FDA Public Workshop Summary-Coccidioidomycosis (Valley Fever): Considerations for Development of Antifungal Drugs.

Coccidioidomycosis is a fungal disease endemic to the southwestern United States, Mexico, and Central and South America. Prevalence rates are increasing steadily, and new endemic areas of Coccidioides are emerging. Standard treatment is often administered for months to decades, and intolerance to medications and treatment failures are common. No new treatments for coccidioidomycosis have been approved in the United States in nearly 40 years. On 5 August 2020, the US Food and Drug Administration convened experts in coccidioidomycosis from academia, industry, patient groups, and other government agencies to discuss the disease landscape and strategies to facilitate product development for treatment of coccidioidomycosis. This article summarizes the key topics concerning drug development for coccidioidomycosis presented by speakers and panelists during the workshop, such as unmet need, trial designs, endpoints, incentives, research and development support, and collaborations to facilitate antifungal drug development.

Multimodal Mental Practice Versus Repetitive Task Practice Only to Treat Chronic Stroke: A Randomized Controlled Pilot Study.

IMPORTANCE: Occupational therapists are the primary clinicians tasked with management of the more affected upper extremity (UE) after stroke. However, there is a paucity of efficacious, easy-to-use, inexpensive interventions to increase poststroke UE function. OBJECTIVE: To compare the effect of a multimodal mental practice (MMMP) regimen with a repetitive task practice (RTP)-only regimen on paretic UE functional limitation. DESIGN: Secondary analysis of randomized controlled pilot study data. SETTING: Outpatient clinical rehabilitation laboratory. PARTICIPANTS: Eighteen chronic stroke survivors exhibiting moderate, stable UE impairment. INTERVENTION: Participants administered RTP only participated in 45-min, one-on-one occupational therapy sessions 3 times per week for 10 wk; participants administered MMMP completed time-matched UE training sessions consisting of action observation, RTP, and mental practice, delivered in 15-min increments. Outcomes and Measures: The Action Research Arm Test, the UE section of the Fugl-Meyer Scale, and the Hand subscale of the Stroke Impact Scale (Version 3.0) were administered 1 wk before and 1 wk after intervention. RESULTS: The MMMP group exhibited significantly larger (p < .01) increases on all three outcome measures compared with the RTP group and surpassed minimal clinically important difference standards for all three UE outcome measures. CONCLUSIONS AND RELEVANCE: Because of the time-matched duration of MMMP and RTP, findings suggest that MMMP may be just as feasible as RTP to implement in clinical settings. Efforts to replicate results of this study in a large-scale trial are warranted. What This Article Adds: This study shows the efficacy of an easy-to-use protocol that significantly increased affected arm function even years after stroke.

Effects of acute and chronic nicotine on catecholamine neurons of the nucleus of the solitary tract.

Nicotine is an addictive drug that has broad effects throughout the brain. One site of action is the nucleus of the solitary tract (NTS), where nicotine initiates a stress response and modulates cardiovascular and gastric function through nicotinic acetylcholine receptors (nAChRs). Catecholamine (CA) neurons in the NTS influence stress and gastric and cardiovascular reflexes, making them potential mediators of nicotine's effects; however nicotine's effect on these neurons is unknown. Here, we determined nicotine's actions on NTS-CA neurons by use of patch-clamp techniques in brain slices from transgenic mice expressing enhanced green fluorescent protein driven by the tyrosine hydroxylase promoter (TH-EGFP). Picospritzing nicotine both induced a direct inward current and increased the frequency of spontaneous excitatory postsynaptic currents (sEPSCs) in NTS-CA neurons, effects blocked by nonselective nAChR antagonists TMPH and MLA. The increase in sEPSC frequency was mimicked by nAChRα7 agonist AR-R17779 and blocked by nAChRα7 antagonist MG624. AR-R17779 also increased the firing of TH-EGFP neurons, an effect dependent on glutamate inputs, as it was blocked by the glutamate antagonist NBQX. In contrast, the nicotine-induced current was mimicked by nAChRα4ß2 agonist RJR2403 and blocked by nAChRα4ß2 antagonist DHßE. RJR2403 also increased the firing rate of TH-EGFP neurons independently of glutamate. Finally, both somatodendritic and sEPSC nicotine responses from NTS-CA neurons were larger in nicotine-dependent mice that had under gone spontaneous nicotine withdrawal. These results demonstrate that 1) nicotine activates NTS-CA neurons both directly, by inducing a direct current, and indirectly, by increasing glutamate inputs, and 2) NTS-CA nicotine responsiveness is altered during nicotine withdrawal.

