Translating Intensive Arm Rehabilitation in Stroke to a Telerehabilitation Format

 描述(由申请人提供)： 背景：中风是成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。发病6个月后，55%或更多的中风幸存者仍有残存的手臂缺陷。上肢(UE)是康复的重要目标，因为它影响日常生活活动的独立性(ADL)和生活质量。UR研究利用机器人辅助治疗的高强度重复和任务特异性，对降低中风后6个月≥中重度缺陷退伍军人的UE损害有积极效果。我们工作的扩展表明，密集的机器人辅助到达与短暂的特定任务(过渡到任务训练(TTT))相结合，比单独进行机器人训练会产生更大的收益。目前的机器人设备很大，大量部署也很昂贵。另一种在这一人群中被证明具有积极效果的替代方案是双侧手臂训练和节奏听觉提示(BATRAC)。这是一款基于类似运动学习功能的低成本机械设备。与机器人不同，它没有辅助模式，需要损伤较少的手臂参与才能与受影响的手臂协调工作。这种双边练习可能会增强受损运动皮质的半球间耦合，以促进手臂的空间和时间互动，这在其他形式的重复训练中是看不到的。目的：我们建议将基于实验室的BATRAC训练转变为具有远程康复平台的家庭模式。我们将添加TTT，因为根据中风冲击等级手部分，TTT似乎在促进偏瘫患者的手使用方面相当强大。我们的主要目标是比较为期6周的使用家庭BATRAC远程康复和TTT的UE神经康复对慢性中风患者手臂功能的影响，以及在这个时间点提供的常规和常规护理。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-社会结果产生影响。方法：因中风导致UE缺陷≥持续6个月的参与者将按损害分层，并随机分配到立即治疗或延迟进入治疗。立即治疗组将被随机分配到两个研究小组中的一个：(1)基于实验室的BATRAC+TTT或(2)基于家庭的BATRAC远程康复治疗，用于重复的、剂量匹配的REACH+TTT。同样，在作为常规护理对照6周后，延迟进入组将被随机分为研究组1或研究组2。当延迟进入组完成干预后，两组(在6周训练后和8周保留后)将与即时治疗研究组进行比较。主要的结果衡量标准是由盲法评估小组在基线、第6周和第14周进行的WMFT。每组的所有评估都将在临床环境中进行。结果：通过家庭远程康复模式扩展卒中护理的连续性，有可能增加强化UE实践和将所获成果转化为现实应用的机会。当我们完成这些目标后，我们希望这些结果将为在创伤性脑损伤、多发性硬化症等神经科人群中扩大UE培训提供客观基础，并设计一个可以通过“MyHealtheVet”网络系统更广泛传播的计划。

 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.