Combined Neural and Behavioral Therapies to Enhance Stroke Recovery
| Status: | Completed |
|---|---|
| Conditions: | Neurology |
| Therapuetic Areas: | Neurology |
| Healthy: | No |
| Age Range: | 18 - 80 |
| Updated: | 6/2/2016 |
| Start Date: | August 2010 |
| End Date: | November 2015 |
Combining Neural and Behavioral Therapies to Enhance Stroke Recovery
Stroke is the leading cause of long-term disability in this country with more than 1 million
Americans reporting difficulty with daily activities. Loss of independence in self-care
tasks is primarily due to limited recovery of the arm. This study will determine if the
addition of Transcranial Magnetic Stimulation (TMS) to excite the lesioned hemisphere (side
of the brain affected by the stroke), to progressive functional task exercise either of the
weakened arm alone or of both arms together will improve arm recovery to a greater degree
than one of these two types of arm exercise alone. Individuals post-stroke will participate
in 16 sessions of 1) arm rehabilitation alone (with the weaker arm only or with both arms
together) or 2) arm rehabilitation plus TMS. The investigators will assess arm movement
ability and function immediately following the 4-week intervention and at a 30-day follow-up
to determine retention of immediate gains. The investigators hypothesize that those who
receive TMS as an adjuvant will have improved arm movement ability than those who only
exercise.
Americans reporting difficulty with daily activities. Loss of independence in self-care
tasks is primarily due to limited recovery of the arm. This study will determine if the
addition of Transcranial Magnetic Stimulation (TMS) to excite the lesioned hemisphere (side
of the brain affected by the stroke), to progressive functional task exercise either of the
weakened arm alone or of both arms together will improve arm recovery to a greater degree
than one of these two types of arm exercise alone. Individuals post-stroke will participate
in 16 sessions of 1) arm rehabilitation alone (with the weaker arm only or with both arms
together) or 2) arm rehabilitation plus TMS. The investigators will assess arm movement
ability and function immediately following the 4-week intervention and at a 30-day follow-up
to determine retention of immediate gains. The investigators hypothesize that those who
receive TMS as an adjuvant will have improved arm movement ability than those who only
exercise.
Limited recovery of upper extremity (UE) function post-stroke continues to be one of the
greatest challenges faced in neurorehabilitation. There is an urgent unmet need to identify
effective approaches to drive UE recovery in this population. In response to this challenge,
the overall purpose of this proposed research plan is to develop rehabilitation
interventions that restore UE motor recovery. Contemporary approaches to motor
rehabilitation are based on evidence that behavioral experience drives cortical
reorganization following neural injury. Although the rationale of driving the damaged motor
cortex by focused training of the paretic UE appears straightforward, and has historically
been the focus of rehabilitation, functional recovery remains limited. There remains a gap
between this central neurobiological change and a meaningful behavioral change. There is a
need, therefore, to augment or potentiate behavioral experience. This proposal will address
this gap by examining two potential drivers of the lesioned hemisphere: 1) the non-lesioned
hemisphere via engagement of the unaffected UE in behavioral training and 2) stimulation of
the lesioned hemisphere via repetitive Transcranial Magnetic Stimulation (rTMS). This
proposal builds on the foundation of the applicant's previous work which suggested that the
contralesional, intact, hemisphere could be used to drive the lesioned hemisphere through
bimanual movement. Additionally, it is possible to drive the lesioned hemisphere externally
using rTMS to enhance cortical stimulation. Thus, pairing externally-driven enhancement of
cortical excitability with internally-driven activation of the intact hemisphere during
bilateral movements could combine to further increase excitability in the lesioned
hemisphere and manifest improved movement capability of the paretic UE. The fundamental
hypothesis guiding this proposal is that increased excitability of the lesioned cortex will
improve behavioral function of the paretic UE post-stroke. To investigate the overall
hypothesis the investigators will examine these drivers of cortical excitability and their
role in UE recovery by addressing the following aims:
Specific Aim 1. Determine the magnitude of difference in central and behavioral changes in
individuals with post-stroke hemiparesis randomized to a bilateral versus unilateral UE
motor training program.
Specific Aim 2a. Determine the magnitude of difference in central and behavioral changes in
individuals with post-stroke hemiparesis randomized to behavioral UE training compared to
behavioral UE training + rTMS.