Ohio Modified Arm-Motor Ability Test (OMAAT): An Optimized Measure of Upper Extremity Functional Limitation in Hemiparetic Stroke.

This secondary analysis quantified the psychometric properties of the Ohio Modified Arm-Motor Ability Test (OMAAT) in a sample of neurologically stable chronic stroke survivors (n = 67, 40 men; mean age 59.8 yr, standard deviation = 12.8; 42 White, 23 Black, 2 other; 92.5% right-sided lesion; 44 ischemic stroke). Findings indicate high OMAAT internal consistency (Cronbach's α = .97, ordinal α = .98, Gugiu's bootstrap reliability = .97), unidimensionality, and strong positive factor loadings for all 20 OMAAT items. Convergent validity between OMAAT and Action Research Arm Test total scores was strong (r = .90, p < .0001). The OMAAT is the first short measure of upper extremity functional limitation available to clinicians and researchers that includes an administration manual and that has been examined using nonparametric psychometrics. A detailed administration manual is provided as a supplement to this article.

Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke.

OBJECTIVE: To determine the immediate effect of a portable, myoelectric elbow-wrist-hand orthosis on paretic upper extremity (UE) impairment in chronic, stable, moderately impaired stroke survivors. DESIGN: Observational cohort study. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Participants exhibiting chronic, moderate, stable, poststroke, UE hemiparesis (N=18). INTERVENTIONS: Subjects were administered a battery of measures testing UE impairment and function. They then donned a fabricated myoelectric elbow-wrist-hand orthosis and were again tested on the same battery of measures while wearing the device. MAIN OUTCOME MEASURES: The primary outcome measure was the UE Section of the Fugl-Meyer Scale. Subjects were also administered a battery of functional tasks and the Box and Block (BB) test. RESULTS: Subjects exhibited significantly reduced UE impairment while wearing the myoelectric elbow-wrist-hand orthosis (FM: t17=8.56, P<.0001) and increased quality in performing all functional tasks while wearing the myoelectric elbow-wrist-hand orthosis, with 3 subtasks showing significant increases (feeding [grasp]: z=2.251, P=.024; feeding [elbow]: z=2.966, P=.003; drinking [grasp]: z=3.187, P=.001). Additionally, subjects showed significant decreases in time taken to grasp a cup (z=1.286, P=.016) and increased gross manual dexterity while wearing a myoelectric elbow-wrist-hand orthosis (BB test: z=3.42, P<.001). CONCLUSIONS: Results suggest that UE impairment, as measured by the Fugl-Meyer Scale, is significantly reduced when donning a myoelectric elbow-wrist-hand orthosis, and these changes exceeded the Fugl-Meyer Scale's clinically important difference threshold. Further, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Future work will integrate education sessions to increase subjects' ability to perform multijoint functional movements and attain consistent functional changes.

Navigated Transcranial Magnetic Stimulation: A Biologically Based Assay of Lower Extremity Impairment and Gait Velocity.

Objectives. (a) To determine associations among motor evoked potential (MEP) amplitude, MEP latency, lower extremity (LE) impairment, and gait velocity and (b) determine the association between the presence of a detectable MEP signal with LE impairment and with gait velocity. Method. 35 subjects with chronic, stable LE hemiparesis were undergone TMS, the LE section of the Fugl-Meyer Impairment Scale (LE FM), and 10-meter walk test. We recorded presence, amplitude, and latency of MEPs in the affected tibialis anterior (TA) and soleus (SO). Results. MEP presence was associated with higher LEFM scores in both the TA and SO. MEP latency was larger in subjects with lower LEFM and difficulty walking. Conclusion. MEP latency appears to be an indicator of LE impairment and gait. Significance. Our results support the precept of using TMS, particularly MEP latency, as an adjunctive LE outcome measurement and prognostic technique.

Functional Brain Stimulation in a Chronic Stroke Survivor With Moderate Impairment.

