In the unilateral vs. bilateral hybrid rehabilitation trials, we will conduct two separate clinical trials: one to recruit subacute stroke patients and another to recruit chronic stroke patients. The two trials will have identical study designs and interventions. The overall goal of this research project is to provide scientific evidence of the treatment effects of unilateral and bilateral hybrid therapies in subacute and chronic stroke patients and thus to contribute to evidence-based stroke rehabilitation and translational research for neurorehabilitation.
The first aim of the project will be to compare treatment effects between hybrid rehabilitation and conventional rehabilitations (CR) on motor function, daily functions, mobility, quality of life, and kinematic variables. We hypothesize that patients receiving hybrid rehabilitation will gain more recovery than patients receiving CR in proximal (e.g., motor function) and in distal outcomes (e.g., quality of life) and that patients in the hybrid rehabilitation groups will show more genuine upper extremity motor recovery than those in conventional rehabilitation groups, as indicated by kinematic measures.
The second aim will be to examine the comparative treatment effects between unilateral hybrid and bilateral hybrid rehabilitation on various aspects of outcomes. We hypothesize that the unilateral group will improve more on outcomes associated with distal upper limb (UL) control and that the bilateral rehabilitation group will improve more on outcomes associated with proximal UL control.
Third, we will collect biomarker indexes before and after the interventions to monitor the changes of oxidative stress and inflammatory levels.
- Conventional rehabilitation Behavioral
Intervention Desc: Participants in CR group will receive therapist-mediated functional tasks training based on neurodevelopmental techniques with emphasis on functional tasks and muscle strengthening that will involve (1) active/passive range of motions, abnormal muscle tone/reflex inhibition techniques (such as stretching and/or weight bearing), and strengthening of affected arm for 15 to 20 minutes, (2) functional tasks for training fine motor or manual dexterity for 20 minutes, and (3) activities of daily living or functional tasks involving gross motor activities, coordination tasks, transition, mobility, and posture/balance for 15 to 20 minutes. The activities will be individualized according to the level of impairment and the needs of the patients. ARM 1: Kind: Experimental Label: Conventional Rehabilitation (CR) Description: The CR intervention will be designed to match the duration and intensity of the hybrid interventions.
- Unilateral Hybrid (InMotion3 plus CIT) Intervention Behavioral
Intervention Desc: During the 3-week InMotion3 period, participants will receive 5 minutes of muscle tone normalization preparation and passive range of motion, then 85 minutes of training using the InMotion3 robot. The participants will practice about 5 to 8 minutes of passive, 30 to 35 minutes of assisted-active, and 5 to 8 minutes of active motions in wrist and forearm, respectively. During the 3-week CIT period, participants will receive intensive training of the affected UL in functional tasks with behavioral shaping for 1.5 hours/weekday and will be asked to wear a mitt to restrict the unaffected UL for 6 hours daily. The shaping techniques will involve individualized task selection, graded task difficulty, verbal feedback, prompting, physical assistance with movements, and modeling. Caregivers will use daily logs to document hours of mitt wearing outside the one-on-one intervention sessions. ARM 1: Kind: Experimental Label: Unilateral Hybrid (InMotion3 plus CIT) Intervention Description: Participants will receive 3 weeks of robot-assisted therapy (RT) using the InMotion3 Wrist Robot, followed by 3 weeks of CIT training.
- Bilateral Hybrid (BMT plus BAT) Intervention Behavioral
Intervention Desc: During the 3-week BMT period, patients will play a simple computer game (e.g., picking up apples) that tracks patient movements to provide instant visual feedback. The therapist will also provide verbal feedback. In each training session, the patient will practice 600 to 800 repetitions of passive-passive mode for 15 minutes, 600 to 800 repetitions of active-passive mode for 15 to 20 minutes, and 150 to 200 repetitions of active-active mode for 5 minutes, respectively, for the forearm pronation-supination and the wrist flexion-extension. During the 3-week BAT period, participants will receive training in tasks focusing on bilateral symmetric or alternating movements of both ULs, such as lifting two cups, picking up two pegs, grasping and releasing two towels, and wiping the table with both hands. ARM 1: Kind: Experimental Label: Bilateral Hybrid (BMT plus BAT) Intervention Description: Participants in this bilateral treatment group will receive 3 weeks of RT using the Bi-Manu-Track (BMT) robot (Reha-Stim Co., Berlin, Germany), followed by 3 weeks of therapist-based BAT.
- Allocation: Randomized
- Masking: Single Blind (Outcomes Assessor)
- Purpose: Treatment
- Endpoint: Efficacy Study
- Intervention: Factorial Assignment
|Type||Measure||Time Frame||Safety Issue|
|Primary||Change in Fugl-Meyer Assessment (FMA)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Primary||Change in Wolf Motor Function Test (WMFT)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in MyotonPro||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in 10-Meter Walk Test (10MWT)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Actigraphy||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Functional Independence Measure (FIM)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Motor Activity Log (MAL)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in ABILHAND Questionnaire||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Nottingham Extended Activities of Daily Living Scale (NEADL)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Stroke Impact Scale Version 3.0 (SIS 3.0)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Physiologic Response Measures (Biomarkers)||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|
|Secondary||Change in Kinematic analysis||Baseline, 3 weeks, 6 weeks, and 18 weeks||No|