Bilateral Priming Plus Task Specific Training for Severe Upper Limb Hemiparesis

启动技术，以提高使用依赖性可塑性已在中风康复检查 research.启动可以上调同病灶皮层和/或下调对病灶皮层以改善 后续治疗的有效性。大多数引发技术都很昂贵，而且只被批准用于研究。在这里， 我们描述了一种具有成本效益的预充技术， 实践双侧运动启动（BMP）使用双侧、对称、有节奏的运动来准备运动 用于功能性肢体训练的皮质。一个“摇杆”是用来使较少受影响的肢体可以驱动更多的影响 一个是对称的腕关节屈曲和伸展。受影响的手腕的活动范围是不必要的， 因此，BMP可用于严重受损的参与者。双侧运动启动的有益方面 （与使用rTMS和tDCS的预充相比）包括BMP是：1）成本有效的; 2）可用于 由于缺乏安全性问题，个体样本量较大;（3）不需要熟练的操作员;以及（4） 可以在诊所使用。先前比较双侧预激加治疗的研究发现， 联合治疗比单独治疗更有效。然而，以前的BMP研究没有使用剂量 匹配的设计该项目比较了两组随机分配的参与者， 培训（TST）。76名受试者将随机接受15次2小时的治疗（30小时） BMP + TST或相同剂量的TST单独30小时。参加者将参加3次会议， 每周5周，可能会错过第6周的会议。将收集结局指标， 干预前、干预后和随访（出院后6周）。目标1将决定 接受5周治疗的慢性卒中幸存者上肢损伤和功能的变化 BMP+TST。主要的结果测量是Fugl-Meyer上限功能测试（FMUE）。的 次要结果是Chedoke手臂和手活动指数，一种双手功能任务的评估。 我们希望这两组从干预前到干预后的行为指标都有所改善。但 BMP+TST组预期比单独TST组具有更大的改善。我们也期待这些 BMP+TST组在随访时（停止治疗后6周）持续的措施，但TST组没有 一个人目的2将确定双侧启动对经颅测量的皮层机制的影响。 磁刺激（TMS）。我们希望发现TMS参数的变化，反映了更大的平衡， 仅BMP+TST组的半球兴奋性。我们进一步假设，大脑半球的增加， 兴奋性将与FMUE的改善相关。目前，临床上还没有证明 长期有效治疗严重慢性上肢轻偏瘫患者。重要的是要 为这一服务不足和调查不足的人群确定治疗方法。

Priming techniques to enhance use dependent plasticity have been examined in stroke rehabilitation research. Priming can upregulate ipsilesional cortex and/or down regulate contralesional cortex to improve effectiveness of subsequent therapy. Most priming techniques are costly and approved only for research. Here, we describe a priming technique that is cost-effective and has the potential to significantly change clinical practice. Bilateral motor priming (BMP) uses bilateral, symmetrical, rhythmic movement to ready the motor cortex for functional limb training. A "rocker" is used so that the less affected limb can drive the more affected one in symmetrical wrist flexion and extension. Active range of motion of the affected wrist is not necessary, and, thus, BMP can be used in severely impaired participants. Beneficial aspects of bilateral motor priming (compared to priming using rTMS and tDCS) include the fact that BMP is: 1) cost-effective; 2) available to a larger pool of individuals due to a paucity of safety concerns; (3) does not require a skilled operator; and (4) can be used the clinic. Previous studies comparing bilateral priming plus therapy found the priming and therapy combination to be more effective than therapy alone. However, previous BMP studies have not used dose matched designs. This project compares two groups of randomly assigned participants receiving task specific training (TST). Seventy-six participants will be randomized to receive either fifteen 2-hour sessions (30 hours) of BMP + TST or the same dose matched 30 hours of TST alone. Participants will attend sessions 3 times per week for 5 weeks with possible missed sessions scheduled at week 6. Outcome measures will be collected at pre-intervention, post-intervention, and follow-up (6 weeks post discharge). Aim 1 will determine the magnitude of change in upper limb impairment and function in chronic stroke survivors who have undergone 5 weeks of BMP+TST. The primary outcome measure is the Fugl-Meyer Test of Upper Extremity Function (FMUE). The secondary outcome is the Chedoke Arm and Hand Activity Index, an assessment of bimanual functional tasks. We expect both groups to improve on behavioral measures from pre-to post-intervention. However, the BMP+TST group is expected to have larger improvements than the TST alone group. We also expect these measures to persist at follow-up (6 weeks post cessation of treatment) in the BMP+TST group but not in TST alone. Aim 2 will determine the effects of bilateral priming on cortical mechanisms as measured by transcranial magnetic stimulation (TMS). We expect to find changes in TMS parameters that reflect a greater balance of hemispheric excitability in the BMP+TST group only. We further hypothesize that increases in hemispheric excitability will be associated with improvements in the FMUE. Currently, there is no clinically demonstrated long-term effective treatment for individuals with severe chronic upper limb hemiparesis. It is important to identify treatments for this underserved and under-investigated population.