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有可能中风，3个月后更有可能残疾， 而且不太可能独立行走。SES低的个体难以坚持医生 指南，因为1)残疾增加使患者不符合条件或无法耐受治疗，以及2) 获得优质医疗服务的机会很少，即缺乏前往治疗的交通工具。减少低SES患者卒中后的差异 我们需要投资于开发新的工具，使治疗更容易获得。在过去5年中 多年来，PI一直在开发惊吓辅助康复疗法(START)，这是一种远程启用的低成本 改善中风患者上肢治疗结果的治疗--特别是 重度至中度中风。Start是一种令人震惊的声音刺激(通过耳机)的应用 增加实践的强度，特别是在重症患者群体中。START是佐剂，意思是 这不会取代临床实践，而是加强了当前的循证治疗。目标：我们 寻求确定START是否可用于增强上肢的功能相关运动。 初步数据：中风导致的重度至中度残疾的患者完成了远程分娩， 使用START进行为期3天的物体操作培训。盒子和积木，这是在训练期间的目标， 与对照组(+3.3%)相比，Start组(+47.1%)表现出较大的增长。改良功能前伸 START组(+8.9%)也高于对照组(+1.1%)。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，并可能被证明是一个有价值的辅助工具，以增强上肢的功能性运动。 我们建议在58名受试者中进行一项为期5天的较长时间的临床试验。 建立这种启动机制的目标是：1)增强上肢的功能活动；2) 产生影响生活质量的可持续变化。影响：这项提案意义重大，因为它考验了 有可能直接针对导致对低社会经济地位个人的护理差异的原因的工具。 在美国650万中风患者中，有三分之一(34%)在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) 对我们的少数民族和低社会经济地位人群来说是无法接触到的。START解决了差异，因为它1)针对目标 严重残疾的个人，这不成比例地影响到低社会经济地位和少数群体，以及2)远程- 消除了60%SES低的个人报告为护理障碍的交通。如果 如果成功，这项研究将为更大规模的试验奠定基础：1)START的有效性 结合到传统疗法中，以及患者的依从性、依从性和耐受性-特别是 在低SES组。

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.