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%的中风幸存者患有偏瘫，这种偏瘫影响一侧上肢(UE)，通常 对手的影响大于对肩膀和肘部的影响。目前，对于轻度受损的中风幸存者(约20%-25%)， 强制诱导运动疗法(CIMT)和改良的CIMT已经报道了积极的结果。然而， 对于有中度到重度损害的大部分中风幸存者来说，缺乏干预选择。 已经研究了使用设备来帮助中到重度中风患者的手臂/手功能。 已经报道了积极的临床结果，但证据的质量很低。影响经济增长的因素之一 设备辅助干预的效果在于设备是如何使用的。我们建议，设备应该帮助实践 日常生活活动(ADL)的一种方式，以增强与“正常”运动模式相关的神经活动， 并最大限度地减少不受欢迎的不相关活动。我们称之为“以接近正常的模式训练ADL”。这个 练习ADL的重要性已经在以前的手/手臂干预中得到了证明 个人。当ADL任务的成功成为首要目标时，个体通常会发展成补偿性的 运动并唤起与所需运动无关的神经活动。正如动物实验所证明的那样 模型中，代偿性神经活动对神经可塑性和运动恢复产生负面影响，而接近于 正常训练可提高自体的可塑性，促进恢复。这引发了一种观点，即 干预应侧重于通过补偿最大限度地实现运动恢复而不是任务完成。 我们的目标是研究在更多的情况下最大限度地减少补偿和最大限度地恢复运动的可行性 严重受损的慢性中风后人群。具体地说，我们建议使用设备解决以下两个问题 常见于该人群：1)瘫痪手不能张开，2)UE协同运动异常 图案，定义为肩部、肘部、手腕和手指之间的异常耦合。最近，我们开发了和 测试了肌电触发的功能性电刺激器(RED-HAND)，以在练习期间帮助自愿使用手 在获得手指伸展能力和UE运动功能方面，发现了有希望的初步结果。我们也 有证据表明，在主动伸展过程中，ACT3D机器人对肩外展负荷的调节 会在短期和长期内降低UE的协同效应。通过将Rein-Hand与ACT3D机器人相结合，我们提出了一种 中重度慢性卒中患者的GR3干预。这 设计的目的是以接近正常的运动模式练习ADL，以实现功能目标，同时 最大限度地提高运动恢复的潜力。我们将不仅衡量干预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方面解开运动代偿与 恢复。如果成功，预期的结果可能会通过推动实施来影响当前的临床实践 设备辅助的ADL实践接近正常模式，并有可能造福于大量人群。

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.