OBJECTIVE: To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment. METHOD: The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session. RESULTS: Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl-Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales). CONCLUSION: These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.

Retention of the spacing effect with mental practice in hemiparetic stroke.

Mental practice (MP) is a promising adjuvant to physical practice that involves many of the same mechanisms and takes on many of the same properties as physical practice. This study compared efficacy of a "massed" MP regimen versus a "distributed" MP regimen on upper extremity (UE) motor impairment and functional limitation. Twenty-seven chronic stroke survivors were administered the UE section of the Fugl-Meyer (FM) and Action Research Arm Test (ARAT), followed by standardized physical practice and MP regimens. One group was administered "massed" MP (60 min of MP during a single daily session) and a second group administered distributed MP (20 min of MP occurring three times/day). After intervention, changes in FM and ARAT scores of subjects in the distributed condition were significantly higher than those of subjects in the massed condition (FM 3.65, 95 % CI 0.82-6.49, p value = 0.01; ARAT 3.95, 95 % CI 1.24-6.67, p value = 0.006). Likewise, at POST 3, subjects in the distributed group showed significantly higher change in ARAT scores (ARAT 4.90, 95 % CI 0.57-9.22, p value = 0.03); the change in FM scores at POST 3 was 3.18 points higher among subjects in the distributed condition, but only approached significance (95 % CI -1.27 to 7.63, p value = 0.15). Results suggest that a distributed MP schedule is more efficacious in bringing about paretic UE changes than a massed practice schedule, especially in terms of reducing UE functional limitation.

"Reps" Aren't Enough: Augmenting Functional Electrical Stimulation With Behavioral Supports Significantly Reduces Impairment in Moderately Impaired Stroke.

OBJECTIVE: To determine the impact of repetitive task-specific practice (RTP) integrating electrical stimulation and behavioral supports on upper extremity (UE) impairment, gross manual dexterity, and paretic UE amount and quality of use in chronic stroke survivors exhibiting moderate, stable UE deficits. DESIGN: Case series with 3-month follow-up. SETTING: Outpatient rehabilitation hospital. PARTICIPANTS: Persons (N=9) who experienced a stroke >12 months before enrollment and exhibiting chronic, moderate, stable UE impairment. INTERVENTIONS: After administering outcome measures, RTP was administered 3d/wk for 120 minutes with an electrical stimulation neuroprosthesis (60min in a supervised clinical setting; 60min at home) over 8 weeks. Behavioral supports (eg, behavior contract; weekly reviews of UE use) were provided during clinical sessions and integrated into home exercise sessions to increase paretic UE use and maximize carryover to subjects' community environments. MAIN OUTCOME MEASURES: The UE section of the Fugl-Meyer Impairment Scale, the Box and Block Test, and the Motor Activity Log. RESULTS: Subjects exhibited statistically significant (P<.01) increases on all measures at both time-point comparisons (ie, preintervention to postintervention; preintervention to 3mo postintervention). Subjects reported a new ability to perform valued activities they had not performed in months. CONCLUSIONS: Addition of behavioral supports to RTP augmented by electrical stimulation significantly increased paretic UE use and function. Significant motor changes were exhibited across ages and etiologies, and no other intervention was administered to this stable population, making it likely that results were not due to chance and suggests a larger trial is justified.

Frequency-dependent facilitation of synaptic throughput via postsynaptic NMDA receptors in the nucleus of the solitary tract.

