A multimodal intervention to improve manual dexterity in subacute stroke survivors

摘要 手是人类与外部世界接触的主要方式。越来越多地， 这些相互作用涉及诸如工具之类的物体，这些物体需要显著的手动灵活性才能正确使用。 手的精细运动控制受损，例如通常发生在中风后，可以深刻地影响物体 这会导致手的功能和整个上肢的功能显著降低。 尽管手的频率很高，但支持精细手灵巧性康复的临床工具有限。 中风幸存者的损伤以及手对整体功能和日常生活的重要性。 因此，本研究将重点评估一种新型的多模式治疗方法， 电刺激（FES）与软手外骨骼的使用相结合，以促进 中风后独立的手指运动。这些模式将与FES协调使用 帮助激发适当的运动单位以引导神经可塑性 其他数字来协助任务执行。FES将靶向神经而不是肌肉，以使神经兴奋。 更大范围的肌肉和减少疲劳。柔软的外骨骼将允许所有人的全主动运动范围 未激活时阻抗最小的手指。它们将与驱动式 虚拟键盘（AVK）虚拟现实平台。有了这个系统，用户的手指弯曲的结果是“玩” 显示键。按键的虚拟性有助于重复练习，并具有适当的挑战水平， 最大化学习。例如，弹奏琴键所需的关节屈曲量可以在弹奏过程中容易地调节。 训练课程，以及提供给用户的FES和外骨骼辅助的水平。随着用户 随着技术的进步，外骨骼还可以用于抵抗预期的运动以提供进一步的挑战。在这些 任务难度与用户能力相匹配。该系统提供成功的视觉和听觉反馈， 击键失败，以及记录产生错误的手指运动，以通知用户和治疗师。 处于亚急性恢复期的中风幸存者将用这种新疗法完成18次训练 范例超过6周。一组匹配的中风幸存者将参加18个类似的训练课程， 持续时间和强度，但采用标准的治疗技术集中在手。评价会议将 在培训开始前、培训中途、所有培训结束后进行 会议，一个月后。参与者创造独立运动和等距力量的能力 每个数字将被量化;高密度电极阵列将用于测量激活模式， 针对手部肌肉。预计接受AVK系统多式联运培训的小组将 在手部运动控制的临床评估中表现出显著更大的改善， 个体化和肌肉和肌肉隔室的独立激活。令人鼓舞的成果 本研究中引入的新型治疗干预措施将对临床实践产生直接影响。

ABSTRACT The hands constitute the primary means by which humans interface with the external world. Increasingly, these interactions involve objects such as tools that require significant manual dexterity to use properly. Impairment of fine motor control of the hand, such as commonly occurs after stroke, can profoundly impact object manipulation, thereby substantially reducing functionality of the hand, and of the entire upper limb in general. Clinical tools to support rehabilitation of fine manual dexterity are limited despite the high frequency of hand impairment in stroke survivors and the importance of the hand to overall function and daily living. Thus, this study will focus on the evaluation of a novel, multimodal treatment approach in which functional electrical stimulation (FES) is combined with use of a soft hand exoskeleton to promote active training of independent digit movement after stroke. These modalities will be used in a coordinated manner, with FES helping to excite appropriate motor units to guide neuroplasticity while the exoskeleton inhibits unwanted flexion of other digits to assist task performance. The FES will target nerves rather muscles to enable excitation of a greater range of muscles and to reduce fatigue. The soft exoskeleton will allow full active range of motion of all digits with minimal impedance when unactuated. Together they will be used in conjunction with the Actuated Virtual Keyboard (AVK) virtual reality platform. With this system, flexion of the user’s digits results in “playing” displayed keys. The virtual nature of the keys facilitates repetitive practice with the proper level of challenge to maximize learning. For example, the amount of joint flexion required to play a key can be easily adjusted during a training session, as well as the level of FES and exoskeleton assistance provided to the user. As the user progresses, the exoskeleton can also be used to resist intended movement to provide further challenge. In these ways, task difficulty is matched to user ability. The system provide visual and audio feedback of success or failure of key strikes, as well as recording of finger movements producing errors, to inform the user and therapist. Stroke survivors in the subacute phase of recovery will complete 18 training sessions with this novel therapy paradigm over 6 weeks. A matched group of stroke survivors will participate in 18 training sessions of similar duration and intensity, but employing standard therapy techniques focused on the hand. Evaluation sessions will be conducted prior to initiation of training, midway through the training, after the completion of all training sessions, and one month later. The ability of participants to created independent movement and isometric force with each digit will be quantified; a high-density electrode array will be used to measure activation patterns of targeted hand muscles. It is anticipated that the group receiving the multimodal training with the AVK system will exhibit significantly greater improvement on clinical assessments of motor control of the hand, and in digit individuation and independent activation of muscles and muscle compartments. Encouraging outcomes for the novel therapeutic intervention introduced in this study would have direct ramifications for clinical practice.