Incline Training to Personalize Motor Control Interventions after Stroke

这项研究的长期目标是推进个人行走康复的个性化。 通过制定针对个人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 一些个人、团体的影响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，证据支持机制通过这些机制 步行的改善是有限的，而且我们目前缺乏预测哪些人可能会对 一种干预和改善它们的机制。迫切需要最大限度地发挥治疗效果 通过针对特定的运动控制障碍，通过开发基于理论的 临床决策框架，将针对特定缺陷量身定做的干预措施转化为行走康复 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，我们 为今后个性化干预措施的翻译提供必要的信息。我们 先前发表的研究表明，中风后存在明显的运动控制缺陷，基于 由偏瘫腿产生的总推进力被称为偏瘫推进(PP)，这是一种被广泛接受的 我们开发的生物力学结果测量方法。1)低PP与大而早期的偏瘫屈肌有关 肌电活动，偏瘫步长延长，偏瘫髋关节伸展减少；2)高PP模式 特点是偏瘫摆动时膝关节屈曲程度降低，偏瘫步长缩短和延长 偏瘫的髋关节伸展。我们的试点数据显示，拥有这些行走模式的人是最有效的 通过独特的治疗策略进行康复：1)通过在倾斜的跑步机上行走来降低脉压，需要增加 强迫生产；2)通过在倾斜的跑步机上行走来提高PP，提高有效的摆动姿势 通过关节运动学和运动学的标准化进行过渡。假想的理想训练策略 (低PP倾斜，高PP下降)是个性化策略，将与非 个性化策略(低PP下降，高PP倾斜)。这两种个性化战略都将是 与对照组相比，他们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，个性化策略对自己选择的步行速度有更大的影响 (SSWs)和PP的对称性。因此，本建议的目的是比较临床和生物力学。 从个性化战略到非个性化战略和控制干预的结果以及 确定预测SSW中有意义的变化的变量。为了实现这些目标，我们将平等地 随机选择60名年龄在25岁到75岁之间的慢性中风患者(高PP组30人，低PP组30人) 转向三种干预措施之一(倾斜、下降或控制)。培训将每周进行3次，为期4周 将在培训前和培训后以及一个月的随访中进行评估。AIMS将评估以下方面的改进 与对照组相比，斜坡组和下坡组的功能和生物力学结果 一群人。第三个目标将确定对倾斜和下降训练作出反应的因素。 定义为SSW中0.16m/S的改善，基于以前运动中应答者的结果 康复试验。为给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发挥运动康复干预的临床效果 卒中。这种方法的基础是建立改善运动控制缺陷的能力，而不是培训 特别是与目标功能结果有关。临床个体化干预效果的确定 生物力学结果和确定预测反应的因素有很高的改善可能性 中风后退伍军人的运动康复。

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.