Neuromodulation for Exercise Adherence in Older Veterans

背景：与跌倒相关的住院以及随之而来的发病率和死亡率继续上升，尽管 20多年来基于证据的跌倒预防计划的可用性。这是一个大问题，因为 在美国，每年有超过250万老年人因跌倒而接受治疗。防跌倒 注重力量和平衡练习的项目在设施环境中取得了成功，但锻炼 由于缺乏坚持，这些计划在国内是无效的。据估计，只有五分之一的人 坚持居家锻炼预防跌倒。因此，迫切需要提高对 老年人为了预防跌倒而在家中进行的运动，目的是为了改善平衡。 行为干预未能始终如一地提高锻炼的坚持性。贫困的生物学原因 运动的坚持性，如执行功能障碍，还没有得到研究。坚持长期锻炼 依赖于执行功能(EF)，该功能由[背外侧前额叶皮质(DLPFC)]控制 大脑。EF影响日程安排的选择，放弃竞争的活动，忍受微妙的时间成本和 不方便，以及推迟满足的能力。重复经颅磁刺激是一种 非侵入性神经调节越来越多地用于神经网络的特异性干预。DLPFC的RTMS 提高EF、记忆力、动力和心理灵活性。到目前为止，rTMS研究已经刺激了运动皮质 改善步态和平衡。DLPFC在运动依从性中的作用还没有被探索。这个 拟议中的研究将第一次测试DLPFC刺激提高运动坚持性。 摘要目的：探讨rTMS治疗额背外侧前额叶的疗效。 皮层与假手术的比较：[1.执行功能的短期(2周)变化；]2.长期(24周) 坚持家庭锻炼计划；3.长期(24周)的平衡和步态变化；以及[4. 自我效能感和延迟折扣的短期(2周)变化。] 方法：久居社区的老年退伍军人(年龄≥65岁，N=106)将参加一项双 随机、盲法、假对照三阶段研究。这项拟议的研究将使用任天堂Wii-Fit练习。 第一阶段将包括为期两周的基于设施的安全评估和学习计划的演习， 然后是为期12周的家庭训练。[依从性差和依从性好的研究对象 低EF的依从性]随后将被随机分为rTMS或假治疗。第二阶段将包括10个 连续几个工作日接受rTMS或Sham治疗，同时对贫困患者进行运动训练 坚持[以及那些坚持良好和EF低的人]并继续进行基于家庭的练习 依从性和EF较好的患者。第三阶段包括为期24周的家庭锻炼计划。全 受试者每周锻炼五天，每次45分钟。[从Wii-Fit收集的依从性客观测量 Console和Conner对EF的持续性能测试将是主要的结果衡量标准。]天平 并对步态进行评估。[自我效能感、延迟打折和害怕摔倒，以及跌倒的发生率 评估过了。将在基线、14周、16周和40周评估成果衡量标准。] 意义：这个项目将对提高对锻炼计划的遵从性产生重大影响，反过来， 改善久居社区的老年退伍军人的平衡。在拟议的项目结束时，我们将 了解rTMS在改善EF和锻炼依从性方面的有效性。关于以下方面的知识 坚持以家庭为基础的锻炼将适用于糖尿病等多种疾病。自.以来 Wii-Fit和rTMS很容易获得，将研究结果转化为临床实践将是迅速的。

Background: Fall-related hospitalizations and consequent morbidity and mortality continue to rise despite the availability for over two decades of evidence-based fall-prevention programs. This is a major problem since more than 2.5 million older adults are treated annually for fall-related injuries in the US. Fall-prevention programs focusing on strength and balance exercises have been successful in facility settings but exercise programs are ineffective at home due to lack of adherence. Estimates indicate that only 1 in 5 individuals adhere to home exercise programs for fall prevention. Thus, there is an urgent need to improve adherence to exercise performed at home by older adults seeking to improve balance for the sake of fall prevention. Behavioral interventions have failed to consistently improve adherence to exercise. Biological reasons for poor exercise adherence, such as executive dysfunction, have not been explored. Adherence to long-term exercise is dependent on executive function (EF), which is controlled by the [dorsolateral prefrontal cortex (DLPFC)] of the brain. EF influences choices in scheduling, forgoing competing activities, enduring subtle costs of time and inconvenience, and the ability to delay gratification. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation increasingly used for neural network specific interventions. rTMS of the DLPFC improves EF, memory, motivation, and mental flexibility. rTMS studies to date have stimulated the motor cortex for gait and balance improvements. The role of DLPFC in exercise adherence has not been explored. The proposed study will be the first to test DLPFC stimulation for improving exercise adherence. Objective: The study objective is to determine the effects of rTMS treatment of the dorsolateral prefrontal cortex compared to sham on: [1. Short-term (2-wk) changes in executive function;] 2. Long-term (24-wk) adherence to a home-based exercise program; 3. Long-term (24-wk) changes in balance and gait; and [4. Short-term (2-wk) changes in self-efficacy and delay discounting.] Methods: Sedentary community-dwelling older Veterans (age ≥ 65 years, [N=106]) will participate in a double- blind randomized sham-controlled three-phase study. The proposed study will use Nintendo Wii-Fit exercises. Phase I will include two weeks of facility-based exercise for safety assessment and learning the program, followed by 12 weeks of home-based exercises. [Subjects with poor adherence and those with good adherence with low EF] will then be randomized to rTMS or sham treatments. Phase II will include ten consecutive weekdays of rTMS or sham treatment along with exercise training for subjects with poor adherence [and for those with good adherence and low EF] and continuation of home-based exercises for those with good adherence and EF. Phase III includes 24-weeks of a home-based exercise program. All subjects will exercise for 45 minutes five days/week. [Objective measure of adherence collected from Wii-Fit console and Conner’s continuous performance test for EF will be the primary outcome measures.] Balance and gait will be assessed. [Self-efficacy, delay discounting along with fear of falls, and falls incidence will be assessed. Outcome measures will be assessed at baseline, and at 14, 16, and 40 weeks.] Significance: This project will have a major impact in improving adherence to an exercise program and in turn, improve balance in sedentary community-dwelling older Veterans. At the end of the proposed project, we will gain knowledge about the efficacy of rTMS in improving EF and exercise adherence. Knowledge gained about the adherence to home-based exercises would be applicable to multiple conditions such as diabetes. Since Wii-Fit and rTMS are readily available, translation of the study results to clinical practice would be expeditious.