Incline Training to Personalize Motor Control Interventions after Stroke

这项研究的长期目标是推进个性化的步行康复后， 通过开发针对个体特定运动控制缺陷的治疗策略来治疗中风。中风是一种 令人难以置信的异质性人群，虽然各种治疗方法在 对于某些个体，群体效应往往被那些未能对干预做出反应的人最小化，导致 缺乏有效的随机对照试验。此外，证据支持机制， 步行的改善是有限的，我们目前缺乏模型预测哪些人可能会作出反应， 一种干预措施和改善的机制。迫切需要最大限度地提高治疗效果 通过针对特定的运动控制障碍，并通过开发基于理论的 临床决策框架，以翻译针对步行康复特定缺陷的干预措施 中风后我们这个项目的总体目标是测试一种基于运动控制缺陷的治疗方法， 开发了一个新的数据库，以便为今后翻译个性化干预措施提供必要的信息。我们 先前发表的存在不同的中风后运动控制缺陷的基础上的百分比， 由麻痹腿产生的总推进力称为麻痹推进力（Pp），这是一种广泛接受的 生物力学结果的衡量标准。1)低Pp与大的和早期的麻痹性屈肌相关 肌电图活动，延长麻痹步长，减少麻痹髋关节伸展;和2）高Pp模式是 其特征在于在轻瘫摆动期间膝关节屈曲减少，轻瘫步长缩短， 麻痹性髋关节伸展。我们的试验数据显示，具有这些行走模式的人最有效地 通过独特的治疗策略康复：1）通过在倾斜的跑步机上行走，需要增加 力的产生; 2）通过在倾斜的跑步机上行走，促进有效的摆动姿势， 通过关节动力学和运动学的标准化进行过渡。假设的理想训练策略 （低Pp时的下降和高Pp时的下降）是个性化策略，将与非个性化策略进行比较。 个性化策略（低Pp时下降，高Pp时下降）。这两种个性化策略都将 对照组在平板跑步机上进行等量的步行训练。飞行员培训 数据表明，个性化策略对自我选择的步行速度有更大的影响 （SSWS）和对称性的PP。因此，本提案的目的是比较临床和生物力学 从个性化策略到非个性化策略和对照干预的结果， 确定预测SSWS有意义变化的变量。为了实现这些目标，我们将 随机选择60名年龄在25岁至75岁之间的慢性卒中患者（30名高血压患者和30名低血压患者） 三种干预措施之一（下降、下降或控制）。培训将每周进行3次，持续4周， 将在培训前后以及一个月的随访中进行评估。目标将评估以下方面的改进 与对照组相比，DECLINE和DECLINE组的功能和生物力学结局 组第三个目标是确定有助于对“减少”和“减少”训练作出反应的因素 定义为基于先前运动中的应答者结果，SSWS改善0.16 m/s 康复试验。针对特定的运动控制缺陷选择正确的干预措施，而不是应用 一刀切的策略，可能有助于最大限度地提高运动康复干预的临床效果， 中风这种方法的基础是建立能力，以改善运动控制缺陷，而不是训练 具体到目标功能结果。确定个性化干预措施对临床 和生物力学结果，并确定预测反应的因素， 为中风退伍军人提供运动康复服务。

The long term goal of this research is to advance personalization of walking rehabilitation for individuals post- stroke by developing therapeutic strategies targeting an individual’s specific motor control deficit. Stroke is an incredibly heterogeneous population, and while various therapeutic approaches have produced large effects in some individuals, group effects are often minimized by those who fail to respond to the intervention, leading to a paucity of efficacious randomized controlled trials. In addition, evidence supporting mechanisms by which walking is improved is limited, and we currently lack models predicting which individuals are likely to respond to an intervention and the mechanisms by which they improve. An urgent need exists to maximize treatment effect by targeting specific motor control impairments and improve predictive capability by developing theory-based clinical decision-making frameworks to translate interventions tailored to specific deficits for walking rehabilitation after stroke. Our overall goal for this project is to test a motor control deficit-based treatment approach that we developed, in order to provide information necessary for future translation of personalized interventions. We previously published the existence of distinct post-stroke motor control deficits based on the percentage of overall propulsive forces generated by the paretic leg termed paretic propulsion (Pp), a widely accepted biomechanical outcome measure that we developed. 1) Low Pp is associated with large and early paretic flexor EMG activity, lengthened paretic step length, and decreased paretic hip extension; and 2) High Pp pattern is characterized by decreased knee flexion during paretic swing, shortened paretic step length, and prolonged paretic hip extension. Our pilot data reveal that individuals with these walking patterns are most effectively rehabilitated by unique treatment strategies: 1) Low Pp by walking on an inclined treadmill requiring increased force production; and 2) High Pp by walking on a declined treadmill, promoting effective stance to swing transitions through normalization of joint kinetics and kinematics. The hypothesized ideal training strategy (INCLINE for low Pp and DECLINE for high Pp) is the personalized strategy and will be compared to non- personalized strategies (DECLINE for low Pp and INCLINE for high Pp). Both personalized strategies will be compared to a CONTROL group training on a flat treadmill at equivalent amounts of walking activity. Pilot training data demonstrate that personalized strategies demonstrate a larger effect on self-selected walking speed (SSWS) and symmetry of Pp. Thus, the purposes of this proposal are to compare clinical and biomechanical outcomes from personalized strategies to both non-personalized strategies and control interventions and to identify the variables that predict meaningful changes in SSWS. To accomplish these purposes, we will equally randomize 60 individuals (30 with high Pp and 30 with low Pp) between the ages of 25 and 75 with chronic stroke to one of three interventions (INCLINE, DECLINE, or CONTROL). Training will occur 3x/week for 4 weeks and will be evaluated pre- and post-training and at a one-month follow-up. Aims will evaluate the improvement in functional and biomechanical outcomes in both the INCLINE and DECLINE groups compared to a CONROL group. A third aim will determine the factors that contribute to response to INCLINE and DECLINE training defined as an improvement of 0.16 m/s in SSWS based on responder outcomes in previous locomotor rehabilitation trials. Selecting the correct intervention for a given motor control deficit, as opposed to applying a one-size-fits-all strategy, is likely to aid in maximizing clinical effects of locomotor rehabilitation interventions after stroke. This approach is based on building capacity to improve motor control deficits as opposed to training specifically to the targeted functional outcome. Determining the efficacy of personalized interventions on clinical and biomechanical outcomes and determining the factors that predict response has high likelihood of improving locomotor rehabilitation for Veterans who have experienced a stroke.