IMPROVEMENT OF GAIT, FUNCTIONAL AND COGNITIVE PERFORMANCE IN PATIENTS WITH
PARKINSON’S DISEASE AFTER GAIT TRAINING ASSOCIATED WITH EXECUTIVE FUNCTION TASKS
BEDESCHI, C; PIEMONTE, MEP
Department of Physical Therapy, Faculty of Medical Science - University of Sao Paulo
patients.
EXECUTIVE FUNCTION GAIT TRAINING
23,5
23,0
22,5
22,0
VOLITION
SELFAWARENESS
PLANNING
RESPONSE
INHIBITION
RESPONSE
MONITORING
ATTENTION
MEAN SCORE - DIG
The purpose of this study was to compare the
effectiveness of gait training associated with executive
function tasks versus gait training alone, to improve gait,
functional performance and cognitive functions in PD
GAIT PERFORMANCE
Current effect: F(2, 40)=3.756, p=.03
Vertical bars denote 0.95 confidence intervals
21,5
21,0
20,5
20,0
19,5
19,0
18,5
MOTOR DEFICIENCY
LACK IN AUTOMATIC
CONTROL
THE ABILITY FOR
INTENTIONAL
BEHAVIOR
DISRUPTION IN
EXECUTIVE
FUNCTION
MOTOR AND
COGNITIVE
COMPONENTS
CUES OR
ATTENTIONAL
GAIT TRAINING
MOTOR
GAIT TRAINING
ASSOCIATED WITH
EXECUTIVE FUNCTION
TASKS
• STIMULATE THE AUTOMATIC
CONTROL ON GAIT
• IMPROVE THE
FUNDAMENTALEXECUTIVE
FUNCTIONS NEEDED TO SUPPORT
THE FUNCTIONAL GAIT
• STIMULATE THE
CORTICAL CONTROL ON
GAIT
COMPONENTS
• DECREASE CORTICAL
RESOURCES AVAILABLE
FOR OTHER TASKS
EXCLUDED (DID NOT MEET
INCLUSION CRITERIA)
N=8
RANDOMIZED
20
GAIT TRAINING (GT) N=10
ASSESSMENT BEFORE
TRAINING
N=10
N=10
N=10
N=10
ASSESSMENT AFTER
TRAINING
N=10
N=10
N=10
N=10
7 DAYS AFTER END OF TRAINING
FOLLOW-UP
30 DAYS AFTER END OF TRAINING
THE ABILITY TO
APPROPRIATELY
ALLOCATE
ATTENTION
DATA ANALYSIS
• The following measures were compared: (1) Unified Parkinson Disease Rating
Scale (UPDRS), for assessing functionality; (2) Montreal Cognitive Assessment
(MOCA), for assessing cognitive functions; and (3) Dynamic Gait Index (DGI), for
functional gait performance before training (BT), 7 days (AT), 30 days(FOLLOWUP) after end of training, using ANOVA for repeated measures
17,0
BT
AT
FOLLOW-UP
ASSESSMENTS
COGNITIVE PERFORMANCE
Current effect: F(2, 32)=4.9123, p=.01
Vertical bars denote 0,95 confidence intervals
GT
EFGT
30
DEFICT TO
ESTIMATE ONE’S
PHYSICAL
LIMITATIONS
AND TO
EVALUATE THE
ENVIRONMENT
GAIT IN RISK
CONDITION
PATIENTS WERE
ASKED TO WALK
AND AVOID
PREDICTED RISKS
DEFICITS IN
DECISIONMAKING
ABILITIES WHILE
WALKING IN A
COMPLEX
ENVIRONMENT
DEFICT TO WALK
IN COMPLEX,
EVERYDAY
ENVIRONMENTS
DECISIONMAKING IN GAIT
STROOP-TEST IN
GAIT
PATIENTS WERE
ASKED TO WALK
FOLLOWING ONGOING VERBAL
INSTRUCTIONS
PATIENTS WERE
ASKED TO SOLVE
THE AUDITORY
STROOP-TEST
WHILE WALKING
REDUCED ABILITY
IN MONITORING
THE
PERFORMANCE
LEADING TO
INCREASED GAIT
VARIABILITY
DEFICT TO
MANAGE THE
ATTENTION
DURING MULTITASKS
GAIT WITH A
COMPLEX
PURPOSE
GAIT WITH HIGHLOAD COGNITIVE
DEMAND
PATIENTS WERE
ASKED TO WALK
IN ORDER TO GET
PRODUCTS FROM
A PREVIOUSLY
MEMORIZED LIST
PATIENTS WERE
ASKED TO WALK
WHILE DECIDING
WHICH
PRODUCTS TO
BUY
26
24
22
20
18
16
14
BT
AT
FOLLOW-UP
ASSESSMENTS
GT
EFGT
UPDRS
Current effect: F(2, 38)=10.301, p=.0002
Vertical bars denote 0,95 confidence intervals
40
38
CONTROL TRAINING
In the GT, gait was trained using the same trajectory and over the
same period of time but with no associated tasks.
