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Sand from a small dune on the southwest side of Isla Coronados with an estimated volume of 30,000 m3 is enriched as much as 86.5% by calcium-carbonate detritus from beached rhodoliths. Elsewhere in the Gulf of California, coastal sand dunes often occur on the north sides of islands or north-facing peninsular shores, and calcium-carbonate input is more commonly linked to bivalve mollusks from adjacent sand flats. The local calcium-carbonate budget for the west-facing shore of Isla Coronados must take into account how many rhodoliths of a given size are required to build a sand dune with a known composition and volume. To this end, 135 whole rhodoliths were collected from above the tide line at Punta El Bajo, across from Isla Coronados, on the peninsular mainland. One cubic meter is calculated to accommodate 8640 whole rhodoliths with an average diameter of 5 cm and an average sphericity of 0.86. The age of a rhodolith this size could be several decades. Through stages, the sample rhodoliths were crushed to a maximum grain size ≤ 2.38 mm in diameter (-1.25ø equivalent), and the product was used to estimate the proportion required to generate 1 m3 of pure carbonate sand. Accounting for 2% loss throughout the reduction process, about 16,265 crushed rhodoliths are needed to produce 1 m3 of carbonate sand. Thus, a 30,000-m3 dune requires approximately 488,000,000 rhodoliths to generate 86% of the dune's volume. Dunes of this kind may be rare, but the computation is applicable to other rhodolith-derived dunes in the Gulf of California. [ABSTRACT FROM AUTHOR]

This contribution describes and discusses the development of the Isla Coronados Pleistocene coastal deposits. The south side of the 700,000-160,000 year-old volcanic cone on Isla Coronados (Baja California Sur, Mexico) forms a shelf that converges on older Miocene andesite from the Comondú Group. Later Pleistocene carbonates accumulated on and around the antecedent topography as related by stratigraphic sections strategically located with respect to small andesite islets that formed a fixed barrier along the outer margin of a large lagoon at the foot of the volcano. Distinct facies show the progressive foundering on the island and the infilling of the lagoon about 121,000 years ago during events correlated with marine isotope substage 5e. On the seaward side of the barrier, a basal conglomerate of andesite boulders and cobbles grades into limestone with a diverse shelly fauna and whole rhodoliths in a matrix of rhodolith sand. Similar limestone is found on the lagoon side of the barrier, but features the bivalve Pina corteziana from a sheltered environment. Other facies are represented by populations of the coral Porites panamensis at different levels of growth and integration. Biocalcarenite derived from the debris of crushed rhodoliths occurs as the most extensive facies in terms of area and thickness. Sheeted layers that dip 20° off the top of the islets toward the volcano are regarded as washover deposits typical of barrier systems. A cobble pavement, interpreted as a ravinement surface, marks a widespread unconformity at the top of the biocalcarenite. This surface was the foundation for a short-lived rocky-shore biota in transition to dense growth of branching P. panamensis. The sequence ends with a thin marine terrace deposit that buried the coral thickets at the present 12-m level. [ABSTRACT FROM AUTHOR]

This study aimed to explore the potential of a mobile health (mHealth) application (app) to support the delivery of a fall prevention and management program, Individualized Reduction of FaLLs (iROLL), for people with spinal cord injury (SCI) and multiple sclerosis (MS) who use wheelchairs and scooters (WC/S) full-time by seeking end-users' input into the functioning and ongoing design of the iROLL-O + mobile app. Two focus group discussions included nine adults with SCI or MS who used a WC/S for at least 75% of mobility, who experienced at least one fall in the past three years and have internet and access to an internet-capable device. One group had prior iROLL experience ( n  = 4); while the other had none ( n  = 5). The focus groups examined the app's usefulness, accessibility, appearance, and ease of use. The participants with prior iROLL experience also discussed how the app would enhance their experience with the program. Thematic analysis revealed five app-related themes: perceived usefulness, perceived usability, accessibility, appearance, and enhancement of the iROLL experience, with participants providing actionable suggestions for improvement. Participants with previous exposure to the iROLL program emphasized the app's potential to facilitate flexible access to the program and expand its reach to a wider audience. The iROLL-O + app was perceived positively, especially with respect to the enhancement of users' access and experience with the program. Focus group findings will inform ongoing app development for optimized usability and reduced likelihood of technology abandonment.IMPLICATIONS FOR REHABILITATIONEnd-users' impressions of the Individual Reduction of faLLs Online application (iROLL-O + app) highlight the potential for integrating mHealth apps in fall prevention and management education efforts, offering a promising and accessible avenue to support the delivery of tailored programs.The study notes that the app facilitates flexible access and wider reach to the program, indicating the importance of incorporating features that enhance accessibility and accommodate the diverse needs of individuals who use wheelchairs and scooters.Actionable suggestions provided by participants underscore the importance of a user-centered design approach in developing rehabilitation-related mobile apps.

