Dose-Response of Movement Practice During Stroke Rehabilitation

描述（申请人提供）：剂量已成为促进脑卒中后功能恢复的关键因素。目前，缺乏剂量-反应关系的数据阻碍了脑卒中康复领域的进展。拟议项目的目标是确定运动练习的剂量范围，对慢性中风患者的预后产生最大的改善。借鉴中风的动物模型，人类的剂量可以通过特定任务练习的重复次数来量化。我们的中心假设是，对于中风患者来说，存在一定剂量范围，低于这个范围，益处就微乎其微，超过这个范围，进一步的实践就不会产生进一步的益处。有益剂量的范围可能根据运动缺陷的严重程度和其他领域非运动缺陷的存在而变化。采用随机、平行剂量-反应设计，我们将对100名慢性中风患者进行四种不同剂量的上肢特定任务训练的益处进行评估，这些训练分别为1小时、4次/周，持续8周。待评估的总重复剂量（3200、6400、9600和个体化最大剂量）基于我们的初步数据。个体化最大限度组可以延长疗程超过8周，直到达到规定的停止标准。我们的主要目的是检验大的总剂量是否比小的总剂量产生更好的结果。四种剂量的益处将在损伤、活动和参与水平上进行评估，因为了解所有测量水平的剂量-反应关系对推进康复研究至关重要。我们假设9600和个体化最大剂量组的改善最大，其次是6400，然后是3200重复剂量组。我们的第二个目的是表征上肢特定任务练习的剂量-反应关系。根据来自多个评估点的数据，将使用单独的曲线建模来估计剂量范围，低于该剂量范围，效益最小，超过该剂量范围，进一步的实践不会产生进一步的效益。此外，我们将确定各种因素如何改变剂量估计。我们假设运动缺陷的严重程度将是剂量-反应关系的主要调节因素，运动缺陷较轻的患者需要更大的剂量。我们进一步预计，对于患有抑郁症和半脑忽视的患者，所需的剂量将会更大。由于我们在脑卒中康复研究和测量方面的专业知识，我们对临床实践和临床研究的挑战的理解，以及我们对这一患者群体的随时可用性，我们的团队在调查剂量的关键问题方面处于有利地位。该项目的预期结果是经验驱动的估计，表明推动最大改善所需的运动练习剂量，以及如何对接受中风康复治疗的患者单独修改这些估计。我们的估计将立即影响康复研究和临床实践。这个项目的重要性超越了中风康复；我们的初步结果将对许多其他康复人群具有很高的价值，这些人群也因缺乏关于剂量-反应关系的知识而受到阻碍。

DESCRIPTION (provided by applicant): Dose has emerged as a key factor promoting functional recovery after stroke. Currently, a lack of data on the dose-response relationship impedes progress in the field of stroke rehabilitation. The goal of the proposed project is to define the range of doses of movement practice that produce the greatest improvements in outcomes in people with chronic stroke. Borrowing from animal models of stroke, dose in humans can be quantified by the number of repetitions of task-specific practice. Our central hypothesis is that there exists a range of doses for people with stroke, below which, there is minimal benefit, and above which, further practice does not result in further benefit. The range of beneficial doses is likely to vary based on the severity of motor deficits and the presence of non-motor deficits in other domains. Using a randomized, parallel dose-response design, we will evaluate the benefits of four different doses of task-specific upper extremity training with matched schedules of 1 hr sessions, 4 sessions/wk for 8 wks, in 100 people with chronic stroke. Total repetition doses to be evaluated (3200, 6400, 9600, & individualized-maximum) are based on our preliminary data. The individualized-maximum group may extend their sessions beyond 8 wks until meeting defined stop criteria. Our primary aim will test whether larger total doses result in better outcomes than smaller total doses. Benefits of the four doses will be evaluated at the impairment, activity, and participation levels, since understanding the dose-response relationship at all levels of measurement is critical for advancing rehabilitation research. We hypothesize that improvements will be greatest in the 9600 and individualized-maximum, followed by the 6400, and then the 3200 repetition dose groups. Our secondary aim is to characterize the dose-response relationship of upper extremity task-specific practice. With data from multiple assessment points, individual curve modeling will be used to estimate dose ranges, below which, there is minimal benefit, and above which, further practice does not result in further benefit. Furthermore, we will determine how various factors modify the dose estimates. We hypothesize that the severity of motor deficits will be the primary modifier of the dose- response relationship, with larger doses needed for those with more mild motor deficits. We further expect that needed doses will be larger for those with depression and hemispatial neglect. Our team is well-positioned to investigate the critical issue of dose because of our expertise in stroke rehabilitation research and measurement, our understanding of the challenges of clinical practice and clinical research, and our ready access to this patient population. Expected outcomes from this project are empirically-driven estimates indicating the dose of movement practice required to drive maximal improvements and how these estimates can be individually modified for people undergoing stroke rehabilitation. Our estimates will immediately impact rehabilitation research and clinical practice. The importance of this project transcends stroke rehabilitation; our primary results will be of high value to many other rehabilitation populations also impeded by the lack of knowledge regarding dose-response relationships.