Patients from both groups were instructed to stride as quickly as
possible.
• PRIMARY
– DYNAMIC GAIT INDEX
EXECUTIVE FUNCTION GAIT
TRAINING (EFGT) N=10
10 SESSIONS (2 PER WEEK)
17,5
OUTCOME MEASURES
ALLOCATED TO
INTERVENTION
INTERVENTION
LOSS OF
MOBILITY DUE
TO REDUCED
MOTIVATION
PATIENTS WERE
ASKED TO WALK
TO AS FAST AS
POSSIBLE TO
BEAT A RECORD
N=28
ASSESSED FOR ELEGIBILITY
18,0
28
GAIT GOALDIRECTED
DESIGN: Double-blinded, randomized, controlled, longitudinal clinical trial
PARTICIPANTS: 20 patients with idiopathic PD, mean age of 68.5 years (S.D = 5.24),
12 men and 8 women, at stages 1 and 2 of the disease according to the Hoehn and
Yahr Classification, and asymptomatic for depression and dementia.
All participants signed the HCFMUSP informed consent term.
THE ABILITY TO
COMPARE
ONGOING
ACTIONS WITH
AN INTERNAL
PLAN AND TO
DETECT ANY
POSSIBLE ERRORS
MEAN SCORE - MOCA
COGNITIVE
DEFICIENCY
THE ABILITY TO
IGNORE
IRRELEVANT
SENSORY INPUTS
AND FILTER OUT
DISTRACTIONS IN
ORDER TO SOLVE
PROBLEMS AND
RESPOND
• SECUNDARY
–MONTREAL COGNITIVE ASSESSMENT (MoCa)
–UNIFED PARKINSONS DISEASE RATING SCALE (UPDRS)
RESULTS
The results revealed significant interaction between training types
(EFGT and GT) and assessments (BT; AT; FOLLOW-UP) on UPDRS,
MOCA and DGI scores (ANOVA, p< 0.001), confirmed by Tukey’s
post-hoc test which showed that EFGT led to superior improvement
and retention compared to GT.
36
34
32
MEAN SCORE
GAIT
IMPAIRMENT
IN DAILY
LIVING
ACTIVITIES
THE ABILITY TO
PLACE ONESELF
IN THE PHYSICAL
ENVIRONMENT
AND THE ONGOING
SITUATION
THE ABILITY TO
IDENTIFY AND
ORGANIZE THE
STEPS AND
ELEMENTS
NEEDED TO
CARRY OUT AN
ACTION
30
28
26
24
22
20
18
16
14
BT
AT
FOLLOW-UP
ASSESSMENTS
GT
EFGT
CONCLUSION
EFGT was found more effective compared to GT for improving
motor and cognitive performance in PD patients.
IMPLICATIONS
The findings of this study demonstrate the importance of motor
training associated with cognitive functions to attenuate the
functional impairments in PD patients, and thereby show that
despite automatic motor control dysfunctions and cognitive
deficiencies, performance of this patient group on multiple tasks
can be improved.