Guided Versus Directed Training in Acute Stroke Rehabilitation

描述(由申请人提供)：30%至50%的中风患者经历过认知障碍。中风后有认知障碍的人比中风后没有认知障碍的人更不可能在日常生活活动中恢复独立。丧失独立性与巨大的成本有关，因为持续性残疾的个人需要更多的康复服务和更多的资源来支持他们的生活，无论是在机构还是在社区环境中。最适合训练有认知障碍的人的干预措施有可能促进独立性，并减少中风后的医疗支出。通过日常活动开始训练以促进独立的最佳时机是在急性康复期间。然而，最好的培训方法仍不清楚。定向培训最大限度地发挥康复从业者的专业知识，他们识别并优先处理有问题的活动，确定执行这些活动的障碍，制定解决这些障碍的策略，并指导患者使用这些策略，并通过在康复计划期间发现的各种问题活动重复这一过程。指导培训通过教患者如何自己应用相同的4步流程来最大限度地发挥患者的专业知识。因此，患者识别并确定活动的优先顺序，识别执行活动的障碍，生成他们自己的应对这些障碍的策略，并通过迭代实践来学习这一过程。在这样做的过程中，指导性培训使患者具备“实用”技能，这些技能有可能超越干预计划期间解决的活动，推广到干预计划后出现的新的有问题的活动，从而促进长期独立性。虽然有证据表明，这两种训练方法对认知障碍患者都是可行的，也是有益的，但目前还不清楚哪种方法在促进急性中风后的独立性方面更好。拟议的试点研究的目的是检查定向训练和指导训练在日常活动中对独立性的影响。PIs预测，在康复入院后的前6个月，两组认知障碍的个体在日常活动中的独立性都会有显著的改善，但接受指导性训练的个体将比接受定向训练的个体表现出更大的改善。在这项初步研究结束时，私人投资顾问将能够找出最佳的 促进独立的培训方法，特别是在从事急性康复的认知障碍患者中。此外，他们将收集试点数据，这些数据将使他们能够检查影响治疗反应的潜在解释因素，并开始检查从这些培训方法中受益的个人的特征。PIS将使用本研究的结果来完善他们的方案，然后进行未来的大规模临床试验，检查训练方法对急性中风后认知障碍患者的疗效。 公共卫生相关性：中风后有认知障碍的人在日常工作中存在严重残疾。这项拟议的研究审查了训练方法，以确定最佳康复方法，以帮助认知障碍患者从康复中获得更多好处，并潜在地减少他们的长期残疾。

DESCRIPTION (provided by applicant): Anywhere from 30 to 50% of individuals who sustain stroke experience cognitive impairments. Individuals with cognitive impairments after stroke are less likely to regain independence with activities of daily living than individuals without cognitie impairments after stroke. Loss of independence is associated with significant costs, as individuals with persistent disabilities require more rehabilitation services, and more resources to support their living, whether in institutional or community settings. Interventions ideally suitd for training individuals with cognitive impairments have the potential to promote independence, and reduce health care expenditures after stroke. The best time to initiate training to promote independence with daily activities is during acute rehabilitation. However, the best method for training remains unclear. Directed training maximizes the expertise of the rehabilitation practitioner, who identifies and prioritizes problematic activities, identifies barriers to performng these activities, generates strategies to address these barriers and instructs patients in these strategies, and repeats the process with a variety of problematic activities identified during the rehabilitation program. Guided training maximizes the expertise of the patient, by teaching the patient how to apply the same 4-step process themselves. Thus, the patients identify and prioritize activities, identify barriers to performing activities, generate their own strategies fo addressing these barriers, and learn this process through iterative practice. In doing so, guided training equips patients with "practical" skills that have the potential to generalize beyond activities addressed during the intervention program to novel problematic activities that arise after the intervention program, thereby promoting long-term independence. While evidence suggests that both training methods are feasible and beneficial for individuals with cognitive impairments, it is unclear which method may be superior in promoting independence after acute stroke. The aim of the proposed pilot study is to examine the effects of directed training and guided training on independence with daily activities. The PIs predict that individuals with cognitive impairments in both groups will demonstrate significant improvement in independence with daily activities in the first 6 months after rehabilitation admission, but that individuals wh receive guided training will demonstrate significantly more improvement than individuals who receive directed training. At the end of this pilot study, the PIs will be able to identify optimal training methods for promoting independence, particularly among individuals with cognitive impairments engaged in acute rehabilitation. In addition, they will gather pilot data that will allw them to examine potential explanatory factors influencing treatment response, as well as begin to examine characteristics of individuals who benefit from these training methods. The PIs will use findings from the present study to refine their protocols before conducting future large scale clinical trials examining the efficacy of training methods in individuals with cognitive impairment after acute stroke. PUBLIC HEALTH RELEVANCE: Individuals with cognitive impairments after stroke sustain significant disability in their daily tasks. The proposed study examines training methods to identify the best rehabilitation approach to help individuals with cognitive impairment gain more benefit from rehabilitation and potentially reduce their long-term disability.