Knee osteoarthritis (OA) is prevalent and knee replacement surgeries are increasing. Quadriceps weakness is one of the most modifiable risk factors and treatments for knee OA, but strengthening efforts are limited by neural mechanisms that contribute to persistent quadriceps inhibition and pain. Interventions that affect neural mechanisms may serve as valuable adjuncts to exercise for quadriceps weakness. However, there is a considerable gap in our understanding of how to effectively treat knee OA-related quadriceps inhibition and how critical factors such as pain sensitization and catastrophizing interact with motor inhibition to influence quadriceps voluntary activation, strength, and function in knee OA. A critical first step is to establish a comprehensive infrastructure to explore factors that contribute to persistent quadriceps weakness with knee OA. The objective of this research is to overcome natural barriers to strengthening quadriceps muscles weakened with knee OA and to provide laboratory and clinical methods to evaluate deficits and treatment efficacy. Our intervention approach is innovative because repetitive transcranial magnetic stimulation (rTMS) can increase motor excitability in neurological conditions such as stroke and can relieve chronic pain, but rTMS has not been applied to rehabilitate knee OA. We hypothesize that rTMS over the primary motor cortex will increase motor excitability and interfere with the knee OA-related inhibition of maximal quadriceps contraction and reduce pain. The proposed study will initiate this research program and develop pilot statistics to facilitate the design of a large scale, prospective, randomized controlled trial of treatments that replace or delay invasive, irreversible interventions for knee OA.

Improving walking ability is an important clinical goal for people with hemiparesis after stroke. Frequently after stroke, individuals walk with a slow, asymmetrical, and energy-inefficient gait. In fact, almost one third of people living at home after stroke are unable to walk unsupervised in their communities. This study intends to initiate investigation into an intervention to maximize walking recovery after stroke. Task-specific training and increased repetition of practice are essential elements to optimize walking recovery. Specificity of training and repetition promote activity-dependent plasticity of the central nervous system after stroke. Walking recovery may be maximized by providing appropriate training within the first four weeks post stroke, when potential for neuroplasticity is greatest. Sufficient, high quality movement practice is difficult to achieve for many patients during inpatient rehabilitation due to the severity of gait limitations, yet this is a critical window of time in recovery when repetitive practice is needed to maximize adaptive neuroplasticity. We hypothesize that external support to the affected lower extremity will aid task-specific, repetitive gait training after stroke. Specifically, we will test the immediate effects on gait of external support provided by a stance-control knee-ankle-foot orthosis (SCKAFO). SCKAFOs stabilize the knee in stance and provide limb advancement assistance in swing, facilitating improved gait speed and symmetry compared to walking with conventional locked-knee KAFOs and to walking without orthoses in people with chronic stroke. We expect to see that people with recent stroke walk at faster velocities and with greater stance time and step length symmetry when walking with stance control knee support than when walking without support to the lower extremity. In future studies, we expect to see that by using training SCKAFOs for gait training in short-term inpatient rehabilitation after stroke, individuals can initiate walking practice earlier and at increased intensity, duration, and number of repetitions than would be possible without a SCKAFO. This intense walking practice, in turn, is expected to promote neuroplasticity for appropriate amplitude and timing of muscle activation, resulting in a faster and more symmetrical gait pattern.

The purpose of this project is to provide biomechanical evaluation of throwing techniques to elite US discus throwers and javelin throwers. This is part of the High Performance program of USA Track & Field. We collect kinematic data for elite US athletes using three-dimensional videographic techniques, and compare their data to the data of world elite athletes, and suggest changes in throwing techniques to improve performance and prevent injury.

The objective of this pilot study is to use a Geographic Information System (GIS) approach to understand how population density and accessibility to community resources relates to service use, social participation, and functional outcomes in adults with autism spectrum disorder (ASD). Examining the impact of accessibility on community function outcomes may highlight discrepancies in service availability and use by size of community (urban versus rural) and concentration of resources.

This is a multisite study where the primary goal of this project is to investigate the growth, neurocognitive functioning, and disease progression of children with mild to moderate CKD. This is the 12th year of the study.

This study combines innovative Global Positioning System (GPS) and Geographic Information System (GIS) measures to describe real-time community integration activities of adults with ASD living with family or in a group home, and investigates critical person and environmental factors associated with participation. These results will be combined with adult outcome survey data to examine the role of personal factors such as motivation and skill level in a variety of areas (for example communication, vocational, social, and daily living skills) on community participation. The relationship between participation, service use, and caregiver support will also be examined.

An estimated one of three adults over 65 years of age falls each year, and this proportion increases to one in two by the age of 80 years. Falls are extremely costly, both in terms of the economic burden on society and the physical, financial, and emotional toll on the individual and his/her family. By 2020, the total cost of falls among older adults is projected to reach $43 billion. According to the North Carolina Department of Health and Human Services, unintentional fall-related injuries and deaths are increasing in North Carolina, and falls are the leading cause of accidental death among older North Carolinians. Even in the absence of physical injury, a fall may induce a downward spiral of increased fear of falling, self-imposed activity restriction, functional dependence, and reduced quality of life. This project will implement a validated process to identify, risk stratify, and provide intervention for patients at risk for falls, and ultimately to decrease risk of falls and fall-related injuries among older adult patients. We will initially test implementation in the UNC Family Medicine Center (FMC) as a model to subsequently spread throughout UNC Primary Care Improvement Collaborative (PCIC) practices. The intervention will start with a defined process to identify modifiable risk factors for falls before or during an FMC clinic visit using the CDC’s validated Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. Patients who screen positive will subsequently be offered an evidence-based intervention, the physical therapist-managed Otago Exercise Program. Various methods for implementing the initial STEADI assessment will be tested, including pre-visit mailings and evaluation, in-clinic CMA evaluation (with CMA training), Epic BPA refinement, and provider training. We also will test best strategies for engaging physical therapists at point of care and through Epic referrals to facilitate implementing the second step of the intervention, the Otago program, by training therapists at three UNC outpatient physical therapy clinics. We will then disseminate these best practices through UNC PCIC and UNC outpatient physical therapy services, ultimately affecting more than 35,000 eligible patients.