Background: Multiple sclerosis (MS) is a leading cause of neurological disability among young and middle-aged adults worldwide, and disability is measured using a variety of approaches, including patient reported outcome measures (PROMs) such as the Patient Determined Disease Steps (PDDS) scale. There is limited evidence for the validity of inferences from the middle-range of scores on the PDDS (i.e., 3 "gait disability" - 6 "bilateral support"), but that range of scores seemingly represents moderate disability characterized by varying levels of walking dysfunction., Purpose: The current study examined whether the middle-range of scores from the PDDS reflect varying levels of walking dysfunction among people with MS., Method: Participants (N = 374) completed the Patient Determined Disease Steps (PDDS) scale, Multiple Sclerosis Walking Scale-12 (MSWS-12), timed 25-foot walk (T25FW), six-minute walk (6 MW), Modified Fatigue Impact Scale (MFIS), and Multiple Sclerosis Impact Scale-29 (MSIS-29), and underwent a neurological exam for generating an Expanded Disability Status Scale (EDSS) score as part of screening and baseline data collection for a clinical trial of exercise training in MS. We undertook a series of linear trend analyses that examined differences in the outcomes of EDSS, T25FW, 6 MW, MSWS-12, MFIS subscales, and MSIS-29 subscales across the 4 levels of PDDS scores (i.e., 3-6)., Results: There were statistically significant and strong linear trends for EDSS (F 1,370 = 306.1, p < .0001, η 2  = 0.48), T25FW (F 1,370 = 161.0, p < .0001, η 2  = 0.32), 6 MW (F 1,370 = 178.9, p < .0001, η 2  = 0.34), and MSWS-12 (F 1,370 = 97.0, p < .0001, η 2  = 0.24). There was a strong correlation between PDDS and EDSS scores (r s = 0.695, 95% CI = 0.643, 0.748). Both PDDS and EDSS scores had strong correlations with walking outcomes, yet weaker correlations with measures of fatigue and QOL., Conclusion: The PDDS could serve as a simple, inexpensive, and rapidly administered PROM for remote screening and early detection of walking dysfunction for initial eligibility into clinical trials and practice for managing mobility-specific disability in MS., Registration: The study was registered on ClinicalTrials.gov on March 19, 2018 (NCT03468868)., (© 2024. The Author(s).)

Purpose: The purpose of this systematic review of the literature is to build understanding of the key elements and recommendations for the design of mHealth technology for individuals using wheelchairs and/or scooters and identify key features associated with the use of mHealth to support healthy behaviour changes for this population., Materials and Methods: Eight major electronic databases were systematically searched to identify mobile health (mHealth) interventions, which targeted adult WC/S users. Independent reviewers used Endnote and Covidence to manage articles meeting review criteria and to exclude duplicates. A quality assessment was conducted on each included article., Results: Nine articles describing studies with diverse study designs met criteria to be included in this review. Several interactive application intervention features, such as participant collaboration and goal setting, and key technical features to support mHealth app development and utilisation were identified. Results found intuitive and simple designs of mHealth apps, with the ability to customise to support learning styles and preferences, support usability and acceptability by participants., Conclusions: More research is needed to evaluate best practices to support initial training of end-users, mHealth apps' ability to support long-term behaviour change and maintenance, and the understanding of active ingredients in complex interventions that include mHealth apps. Both interactive mHealth application intervention and technical features support healthy behaviour change among individuals using wheelchairs and scooters.

