Effects of device-assisted practice of activities of daily living in a close-to-normal pattern on upper extremity motor recovery in individuals with moderate to severe stroke

项目摘要 高达85%的中风幸存者有偏瘫，影响一侧上肢（UE），通常 对手的影响大于对肩和肘的影响。目前，对于轻度受损的中风幸存者（约20-25%）， 约束诱导运动疗法（CIMT）和改良的CIMT已经报告了积极的结果。然而，在这方面， 对于大部分中风幸存者，他们有中度到重度的损伤，缺乏干预选择。 已研究器械用于辅助中度至重度卒中患者的手臂/手功能。 已报告了积极的临床结局，但证据质量较低。其中一个影响因素是 器械辅助干预的影响在于器械的使用方式。我们建议，设备应协助实践 日常生活活动（ADL）的一种方式，增强与“正常”运动模式相关的神经活动， 并且最小化不期望的无关活动。我们称之为“以接近正常的模式训练ADL”。的 练习ADL的重要性已经通过先前对轻度受损患者的手/手臂干预得到了证明。 个体当ADL任务的成功成为主要目标时，个体通常会发展代偿性 运动和诱发与所需运动无关的神经活动。如动物实验所示， 模型，代偿性神经活动对神经可塑性和运动恢复产生负面影响，而接近- 正常的训练提高了同损伤的可塑性和促进恢复。这促使人们认为， 干预措施应侧重于通过补偿最大限度地恢复运动功能，而不是完成任务。 我们的目的是调查的可行性，最大限度地减少补偿和最大限度地提高电机恢复在更多的 严重受损的慢性卒中后人群。具体而言，我们建议使用设备来解决2个问题， 在这一人群中常见：1）不能打开麻痹的手，和2）异常UE协同运动 模式，定义为肩、肘、腕和手指之间的异常耦合。最近，我们开发和 测试了EMG触发的功能性电刺激器（ReIn-Hand），以帮助在练习过程中自愿使用手 的ADL，并发现有希望的初步结果，获得手指伸展能力和UE运动功能。我们也 有证据表明，在主动伸展过程中，ACT 3D机器人调节肩关节外展载荷 可以急性和长期地降低UE协同。通过将ReIn-Hand与ACT 3D机器人相结合，我们提出了一种 在中度至重度慢性卒中患者中进行的接触-抓握-取回-释放（GR 3）干预。这 设计旨在通过“接近正常”的运动模式练习ADL，以实现功能目标， 最大化潜在的运动恢复。我们将不仅测量介入引起的临床结果的变化， 而且在UE运动学和功能和形态神经可塑性中， 复苏如果成功，预期结果可能会通过推动实施而影响当前的临床实践。 以接近正常的模式进行ADL的器械辅助实践，并有可能使大量人群受益。

Project Summary Up to 85% of stroke survivors have hemiparesis that affects the upper extremity (UE) on one side and usually impacts the hand more than shoulder and elbow. Currently, for mildly impaired stroke survivors (about 20-25%), constraint-induced movement therapy (CIMT) and modified CIMT have been reporting positive results. However, intervention options for a large percentage of stroke survivors, who have moderate to severe impairment, are lacking. Device use has been studied to assist arm/hand function for individuals with moderate to severe stroke. Positive clinical outcomes have been reported, but the quality of the evidence is low. One of the factors that impact the effects of device-assisted interventions is how the device is used. We suggest that devices should assist the practice of Activities of Daily Living (ADLs) in a way that enhances the neural activities related to ‘normal’ motor patterns, and minimizes undesired irrelevant activities. We call this ‘training ADLs in a close-to-normal pattern’. The importance of practicing ADLs has been demonstrated by previous hand/arm interventions in mildly impaired individuals. When success in ADL tasks becomes the primary goal, individuals usually develop compensatory movements and evoke neural activities unrelated to the required movements. As demonstrated in animal models, compensatory neural activities negatively impact neuroplasticity and motor recovery, while close-to- normal training heightened ipsilesional plasticity and enhanced recovery. This has prompted the opinion that interventions should focus on maximizing motor recovery versus task accomplishment via compensation. We aim to investigate the feasibility of minimizing compensation and maximizing motor recovery in the more severely impaired chronic post-stroke population. Specifically, we propose to use devices to address 2 issues that are commonly presented in this population: 1) inability to open the paretic hand, and 2) abnormal UE synergic movement patterns, defined as the abnormal coupling between shoulder, elbow, wrist, and fingers. Recently, we developed and tested an EMG-triggered functional electrical stimulator (ReIn-Hand) to assist voluntary hand use during the practice of ADLs, and found promising preliminary results in gaining finger extension ability and UE motor function. We also have evidence demonstrating that ACT3D robotic modulation of shoulder abduction loading during actively reaching can reduce the UE synergy both acutely and long-term. By combining ReIn-Hand with an ACT3D robot, we propose a reaching-grasping-retrieving-releasing (GR3) intervention in individuals with moderate to severe chronic stroke. This design aims at practicing ADLs with a ‘close-to-normal’ movement pattern to achieve functional goals while maximizing potential motor recovery. We will measure not only the intervention-induced changes in clinical outcomes, but also in UE kinematics and functional and morphologic neuroplasticity to disentangle motor compensation versus recovery. If successful, the expected results may impact current clinical practice by pushing towards implementing device-assisted practice of ADLs in a close-to-normal pattern and have the potential to benefit a large population.