強調腳跟著地之步態訓練對於巴金森氏症患者動作表現及大腦皮質興奮性之療效

Effects of Gait Training Emphasizing Heel-strike on Motor Performances and Corticomotor Excitability in People with Parkinson's Disease

李旻昊(Min-Hao Li)

指導教授 ： 李亞芸

國立臺灣大學/醫學院/物理治療學研究所/碩士(2019年)

https://doi.org/10.6342/NTU201903407

摘要

背景：步態障礙為巴金森氏症患者常見的動作症狀之一，過去臨床人員常使用不同的口頭指令以改善患者的步態問題，而在病人有小碎步或者凍結步態時，“腳抬高”則為最常被使用的指令之一，然而病人常常抱怨這種誇張的走路步態除了不自然外也不易長時間持續執行，因此找尋另一個合適的口頭指令是十分重要的。從生物力學的角度來說，在走路時保有腳跟先著地的動作可以促進步長以及增加行走速度，然而目前並未有研究探討強調“腳跟先著地”的步態訓練對於巴金森氏症步態的改善效果。因此本研究將會探討一個月的強調“腳跟先著地”的步態訓練在改善巴金森氏症患者步態及其他相關動作表現上的治療效果，並與過去最常使用的“腳抬高”訓練方式進行比較。
研究目的：探討“強調腳跟先著地”之步態訓練對於巴金森氏症患者在動作表現以及大腦皮質興奮性之效果。
研究方法：此研究為一單盲隨機分配控制實驗，總共招募了30位原發性巴金森氏症患者，並隨機分配至「腳跟行走組」(15位)及「腳抬高組」(15位)，所有受試者皆接受12次的跑步機訓練，訓練期間，「腳跟行走組」被要求走路時要“腳跟先著地”、而「腳抬高組」則會被要求走路時要“腳抬高”；所有的結果評量會在訓練前、訓練後和訓練結束後一個月進行，且會在受試者服用藥物後1-2小時評估；步態表現評估參數包含著地腳的踝關節與地板之角度、步長、行走速度以及步頻，其他次要結果評量包含巴金森症狀衡量表第三部分(motor subscale of Unified Parkinson's Disease Rating Scale, UPDRS-III)、巴金森症狀衡量表第三部分中與步態相關題目之總分(UPDRS-III-gait) 、計時起走測試(Timed Up and Go test)、特定活動平衡信心量表(Activities-Specific Balance Confidence Scale)以及巴金森氏症生活品質量表(Parkinson’s Disease Quetionnaire-39)，另外還會使用經顱磁刺激評估步態訓練造成的脛前肌之大腦皮質興奮性改變。
統計分析方法：使用獨立樣本t檢定和卡方檢定來分析受試者基本資料以及在介入前各個結果評量之差異；並在每個結果評量上使用混合變異數分析(2-way mixed model ANOVA)以分析介入的效果，若有發現交互作用(interaction)或者主效果(main effect)，則會使用最小顯著差異法(LSD)進行事後檢定，統計顯著性設為=0.05。
結果：無論是給予強調腳跟先著地或者腳抬高的口頭指令，皆能在十二次的步態訓練後顯著增加患者於走路時著地腳的踝關節角度、步長以及速度，並且維持至1個月後的追蹤評估；此外，兩組在巴金森症狀衡量表第三部分、計時起走測試及巴金森氏症生活品質量表皆在訓練後有顯著改善並維持至追蹤評估，然而在巴金森症狀衡量表第三部分中與步態相關題目之總分和特定活動平衡信心量表的表現上並無顯著改變；另外，兩組之大腦皮質興奮性在介入後並未有顯著的變化；根據病人的回饋，我們更進一步進行次群組分析，以了解是否有凍結步態的患者會對不同的指令有不同效果，我們發現若給予有凍結步態的患者“腳跟先著地”的指令，可以改善其步長以及疾病嚴重程度至訓練後一個月久，但若給予有凍結步態的患者“腳抬高”的指令則無法維持住此效果，而對於沒有凍結步態的患者來說，給予任一口頭指令皆能改善步長並降低疾病嚴重程度。
結論：此篇研究表示在跑步機訓練下，給予巴金森氏症患者不論是腳跟先著地或者腳抬高的口頭指令皆能有效的改善其步態表現、動態平衡能力和生活品質，並降低疾病嚴重程度長達一個月之療效；未來也應該要視病患是否有凍結步態來給予不同的口頭指令，給予腳跟先著地較腳抬高能更有效地改善有凍結步態者之動作表現，而不論哪個口令，對於無凍結步態者皆有療效。

