注意力聚焦策略對無凍凝步態巴金森患者於雙重作業行走訓練及大腦活動的影響

The Effects of Attentional Focus Strategies on Dual-Task Walking Training and Related Brain Activity in Parkinson’s Disease without Freezing of Gait

鄭之姸(Chih-Yen Cheng)

指導教授 ： 黃正雅

國立臺灣大學/醫學院/物理治療學研究所/碩士(2021年)

https://doi.org/10.6342/NTU202103668

摘要

研究背景與目的：由於動作自動化控制困難與注意力資源分配能力不佳，雙重作業行走困難為巴金森氏症患者常見的問題之一。注意力聚焦策略可分為「內聚焦策略」與「外聚焦策略」，為一透過自主注意力控制改變其資源分布，進而影響動作控制與學習的因子之一。相較於專注於動作本身的內聚焦策略，專注於動作所產生現象與外界環境作用的外聚焦策略，能達到較佳的靜態姿勢控制。然而，注意力聚焦策略對巴金森氏症患者之雙重作業行走訓練之成效仍未被探討。由於有、無凍凝步態患者之動作自動化控制受損能力不同，兩族群所適用之注意力策略可能有所不同。因此，本研究的目的為探討內聚焦策略及外聚焦策略何者更能有效增進無凍凝步態巴金森氏症患者之雙重作業行走訓練成果。
研究方法：本研究共招募28名無凍凝步態之巴金森氏症患者，隨機分配至內聚焦策略組及外聚焦策略組，進行為期6週，每週2次的雙重作業行走訓練。於訓練過程中，兩組受試者將依組別接收到不同指令。內聚焦組為將注意力配置在肢體動作本身；而外聚焦組則將注意力配置在動作與外界物體之作用上，意即以外在環境物品為注意力目標。本研究分別於訓練前、訓練後，及8週後於有藥效、無藥效狀態下皆進行評估。評估項目包含單一作業行走表現、動作與認知雙重作業行走表現、行走時腦波頻帶相對強度，以及臨床量表，臨床量表包含：新版世界動作障礙學會巴金森病綜合評量表第三部分、伯格式平衡量表、特定活動平衡信心量表、坐站起走與雙重作業坐站起走時間、行走時手臂擺盪程度。
結果：在6週訓練後，在單一任務行走情境時，無論在有、無藥效狀態下，內聚焦組的行走速度與步長皆顯著增加，步幅時間變異性則在內、外聚焦組皆顯著下降。在動作與認知雙重作業情境時，無論在有、無藥效狀態下，內聚焦組與外聚焦組的行走速度與步長皆顯著增加。然而在步幅時間變異性參數上，雖內聚焦組與外聚焦組在有藥效狀態下皆顯著降低步態變異性，但在無藥效狀態下，僅有內聚焦組可顯著降低步幅時間變異性。在腦波相對頻帶強度改變上，經訓練後在有藥效狀態下，內聚焦組在單一作業行走情境時，於頂葉-枕葉區呈現theta頻帶強度上升與beta頻帶強度降低。在動作雙重作業行走情境時，內聚焦組在頂葉-枕葉區之beta頻帶強度顯著下降，而在認知雙重作業行走情境時，其額葉及頂葉-枕葉區之theta頻帶強度顯著上升。在無藥效狀態下，內聚焦組在單一作業行走情境時，alpha頻帶強度於感覺運動區顯著下降。在動作雙重作業行走情境時，內聚焦組在前額葉、額葉與頂葉-枕葉區之alpha頻帶強度皆顯著下降。在認知雙重作業行走情境下，外聚焦組在前額葉之theta頻帶強度則顯著上升。臨床量表顯示，內聚焦組與外聚焦組經訓練後巴金森病綜合評量表第三部分分數降低、伯格式平衡量表分數增加、坐站起走及雙重作業坐站起走所需的時間減少，但於無藥效下，僅有內聚焦組在三項評估上皆達最小臨床重要差異或最小偵測差異。另行走時手臂擺盪幅度在有藥效時亦顯著增大。
重要性與預估貢獻：本研究探討不同注意力聚焦策略對雙重作業行走訓練之影響，以及其對於大腦神經可塑性之影響。研究顯示經6週雙重作業行走訓練後，單一作業行走情境下內聚焦組有較佳的表現且可持續到8週後之追蹤測試。而內、外聚焦組在動作與認知雙重作業行走情境之行走表現皆顯著進步。然而在有、無藥效時的單一作業行走情境，以及無藥效時的動作與認知雙重作業行走情境下，內聚焦組的行走表現於步態參數上(行走速度、步長、跨步時間變異性)皆反映較外聚焦組更佳的訓練成效。臨床上，建議以內聚焦策略進行雙重作業行走訓練，可有效改善無凍凝步態巴金森氏症患者的單一作業及雙重作業行走表現，並降低動作嚴重度以及提升其平衡控制能力，以達到早期臨床介入成效。