Hindbrain NMDA receptors play important roles in reflexive and behavioural responses to vagal activation. NMDA receptors have also been shown to contribute to the synaptic responses of neurons in the nucleus of the solitary tract (NTS), but their exact role remains unclear. In this study we used whole cell patch-clamping techniques in rat horizontal brain slice to investigate the role of NMDA receptors in the fidelity of transmission across solitary tract afferent-NTS neuron synapses. Results show that NMDA receptors contribute up to 70% of the charge transferred across the synapse at high (>5 Hz) firing rates, but have little contribution at lower firing frequencies. Results also show that NMDA receptors critically contribute to the fidelity of transmission across these synapses during high frequency (>5 Hz) afferent discharge rates. This novel role of NMDA receptors may explain in part how primary visceral afferents, including vagal afferents, can maintain fidelity of transmission across a broad range of firing frequencies. Neurons within the nucleus of the solitary tract (NTS) receive vagal afferent innervations that initiate gastrointestinal and cardiovascular reflexes. Glutamate is the fast excitatory neurotransmitter released in the NTS by vagal afferents, which arrive there via the solitary tract (ST). ST stimulation elicits excitatory postsynaptic currents (EPSCs) in NTS neurons mediated by both AMPA- and NMDA-type glutamate receptors (-Rs). Vagal afferents exhibit a high probability of vesicle release and exhibit robust frequency-dependent depression due to presynaptic vesicle depletion. Nonetheless, synaptic throughput is maintained even at high frequencies of afferent activation. Here we test the hypothesis that postsynaptic NMDA-Rs are essential in maintaining throughput across ST-NTS synapses. Using patch clamp electrophysiology in horizontal brainstem slices, we found that NMDA-Rs, including NR2B subtypes, carry up to 70% of the charge transferred across the synapse during high frequency stimulations (>5 Hz). In contrast, their relative contribution to the ST-EPSC is much less during low (<2 Hz) frequency stimulations. Afferent-driven activation of NMDA-Rs produces a sustained depolarization during high, but not low, frequencies of stimulation as a result of relatively slow decay kinetics. Hence, NMDA-Rs are critical for maintaining action potential generation at high firing rates. These results demonstrate a novel role for NMDA-Rs enabling a high probability of release synapse to maintain the fidelity of synaptic transmission during high frequency firing when glutamate release and AMPA-R responses are reduced. They also suggest why NMDA-Rs are critical for responses that may depend on high rates of afferent discharge.

Rasch Analysis of the Wrist and Hand Fugl-Meyer: Dimensionality and Item-Level Characteristics.

BACKGROUND AND PURPOSE: Clinical administration of the wrist stability, wrist mobility, and hand items of the upper-extremity Fugl-Meyer (W/H UE FM) may provide a rigorous, easily administered, bedside measure of motor impairment in mildly impaired stroke survivors. The purpose of this study was to evaluate the item structure of the W/H UE FM to better understand its measurement properties using Rasch analysis. METHODS: This was a secondary analysis of W/H UE FM data arising from clinical trials of mildly impaired stroke survivors using latent parallel analysis, ordinal factor analysis, and partial credit model Rasch analyses. RESULTS: Latent parallel analysis and ordinal factor analysis indicated that all W/H UE FM items represent a single unidimensional construct, wrist and hand motor ability. Rasch analysis of data from 150 mildly impaired stroke survivors (94 men; mean age, 57.1 ± 11.4 years; mean time since stroke, 19.5 months) revealed that the W/H UE FM operated as a reliable, valid, and effective measure of wrist and hand motor ability. These data were compatible with Rasch model assumptions and are consistent with previous W/H UE FM research. Mass flexion and extension movements were the least difficult W/H UE FM items while the radial and hook grasp items were the most difficult. DISCUSSION AND CONCLUSION: The W/H UE FM is well suited to mildly impaired stroke survivors who exhibit the ability to perform mass flexion and mass extension movements. The full-scale UE FM may be preferable for stroke survivors with lower levels of ability.Video abstract available for additional insight from the authors (Supplemental Digital Content 1, http://links.lww.com/JNPT/A108).

It takes two: noninvasive brain stimulation combined with neurorehabilitation.

The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely. Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient's residual structures in diagnosis and therapy. Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient's brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.

The National Institutes of Health Stroke Scale Lacks Validity in Chronic Hemiparetic Stroke.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is purported to be associated with long-term outcomes. This study determined the concurrent validity of the NIHSS with the Stroke Impact Scale (SIS), a previously validated measure of health status in chronic stroke survivors. METHODS: The NIHSS and the SIS were administered to 147 subjects before participation in a multicenter, randomized, controlled trial. A Spearman's rho was used to determine correlations between NIHSS total score and (1) SIS physical dimension scores, (2) SIS overall perception of recovery scores, and (3) the SIS activities and independent activities of daily living (ADL/IADL) scores. SIS score variation and medians between subjects who scored a zero versus a nonzero on the NIHSS was also assessed. RESULTS: There was no association between total NIHSS scores and SIS physical dimension scores, SIS overall perception of recovery scores, and SIS ADL/IADL scores (P = -.036, P = .782; P = -.039, P = .640; P = -.054, P = .520; respectively). Lastly, significant variation and similar median scores on the SIS were found between those scoring a zero on the NIHSS versus those who did not score a zero. CONCLUSIONS: The NIHSS has no association with health status in chronic stroke and lacks association with measures of impairment and functional limitation. From these findings, we conclude that the NIHSS has poor validity to discern long-term poststroke outcomes and is not associated with health status. Because of possible limitation in the NIHSS's ability to accurately determine outcomes in this population, we recommend restriction of its use to the acute stage of recovery.

