Evaluation of robot assisted neuro-rehabilitation

描述(由申请人提供)： 上肢功能障碍是中风所致残疾的重要组成部分，中风是成人长期残疾的主要原因。一项不断发展的研究表明，即使在持续丧失功能后，特定的康复干预也可以改善受损手臂的功能。我们和其他人已经证明，与基线相比，机器人辅助康复可以减少手臂损伤。我们现在已经证明，与传统的职业治疗相比，机器人辅助康复可以减少随机、单盲试验中的手臂损伤。对机器人训练和约束诱导治疗的研究表明，针对功能任务的特定训练可能会增强将训练成果转化为改善功能的能力。我们建议研究在机器人训练中增加功能训练课程(我们称为过渡到任务训练或TTT)的价值。一项已发表的研究表明，机器人训练会导致大脑皮层运动图的变化。我们将在训练前后对患者的皮质运动兴奋性进行研究，以探讨这一问题。确定机器人训练的最大效益的标准尚未制定。一种方法是在治疗过程中进行常规的上肢评估，但这会显着增加治疗师的时间。机器人记录每一次培训期间向患者提供的帮助，我们将检查是否可以持续使用这些数据来评估患者的利益。基本假设：对于偏瘫中风所致的慢性上肢功能障碍患者，每次机器人训练后立即进行的TTT比单独进行机器人辅助训练的功能改善更大。第二机械假说：机器人训练导致经颅磁刺激检测到的皮质运动兴奋性的改变。第二临床假设：机器人运动学数据将反映训练中看到的功能变化，该信息可用于临床确定患者何时从机器人训练中获得最大好处。为了验证这些假设，我们提出了一项随机、单盲试验，比较了36-60分钟的机器人训练和36次训练，其中包括45分钟的机器人训练和15分钟的TTT训练。结果将包括上臂功能评估、经颅磁刺激结果和机器人产生的运动学数据。第1页 公共卫生相关性： 与VHA护理使命相关的中风是美国永久性残疾的主要原因，每年发生78万例中风(1)。改善其护理管理是退伍军人管理局的一个目标领域。中风可导致永久性的，有时是进行性的神经损害，上肢受累通常见于更严重的损害患者。大多数中风退伍军人每年都会接受住院康复治疗。然而，许多人在参与生活任务方面仍然受到严重限制，因为受影响的上肢功能使用减少(33)。中风导致的上肢功能障碍问题对VHA医疗保健系统产生了不成比例的影响；慢性病和残疾经常导致患者失业，失去医疗保险，耗尽自己的资源，迫使他们通过VHA系统寻求治疗。此外，中风的发病率随着年龄的增长而增加，VHA登记的人群比普通人群年龄更大。大约75,000名中风幸存者由VHA系统护理，其中超过一半的患者上肢功能严重丧失。虽然VHA登记的人口实际上正在减少(随着二战退伍军人的到期)，但由于寿命的延长，康复服务的需求预计在未来几十年内将会增加。上肢神经康复有可能在几个方面改善VA系统的护理提供。为上肢的使用和带入家庭环境提供更有效和更有效的治疗，有可能降低护理的长期成本(疗养院护理和重新住院的需要)。如果机器人训练与过渡到任务训练相结合被发现在改善功能方面明显更有效，那么采用这种组合将提高护理标准。机器人治疗还提供了新的客观措施，通过机器人适应和控制来协助诊断运动缺陷、评估进展和定制治疗(42)。最后，也许更重要的是，中风可以成为其他更难研究的大脑疾病的模型。创伤性脑损伤、多发性硬化症和帕金森氏症都有明显的运动障碍，这些障碍是由脑损伤引起的。有一种可能性是，进一步了解与中风康复相关的治疗的神经机制可能适用于这些其他障碍(42)。特别是对于可能影响年轻退伍军人的创伤性脑损伤患者，扩大康复治疗的范围和特异性将对退伍军人的健康和终身生活质量产生积极影响。第1页

DESCRIPTION (provided by applicant): Upper extremity dysfunction is an important part of the disability caused by stroke, the leading cause of long term disability in adults. An evolving body of research suggests that specific rehabilitation interventions can improve functioning in an impaired arm even after sustained loss of function. We and others have shown that robot assisted rehabilitation can reduce arm impairment compared to baseline. We have now shown that robot assisted rehabilitation can reduce arm impairment in a randomized, single-blind trial compared to conventional occupational therapy. Studies of robotic training and also constraint-induced therapy suggest that specific training on functional tasks may enhance to translation of training gains into improved function. We propose to study the value of adding a functional training session (which we refer to as transition to task training or TTT) to robotic training. One published study suggests that robotic training induces changes in cortical motor maps. We will conduct studies of cortical motor excitability in our patients before and after training to investigate this issue. Criteria for determining the maximum benefit of robotic training have not yet been developed. One approach would be to conduct conventional upper extremity evaluations during the course of therapy but that would significantly increase therapist time. The robots record the assistance provided to patients during each training session and we will examine whether that data might be used on an ongoing basis to evaluate patient benefit. Primary hypothesis: TTT immediately following each robotic training session leads to greater functional improvement than robot- assisted training alone for patients with chronic upper extremity dysfunction due to hemi-paretic stroke. Secondary mechanistic hypothesis: Robotic training results in alterations in cortical motor excitability as detected by transcranial magnetic