聽覺提示結合跑步機訓練對巴金森氏症患者於大腦皮質興奮性與步態表現的影響

Effects of Combined Auditory Cues and Treadmill Training on Cortical Excitability and Gait Performance in Parkinson’s Disease

高珮容(Pei-Jung Kao)

指導教授 ： 陸哲駒

國立臺灣大學/醫學院/物理治療學研究所/碩士(2018年)

https://doi.org/10.6342/NTU201802784

摘要

研究背景：巴金森氏症是常見的神經退化性疾病，由於基底核的退化性病變導致巴金森氏症患者在自動化動作控制上受損，例如：步態失調。臨床上常使用聽覺提示介入以改善行走步伐變異度高、凍結步態等問題。此外，聽覺提示為基礎的步態訓練對步態的改善效果可能來自於一系列神經塑性的累積。然而，目前鮮少研究顯示巴金森氏症患者經過聽覺提示訓練後其神經生理的改變，另外，也少有研究比較聽覺提示對於有或無步態凍結的巴金森氏症患者之效果。
目的：本研究將探討一次性以聽覺提示為基礎之跑步機訓練對於巴金森氏症患者神經生理與步態表現的影響，藉由經顱磁刺激評估大腦皮質興奮度來顯示神經生理之變化。本研究也探討聽覺提示對於有或無步態凍結之巴金森氏症患者是否有不同影響。
方法：此為隨機交叉試驗，收取17位巴金森氏患者(PD)，其中8位有凍結步態(FOG)，9位無凍結步態(nFOG)，且另收取9位健康成年人(Control)作為對照組參與本試驗，每組皆以隨機順序接受兩種情形之介入，兩次訓練中間會相隔至少一星期，兩次訓練分別為30分鐘之以聽覺提示為基礎之跑步機訓練(AC condition)和沒有聽覺提示之跑步機訓練(NC condition)。每位受試者將接受介入前和介入後的評估。主要評估指標為大腦皮質興奮度，次要評估指標為舒適與最快行走速度下的走路表現。
統計分析：使用變異數分析(analysis of variance)檢測組間介入前、後之變化。
結果： 在大腦皮質興奮度方面，無論有無聽覺提示，巴金森氏症患者相較於健康人在接受訓練後其皮質寧靜期(cortical silent period, CSP)顯著延長(p<0.001)，有凍結症狀組只有在合併聽覺提示訓練後有顯著延長的現象(AC: p=0.032; NC: p=0.257)，而無凍結步態組無論有無聽覺提示介入，其皮質寧靜期都有顯著延長(AC: p=0.007; NC: p=0.008)。無論有無聽覺提示，巴金森氏症患者與健康人在經過訓練後，顯著減少刺激間距兩毫秒的皮質內抑制(short intracortical inhibition, SICI)以及增加刺激間距十、十二毫秒的皮質內促進(short intracortical facilitation, ICF)，然而有和無凍結步態組在皮質內抑制與促進方面，經過無論有無聽覺提示的訓練後並無顯著差異。在步態表現方面，無論有無聽覺提示，巴金森氏症患者與健康人在訓練後顯著增加舒服行走速度(p=0.006)與步長(p<0.001)，此外，無論有無聽覺提示，有凍結步態組與無凍結步態組經過訓練後，皆顯著增加其舒服行走的步長(p=0.002)，在舒服行走步伐變異度方面，無論有無聽覺提示介入，有凍結步態組經過訓練後，其行走步伐變異度有下降趨勢，而無凍結步態組則呈相反趨勢。
結論： 一次性的跑步機訓練無論有無結合聽覺提示，可以調控巴金森氏症患者之大腦皮質興奮度並且增加舒服行走時的步長與速度。聽覺提示結合跑步機訓練能增強有或無凍結步態者的皮質脊髓抑制，然而，有凍結步態者若接受沒有聽覺提示的跑步機訓練則沒有顯示此效果。

關鍵字

巴金森氏症 ； 聽覺提示 ； 經顱磁刺激 ； 皮質興奮度 ； 步態 ； 跑步機訓練

並列摘要

Background: Parkinson’s disease (PD) is a common neurodegenerative disorder. Dysfunction of dopaminergic cells in basal ganglia leads to deficits in the automatic execution of movements such as gait disturbances. Auditory cues are often used in clinical setting and revealed benefits in ambulation. Moreover, the effects of cueing-based training on gait pattern might come from the accumulation of a series of neuroplasticity through serial motor training. However, current studies provided little information on the changes of neuroplasticity after the patients with PD carried out the cued-based training. Furthermore, it is still uncertain whether PD with or without freezing of gait (FOG) can achieve equal favorable effects from auditory cues.
Purpose: The present study is to investigate the effects of auditory-cued treadmill training for a single session on the neurophysiology and gait performance in patients with PD. Neurophysiology will be evaluated the cortical excitability through transcranial magnetic stimulation (TMS). The study will further explore whether any different effects of auditory cues between freezers and non-freezers.
Methods: This is a crossover study. Freezers (FOG, n=8), non-freezers (nFOG, n=9), and healthy subjects (control, n=9) were recruited in this study. Each subject randomly carried out training with two condition with at least one-week washout interval. Two conditions were 30-minutes of treadmill training with (AC condition) and without rhythmic auditory cues (NC condition). All subjects received the baseline and post-treatment assessments. Primary outcome measures included the cortical excitability and the secondary outcome measures included the gait performance in both comfortable and fast walking speed.
Statistical analysis: Repeated measure analysis of variance (RM-ANOVA) was used to determine differences of mean scores of the dependent variables between groups under two condition. The statistical significance was set at P<0.05.
Results: PD subjects compared to healthy subjects revealed lengthened CSP duration after training whether with or without auditory cues (p<0.001 and p=0.392, respectively). Significantly increased CSP duration in AC condition (p=0.032), but not in NC condition (p=0.257) for the FOG group was found. The nFOG group presented significantly lengthened CSP duration in both AC and NC condition (p=0.007 and p=0.008, respectively). Both PD and control groups reduced SICI(2ms), increased ICF(10ms), and ICF(12ms) after training whether with or without AC (p=0.003, p=0.009, and p=0.009, respectively), but the FOG and nFOG did not show significant differences in SICI and ICF after training. For the gait performance in comfortable speed, PD and control group showed increased speed (p=0.006) and stride length (p<0.001) after training whether with or without AC. Moreover, both the FOG and nFOG group increased stride length (p=0.002) after treadmill training whether with or without auditory cues. The step time CV in the FOG group presented a downward tendency after training, whereas the non-freezers presented an opposite picture.
Conclusion: One-session treadmill training whether with or without auditory cues played a major role in modulated cortical excitability, increased step length, and gait velocity in comfortable walking speed for patients with PD. The auditory cues with treadmill training enhanced the corticospinal inhibition in both freezers and non-freezers. However, this phenomenon cannot be found in freezers when they received treadmill training without cues.

並列關鍵字

auditory cueing ； transcranial magnetic stimulation ； cortical excitability ； gait ； treadmill training

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