聽覺提示對巴金森氏症病患的節律性動作及大腦皮質興奮性效果

Abstract

前言： 巴金森氏症是一種進行性的退化性中樞疾病，患者之動作功能會受影 響，患者通常表現於動作起始困難，進行節律性動作以及動作執行皆受影響。除 藥物治療及手術治療外，非侵入性的治療及訓練十分重要，而外在提示（external cue）是臨床上常用於訓練巴金森氏症患者的一種技巧，尤其常用於行走及步態訓練；而聽覺提示（auditory cue）是外在提示的一種，其對節律性的動作的效果較為顯著。有相當多文獻佐證聽覺提示在臨床上的應用，但大部分文獻只討論同步給予提示時的臨床表現，鮮少文獻探討其神經生理的變化，且該類文獻的樣本數亦較少。 目的： 本研究採用同步化的聽覺提示，對照沒有同步化聽覺提示，並要求巴 金森氏症患者做出特定頻率的節律性的手指動作(rhythmic finger movement)，觀察這兩種情況下巴金森氏症患者的動作表現，並以經顱磁刺激(transcranial magnetic stimulation, TMS) 評 估 大 腦 皮 質 興 奮 性 及 近 紅 外 線 吸 收 光 譜 (near infrared spectroscopy, NIRS)來偵測執行動作時腦部血流量變化，以研究巴金森氏症患者於進行聽覺提示訓練時的神經生理改變並探討其可能機轉。 方法： 此為隨機交叉實驗，受試者為確診的巴金森氏症患者，並以隨機次序 接受兩種介入，外在提示組是指於同步化的聽覺提示下進行節律性手指動作，自 我引導組則先聽提定頻率的節奏，再進行動作，兩次介入間的洗脫時間為一至兩 週。本實驗收集並分析兩者的動作表現，以近紅外線吸收光譜偵測執行動作時腦 部血流量變化，並於實驗前後以經顱磁刺激評估大腦皮質興奮性。 結果： 共 18 名（年齡為 60.3±6.5 歲）巴金森氏症患者參加本實驗，受試者的 巴金森症病情的分期（Modified Hoehn & Yahr Stage）為 I 至 III 期。外在提示組在練習過後，其快速手指動作的變異度顯著減少（Z = -2.635, p = .008），大腦皮質內的抑制強度（short intracortical inhibition, SICI）也顯著增加（刺激間距為 2 毫秒：Z = -3.010, p = .003；3 毫秒：Z = -2.045, p = .041）。而前額葉的血液動力變化中，兩組的血氧差及總血紅素在實驗後皆顯著增加。 結論： 同步化的聽覺提示能顯著增加節律性動作表現，以及調節大腦皮質內興奮性。

Background: Parkinson’s disease (PD) is a progressive degenerative disease of central nervous systems deficit. The clinical symptoms of Parkinson’s disease include many motor tasks: difficult in initiating movement, performing rhythmic movement. Rehabilitation such as physical therapy, which aims to improve patient’s quality of life and functions, is a non-invasive treatment and value for PD patients. Auditory cueing is a technique that widely applied on training patients with Parkinson’s disease. Some studies revealed that auditory cues could improve motor performance. However, the mechanism under this treatment technique is still unknown. Objective： This study was to investigate the effect of auditory cueing on rhythmic finger movement in patients with Parkinson’s disease. Neurophysiological data such as motor cortex excitability and blood flow in prefrontal cortex were assessed by using transcranial magnetic stimulation (TMS) and near infrared spectroscopy (NIRS). Methods: This study was a cross-over study. Patients diagnosed as Parkinson’s disease received two sessions of experiment in random order, one was external triggered (ET) group which received auditory cueing while performing movement, another group was self-initiated (SI) group which performing movement after listening to required movement rhythm and initiate the movement themselves. Results: Eighteen PD patients aged 60.3 ± 6.5 years participated in this study. The Hoehn and Yahr stage was I-III. The CV of fast tapping was significantly decreased in ET group (Z = -2.635, p = .008). The short intracortical inhibition (SICI) in 2 ms and 3 ms were significant larger (Z = -3.010, p = .003; Z = -2.045, p = .041, respectively) after tapping with concurrent external cues. For hemodynamics in prefrontal cortex, the concentration of Hb-Diff and tHb was significantly increased over time in both ET group and SI group. Conclusions: Concurrent auditory cueing had significant benefit in rhythmic movement and able to modulate the cortical excitability in the motor cortex.