Background: The Multiple Sclerosis Walking Scale-12 (MSWS-12) has typically been delivered through paper-and-pencil or computer-based administration., Purpose: This study examined the validity of inferences from scores derived via a telephone administration of the MSWS-12 applied as part of screening of participants with walking dysfunction into a clinical trial of exercise training in MS., Method: The MSWS-12 was administered on two occasions separated by approximately 2 weeks through the telephone and then in-person (i.e., computer-based administration). Participants further completed the Patient Determined Disease Steps (PDDS) scale, timed 25-foot walk (T25FW), six-minute walk (6MW), Modified Fatigue Impact Scale (MFIS), and Multiple Sclerosis Impact Scale-29 (MSIS-29), and underwent a neurological exam for generating an expanded disability status scale (EDSS) score. The primary set of data (Full Sample) for analyses included all persons who passed the telephone screening for inclusion with MSWS-12 scores between 25 and 75 (N = 374). The secondary set of data (Truncated Sample) included only persons with MSWS-12 scores between 25 and 75 for both the telephone and computer administrations of the MSWS-12 (N = 248)., Results: The results in the Full Sample indicated a difference in overall and item levels scores between the telephone and computer data collections, and the computer version had higher internal consistency and stronger unidimensionality. Nevertheless, MSWS-12 scores from both modes of administration had comparable correlations with the T25FW, 6MW, EDSS, PDDS, MFIS, and MSIS-29, but the correlation between the two MSWS-12 administrations did not approach unity. There was a systematic difference in scores between telephone and computer administrations across levels of walking dysfunction based on a Bland-Altman plot, and the difference was predicted by MFIS physical, 6MW, and EDSS scores. The comparison of results between the Full and Truncated Samples suggested that the primary analysis might have been influenced by the larger range of scores on the computer than telephone administrations of the MSWS-12., Conclusion: The telephone administration of the MSWS-12 provides an efficient and cost-effective measure of walking dysfunction in persons with MS., Competing Interests: Declaration of competing interest The authors report no conflicts of interest in the publication of this paper., (Copyright © 2024. Published by Elsevier B.V.)

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

Background: Successful translation of evidence-based exercise training interventions from research to clinical practice depends on the balance of treatment fidelity and adaptability when delivering the exercise program across settings. The current paper summarizes fidelity of study design, provider training, and intervention delivery strategies from best practice recommendations, and reports challenges experienced and adaptations instrumented by behavioral coaches delivering the multi-site Supervised versus Telerehabilitation Exercise Programs for Multiple Sclerosis (STEP for MS) Trial., Methods: Using a reflexive thematic analysis approach, open-ended survey questions were analyzed to explore experiences of behavioral coaches, transcripts from team meetings among behavioral coaches, and notes from audits of one-on-one sessions between behavioral coaches and participants., Results: Themes related to the fidelity of study design and delivery of the STEP for MS Trial included adaptations to the intervention itself (e.g., completion of virtual supervised exercise sessions with behavioral coaches in place of face-to-face sessions during COVID-19 pandemic restrictions), modification of exercise equipment, and adjustments of program delivery. The adjustments of program delivery reported by behavioral coaches included increasing program fit, maintaining engagement, and addressing participant safety concerns; however, these adaptations did not jeopardize the content of the essential elements of the program model., Conclusions: The current paper demonstrates that when best practice recommendations are implemented, it is possible to address challenges to study design and evidence-based intervention delivery in ways that adaptations to overcome real-world obstacles can be accomplished without compromising fidelity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

In 2018, chronic obstructive pulmonary disease (COPD) was estimated to affect 16.4 million people, or 6.6% of adults in the United States alone. In older people, the estimated prevalence is even higher with reported rates as high as 14.2% in adults older than 65 years of age. COPD is a preventable disease caused by repetitive exposure to noxious particles, especially inhaled toxins from cigarette smoke. It is associated with decreased quality of life, increased hospitalization, increased mortality, and significant financial burden to patients and health care systems. Senior care pharmacists are well-suited to provide assessment, treatment, and patient education related to COPD and smoking cessation. Early and frequent interventions can decrease symptom burden, reduce costs, and improve the lives of those with COPD.

