Addressing socioeconomic disparities in post-stroke disability through the development of an accessible, new tool

社会经济地位低的人更容易中风，3个月时残疾更多， 并且不太可能独立行走。社会经济地位低的人很难坚持医生 指南，因为1）残疾增加使患者不合格或无法耐受治疗，以及2） 难以获得高质量的护理，即，缺乏前往治疗的交通工具。减少低SES患者的卒中后差异 我们需要投资开发新的工具，使治疗更容易获得。过去5 多年来，PI一直在开发惊吓辅助康复治疗（START），一种远程启用，低成本 改善中风患者上肢治疗结果的治疗-特别是 重度到中度中风START是一种令人吃惊的声音刺激（通过耳机）， 增加了实践的强度，特别是在严重的患者群体中。START是辅助性的， 它并没有取代临床实践，而是加强了目前的循证治疗。目的：通过 寻求确定START是否可以用于增强上肢的功能相关运动。 初步数据：患有严重至中度中风残疾的个体完成了远程递送， 3-使用START进行对象操作的日间培训。盒子和积木，这是在训练中的目标， 与对照组（+3.3%）相比，START组（+47.1%）显示出大幅增加。修正功能河段 与对照组（+1.1%）相比，START组（+8.9%）也有所增加。减值也有所减少， START（上肢-Fugl-Meyer：+8.6%）导致受试者报告的手臂功能增加， 数量（运动活动日志：+26.2%）和质量（+20.2%）。这些结果表明，START可以 远程部署，可以证明是一个有价值的辅助工具，以提高功能性上肢运动。 我们建议在58名受试者的更大队列中进行1期临床试验，并进行更长时间的5天培训 目的是确定START可以1）增强上肢的功能性运动，以及2） 产生影响生活质量的可持续变化。影响：该提案意义重大，因为它测试了 该工具有可能直接针对导致低社会经济地位个人护理差异的原因。 在美国，650万中风患者中有三分之一（34%）接受医疗补助或没有保险。我们最好的证据- 基于疗法（例如，高强度，CIMT）和我们新兴的康复技术（例如，TMS，机器人） 我们的少数民族和低社会经济地位人口无法获得。START解决了不平等问题，因为它1）针对 严重残疾的个人，这对低社会经济地位和少数群体产生了不利影响，2）远程- 消除了60%的社会经济地位低的人认为是护理障碍的交通。如果 如果成功，这项研究将为更大规模的试验奠定基础，以确定1）START的有效性， 结合到传统治疗中，以及患者的依从性，依从性和耐受性-特别是 在低社会地位群体中。

Individuals with low socioeconomic status (SES) are more likely to have a stroke, more disabled at 3 months, and less likely to be independently ambulatory. Individuals with low SES struggle to adhere to physician guidelines because of 1) increased disability leaves patients ineligible or unable to tolerate therapy, and 2) poor access to quality care i.e., lack of transportation to therapy. To reduce post-stroke disparity in low SES groups, we need to invest in development of novel tools that make therapy more accessible. For the past 5 years, the PI has been developing Startle Adjuvant Rehabilitation Therapy (START), a tele-enabled, low-cost treatment to improve upper-extremity therapy outcomes in individuals with stroke – in particular individuals with severe-to-moderate stroke. START is the application of a startling, acoustic stimulus (via headphones) which increases the intensity of practice, particularly in severe patient populations. START is adjuvant, meaning it does not replace clinical practice but instead enhances current evidence-based treatments. Objective: we seek to determine if START can be used to enhance functionally relevant movement of the upper extremity. Preliminary data: Individuals with severe-to-moderate disability from a stroke completed a remotely delivered, 3-day training of object manipulation with START. Box and Blocks, which was targeted during training, demonstrated a large increase under START (+47.1%) compared to Control (+3.3%). Modified functional reach was also increased under START (+8.9%) compared to Control (+1.1%). Impairment also decreased under START (Upper-Extremity-Fugl-Meyer: +8.6%) resulting in subject-reported increase in arm function both in quantity (Motor Activity Log: +26.2%) and quality (+20.2%). These results indicate that START can be deployed remotely and may prove a valuable, adjuvant tool to enhance functional upper extremity movement. We propose to perform a Phase 1 clinical trial on a larger cohort of 58 subjects, with a longer, 5-day training with the goal of establishing that START can 1) enhance functional movement of the upper extremity and 2) generate sustainable changes that impact quality of life. Impact: This proposal is significant because it tests a tool that has the potential to directly target the causes leading to disparity of care for individuals with low SES. A third (34%) of 6.5 million people in the U.S. with stroke are on Medicaid or uninsured. Our best evidence- based therapies (e.g., high-intensity, CIMT) and our emerging rehabilitation technologies (e.g., TMS, robotics) are inaccessible to our minority and low SES populations. START addresses disparity because it 1) targets individuals with severe disability, which disproportionally affects low SES and minority groups, and 2) is tele- enabled eliminating transportation which 60% of individuals with low SES report as a barrier to care. If successful, this study will set the stage for larger trials to establish 1) the effectiveness of START to be incorporated into traditional therapy and as well as patient compliance, adherence, and tolerance – particularly in low SES groups.