關鍵字

巴金森氏症 ； 步態 ； 口頭指令 ； 注意力策略 ； 經顱磁刺激

並列摘要

Background: Gait disorder is a common motor symptom for people with Parkinson’s disease (PD). Clinicians often use verbal instructions to improve walking ability in people with PD. One of the most commonly used verbal instructions in the clinics is “lift your foot up high/ take big steps.” However, patients often complain that this exaggerated gait pattern is not easy to maintain for a long period of time and they may get fatigue pretty easily. Therefore, seeking another effective verbal instruction to improve walking ability is necessary for people with PD. Biomechanical studies revealed that presence of heel-strike at the initial contact phase could facilitate the generation of longer step length and faster walking speed. Thus, emphasizing “heel-strike at initial contact” may be an alternative effective verbal instruction to restore walking ability in people with PD. This study, we were interested in determining the benefits of 1-month gait training emphasizing heel-strike walking on gait and other behavioral outcomes. Besides, changes in corticomotor excitability associated with the verbal instruction and gait training would be documented.
Purpose: To determine the effects of gait training emphasizing heel-strike walking on motor behavioral outcomes and corticomotor excitability in people with PD.
Methods: This study was a single-blinded, randomized controlled trial. Thirty people with idiopathic PD were recruited and randomly allocated to the heel-strike (HS) group (n=15) and the big steps (BIG) group (n=15). All participants received 1 hour of treadmill training program for 12 sessions. The verbal instructions of “strike your foot with heel” and “lift your foot high” were given to the participants in the HS group and the BIG group, respectively. All assessments were completed at pre-test, post-test and 1-month follow-up, and the participants were assessed during “ON” medication status. The primary outcomes were gait performances, including the foot-strike (FS) angle, step length, gait velocity and cadence. The secondary outcomes were the motor subscale of Unified Parkinson's Disease Rating Scale (UPDRS-III), gait-related items of UPDRS-III (UPDRS-III-gait), the Timed Up and Go test (TUG), the Activities-Specific Balance Confidence Scale (ABC scale) and the Parkinson’s Disease Quetionnaire-39 (PDQ-39). In addition, change of corticomotor excitability of tibialis anterior (TA) was assessed with transcranial magnetic stimulation (TMS).
Statistical analysis: Independent t-test and chi-square test were used to analyze the demographic characteristics and outcome measures at baseline. Two-way mixed model ANOVA was used to assess the intervention effects for each outcome measures. If group by time interactions or main effects were found, LSD post hoc analysis was further performed. A significant level was set at =0.05.
Results: Regardless of the verbal instruction emphasizing on heel-strike or taking BIG steps, participants showed significant increases in step length, gait velocity and FS angle after intervention, and the improvement maintained for at least 1 month after intervention. The participants in both groups also showed equivalent amount of improvement on UPDRS-III, TUG and PDQ-39. However, the score of UPDRS-III-gait, ABC scale, and corticomotor excitability did not change significantly after the training sessions in both groups. Based on the feedback from our participants, we further conducted a subgroup analysis to determine whether different verbal instruction might have different effects on patients who had greater gait disturbances, that is those with freezing of gait (FOG). Subgroup analysis interestingly showed that participants with FOG who received “strike your foot with heel” showed a trend of increased step length and decreased UPDRS-III after intervention, while those who received “lift your foot high” did not improve after intervention. On the other hand, patients without FOG showed similar amount of improvement in step length and UPDRS-III regardless of the instructions they received.
Conclusion: This study provided a preliminary evidence showing that treadmill training with verbal instruction emphasizing heel-strike walking was as effective as taking BIG steps in reducing gait disturbances for people with PD. Additionally subgroup analysis suggested that clinicians may provide verbal instruction of “heel-strike walking” instead of “BIG steps” to improve walking ability in patients with FOG.

並列關鍵字

Parkinson’s disease ； gait ； verbal instructions ； attentional strategy ； transcranial magnetic stimulation

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