests that instead of letting patients develop respiratory failure resulting from weakening respiratory musculature, physiatrists developed virtually every aspect of supporting patients noninvasively, including noninvasive ventilation and mechanically assisted coughing, and complementary interventions to prevent hospitalization and institutionalization.

January 2011
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Because electrocardiographic changes in stress tests may represent a false-positive finding, myocardial perfusion scintigraphy is an additional examination used by clinicians and researchers to better characterize the association between angina and myocardial ischemia. The front cover image shows composite polar maps of the myocardial perfusion scintigraphy at stress and at rest before aerobic training (on the left) and after aerobic training (on the right). Visual comparison reveals the absence of the reversible perfusion defects. A related Case Report by Eduardo Elias Vieira de Carvalho et al. in this issue describes the effect of aerobic physical training on changes in myocardial perfusion, in endothelial function, and in quality-of-life measures in a patient with microvascular myocardial ischemia.