Background: Falls are common among people living with multiple sclerosis (MS) who use wheelchairs or scooters. Falls may lead to severe consequences including physical injuries. However, very little is known about the circumstances associated with injurious falls in this population. Therefore, we aimed to explore the differences in fall-related characteristics between injurious and non-injurious falls among people with MS who use wheelchairs or scooters., Methods: A convenience sample of 48 people with MS (age = 62.0 [13.0] years, gender = 81.3% female, primary mobility aid = power wheelchair) completed a fall-history survey that examined the characteristics and consequences of their most recent fall. Participants also completed standard questionnaires on quality of life, community participation, and fear of falling., Results: Most falls (85.4%) reported by participants occurred inside the house. Twelve (25.0%) participants reported experiencing fall-related injuries such as bruises, cuts, muscle strains, and fractures. People who reported being injured after a fall had a higher proportion of falls that occurred during transfers compared to those who were not injured (n = 10, 83.3% vs n = 17, 47.2%). Most participants (45.8%) did not receive any information from healthcare professionals on how to manage their fall-risk after their fall experience. No differences between injurious and non-injurious fallers in quality of life, community participation, and fear of falling were observed., Conclusions: This cross-sectional investigation provides compelling evidence that people with MS who use wheelchairs or scooters are at high risk of fall-related injuries. The study findings underscore the importance of increasing health care providers' awareness about the frequency and consequences of falls. Further, it demonstrates the critical need for evidence-based interventions specifically designed to minimize fall-related injuries in this vulnerable population., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier B.V.)

Impaired mobility is amongst the most debilitating symptoms reported by people with multiple sclerosis (MS). Historically, it has been viewed that walking impairments in people with MS are directly caused by the physical damage to the neurons in the central nervous system (CNS) which results from the immunopathology of MS. However, research from over the past 4 decades has revealed that physical function in people with MS is also affected by skeletal muscle dysfunction characterized by a reduced capacity to produce, regulate, and sustain the force-generating muscle contractions that propel human movement. While the immediate CNS damage caused by MS can alter the neural activation of muscle by disrupting neuromotor transmission, chronic reductions in mobility and extreme fatigue can lead to physically inactive lifestyles that negatively affect skeletal muscle through mechanisms of deconditioning. Consequently, people with MS can experience alterations in activation patterns, muscle mass and tissue composition, contractility, metabolism, and perfusion that contribute to reductions in muscle function that ultimately impair key physical functions such as walking. This article provides an overview of the cellular mechanisms that contribute to skeletal muscle dysfunction in people with MS and a discussion of the current evidence suggesting that skeletal muscle may be a key physiological target for interventions aiming to improve mobility in this population. We specifically highlight recent evidence demonstrating the potential for rehabilitation and exercise interventions to induce muscle plasticity in people with MS who have moderate to severe levels of disability. In conclusion, we discuss future directions in basic science and clinical research that may advance our understanding of muscle dysfunction in MS and lead to the development of more precise and effective treatment strategies., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: People with multiple sclerosis (MS) who use a wheelchair or scooter full-time fall frequently; however, fall prevention programming that meets the unique needs of this population is limited. This study examined the preliminary efficacy of a group-based online fall prevention and management intervention designed specifically for people with MS., Methods: This pre/post intervention, mixed-methods study included people with MS who used a wheelchair or scooter full-time, experienced at least 1 fall within the past year, and transferred independently or with minimal or moderate assistance. Participants engaged in a 6-week, online, individualized, multicomponent fall prevention and management intervention: Individualized Reduction of Falls-Online (iROLL-O)., Results: No statistically significant change in fall incidence occurred after iROLL-O. However, fear of falling significantly decreased ( P < .01) and knowledge related to fall management ( P = .04) and fall prevention and management ( P = .03) significantly improved. Qualitative results indicated that participants valued the opportunity for peer learning and iROLL-O's attention to diverse influences on fall risk., Conclusions: This study is the first to examine the preliminary efficacy of an online fall prevention and management intervention for people with MS who use a wheelchair or scooter full-time. iROLL-O has promise, and participants found it valuable. Further efforts are needed to retain iROLL-O participants with lower confidence and functional mobility, and more research is needed to investigate the impact of the intervention on key outcomes over time., Competing Interests: Financial Disclosures: The authors declare no conflicts of interest., (© 2023 Consortium of Multiple Sclerosis Centers.)

