Optimizing the Dose of Rehabilitation After Stroke

描述（由申请人提供）：因为每个中风后的患者都有独特的损伤和功能，所以重要的是不要采用“一刀切”的康复方法。虽然现在有证据表明运动疗法可以改善中度至轻度损伤患者的功能和更受影响肢体的使用，但治疗后几个月的使用变化是可变的：对一些患者来说，使用增加，但对另一些患者来说，使用减少。我们的长期目标是前瞻性地确定治疗剂量，使个体患者在治疗后的使用得到进一步改善，同时将成本保持在合理的水平-我们称之为临界剂量。我们的目的是研究长期使用的预测，作为治疗剂量和患者的神经和行为特征的函数。我们的一般假设是，对于一部分患者，治疗后手臂和手的功能达到一个阈值水平，如果治疗使功能超过这个阈值，自发使用和功能将在一个良性循环中相互加强。我们在计算模型的基础上提出了我们的假设，这些模型证明了这样一个阈值，并考虑了现有的数据。我们将讨论我们的一般假设，并通过两个目标来实现我们的目标。目的1。确定分布剂量治疗对上肢使用的近期和长期获益的影响。目标2：开发一种计算个体患者临界剂量的方法。第一个目标，我们将检验我们的一般假设，并生成相关的功能和使用的临床数据。然后，这些数据将用于第二个目标，基于扩展卡尔曼滤波，开发一个预测模型，将手臂和手的长期使用作为治疗剂量以及行为和神经学数据的函数。我们提出的工作意义重大，因为这样一个中风恢复的预测模型，一旦在未来的临床试验中得到资助，就可以用来影响有关有效治疗的必要剂量的政策，以合理的成本为越来越多的中风幸存者提供治疗。这项工作也将做出重要的神经科学贡献，因为我们将建立模型，并在行为上测试，决定使用受影响的手臂和运动功能恢复之间的因果和适应性联系。

DESCRIPTION (provided by applicant): Because each patient post stroke has unique impairments and function, it is important to depart from a "one size fits all" approach to rehabilitation. Although there is now evidence that motor therapy can improve function and use of the more affected limb for patients with moderate to mild impairments, change in use in the months following therapy is variable: for some patients there is an increase in use, but for others a decrease in use. Our long-term goal is to determine prospectively the dose of therapy that leads to further improvements of use after therapy for individual patients while keeping cost at reasonable levels - we call this dose critical dose. Our objective here is to investigate long-term predictions of use as a function of the dose of therapy and of the patient's neurological and behavioral characteristics. Our general hypothesis is that, for a subset of patients, there is a threshold level for arm and hand function to be achieved after therapy, such that if therapy brings function above this threshold, spontaneous use and function will reinforce each other in a virtuous circle. We formulated our hypothesis based on computational models that demonstrate such a threshold and account for existing data. We will address our general hypothesis and accomplish our objective with two aims. Aim 1. Determine the effect of a distributed dose of therapy on immediate and long-term gains in upper extremity use. Aim 2: Develop a means to compute the critical dose for individual patients. With the first aim, we will test our general hypothesis and generate relevant clinical data of function and use. The data will then be used in the second aim to develop a predictive model, based on the Extended Kalman Filter, of long-term arm and hand use as a function of the dose of therapy as well as behavioral and neurological data. Our proposed work is significant because such a predictive model of stroke recovery, once subjected under future funding to clinical trials, can be used to influence policy regarding the necessary dosage of effective treatments at a reasonable cost for the growing number of persons who have survived stroke. This work will also make an important neuro- scientific contribution as we will model, and test behaviorally, the causal and adaptive linkages between the decisions to use the affected arm and recovery of motor function. PUBLIC HEALTH RELEVANCE: Stroke is the leading cause of disability in the US, and about 65% of stroke survivors experience mostly unilateral long-term upper extremity functional limitations. Improving use of the more affected arm is important because difficulty in using this arm in daily tasks has been associated with reduced quality of life. Although there is now definite evidence that motor training can improve recovery of function and use for patients with moderate to mild impairments, in some cases, the gains in arm use due to therapy are small and may not be sustained. We propose here a novel evidence-based method to allow therapists to determine in advance of treatment and for individual patients, the dose of therapy that maximizes the efficacy of treatment while keeping cost at reasonable levels for each patient.