Mental practice--triggered electrical stimulation in chronic, moderate, upper-extremity hemiparesis after stroke.

OBJECTIVE: To determine the feasibility and impact of home-based, mental practice-triggered electrical stimulation among stroke survivors exhibiting moderate upper-extremity (UE) impairment. METHOD: Five participants with moderate, stable UE hemiparesis were administered the Fugl-Meyer Assessment, the Box and Block Test, and the Activities of Daily Living, Hand Function, and overall recovery domains of the Stroke Impact Scale (Version 3). They were then administered an 8-wk regimen consisting of 1 hr of mental practice-triggered electrical stimulation every weekday in their home. At the end of every 2 wk, participants attended supervised stimulation to progress therapeutic exercises and stimulation levels and monitor compliance. RESULTS: Six instances of device noncompliance were reported. Participants exhibited reduced UE motor impairment and increased UE dexterity and participation in valued activities. CONCLUSION: The regimen appears feasible and had a substantial impact on UE impairment, dexterity, and participation in valued activities as well as perceptions of recovery.

Occupational Therapists' Opinions of Two Pediatric Constraint-Induced Movement Therapy Protocols.

OBJECTIVE: We sought to determine occupational therapists' opinions of two pediatric constraint-induced movement therapy (pCIMT) protocols. METHOD: A total of 272 therapists in pediatric rehabilitation clinics completed an electronic survey to determine their opinions of two published pCIMT protocols. In Protocol A, restraint is worn 24 hr/day on the nonparetic upper extremity (UE), and in-clinic, therapist-supervised practice sessions occur 7 days/wk for 6 hr/day over 3 wk. In Protocol B, restraint is worn 2 hr/day on the nonparetic UE, and in-clinic, therapist-supervised practice sessions occur 1 day/wk for 2 hr/day over 8 wk. RESULTS: The majority of participants reported moderate to high concerns about every facet of Protocol A. Conversely, >50% of participants reported low or no concerns about five of seven facets of Protocol B. CONCLUSION: This study adds to a growing body of evidence suggesting that therapists strongly prefer low-duration pCIMT protocols.

Effect of overground training augmented by mental practice on gait velocity in chronic, incomplete spinal cord injury.

OBJECTIVE: To compare the efficacy of a regimen combining mental practice (MP) with overground training (OT) with the efficacy of a regimen consisting of OT only on gait velocity and lower extremity motor outcomes in individuals with chronic (>12mo postinjury), incomplete spinal cord injury (SCI). DESIGN: Randomized, controlled, single-blinded study. SETTING: Outpatient rehabilitation laboratories. PARTICIPANTS: Subjects with chronic, incomplete SCI (N=18). INTERVENTIONS: Subjects were randomly assigned to receive (1) OT only, occurring 3d/wk for 8 weeks; or (2) OT augmented by MP (MP + OT), during which randomly assigned subjects listened to an MP audio recording directly after OT sessions. MAIN OUTCOME MEASURES: Subjects were administered a test of gait velocity as well as the Tinetti Performance Oriented Mobility Assessment, Spinal Cord Injury Independence Measure, and Satisfaction With Life Scale on 2 occasions before intervention, 1 week after intervention, and 12 weeks after intervention. RESULTS: A significant increase in gait velocity was exhibited across subjects at both 1 week posttherapy (P=.005) and at 12 weeks posttherapy (P=.006). However, no differences were seen in intervention response at either 1 or 12 weeks postintervention among subjects in the MP + OT group versus the OT-only group. CONCLUSIONS: OT was associated with significant gains in gait velocity, and these gains were not augmented by further addition of MP.

Speech language pathologists' opinions of constraint-induced language therapy.