Background: Fatigue is a particularly debilitating symptom for people with multiple sclerosis (MS). Although personality traits and MS have been studied, interoception and emotional susceptibility and their links to fatigue have not yet been explored., Methods: Study participants provided demographic information and completed standardized patient-reported outcomes of walking function, physical activity, subjective fatigue, interoceptive awareness, and emotional susceptibility. A subset of participants participated in semistructured interviews discussing fatigue, body sensations, emotions, and their effects on exercise. Quantitative data were analyzed using multiple regression. Qualitative data were analyzed using thematic analysis., Results: Mean ± SD Fatigue Severity Scale scores (5.0 ± 1.3) indicated that fatigue was a problematic symptom. Mean ± SD Multidimensional Assessment of Interoceptive Awareness, Version 2 (2.8 ± 0.6) and Emotional Susceptibility Scale (3.0 ± 1.0) scores indicated lower levels of interoceptive awareness and emotional susceptibility. Quantitative data indicated no relationship between fatigue and interoceptive awareness (β = -0.20; P = .88) and emotional susceptibility (β = 0.03; P = .83), and neither were these related to physical activity (β = -0.07; P = .64). Qualitative themes indicated strong fatigue experiences involving the whole body and individual limbs, anger and frustration, and effects on physical activity., Conclusions: Physically active people with MS report strong sensations of fatigue closely linked to frustration and helplessness. There was agreement between qualitative and quantitative assessments of fatigue but dissonance regarding interoceptive awareness and physical activity. The practice of clinicians, particularly those involved with facilitating or planning physical activity for persons with MS, would benefit from these findings about fatigue., Competing Interests: FINANCIAL DISCLOSURES: The authors declare no conflicts of interest., (© 2023 Consortium of Multiple Sclerosis Centers.)

Objective: To identify how prediagnosis employment, education, demographic statuses, and disease factors relate to job retention among people with multiple sclerosis (MS)., Design: Cross-sectional logit model., Setting: Data were collected at an academic Medical University and a specialty hospital, both in the Southeastern US., Participants: People with MS (N=1126) who were employed at the time of MS diagnosis., Interventions: Not applicable., Main Outcome Measures: Job retention was measured by employment status at the time of follow-up assessment., Results: Prediagnostic educational attainment was predictive of job retention. Among several prediagnostic employment characteristics, only working in production, transportation, and material moving was significantly related to a lower odds of job retention compared with those working in professional/managerial occupations. Aging factors were strongly related to job retention, with declines in job retention observed with increasing age and years since diagnosis. Non-Hispanic Black and Hispanic participants reported lower odds of job retention than non-Hispanic White participants, although there were no observed effects of sex. A significantly lower job retention rate was observed among those with progressive MS, compared with relapsing-remitting. Job retention was also less likely among people with greater MS severity and fatigue., Conclusions: Job retention strategies and interventions should target people with greater MS complications and severity, as well as non-Hispanic Black and Hispanic persons, because these characteristics are more highly related to job retention than our prediagnostic employment and vocational history., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: During spring and summer 2020, US states implemented COVID-19 pandemic restrictions, resulting in the closure of rehabilitation facilities and, with them, some of the clinical trials that were taking place. One such trial was the Supervised Versus Telerehabilitation Exercise Program for Multiple Sclerosis ("STEP for MS") comparative effectiveness multiple sclerosis (MS) exercise trial. Although 1 study arm was implemented via telerehabilitation, the comparative arm took place in rehabilitation facilities nationwide and was subsequently closed during this time frame. The experience of the STEP for MS participants provides insights into the impact of lockdown restrictions on exercise behavior by mode of exercise delivery (telerehabilitation vs conventional facility based)., Objective: This study sought to understand the impact of COVID-19 lockdown restrictions on exercise behavior among people with MS enrolled in an exercise trial at the time of the restrictions., Methods: Semistructured phone and video interviews were conducted with a convenience sample of 8 participants representing both arms of the exercise trial. We applied reflexive thematic analysis to identify, analyze, and interpret common themes in the data., Results: We identified 7 main themes and 2 different narratives describing the exercise experiences during lockdown restrictions. Although the telerehabilitation participants continued exercising without interruption, facility-based participants experienced a range of barriers that impeded their ability to exercise. In particular, the loss of perceived social support gained from exercising in a facility with exercise coaches and other people with MS eroded both the accountability and motivation to exercise. Aerobic exercises via walking were the most impacted, with participants pointing to the need for at-home treadmills., Conclusions: The unprecedented disruption of COVID-19 lockdown restrictions in spring and summer 2020 impacted the ability of facility-based STEP for MS exercise trial participants to exercise in adherence to the intervention protocol. By contrast, the participants in the telerehabilitation-delivered exercise arm continued exercising without interruption and reported positive impacts of the intervention during this time. Telerehabilitation exercise programs may hold promise for overcoming barriers to exercise for people with MS during COVID-19 lockdown restrictions, and potentially other lockdown scenarios, if the participation in telerehabilitation has already been established., (©Louise C Palmer, Whitney N Neal, Robert W Motl, Deborah Backus. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 22.11.2022.)

