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Effects of Gait Training Emphasizing Heel-strike on Motor Performances and Corticomotor Excitability in People with Parkinson's Disease
Parkinson’s disease,gait,verbal instructions,attentional strategy,transcranial magnetic stimulation,
|Publication Year :||2019|
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。
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.
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