- 學位論文
節律性聽覺提示對於巴金森氏症病人原地踏步動作的效果
Effects of Rhythmic Auditory Cueing on Stepping in Place in Patients with Parkinson’s Disease
摘要
前言: 巴金森氏症是常見的神經退化性及動作障礙疾病，因為基底核的退化性病變，導致巴金森患者的內生節律功能受損，因此在執行節律性動作時(如行走)也會出現困難。針對節律性動作困難的問題，臨床上常使用聽覺提示介入來改善行走步伐節奏不一、凍結步態等問題。目前對於巴金森氏症患者的下肢節律性運動的研究多採用行走為主要的動作模式，而原地踏步動作(stepping in space, SIP)對於一些空間受限或是平衡功能不佳的患者是行走訓練的取代方式。然而以原地踏步做為巴金森氏症患者下肢節律性運動的研究甚少，也少有研究探討聽覺提示介入原地踏步動作時對於大腦神經生理的影響。 目的: 本研究希望能夠透過原地踏步動作來評估巴金森患者下肢節律性動作問題，比較在聽覺提示介入期間以及介入前後原地踏步動作以及行走的動作表現；並使用經顱刺激 (Transcranial magnetic stimulation, TMS)評估介入前後的大腦皮質興奮度的變化，藉以討論聽覺提示介入對於大腦的影響。 方法: 此為隨機交叉實驗，共收取21位巴金森氏症患者(平均年齡63.4 ± 6.2 歲)，依據症狀會被分成兩組: 有凍結症狀組(FOG+,10位)以及無凍結症狀組(FOG-,11位)。每組皆會以隨機順序接受兩種情形下的實驗介入，兩次實驗中間會相隔至少一個星期，兩次實驗分別為(1)聽覺提示介入原地踏步動作(AC condition): 聆聽等時性節律(110%步頻)，並同時按照節律的頻率作出對應同步化之原地踏步動作 50下，重覆10組；(2)無聽覺提示介入原地踏步動作(NC condition): 以自然的步頻進行原地踏步動作 50下，重覆10組。而實驗前後皆會以原地踏步測試、行走及經顱磁刺激器作為評估。 統計分析: 本研究之受試者基本資料採用獨立t檢定進行分析，實驗結果先以Shapiro-Wilk 檢定檢驗是否符合常態分布，因數據不符合常態分佈，因此組內比較採用Wilcoxon符號檢定，組間比較採用Mann-Whitney U檢定。 結果: 從動作表現來看，無論有無聽覺提示，受試者接受原地踏步訓練之後的踏步變異度有下降(AC: p=0.033, NC: p=0.009)，並且行走步頻有增快的情形(AC: p=0.019, NC: p=0.0023)。有凍結症狀組在兩種情形下的行走步伐變異度都有下降；無凍結症狀組僅在無聽覺提示訓練的踏步變異度有下降的情形。在經顱磁刺激檢查中，僅有聽覺提示訓練下的大腦興奮度受到調節，皮質寧靜期(cortical silent period, CSP)顯著延長(p=0.005)，刺激間距兩毫秒的皮質內抑制(short intracortical inhibition, SICI)的興奮性提高(p=0.001)。而有凍結症狀組別在休息動作閾值(resting motor threshold, RMT)以及皮質寧靜期有抑制增強的現象，此現象在無凍結症狀組別並無特別差異；兩組的皮質內抑制以及皮質內促進也受到聽覺提示調節。 結論: 節律性聽覺提示配合原地踏步動作訓練能夠改善巴金森氏症患者下肢動作變異程度以及調節大腦興奮程度，而有凍結症狀的巴金森氏症患者對於聽覺提示介入的效果更加顯著。
並列摘要
Background: Parkinson’s disease (PD) is a common neurodegenerative disease and movement disorder. Due to the degeneration of basal ganglia, patients suffered from PD demonstrate internal rhythm dysfunction, thus lead to difficulty in rhythmic movements such as ambulation. For improving the performance of the rhythmic movements, auditory cueing is often used in clinical setting and shows benefits in ambulation. Finger tapping test and ambulation were commonly used to assess the rhythmic movement problems. On the other side, stepping in place (SIP) is an alternative exercise program for the patients who don’t have sufficient space or lack of enough balance ability to perform ambulation training. However, only few study used SIP to evaluate or train rhythmic movements in the lower extremity of patients with PD. Besides, no study investigates the effects of auditory cueing on brain neurophysiology in SIP task either. Objective: In this study, we used stepping-in-place movements to assess the rhythmic dysfunction of the patients with PD. Motor performances such as stepping in place and walking before and after auditory cueing training were used to explore the effects of auditory cueing on rhythmic movements. Cortical excitability was assessed by transcranial magnetic stimulation (TMS) to investigate the effects of auditory cueing on brain neurophysiology. Methods: This is a cross-over study. 21 participants were classified into FOG+ or FOG- group according to the FOG questionnaire. Each participant received two experiments in random order. There was one-week wash-out period between two experiments. Two experiments were the following: (1) Stepping in place with concurrent auditory cues (AC condition): participants should step according to the rhythmic auditory cues (110% step frequency) we gave, 50 steps per session, totally 10 sessions. (2) Stepping in place without any auditory cue (NC condition): participants should step at a comfortable speed, 50 steps per session, totally 10 sessions. Assessments consisted of stepping in place test, walking test and TMS, and were done before and after experiments. Statistically analysis: The demographic data were analyzed by independent t-test. The results were first examined by Shapiro-Wilk test to ensure normal distribution. Because the data didn’t fit in a normal distribution, Wilcoxon signed-rank test was applied for within group comparison, and Mann-Whitney U test was used for between-group comparison. Results: In the movement assessments, the stepping variability decreased significantly (AC: p=0.033, NC: p=0.009) and the walking cadence increased (AC: p=0.019, NC: p=0.0023) no matter there was auditory cues or not. The freezers showed dropped walking variability in both conditions and the non-freezers only improved in stepping variability in NC condition. In TMS assessments, cortical excitability was modulated only in AC condition. Lengthened CSP duration (p=0.005) and decreased SICI (p=0.001) were noted. The freezers demonstrated enhanced inhibition in RMT and CSP duration. This phenomenon was not found in the non-freezers. SICI and ICF were modulated in both groups under AC condition. Conclusion: Auditory-cued SIP training could improve the lower-limb movement variability and modulate the cortical excitability for patients with PD. The freezers may benefit more from this training.
參考文獻
延伸閱讀
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