Purpose: This study is a secondary analysis of data from a mixed methods exploration of fatigue in people with multiple sclerosis (MS), a chronic autoimmune disease affecting the central nervous system. During initial analysis, worry emerged during discussions of the fatigue experience. The purpose of this study is to explore worry in relationship to exercise and physical activity behavior., Methods: Mixed methods were used to address the research question. 55 people with MS provided demographic and survey data (habitual physical activity, body perception, functioning). 35 participated in semi-structured interviews on the topics of fatigue, body sensations, emotions, and their effects on physical activity. Qualitative data were analyzed utilizing constructivist grounded theory. Quantitative data were analyzed utilizing multiple regression., Results: Qualitative theory described participants' thoughts and experiences regarding the consequences of fatigue during activity, and how they appear to influence subsequent actions. Worry played a critical role in thought processes regarding physical activity. Aspects of body perception were weak quantitative predictors of physical activity behavior after control of physical functionality., Conclusions: The most significant finding of this study was the description and dialogue about worry as a factor that shapes perceptions of the benefits and value of exercise and physical activity. Physical activity practitioners could benefit from seeking to understand physical-activity-related worry when examining physical activity behavior and designing programming., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Objective: To examine the efficacy of a fall prevention/management intervention among persons with multiple sclerosis (PwMS) who use a wheelchair (WC) or scooter full-time., Design: Pre-post/follow-up trial., Setting: Community and research laboratory., Participants: Twenty-one PwMS who used a WC or scooter full-time, self-reported at least 1 fall/12 months, and could transfer independently or with minimal/moderate assistance (N=21)., Intervention: Six-week, group and community-based fall prevention and management intervention. The intervention included six 2-hour in-person weekly sessions led by a physical or occupational therapist featuring interactive group discussions, skill practice, and action planning opportunities., Main Outcome Measures: Fall frequency tracked 12 weeks pre- and 24 weeks post intervention. Outcomes were assessed pre- and post intervention and 12 weeks post intervention. Measures included surveys to examine fear of falling (FOF), fall prevention/management, quality of life, community participation, and assessment of functional mobility skills. Semistructured interviews were administered post intervention to ascertain overall experiences with the program and effect on daily life. A Friedman test with signed-rank post hoc analysis was run to determine differences across the 3 study visits., Results: After the intervention, fall incidence did not significantly change, but fall management strategies ( P =.01-0.05), importance of community participation ( P =.01), and transfer quality ( P =.02) significantly improved. Moderate effect sizes were noted among concerns about falling, activity curtailment because of to FOF, and WC skills. Qualitative results indicate that participants found the intervention beneficial and applied intervention content in their daily lives., Conclusions: This study is the first to describe the effect of a multicomponent fall prevention/management intervention designed specifically for PwMS who use a WC or scooter full-time. Results indicate the program has potential to reduce fall risk; however, further testing is needed to fully examine the effect of the program., (© 2022 The Authors.)

Background: Seventy-five percent (75%) of full-time wheelchair or scooter users with multiple sclerosis (MS) experience at least one fall in a period of 6 months. Falls are detrimental for the independence, quality of life, and community participation. No previous prospective study has evaluated fall risk factors in this segment of MS community., Objective: To develop a multivariable falls risk prediction model for people with MS (PwMS) who use a wheelchair or scooter full-time., Methods: This prospective cohort study is a secondary data analysis that recruited PwMS from the community across the US. Forty-eight adults with MS who use a wheelchair or scooter as their main form of mobility were included. Dependent variable was fall incidence over 3-month recorded through diaries. Dependent variable was categorized as fallers (≥ 1 fall) and non-fallers (0 fall). Predictors were demographics, history of falls in the past 6 months, measures of fear of falling, Spinal Cord Injury- Falls Concern Scale, California Verbal Learning Test II, and Multiple Sclerosis Quality of Life- mental health. Multivariable logistic regression analyses were conducted to identity predictors of future falls., Results: In total, 63 falls (range 0 - 8) were reported over the 3-month period from a total of 26 fallers (54%). Multivariate logistic regression analyses indicated that the risk factor with the best predictive ability of future falls included history of falls in the past 6 months (sensitivity 77%, specificity 54%, and area under the receiving operating curve statistic = 0.76, 95% CI 0.62 to 0.89)., Conclusion: Findings highlight the importance of asking full-time wheelchair and scooter users with MS if they have fallen in the past 6 months to quickly identify those who are at increased fall risk and in need of follow up assessment and intervention to identify and address modifiable risk factors. More attention to fall risks among full-time wheelchair or scooter users with MS is suggested to increase the understanding among clinicians and researchers of modifiable risk factors., (Copyright © 2022. Published by Elsevier B.V.)

