Translating Intensive Arm Rehabilitation in Stroke to a Telerehabilitation Format

 描述（由申请人提供）： 背景：中风是成年人长期残疾的主要原因，其发病率预计将随着人口老龄化而上升。55%或更多的卒中幸存者在发病后6个月仍存在手臂残留缺陷。上肢（UE）是康复的重要目标，因为它影响日常生活活动（ADL）和生活质量的独立性。我们的研究利用机器人辅助治疗高强度重复和任务特异性，对减少卒中后≥ 6个月中度至重度缺陷的退伍军人的UE损伤产生了积极影响。我们的工作的扩展表明，密集的机器人辅助达到结合一个短暂的特定任务（过渡到任务训练（TTT））导致更大的收益比机器人单独训练。当前的机器人设备对于大量部署来说是大的且昂贵的。另一种在该人群中显示出积极效果的方法是双侧手臂训练与节律性听觉提示（BATRAC）。这是一种基于类似运动学习功能的低成本机械装置。与机器人不同的是，它没有辅助模式，并需要参与较少受损的手臂与受影响的arm. This双边的做法可以增强受损的运动皮层的半球间耦合，以促进空间和时间的相互作用的武器没有看到在其他形式的重复训练。目的：我们建议将基于实验室的BATRAC训练适应于具有远程康复平台的基于家庭的模型。我们将增加TTT，因为根据中风影响量表手部部分，TTT在促进麻痹手部使用方面似乎非常强大。我们的主要目的是比较6周UE神经康复（使用家庭BATRAC远程康复和TTT）对慢性卒中患者手臂功能的影响，以及在此时间点提供的常规和习惯护理。其他目标是确定基于家庭的BATRAC远程康复+ TTT是否至少与基于实验室的一样有效，以及以患者为中心的远程康复是否对行为-心理社会结局产生影响。研究方法：因卒中导致UE缺陷持续时间≥ 6个月的受试者将按损害分层，并随机分配至立即治疗或延迟治疗组。立即治疗组将被随机分配到两个研究组中的一个：（1）基于实验室的BATRAC+TTT或（2）基于家庭的BATRAC远程康复，用于重复的、剂量匹配的达到+TTT。同样，在作为常规护理对照6周后，延迟入组组将随机分配至研究组1或2。当延迟入组个体完成干预后，将两组（1和2）与立即治疗研究组进行比较（6周训练后和8周保留后）。主要结局指标是设盲评估团队在基线、第6周和第14周进行的WMFT。每组的所有评估将在诊所环境中进行。结果如下：通过家庭远程康复形式扩展卒中护理的连续性有可能增加强化UE实践的机会，并将收益转化为真实的世界使用。当我们完成这些目标时，我们期望结果为在神经系统人群中扩展UE培训提供客观基础，例如创伤性脑损伤，多发性硬化症以及设计一个可以通过“MyHealthVet”网络系统更广泛传播的程序。

 DESCRIPTION (provided by applicant): Background: Stroke is the primary cause of adult long-term disability and its incidence is predicted to rise with our aging population. Residual arm deficits persist in 55% or more of stroke survivors six months post onset. The upper extremity (UE) is an important target for rehabilitation as it impacts independence in activities of daily living (ADL) and quality of life. ur investigations utilizing robot-assisted therapy for intense repetition and task specificity have resulted in positive effects on reducing UE impairment in Veterans with moderate to severe deficits ≥ six months post stroke. An expansion of our work suggests that intensive robot- assisted reaching combined with a brief period of task specific (Transition to Task Training (TTT)) leads to greater gains than robot training alone. Current robotic devices are large and expensive to deploy in large numbers. An alternative shown to have positive effect in this population is Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC). This is a low- cost mechanical device based on similar motor learning features. Unlike the robot, it does not have an assist mode and requires engagement of the less impaired arm to work in concert with the affected arm. This bilateral practice may enhance inter-hemispheric coupling of the damaged motor cortex to promote spatial and temporal interactions of the arms not seen in other forms of repetitive training. Objective: We propose to adapt the lab-based BATRAC training into a home-based model with a telerehabilitation platform. We will add TTT since it appears to be quite powerful in promoting paretic hand use based on the Stroke Impact Scale Hand Section. Our primary objective is to compare the effects of 6 weeks of UE neuro-rehabilitation using Home-based BATRAC telerehabilitation with TTT on arm function in patients with chronic stroke to the usual and customary care provided at this time point. Additional objectives are to determine whether Home-based BATRAC telerehabilitation + TTT will be at least as effective as lab-based and whether patient-centered telerehabilitation has an effect on behavioral-psychosocial outcomes. Methods: Participants with UE deficits ≥ 6 months duration due to stroke will be stratified by impairment and randomly assigned to immediate therapy or delayed-entry therapy. The immediate therapy group will be randomly assigned to one of two study arms: (1) lab-based BATRAC+TTT or (2) a home-based BATRAC telerehabilitation for repetitive, dose-matched reaching+TTT. Similarly, after serving as a usual care control for 6 weeks, the delayed-entry group will be randomized to either study arm 1 or 2. When the delayed entry individuals have completed their interventions, the two groups (1 and 2) will be compared (after 6 week training and after 8 week retention) to the immediate therapy study arms. The primary outcome measure is the WMFT conducted by the blinded assessment team at baseline, week 6, and week 14. All assessments for each group will occur in the clinic setting. Results: Expanding the continuum of stroke care with a home telerehabilitation format has the potential to increase opportunity for intensive UE practice and translation of gains to real world use. When we have completed these aims we expect the results to provide an objective basis for expansion of UE training in neurological populations such as traumatic brain injury, multiple sclerosis as well as design a program that can be disseminated more broadly through the "MyHealtheVet" web system.