BACKGROUND: Constraint-induced language therapy (CILT) has received recent attention as a possible intervention to improve expressive language in people with nonfluent aphasia. Difficulties have been reported with the practical implementation of constraint-induced movement therapy due to its intensive treatment parameters. It remains unknown whether similar challenges may exist with CILT. OBJECTIVE: To determine the opinions of speech-language pathologists (SLPs) about CILT for people with nonfluent aphasia. METHOD AND PROCEDURES: One hundred sixty-seven SLPs completed an electronic survey assessing their opinions of various aspects of CILT. OUTCOMES AND RESULTS: Over 60% of participants felt that people with aphasia would be very unlikely or somewhat unlikely to adhere to CILT. The majority felt that people with aphasia would hold high or moderate concerns with the number of hours spent in therapy (high, 41.8%; moderate, 31.4%), the number of days spent in therapy (high, 44.4%; moderate, 24.8%), likelihood for managed care reimbursement (high, 74.8%; moderate, 15.2%), and other logistical issues (high, 39.2%; moderate, 30.7%). With respect to providing CILT, participants cited the number of hours of therapy (high, 37.3%; moderate, 21.6%) and the number of consecutive days of therapy (high, 29.4%; moderate, 20.3%) as concerns. There were 70.6% who indicated that their facilities lacked resources to provide CILT, and 90.9% felt that most facilitates do not have the resources to provide CILT. CONCLUSIONS: Some SLPs hold significant concerns with the administration of CILT, particularly related to its dosing and reimbursement parameters. Additional work is needed to investigate the issues that were identified in this survey using qualitative methods with SLPs and people with aphasia and to examine modified CILT protocols.

Modified constraint-induced movement therapy for upper extremity recovery post stroke: what is the evidence?

BACKGROUND: Constraint-induced movement therapy (CIMT) is an effective treatment for upper extremity (UE) recovery post stroke. Difficulties implementing a traditional CIMT approach have led to development of protocols featuring varying practice schedules, including a 10-week, 3 times per week intervention, termed modified CIMT (mCIMT). To date, systematic reviews of CIMT have grouped the various protocols, precluding the ability to ascertain the level of evidence (LOE) of specific CIMT protocols. Knowing the LOE for various protocols and their relative effectiveness may facilitate decision making regarding which protocol to implement. OBJECTIVE: The aim of this study was to determine the LOE of mCIMT in promoting UE recovery post stroke. METHODS: A comprehensive literature search and subsequent analysis identified studies of a range of designs that investigated the mCIMT protocol. Two independent reviewers assigned an LOE to each of the identified studies, which were then examined collectively to determine the overall LOE for mCIMT. Study results were reviewed to assess the effectiveness of mCIMT for improving UE recovery. RESULTS: Of 473 studies identified, 15 utilized mCIMT. The lack of randomized controlled trials (RCT) resulted in assigning an intermediate LOE (C). Study results indicated that participants receiving mCIMT experienced clinically significant improvements in UE impairment and activity-level attributes. CONCLUSION: The mCIMT protocol is an effective intervention for UE recovery post stroke. Future research including large RCTs could potentially increase the LOE for mCIMT. Additional investigation into the effectiveness of mCIMT in acute and subacute stroke populations is warranted given the limited number of studies performed to date.

Relationship between touch sensation of the affected hand and performance of valued activities in individuals with chronic stroke.

OBJECTIVE: To investigate the association between touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with chronic stroke. METHODS: Using a cross-sectional study design, this study correlated factors related to hand sensation and activity performance in individuals with chronic stroke. The Touch Test Evaluators and Canadian Occupational Performance Measure (COPM) were used. Correlations were used to determine the relationships between touch sensation of the affected hand and individuals' performance and satisfaction with performance of valued activities. RESULTS: There was a good to excellent relationship between sensation and performance and satisfaction with performance of valued activities for individuals with intact touch sensation of the affected hand who scored higher on the COPM. There was little to no relationship between touch sensation of the affected hand and performance of valued activities for individuals with impaired sensation. CONCLUSION: This is the first study to relate touch sensation of the affected hand and performance and satisfaction with performance of valued activities in individuals with stroke. The findings suggest that rehabilitation therapists need to continue to address sensory function in evaluation and intervention as it relates to performance in valued activities. This study serves as a foundation for future research in sensation and performance of valued activities in individuals with chronic stroke.