Root nodulating rhizobia are nearly ubiquitous in soils and provide the critical service of nitrogen fixation to thousands of legume species, including staple crops. However, the magnitude of fixed nitrogen provided to hosts varies markedly among rhizobia strains, despite host legumes having mechanisms to selectively reward beneficial strains and to punish ones that do not fix sufficient nitrogen. Variation in the services of microbial mutualists is considered paradoxical given host mechanisms to select beneficial genotypes. Moreover, the recurrent evolution of non-fixing symbiont genotypes is predicted to destabilize symbiosis, but breakdown has rarely been observed. Here, we deconstructed hundreds of genome sequences from genotypically and phenotypically diverse Bradyrhizobium strains and revealed mechanisms that generate variation in symbiotic nitrogen fixation. We show that this trait is conferred by a modular system consisting of many extremely large integrative conjugative elements and few conjugative plasmids. Their transmissibility and propensity to reshuffle genes generate new combinations that lead to uncooperative genotypes and make individual partnerships unstable. We also demonstrate that these same properties extend beneficial associations to diverse host species and transfer symbiotic capacity among diverse strains. Hence, symbiotic nitrogen fixation is underpinned by modularity, which engenders flexibility, a feature that reconciles evolutionary robustness and instability. These results provide new insights into mechanisms driving the evolution of mobile genetic elements. Moreover, they yield a new predictive model on the evolution of rhizobial symbioses, one that informs on the health of organisms and ecosystems that are hosts to symbionts and that helps resolve the long-standing paradox. IMPORTANCE Genetic variation is fundamental to evolution yet is paradoxical in symbiosis. Symbionts exhibit extensive variation in the magnitude of services they provide despite hosts having mechanisms to select and increase the abundance of beneficial genotypes. Additionally, evolution of uncooperative symbiont genotypes is predicted to destabilize symbiosis, but breakdown has rarely been observed. We analyzed genome sequences of Bradyrhizobium, bacteria that in symbioses with legume hosts, fix nitrogen, a nutrient essential for ecosystems. We show that genes for symbiotic nitrogen fixation are within elements that can move between bacteria and reshuffle gene combinations that change host range and quality of symbiosis services. Consequently, nitrogen fixation is evolutionarily unstable for individual partnerships, but is evolutionarily stable for legume- Bradyrhizobium symbioses in general. We developed a holistic model of symbiosis evolution that reconciles robustness and instability of symbiosis and informs on applications of rhizobia in agricultural settings.

Objective: To compare self-reported barriers and facilitators to employment among employed and unemployed participants with multiple sclerosis (MS) and spinal cord injury (SCI)., Design: Cross-sectional study using self-report assessment obtained by mail or online., Setting: Medical university in the southeastern United States., Participants: Participants (N=2624) identified from either a specialty hospital or a state-based surveillance system in the southeastern United States, including 1234 with MS and 1390 with SCI. All participants were aged <65 years at the time of assessment., Interventions: Not applicable., Main Outcome Measures: Self-reported barriers and facilitators to employment., Results: Overall, the MS participants reported more barriers, particularly stress, cognition, and fatigue, whereas those with SCI were more likely to report not having the proper education and training, resources, transportation, and attendant care. Follow-up analyses broken down by employment status indicated that several barriers and facilitators were significantly related to diagnosis for either employed or unemployed participants, but not both. Among those employed, participants with SCI were more likely to report they could not do the same types of jobs as they could pre-SCI and those with MS were more likely to state that they did not know much about jobs for people with disabilities (no differences were noted for these variables among unemployed participants). Unemployed individuals with SCI were more likely to report that the jobs for which they were trained were not accessible., Conclusions: The primary barriers for individuals with MS revolve around the condition itself, whereas the barriers for SCI appear to be more related to modifiable factors. Vocational rehabilitation specialists need to identify diagnostic-specific barriers to promote employment outcomes., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF)., Design: Cross-sectional study design., Setting: University research laboratory., Participants: Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users., Interventions: Not applicable., Main Outcome Measures: To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF., Results: A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F 2,82 =4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F 4,63 =3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF., Conclusions: FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)