NeuroMuscular Electrical Stimulation to facilitate perturbation-based REACtive balance Training for fall-risk reduction post-stroke: The REACTplusNMES Trial

本研究旨在改善中、重度慢性病患者的预防跌倒干预措施。 通过提供同步神经肌肉电刺激(NMES)和 基于扰动的反应性平衡训练(REACT)。反应是一种新兴的干预措施，包括 在安全和受控的环境中反复进行支撑面干扰，以改善反应反应。瀑布 造成重大的身体、心理和经济负担，社区居住的普华永道大约 比健康的同龄人多三倍。我们之前的研究表明，普华永道 反应性平衡中的生物力学损害，包括瘫痪肢体不能提供足够的肢体 在反应性踏步时使用首选的非偏瘫肢体进行支撑，特别是在高强度扰动时。 目前的预防跌倒干预措施，包括常规运动和平衡训练，在其作用上是有限的 增强PwCHS的反应性平衡(失去平衡后的保护性反应)的能力。我们还展示了 当PwCHS暴露于偏瘫一侧的大幅度滑移时，PwCHS的适应速度较慢。此外，我们 结果显示，运动障碍程度较高的PwCHS患者在踏车站立后的改善较小 做出反应。因此，迫切需要制定干预措施，重点加强对 PwCHS中的偏瘫肢体(尤其是高度受损)。NMES是一种已知的促进瘫痪肢体的干预措施 表现和运动学习；然而，使用NMES作为促进剂来增强反应性 改善平衡(在步进反应中的稳定性和肢体支撑)以防止跌倒 从未被测试过。我们发表的研究表明，人们在跑步机上使用NMES(偏瘫股四头肌) 与没有NMES的人相比，站立滑步的跌倒次数更少。此外，NMES和REPACT干预措施都将 改善临床平衡(MINI-BEST)、活动能力(10米步行测试)和跌倒疗效 (活动特定余额置信度，ABC)。因此，这项新的研究旨在检查治疗效果 向截瘫肢体股四头肌提供NMES以改善生物力学和临床结果 在六周(12次)的REPACT(REACT+NMES)期间，PwCHS中度到严重受损。新兴 证据表明，单独的反应和NMES可以导致皮质电位的变化和 皮质脊髓兴奋性与腿部肌肉激活的相应变化。然而，这些影响并没有 检查过PwCHS，尤其是高度受损的。因此，我们还打算检查神经肌肉 以及REACT+NMES的神经再生效应，这将加深对长期改善的理解 在抗跌倒技能和提高反应+NMES的临床翻译方面。这项研究的结果将提供 临床翻译REACT+NMES作为降低PwCHS跌倒风险的技术可行性的证据。这 研究将有助于开发有效的预防跌倒干预措施，潜在地促进反应性平衡 改进，减少培训时间，并包括高度损伤的人。

This study aims to improve fall prevention interventions in moderate to severely impaired people with chronic hemiparetic stroke (PwCHS) by providing synchronous neuromuscular electrical stimulation (NMES) and perturbation-based reactive balance training (REACT). REACT is an emerging intervention consisting of repeated support surface disturbances in a safe and controlled environment to improve reactive responses. Falls pose a significant physical, psychological, and economic burden, with community dwelling PwCHS falling about three-times more than their healthy counterparts. Our previous research shows that PwCHS have biomechanical impairments in reactive balance, including failure of paretic limb to provide adequate limb support during reactive stepping with the preferred non-paretic limb, especially at high intensity perturbations. Current fall prevention interventions, including conventional exercise and balance training, are limited in their ability to enhance reactive balance (protective responses following balance loss) in PwCHS. We also showed that PwCHS had slower adaptation when exposed to large magnitude slips on the paretic side. Further, we demonstrated that PwCHS with higher motor impairment showed less improvement after treadmill stance REACT. Hence, there is an urgent need to establish interventions that focus on enhancing reactive balance on paretic limb in PwCHS (especially highly impaired). NMES is an intervention known to facilitate paretic limb performance and motor learning; however, the use of NMES as a facilitatory agent to enhance reactive balance improvements (stability and limb support during stepping responses) for fall prevention has never been tested. Our published study showed that people given NMES (to paretic quadriceps) during treadmill stance slips had in lower falls than those without NMES. Further, NMES and REACT interventions both translate to improvements in clinical measures of balance (mini-BESTest), mobility (10m walk test), and falls efficacy (Activities specific Balance Confidence, ABC). Thus, this novel study aims to examine therapeutic effects of NMES provided to quadriceps muscle of the paretic limb to improve biomechanical and clinical outcomes in moderate to severely impaired PwCHS during six weeks (12 sessions) of REACT (REACT+NMES). Emerging evidence indicates that REACT and NMES independently can result in changes in cortical potentials and corticospinal excitability with corresponding changes in leg muscle activations. However, these effects have not been examined PwCHS, especially with high impairment. Therefore, we also aim to examine neuromuscular and neuroplastic effects of REACT+NMES, which would further the understanding of long-term improvements in fall-resisting skills and improve clinical translation of REACT+NMES. The findings of this study will provide evidence for feasibility of clinical translation of REACT+NMES as a technique to lower fall-risk in PwCHS. This study will aid the development of effective fall prevention interventions that potentially facilitate reactive balance improvements, reduce training times, and include persons with high impairment.