Gauthier Lynne V, Nichols-Larsen Deborah S, Uswatte Gitendra, Strahl Nancy, Simeo Marie, Proffitt Rachel, Kelly Kristina, Crawfis Roger, Taub Edward, Morris David, Lowes Linda Pax, Mark Victor, Borstad Alexandra
University of Massachusetts Lowell, Dept. Physical Therapy and Kinesiology.
The Ohio State University, School of Health and Rehabilitation Sciences.
EClinicalMedicine. 2021 Dec 17;43:101239. doi: 10.1016/j.eclinm.2021.101239. eCollection 2022 Jan.
Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.
This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.
Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.
Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.
PCORI, NIH.
将行为干预融入运动康复对于改善日常生活中患侧手臂的使用至关重要。然而，治疗师的时间有限，限制了诸如强制性运动（CI）疗法等行为项目的采用。自我管理的运动练习可以腾出治疗师的时间用于行为干预，但自我管理方法的疗效证据仍然不足。
这项已完成的、平行的、五中心、实用的、单盲试验确定了使用家庭游戏自我管理作为一种手段的比较有效性，以将宝贵的治疗师时间重新导向行为干预。患有中风后（>6个月）轻度/中度上肢偏瘫的社区居住成年人在3周内被随机分配接受4种不同干预措施中的一种：5小时以行为为重点的干预加游戏自我管理（自我游戏组），同样加上额外的以行为为重点的远程康复（远程游戏组），5小时传统的以运动为重点的康复，或35小时的CI疗法。主要结局在治疗前、治疗后立即以及6个月后评估日常手臂使用情况（运动活动日志运动质量，MAL）和运动速度/功能（Wolf运动功能测试，WMFT）。对2016年3月15日至2019年11月21日收集的数据采用线性混合效应模型进行意向性分析。ClinicalTrials.gov，NCT02631850。
在193名登记参与者中，167名开始治疗并进行分析，150名（90%）完成治疗，115名（69%）完成随访。远程游戏组和自我游戏组在临床上产生了有意义的MAL改善，分别比传统护理组高1.0分（95%CI 0.8至1.3）和0.8分（95%CI 0.5至1.0）。自我游戏组的效果不如CI疗法（-0.4分，95%CI -0.6至-0.2），而远程游戏组则不然（-0.2分，95%CI -0.4至0.1）。所有组MAL改善的6个月保持率为57%。所有组在临床上都有相似的有意义的WMFT改善；WMFT改善的6个月保持率为92%。
行为远程医疗访问的自我管理运动游戏产生的结果与门诊CI疗法相似。它解决了大多数获取障碍，只需要五分之一的治疗师时间，这些时间被重新导向行为干预，以增强患侧手臂在日常生活中的参与度。
PCORI，NIH。
