EXplaining PLastICITy After Stroke (acronym: EXPLICIT)
02 / 2008 - 02 / 2013
EXPLICIT-stroke staat voor EXplaining PLastICITy after stroke . Het is een translationeel revalidatieonderzoek waarbij vijf universiteiten in Nederland betrokken zijn (LUMC,VUmc,UMC St Radboud, UMC Utrecht en TU-Delft). In het EXPLICIT-stroke programma onderzoeken wij of bij het vroegtijdig starten met intensieve therapie van de arm en hand door middel van gedwongen gebruik (CIMT-therapie) dan wel door elektromyografisch gestuurde neuromusculaire elektrostimulatie (EMG-NMS) effectiever is dan de reguliere oefentherapie na een beroerte. Het resultaat van beide therapieën wordt beoordeeld door middel van verschillende metingen in de tijd, waarbij naast klinische uitkomstmaten ook hersenactiviteit, intactheid van innervatie vanuit de hersenen naar de spieren, bewegingssturing en spierstijfheid in de eerste 6 maanden wordt onderzocht. Aan dit programma nemen naast genoemde universitaire ziekenhuizen nog eens 5 revalidatiecentra, 6 perifere ziekenhuizen en 10 verpleeghuizen mee.
EXPLICIT will address a number of key questions in the field of stroke rehabilitation. A selection of 7 research questions related to different projects of EXPLICIT are adressed in this section. (1) Is an early intensive physical therapy and occupational therapy programme lasting 30 minutes with additionally 2 hours of CIMT on 5 consecutive working days over a 3 week period more effective in terms of recovery of the paretic upper limb than an equally intensive conventional treatment programme in patients suffering from a first-ever middle cerebral artery (MCA) stroke with a favourable prognosis for recovery of the upper limb? (Project A1 of EXPLICIT) (2) Is an early EMG-NMS programme for wrist and finger extensors lasting 30 minutes per working day over a 3 week period more effective in terms of return of dexterity in the first 6 months than an equally intensive 3-week conventional exercise programme in patients with initially poor prognosis for upper limb recovery? (Project A2 of EXPLICIT)(3) Are CIMT-induced gains reinforced by recruitment of cortical activation in the ipsilesional hemisphere when compared to usual care? (Project B1 of EXPLICIT) (4) Can improved performance of a functional reaching task be explained on the basis of behavioural compensation strategies? (Project B2 of EXPLICIT) (5) How and to what extent do endpoint mechanical behaviour measured at the wrist joint and peripheral reflex chain properties change in the first 6 months post stroke? (Project B3 of EXPLICIT) (6) Does CIMT affect endpoint mechanics and peripheral reflex chain properties? (Project B3 of EXPLICIT) (7) How are improvements in dexterity longitudinally related to changes observed in neurological impairments, kinematics, biomechanics and changes in cortical activation patterns, as revealed by fMRI and TMS? (Project C of EXPLICIT). Prospective cohort studies show that about 80% of all stroke survivors have an upper limb paresis immediately after stroke. Only one third of all stroke patients will regain some dexterity, whereas well-researched evidence based therapies for an effective treatment of the upper limb are lacking. However, the main claim of the literature is that functional recovery of the upper paretic limb is mainly defined within the first month post stroke and that rehabilitation services should be applied preferably within this time window of recovery. Furthermore, it is known that exercise-related interventions are most effective when they are applied intensively in a task-oriented way. The program EXplaining PLastiCITy after stroke (acronym: EXPLICIT) builds on the existing knowledge about functional prognosis and effectiveness of exercise therapy in patients with a first-ever MCA stroke. The first RCT of EXPLICIT is aimed to investigate the effects of early applied Constrained Induced Movement Therapy (CIMT) in patients with a known favourable prognosis for functional recovery. The second RCT of EXPLICIT will focus on the effects of an early started sensorimotor stimulation program by EMG-NMS in patients with a poor probability for functional recovery of the upper limb. In both single-blinded RCTs, interventions will be compared to a dose-matched control treatment based on usual practice. To improve our knowledge on what patients learn when they show functional recovery, EXPLICIT will explore the underlying mechanisms that are involved in regaining dexterity. For this latter purpose, the impact of intactness of the primary motor system as revealed with TMS will be related to: 1) changes in cortical activation patterns of ipsi- and contralateral brain by fMRI; 2) adaptive motor control of the upper limb (kinematics) and 3) changed stiffness of the upper paretic limb by haptic robotics in a repeated measurement design. By this, EXPLICIT will provide an answer to the key question whether therapy induced improvements are due to either a reduction of basic motor impairment by neural repair (i.e., restitution of function) and/or the use of behavioural compensation strategies (i.e., substitution of function).