stimulation. Secondary clinical hypothesis: Robot kinematic data will reflect the functional changes seen in the training and that this information can be used clinically to determine when a patient has reached maximum benefit from robotic training. In order to test these hypotheses we propose a randomized, single-blind trial comparing 36-60 minute robotic training sessions with 36 training session consisting of 45 minutes of robotic training and 15 minutes of TTT training. Outcomes will include upper arm functional assessments, the results of transcranial magnetic stimulation and robot generated kinematic data. Page 1 PUBLIC HEALTH RELEVANCE: Relevance to the VHA Care Mission Stroke is the leading cause of permanent disability in the United States with 780,000 strokes occurring each year (1). Improvement in the management of its care is one area targeted by the VA. Stroke can lead to permanent, sometimes progressive, neurological impairment with upper extremity involvement often seen in more severely impaired patients. The majority of veterans with stroke each year receive inpatient rehabilitation. Yet many of individuals remain severely limited in their participation in life tasks because of decreased functional use of the affected upper extremity (33). The problem of upper extremity dysfunction due to stroke has a disproportionate effect on the VHA health care system; the chronicity and disability frequently causes patients to become unemployed, loose their health insurance and to deplete their own resources so that they are forced to seek care through the VHA system. In addition, the incidence of stroke increases with age and the VHA enrolled population is older than the general population. Approximately 75,000 stroke survivors are cared for by the VHA system and more than half of those patients have significant loss of upper extremity function. While the VHA enrolled population is actually decreasing (as WWII vets expire), the demand for rehabilitation services is expected to in the coming decades due to increased longevity. Upper extremity neuro-rehabilitation has the potential for improving the VA systems delivery of care in several ways. The delivery of more efficient and effective therapy for upper extremity use and carry-over to the home environment has the potential to reduce long-term costs of care (need for nursing home care, and hospital readmissions). If robot training combined with transition to task training is found to be significantly more effective in improving function, then adopting this combination will improve the standard of care. Robotic therapy also provides new, objective measures to assist in diagnosis of movement deficits, evaluate progress, and customize therapy through robot adaptation and control (42). Finally, perhaps even more important, stroke can be a model for other brain disorders that are more difficult to study. Traumatic brain injury, multiple sclerosis, and Parkinsonism have prominent motor impairments that result from brain lesions. There is a possibility that further understanding of the neural mechanisms of therapy-related to recovery of stroke may be applicable to these other disorders (42). Particularly for individuals with traumatic brain injury, which may affect younger veterans, expanding the range and specificity of rehabilitation therapies will have a positive impact on veterans' health and quality of life over the course of a lifetime. Page 1