Mechanisms and long-term effects of separate vs. coupled rehabilitation approaches after stroke

The incidence of stroke has been increasing, while mortality from stroke has decreased and the need for effective rehabilitation is growing. Due to the progress in neurological sciences such as principles of neuroplasticity and motor control, more active rehabilitation of stroke has become possible. Recently, several rehabilitation protocols for upper extremity (UE) training have been advocated and the intervention efficacy is empirically examined. In addition to question whether patients may benefit from certain intervention, it is important to address how to optimize rehabilitation outcomes and underscore possible mechanisms for therapeutic change. For example, what are the relative effects of different rehabilitation approaches with different characteristics of patients? What are the combined effects of two rehabilitation approaches versus one with different characteristics of patients? And who can benefit the most from each of rehabilitation approach? That is, what type of clinical predictors can predict the functional outcome of each rehabilitation protocol? This project will investigate these possibilities. The long-term objective is to identify the possible mechanisms and the relative effectiveness of existing rehabilitation approaches that target UE deficits of stroke patients on the ground that these approaches are based on neuroplasticity principles and sound motor control theories. The specific aims are four-fold. The first is to evaluate brain and movement reorganization immediately after separate and combined rehabilitation approaches applied in the UE training of stroke patients. The brain and movement reorganization will be examined in terms of functional magnetic resonance (fMRI) and kinematic analysis. The rehabilitation approaches will involve bilateral movement training, task-related training with trunk restraint, coupled bilateral movement training and task-related training with trunk restraint, and conventional intervention. The second purpose is to evaluate motor impairment, functional performance and quality of life immediately and 6 months after intervention. The intervention effects on these three aspects of health-related outcomes will be evaluated using clinical measures. The third one is to investigate the possible predictors of functional outcome for each type of rehabilitation approach. The possible predictors will involve side of lesion, the fine motor performance, and trunk control. The final one is to analyze the association between brain/motor reorganization and clinical measures involving motor impairment, functional performance and quality of life. A total of 144 stroke patients with onset ranging from 6 -24 months and with age ranging from 40 to 75 years old will be recruited from two hospitals (Chang Gung Memorial Hospital and Tzu-Chi General Hospital). A randomized-blocks pretest and posttest control group design will be applied. Four groups will be involved in this project and the subjects will be stratified on two variables: impairment level of the hand and side of lesion. Randomization will be done in blocks of six and each block randomization scheme is within each stratum. Treatment regimens will be designed to ensure that patients in 4 groups receive equivalent intensity of treatment (5 days/week for 1.5 hours/day for 4 consecutive weeks) directly supervised by the occupational therapists. The intervention will be provided at two hospitals under the supervision of two separate certified occupational therapists. These two therapists will be trained in the administration of the four types of rehabilitation protocols by the principle investigator and one coprinciple investigator and complete a written competency test before subject treatment. Brain and movement reorganization will be evaluated with fMRI and kinematic instrument, respectively before and after the 4-week intervention period. Clinical measures on motor impairment, daily function and quality of life will be assessed before, immediately and six months after intervention. Two examiners blind to group allocation will collaborate to provide both fMRI and kinematic evaluations and one of them will administer clinical measures. Before being allowed to work with subjects, the examiner competence will be assessed by principle investigator and co-principle investigators. Multivariate analyses of covariance will be used to examine change in brain activation, kinematic variables and clinical measures as a function of intervention while controlling for pretest data, age and onset post stroke. Multiple regression models will be established to examine the possible predictor(s) for functional outcome of each rehabilitation approach. Canonical correlation analyses will be conducted to quantify the relationship between brain/motor reorganization and clinical measures.

Project ID:PG9703-0137
External Project ID:NHRI-EX97-9742PI