Exercise-primed Upper Extremity Motor Practice in Chronic Stroke
Condition: Stroke
MeSH terms: Stroke
Study type: Interventional

Summary: 
      The purpose of this project is to establish initial feasibility and tolerability of a
      combined aerobic exercise (AEx) and upper extremity motor practice intervention on upper
      extremity (UE) function in chronic stroke survivors. This novel intervention pairs AEx with a
      virtual reality-based upper extremity rehabilitation game, Duck Duck Punch (DDP). AEx has
      been shown to improve overall brain function and promote a healthy brain environment; thus it
      may serve as an effective 'primer' and enhance the effects of DDP. Movement-based priming for
      rehabilitation involves performing movement or exercise before, or simultaneous to, an
      intervention with the goal of improving the effectiveness of the intervention. AEx combined
      with UE rehabilitation can improve UE function and self-reported health status in chronic
      stroke survivors. However, gaps remain regarding the clinical applicability of an AEx priming
      session and the mechanisms contributing to changes in UE functions in response to AEx-primed
      UE rehabilitation. Therefore, the aim of this project is to: 1) demonstrate the feasibility
      of pairing AEx + DDP in stroke survivors; 2) quantify the magnitude of the effect of the AEx
      + DDP intervention on UE function; 3) examine relationship of biomarkers of the nervous
      system and response to AEx + DDP.
    

Detailed description: 
      With a surviving cohort of nearly 7 million individuals, stroke is the leading cause of
      long-term disability in the United States. Of the ~795,000 new strokes occurring annually,
      approximately 2/3rds of survivors will have some degree of long term disability. The
      prevalence of post-stroke disability coupled with the fact that more people are surviving
      stroke reflects an increasing need to develop effective rehabilitation strategies aimed at
      reducing disability and improving quality of life for the millions of stroke survivors, their
      families and caregivers.

      The overwhelming majority of stroke survivors, >75%, exhibit upper extremity (UE)
      hemiparesis, and only 15% will recover fully. Furthermore, residual UE impairment is closely
      linked to long-term disability and reduced quality of life. Current meta-analytic evidence
      supports virtual reality stroke rehabilitation interventions for improving UE function
      suggesting that this is a promising area for further therapeutic development.

      Duck Duck Punch (DDP) is an interactive computer game deliberately designed to enhance UE
      movement quality via individualized progressive movement practice along with an array of
      performance metrics allowing for within-session feedback on movement performance. Although
      response to UE virtual reality rehabilitation interventions, such as DDP, involves a
      multitude of factors, neuroplastic changes are a primary mechanism underlying functional
      recovery. Thus, pairing DDP with a priming intervention to facilitate a
      'neuroplastic-friendly' environment may make the CNS more amenable, and enhance response to
      DDP rehabilitation and ultimately improve outcomes.

      Aerobic exercise (AEx) training has positive benefits on overall brain function including
      enhanced global cognition, executive function, and processing speed and attention in healthy,
      older adults. Additionally, a single session of AEx acutely improves motor memory and
      learning in younger, healthy adults. Although AEx has been used to improve cardiovascular
      function following stroke, its neurofacilitatory effects in stroke have yet to be tested
      empirically. Candidate mechanisms through which AEx enhances brain function and motor
      learning include changes in circulating brain-derived neurotrophic factor (BDNF) and
      corticomotor excitability. BDNF is believed to play an integral role in several neuroplastic
      processes and promotes the strengthening of synaptic connections, i.e. long-term potentiation
      (LTP) and current research indicates that AEx can acutely and chronically increase
      circulating BDNF. Corticomotor excitability (CME) is often used as an indicator of LTP-like
      neuroplasticity and may underlie improvements in motor memory and learning. Similarly to
      BDNF, AEx can acutely enhance corticomotor excitability in control and chronic stroke
      subjects. Facilitating central nervous system function provides rationale to determine the
      role of AEx in 'prime' the brain for a subsequent intervention to maximize neuroplastic
      potential.

      Movement-based priming for neurorehabilitation involves performing movement or exercise
      before, or concurrent to, a therapeutic intervention with the goal of improving the efficacy
      of the therapeutic intervention. Emerging evidence supports AEx as a potential priming tool
      for UE stroke rehabilitation. AEx combined with UE task training can improve UE function and
      self-reported health status in chronic stroke survivors. Despite the promising results, there
      are gaps in the literature involving: 1) the clinical applicability of an AEx priming
      session; and 2) mechanisms contributing to changes in UE functions in response to AEx-primed
      UE rehabilitation. Addressing these gaps will be necessary to develop an AEx primer that is
      potent and time efficient, with respect to current clinical models. Therefore, the purpose of
      this pilot proposal will be to establish initial feasibility and tolerability benchmarks via
      the following aims:

        1. Demonstrate the feasibility of pairing AEx + DDP in stroke survivors with UE hemiparesis

        2. Quantify the magnitude of the effect of the AEx + DDP intervention on UE impairment and
           function

        3. Examine the relationship of biomarkers of neuroplasticity (BDNF and corticomotor
           excitability) and response to AEx + DDP

      To accomplish these aims, chronic stroke survivors with moderate UE hemiparesis will undergo
      18 sessions of AEx + DDP training. Each week, for six weeks, subjects will undergo three
      sessions of AEx + DDP. During each session subjects will complete 15 minutes of aerobic
      exercise followed by 200 repetitions of DDP. Assessment of UE function and biomarkers of
      neuroplasticity will be assessed before and after the AEx + DDP intervention.
    

Intervention name(s): Aerobic Exercise + Duck Duck Punch
Intervention type(s): Device
Intervention description(s): Subjects will perform 15 minutes of aerobic exercise on a recumbent stationary cycle. On each session the target intensity of aerobic exercise will be 70% heart rate reserve.
Following a 10-minute rest break subjects will perform 200 repetitions on an upper extremity rehabilitation game called Duck Duck Punch (DDP). Duck Duck Punch is an interactive game with an old school carnival theme. DDP is unique as it uses Microsoft Kinect skeletal tracking technology to assess movement performance. The participant sits in front of the Microsoft Kinect and controls a virtual arm with his/her physical arm; reaching forward to "punch" virtual ducks. A therapist will oversee the subject's safety and progress during DDP. DDP will be dosed based on the number of repetitions performed. A repetition is recorded when the player moves his/her arm so that the avatar leaves a start position. The goal dose for subjects will be 200 repetitions per DDP session.
Intervention model: Single Group Assignment
Intervention model description: All subjects enrolled will receive the same treatment. Upper extremity motor function outcome measures will be assessed.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Rehabilitation; Upper Extremity; Aerobic Exercise; Motor Function