Bilateral Priming Plus Task Specific Training for Severe Upper Limb Hemiparesis

增强使用依赖可塑性的启动技术在中风康复中得到了检验 研究。启动可上调患侧皮质和/或下调对侧皮质以改善 后续治疗的有效性。大多数引爆技术都很昂贵，而且只被批准用于研究。这里, 我们描述了一种具有成本效益并且有可能显著改变临床的启动技术。 练习一下。双侧运动启动(BMP)使用双侧的、对称的、有节奏的运动来准备运动 大脑皮层进行肢体功能训练。使用“摇杆”是为了使受影响较小的肢体能够驱动受影响较大的肢体。 一个是手腕对称的屈伸。受影响的手腕的主动活动范围是不必要的， 因此，BMP可以用于严重受损的参与者。双侧运动启动的有益方面 (与使用rTMS和tDCS的引爆相比)包括这样一个事实：BMP是：1)经济高效；2)可用于 由于缺乏安全考虑，个人人数较多；(3)不需要熟练的操作员；以及(4) 可用于临床。先前比较双侧引爆加治疗的研究发现，引爆和治疗 联合治疗比单独治疗更有效。然而，以前的骨形态发生蛋白研究没有使用剂量 相配的设计。该项目比较了两组随机分配的参与者，这些参与者接受特定于任务的 培训(TST)。76名参与者将随机接受15次2小时的治疗(30小时) BMP TST或相同剂量的TST与单独TST 30小时相匹配。参加者每年参加3次会议。 为期5周，可能缺席的会议安排在第6周。结果衡量标准将在 干预前、干预后和随访(出院后6周)。目标一号将决定震级 慢性卒中存活者5周后上肢损伤和功能的变化 BMP TST。主要结果评估是上肢功能的Fugl-Meyer测试(FMUE)。这个 次要结果是Chedoke手臂和手活动指数，这是对双手功能任务的评估。 我们预计，从干预前到干预后，这两组人的行为指标都会有所改善。然而， BMP TST组较单纯TST组有更大的改善。我们也期待着这些 在BMP TST组中坚持随访(停止治疗后6周)的措施，但在TST组中不坚持 独自一人。目的2将通过经颅测量来确定双侧启动对皮质机制的影响 磁刺激(TMS)。我们预计会发现TMS参数的变化，反映了更大的平衡 大脑半球兴奋性仅见于BMP TST组。我们进一步假设，半球的增加 兴奋性将与FMUE的改善有关。目前，还没有临床证明。 重度慢性上肢偏瘫患者的长期有效治疗。重要的是要 为这一未得到充分服务和未得到充分调查的人群确定治疗方法。

Priming techniques to enhance use dependent plasticity have been examined in stroke rehabilitation research. Priming can upregulate ipsilesional cortex and/or down regulate contralesional cortex to improve effectiveness of subsequent therapy. Most priming techniques are costly and approved only for research. Here, we describe a priming technique that is cost-effective and has the potential to significantly change clinical practice. Bilateral motor priming (BMP) uses bilateral, symmetrical, rhythmic movement to ready the motor cortex for functional limb training. A "rocker" is used so that the less affected limb can drive the more affected one in symmetrical wrist flexion and extension. Active range of motion of the affected wrist is not necessary, and, thus, BMP can be used in severely impaired participants. Beneficial aspects of bilateral motor priming (compared to priming using rTMS and tDCS) include the fact that BMP is: 1) cost-effective; 2) available to a larger pool of individuals due to a paucity of safety concerns; (3) does not require a skilled operator; and (4) can be used the clinic. Previous studies comparing bilateral priming plus therapy found the priming and therapy combination to be more effective than therapy alone. However, previous BMP studies have not used dose matched designs. This project compares two groups of randomly assigned participants receiving task specific training (TST). Seventy-six participants will be randomized to receive either fifteen 2-hour sessions (30 hours) of BMP + TST or the same dose matched 30 hours of TST alone. Participants will attend sessions 3 times per week for 5 weeks with possible missed sessions scheduled at week 6. Outcome measures will be collected at pre-intervention, post-intervention, and follow-up (6 weeks post discharge). Aim 1 will determine the magnitude of change in upper limb impairment and function in chronic stroke survivors who have undergone 5 weeks of BMP+TST. The primary outcome measure is the Fugl-Meyer Test of Upper Extremity Function (FMUE). The secondary outcome is the Chedoke Arm and Hand Activity Index, an assessment of bimanual functional tasks. We expect both groups to improve on behavioral measures from pre-to post-intervention. However, the BMP+TST group is expected to have larger improvements than the TST alone group. We also expect these measures to persist at follow-up (6 weeks post cessation of treatment) in the BMP+TST group but not in TST alone. Aim 2 will determine the effects of bilateral priming on cortical mechanisms as measured by transcranial magnetic stimulation (TMS). We expect to find changes in TMS parameters that reflect a greater balance of hemispheric excitability in the BMP+TST group only. We further hypothesize that increases in hemispheric excitability will be associated with improvements in the FMUE. Currently, there is no clinically demonstrated long-term effective treatment for individuals with severe chronic upper limb hemiparesis. It is important to identify treatments for this underserved and under-investigated population.