關鍵字

雙重作業行走訓練 ； 注意力聚焦策略 ； 巴金森氏症 ； 腦波圖

並列摘要

Background and Purpose: Due to impaired movement automaticity and attentional capacity, patients with Parkinson’s disease (PD) have difficulty in dual-task walking. Attentional focus is a strategy which re-constructs one’s attention allocation through voluntary attentional control, which can be further categorized as “internal focus” strategy and “external focus” strategy. However, it has not been well investigated the effects of attentional focus on dual-task walking in PD. Due to different severity of automaticity dysfunction, the appropriate attentional focus strategy may be varied in freezers and non-freezers. Therefore, this study aimed to investigate the effects of different attentional focus strategies on dual-task walking training and its related brain activity in patients with PD without freezing of gait (FOG).
Method: Twenty-eight patients with PD without FOG were recruited in the study and assigned into internal focus (IF) group and external focus (EF) group randomly. The participants received a 6-week dual-task training protocol with two sessions per week. During training, the instructions of attentional focus on walking were different between the IF and EF groups. Participants in the IF group were instructed to focus on their movements. In contrast, participants in the EF group were instructed to focus on the effects of their movements, such as focusing on the targets in the environments. Evaluations were conducted before training (pre-test), after training (post-test), and 8 weeks after training (follow-up) under both “ON” medication and “OFF” medication states. Gait performance during single-task walking and which during motor and cognitive dual-task walking, suprapostural task performance, relative power recorded by EEG during walking, and clinical evaluations, including Movement Disorder Society-Unified Parkinson’s Rating Scale part III (MDS-UPDRS III), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC scale), Timed Up and Go (TUG), dual-task TUG, and a movement battery for reduced arm swing were recorded.
Results: After the 6-week dual-task walking training, both IF and EF groups decreased stride time variability during single-task walking under both “ON” and “OFF” medication states. However, only the IF group significantly increased gait velocity and step length. During motor and cognitive dual-task walking, although both IF and EF groups increased gait velocity and step length under both “ON” and “OFF” states and reduced stride time variability under “ON” medication state, only the IF group decreased stride time variability under “OFF” medication state. Under “ON” medication state, increased theta power and decreased beta power in parietal-occipital area were found in the IF group during single-task walking. Increased beta power in parietal-occipital area, and increased theta power over frontal and parietal-occipital areas were also found in the IF group during motor and cognitive dual-task walking, respectively. Under “OFF” medication state, the IF group decreased alpha power in sensorimotor area during single-task walking. During motor-dual task walking, alpha power over prefrontal, frontal and parietal-occipital areas decreased in the IF group. On the other hand, during cognitive dual-task walking, theta power in prefrontal area increased in the EF group. In terms of clinical evaluations, both IF and EF group reduced the scores of MDS-UPDRS III, increased the scores of BBS and decreased the completion time of TUG and dual-task TUG after training. In particular, the improvement of these three items achieved minimal clinically important difference or smallest detectable difference under “OFF” medication state in the IF group. In addition, arm swing movements during walking also improved in both IF and EF group under “ON” medication state.
Significance and Contribution: This study investigates the effects of internal focus and external focus on dual-task walking training and the related neural plasticity. The results of our study demonstrated that both IF and EF groups improved dual-task walking performance under both “ON” and “OFF” medication states. However, the IF training strategy led to superior control during single-task walking under both “ON” and “OFF” medication state, and dual-task walking under “OFF” medication state. Dual-task walking paradigm with IF strategy could be used for improving balance/ambulation control and reducing motor severity in PD without FOG.

並列關鍵字

Dual-task training ； Attentional focus ； Parkinson ； Electroencephalography

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