In the United States, there is a lack of safe and affordable housing for individuals with mental illness. Consequently, on any given night, approximately 200,000 people with mental illness are homeless (U.S. Department of Housing and Urban Development, 2011). The absence of stable housing contributes to social isolation and is barrier to occupational participation and community integration. The purpose of this community-based research is to develop an affordable housing option for adults with mental illness that fosters functional independence and community participation. In a collaborative partnership with Habitat for Humanity, UNC’s Center for Excellence in Community Mental Health, and UNC’s School of Social Work, we have designed a 2-phased project to develop a community of Tiny Homes for adults with mental illness. In Phase 1 we will use interviews and focus groups with consumers and stakeholders to (1) test the feasibility and acceptability of this intervention and (2) explore the lived experience of residing in an adapted Tiny Home for adults with mental illness. We will also develop and test an assessment battery to measure outcomes in quality of life, community participation, recovery, and physical and mental health. We will use findings from this phase to inform the development of a community of 5 adapted Tiny Homes in Phase 2. During Phase 2 we will also measure the impact of living in an adapted community of Tiny Homes on consumers’ social participation, sense of belonging, and community integration.

RFA Goal: Efficacy and Replication Purpose: The primary purpose of this project is to establish a stronger scientific foundation for educational practice within the writing domain by utilizing recent advances in cognitive science to examine: (1) the impact of the evidence-based Self-Director Strategy Development (SRSD) model on the written expression of middle school children at-risk for writing problems using a Tier 2 paradigm; (2) specific moderators that can influence response to intervention; and (3) given the executive function-based principles of the SRSD instructional model, whether positive effects of the SRSD intervention on writing are mediated through changes in attention/executive functions. Setting: All middle schools (3) in a single, rural/suburban public school system in North Carolina. Participants: The prospective sample will include 300 sixth grade students who are identified as At-Risk for writing problems. Students will be ascertained at the rate of 100 students each year across a three year recruitment period. Students will be determined as At-Risk if their performance on the WIAT-III Written Expression Scale falls below the 25th percentile. Interventions: We will employ the SRSD intervention model as our evidence-based framework for a randomly selected group of 150 students who are At-Risk for writing problems. Using the SRSD model in a Tier 2 framework, we will teach two specific strategies twice a week for 12 weeks for a total of 24 sessions to improve written language. Each year, this will require 10 groups comprising 5 students who will receive the SRSD intervention during the spring of their sixth grade year. This intervention will be supplemental to the regular state education curriculum. Comparison Condition: For the 150 students At-Risk for writing problems who are not randomized to the SRSD intervention, the control condition, using a free writing model, will involve the provision of supplemental writing tutoring twice a week for 12 weeks for a total of 24 sessions. This will require 10 groups comprising 5 students each year who will engage in free writing activities at the same time of year and for the same amount of time as their SRSD counterparts. This control condition will be supplemental to the regular state education curriculum. Primary Research Method: This project will employ a randomized cohort design, with a 9 month follow-up component, that will permit examination of the efficacy of the SRSD intervention model for sixth grade students at-risk for writing problems. The inclusion of a theoretically driven cognitive assessment also will allow for exploration of selected moderators and mediators of this evidence-based treatment. Randomized assignment of the At-Risk participants to treatment versus control conditions will facilitate the determination of the efficacy of the SRSD model. Measures of Key Outcomes: Students will receive multiple standardized measures of written language and assessment of selected cognitive functions (fine-motor, linguistic, attention/executive functions) in the fall of sixth grade. Selected aspects of the social environment (e.g., socioeconomic status), and associated child (e.g., reading, self-efficacy) and classroom variables (classroom climate) also will be examined as potential moderators of the treatment. Change in writing performance will be assessed using standardized tests and curriculum based measures during and following intervention, as well as at 9 months post-treatment. Data Analytic Strategy: We will use multilevel analysis of covariance to test for the presence of treatment effects post-treatment and at 9 month follow-up (Specific Aim #1), and to test for moderation effects at these time points (Specific Aim #2). Mediation will be assessed via multilevel structural equation modeling with two parallel ANCOVA models (Specific Aim #3).

Anxiety disorders are extremely common among individuals with autism spectrum disorder (ASD), occurring at four times the rate of the general population. The presence of an anxiety disorder negatively affects family functioning, friendship development, and school functioning. Recent research is beginning to provide some clues regarding early risk factors for anxiety in individuals with ASD. Specifically, studies suggest that sensory over-responsivity (SOR) – a set of symptoms characterized by heightened and unusual reactivity to sensory stimuli that occurs more frequently among children with ASD than typically developing children – is associated with anxiety in individuals with ASD. We hypothesize that many of the negative outcomes associated with sensory over-responsivity (SOR), such as avoidance, aggression, and GI problems, primarily occur when SOR leads to the development of an anxiety disorder. The goal of the present research is to conduct an in-depth study of the relationship between SOR and anxiety symptoms in preschool age children with ASD, using parent report, observation, and brain-based measures (brain waves or EEG).