Specific Aim 2b. Determine the differential effects of rTMS on bilateral behavioral training
compared to unilateral behavioral training as measured both centrally and behaviorally in
individuals with post-stroke hemiparesis Post-stroke upper limb paresis and resultant loss
of functional ability continues to present a barrier to those post-stroke in returning to
full societal participation. Interventions that directly target the mechanism of
hemiparesis, including decreased excitability of the lesioned hemisphere, are most likely to
promote true recovery as opposed to the oft observed functional compensation in these
individuals.
greatest challenges faced in neurorehabilitation. There is an urgent unmet need to identify
effective approaches to drive UE recovery in this population. In response to this challenge,
the overall purpose of this proposed research plan is to develop rehabilitation
interventions that restore UE motor recovery. Contemporary approaches to motor
rehabilitation are based on evidence that behavioral experience drives cortical
reorganization following neural injury. Although the rationale of driving the damaged motor
cortex by focused training of the paretic UE appears straightforward, and has historically
been the focus of rehabilitation, functional recovery remains limited. There remains a gap
between this central neurobiological change and a meaningful behavioral change. There is a
need, therefore, to augment or potentiate behavioral experience. This proposal will address
this gap by examining two potential drivers of the lesioned hemisphere: 1) the non-lesioned
hemisphere via engagement of the unaffected UE in behavioral training and 2) stimulation of
the lesioned hemisphere via repetitive Transcranial Magnetic Stimulation (rTMS). This
proposal builds on the foundation of the applicant's previous work which suggested that the
contralesional, intact, hemisphere could be used to drive the lesioned hemisphere through
bimanual movement. Additionally, it is possible to drive the lesioned hemisphere externally
using rTMS to enhance cortical stimulation. Thus, pairing externally-driven enhancement of
cortical excitability with internally-driven activation of the intact hemisphere during
bilateral movements could combine to further increase excitability in the lesioned
hemisphere and manifest improved movement capability of the paretic UE. The fundamental
hypothesis guiding this proposal is that increased excitability of the lesioned cortex will
improve behavioral function of the paretic UE post-stroke. To investigate the overall
hypothesis the investigators will examine these drivers of cortical excitability and their
role in UE recovery by addressing the following aims:
Specific Aim 1. Determine the magnitude of difference in central and behavioral changes in
individuals with post-stroke hemiparesis randomized to a bilateral versus unilateral UE
motor training program.
Specific Aim 2a. Determine the magnitude of difference in central and behavioral changes in
individuals with post-stroke hemiparesis randomized to behavioral UE training compared to
behavioral UE training + rTMS.
Specific Aim 2b. Determine the differential effects of rTMS on bilateral behavioral training
compared to unilateral behavioral training as measured both centrally and behaviorally in
individuals with post-stroke hemiparesis Post-stroke upper limb paresis and resultant loss
of functional ability continues to present a barrier to those post-stroke in returning to
full societal participation. Interventions that directly target the mechanism of
hemiparesis, including decreased excitability of the lesioned hemisphere, are most likely to
promote true recovery as opposed to the oft observed functional compensation in these
individuals.
Inclusion Criteria:
- Diagnosis of 1st stroke > 6 months
- Sub-cortical stroke confirmed with CT or MRI
- Passive range of motion in bilateral shoulder and elbow within functional limits
- UE Fugl-Meyer shoulder/elbow subcomponent score between 15 - 25
- 18-80 years of age
Exclusion Criteria:
- Use of medications that may lower seizure threshold
- History of epilepsy, brain tumor, learning disorder, mental retardation, drug or
alcohol abuse, dementia, major head trauma, or major psychiatric illness
- evidence of epileptiform activity on EEG obtained before beginning treatment
- history or radiographic evidence of arteriovenous malformation, intracortical
hemorrhage, subarachnoid hemorrhage, or bilateral cerebrovascular disease,
- history of cortical stroke
- history of implanted pacemaker or medication pump, metal plate in skull, or metal
objects in the eye or skull
- pregnancy
- pain in either upper extremity that would interfere with movement
- unable to understand 3-step directions
- orthopedic condition in back or UE or impaired corrected vision that would alter
kinematics of reaching
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