A multimodal intervention to improve manual dexterity in subacute stroke survivors

摘要 手构成了人类与外部世界交互的主要手段。越来越多的人， 这些交互涉及需要大量手动操作才能正确使用的对象，如工具。 手的精细运动控制功能受损，如中风后常见的，会对物体产生深远的影响 操作，从而大大减少了手和整个上肢的功能。 尽管手的频率很高，但支持精细手工灵活性康复的临床工具有限 中风幸存者的损害以及手对整体功能和日常生活的重要性。 因此，这项研究将重点评估一种新的、多模式的治疗方法，在这种方法中，功能性 电刺激(FES)结合使用柔软的手外骨骼来促进主动训练 中风后独立的手指运动。这些模式将以协调的方式与FES一起使用 帮助刺激适当的运动单位以引导神经可塑性，同时外骨骼抑制不必要的屈曲 用于辅助任务执行的其他数字。FES将以神经而不是肌肉为目标，以实现对 增加肌肉活动范围，减少疲劳。柔软的外骨骼将允许所有人的全部活动范围 未启动时阻抗最小的数字。它们将与Actuated一起使用 虚拟键盘(AVK)虚拟现实平台。在这个系统中，用户手指的弯曲会导致“弹奏” 显示的关键字。键的虚拟性质促进了具有适当水平的挑战的重复练习 最大限度地学习。例如，弹奏一个键所需的关节屈曲量可以很容易地在 培训课程，以及向用户提供的FES和外骨骼帮助的水平。作为用户 随着运动的进展，外骨骼也可以用来抵抗预定的运动，从而提供进一步的挑战。在这些 方法，任务难度与用户能力匹配。该系统提供成功或失败视觉和声音反馈 按键失败，以及记录手指移动产生错误，以通知用户和治疗师。 亚急性恢复期的中风幸存者将使用这种新疗法完成18次训练 超过6周的范例。一组匹配的中风幸存者将参加18次类似的训练课程 持续时间和强度，但使用标准的治疗技术侧重于手。评估会议将 在培训开始前、培训中途、完成所有培训后进行 会议，以及一个月后。参与者创造独立运动和等长力的能力 每个数字都将被量化；将使用高密度电极阵列来测量 目标是手部肌肉。预计接受AVK系统多模式培训的小组将 在手和手指的运动控制的临床评估中表现出显著的改善 肌肉和肌肉间隔的个体化和独立激活。取得令人鼓舞的成果 这项研究中引入的新的治疗干预措施将对临床实践产生直接的影响。

ABSTRACT The hands constitute the primary means by which humans interface with the external world. Increasingly, these interactions involve objects such as tools that require significant manual dexterity to use properly. Impairment of fine motor control of the hand, such as commonly occurs after stroke, can profoundly impact object manipulation, thereby substantially reducing functionality of the hand, and of the entire upper limb in general. Clinical tools to support rehabilitation of fine manual dexterity are limited despite the high frequency of hand impairment in stroke survivors and the importance of the hand to overall function and daily living. Thus, this study will focus on the evaluation of a novel, multimodal treatment approach in which functional electrical stimulation (FES) is combined with use of a soft hand exoskeleton to promote active training of independent digit movement after stroke. These modalities will be used in a coordinated manner, with FES helping to excite appropriate motor units to guide neuroplasticity while the exoskeleton inhibits unwanted flexion of other digits to assist task performance. The FES will target nerves rather muscles to enable excitation of a greater range of muscles and to reduce fatigue. The soft exoskeleton will allow full active range of motion of all digits with minimal impedance when unactuated. Together they will be used in conjunction with the Actuated Virtual Keyboard (AVK) virtual reality platform. With this system, flexion of the user’s digits results in “playing” displayed keys. The virtual nature of the keys facilitates repetitive practice with the proper level of challenge to maximize learning. For example, the amount of joint flexion required to play a key can be easily adjusted during a training session, as well as the level of FES and exoskeleton assistance provided to the user. As the user progresses, the exoskeleton can also be used to resist intended movement to provide further challenge. In these ways, task difficulty is matched to user ability. The system provide visual and audio feedback of success or failure of key strikes, as well as recording of finger movements producing errors, to inform the user and therapist. Stroke survivors in the subacute phase of recovery will complete 18 training sessions with this novel therapy paradigm over 6 weeks. A matched group of stroke survivors will participate in 18 training sessions of similar duration and intensity, but employing standard therapy techniques focused on the hand. Evaluation sessions will be conducted prior to initiation of training, midway through the training, after the completion of all training sessions, and one month later. The ability of participants to created independent movement and isometric force with each digit will be quantified; a high-density electrode array will be used to measure activation patterns of targeted hand muscles. It is anticipated that the group receiving the multimodal training with the AVK system will exhibit significantly greater improvement on clinical assessments of motor control of the hand, and in digit individuation and independent activation of muscles and muscle compartments. Encouraging outcomes for the novel therapeutic intervention introduced in this study would have direct ramifications for clinical practice.