IMPROVEMENT OF GAIT,
FUNCTIONAL AND COGNITIVE
PERFORMANCE IN PATIENTS WITH
PARKINSON’S DISEASE AFTER GAIT
TRAINING ASSOCIATED WITH
EXECUTIVE FUNCTION TASKS
BACKGROUND
MOTOR
DEFICIENCY LACK IN
AUTOMATIC
CONTROL
GAIT
IMPAIRMENT
IN DAILY
LIVING
COGNITIVE
DEFICIENCY DISRUPTION IN
EXECUTIVE
FUNCTION
BACKGROUND
MOTOR AND
COGNITIVE
COMPONENTS
CUES OR ATTENTIONAL
GAIT TRAINING
•STIMULATE THE CORTICAL
CONTROL ON GAIT
•DECREASE CORTICAL
RESOURCES AVALIABLE TO
OTHER TASKS
MOTOR
COMPONENTS
GAIT TRAINING
ASSOCIATED WITH
EXECUTIVE FUNCTION
TASKS
•STIMULATE THE
AUTOMATIC CONTROLE ON
GAIT
•IMPROVE THE
FUNDAMENTALEXECUTIVE
FUNCTIONS NEDD TO
SUPPORT THE
FUNCTIONAL GAIT
PURPOSE
• The aim 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
patients.
METHODS
• DESING
– A 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 who were asymptomatic for
depression and dementia, took part in the study. All
participants signed the HCFMUSP informed consent
term.
N=28
ASSESSED FOR ELEGIBILITY
EXCLUDED (DID NOT METT
INCLUSION CRITERIA)
N=8
RANDOMIZED
20
ALLOCATED TO INTERVENTION
EXECUTIVE FUNCTION GAIT TRAINING
(EFGT) N=10
GAIT TRAINING (GT) N=10
ASSESMENT BEFORE TRAINING
N=10
N=10
N=10
N=10
N=10
N=10
N=10
N=10
INTERVENTION
10 SESSIONS (2 PER WEEK)
ASSESMENT AFTER TRAINING
7 DAYS AFTER END OF TRAINING
FOLLOW-UP
30 DAYS AFTER END OF TRAINING
OUTCOME MEASURES
• PRIMARY
– GAIT SPEED
• SINGLE TASK
• DUAL TASK
– GAIT + MOTOR TASK
– GAIT + COGNITIVE TASK
• SECUNDARY
– DYNAMIC GAIT INDEX
– MONTREAL COGNITIVE ASSESSMENT (MoCa)
– UNIFED PARKINSONS DISEASE RATING SCALE (UPDRS)
INTERVENTION
• Both types of training session were preceded
by 30 minutes of general mobility exercises.
• In the EFGT, gait was trained in association
with six different tasks simulating daily living
situation of the patients and requiring divided
attention, memory, particularly working
memory, perceptual judgment, decisionmaking, response inhibition, response
monitoring, among others.
VOLITION
SELFAWARENESS
PLANNING
RESPONSE
INHIBITION
RESPONSE
MONITORING
ATTENTION
THE CAPACITY FOR
INTENTIONAL
BEHAVIOR
THE ABILITY TO PLACE
ONESELF IN THE
PHYSICAL
ENVIRONMENT AND
THE ON-GOING
SITUATION
THE ABILITY TO
IDENTIFY AND
ORGANIZE THE STEPS
AND ELEMENTS
NEEDED TO CARRY OUT
AN ACTION
THE CAPACITY TO
IGNORE IRRELEVANT
SENSORY INPUTS AND
FILTER OUT
DISTRACTIONS IN
ORDER TO SOLVE
PROBLEMS AND
RESPOND
ABILITY TO COMPARE
ONGOING ACTIONS
WITH AN INTERNAL
PLAN AND TO DETECT
ERRORS
THE ABILITY TO
APPROPRIATELY
ALLOCATE ATTENTION
LOSS OF MOBILITY DUE
TO REDUCED
MOTIVATION
DEFICT TO ESTIMATE
THE ONE’S PHYSICAL
LIMITATIONS AND TO
AVALUATE THE
ENVIRONMENTAL
DEFICITS IN DECISIONMAKING ABILITIES
WHILE WALKING IN A
COMPLEX
ENVIRONMENT
DEFICT TO WALK IN
COMPLEX, EVERYDAY
ENVIRONMENTS
REDUCTION IN ABILITY
TO MONITORING THE
PERFORMANCE
LEADING TO INCREASE
IN GAIT VARIABILITY
DEFICT TO MANAGE
THE ATTENTION
DURING MULTI-TASKS
GAIT IN RISK
CONDITION – PATIENTS
WERE ASKED TO WALK
AVOIDING PREDICTED
RISKS
DECISION-MAKING IN
GAIT – PATIENTS WERE
ASKED TO WALK
FOLLOWING ON-GOING
VERBAL INSTRUCTIONS
STROOP-TEST IN GAIT –
PATIENTS WERE ASKED
TO SOLVE THE
AUDITORY STROOPTEST WHILE WALKING
GAIT GOAL-DIRECTED –
PATIENTS WERE ASKED
TO WALK TO AS FAST
AS POSSIBLE TO BEAT A
RECORD
GAIT WITH COMPLEX
PURPOSE – PATIENTS
WERE ASKED TO WALK
WITH THE PURPOSE
GETTING PRODUCT S
FROM A PREVIOUSLY
MEMORIZED LIST
GAIT WITH HIGH-LOAD
COGNITIVE – PATIENTS
WERE ASKED TO WALK
WHILE DECIDING TO
PRODUCTS CAN BUY
WITH A SPECIFIC
AMOUNT OF MONEY
INTERVENTION
• In the GT, gait was trained in the same
trajectory and for the same period but with no
associated tasks.
• Patients from both groups were instructed to
walk while taking long steps as quickly as
possible.
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; (3) gait
performance on a single task; (4) gait
performance on a dual-task; and (5) functional
gait performance before training (BT), 7 (AT),
30 (RET 1) days after end of training, using
repeated measures ANOVA.
RESULTS
• The results revealed significant interaction between
training type (EFGT and GT) and scores (BT; AT; RET1;
RET2) on UPDRS and MOCA assessments (ANOVA, p<
0.001) as well as dual-task and functional gait
performance (ANOVA, p< 0.0001), confirmed by
Tukey’s post-hoc test which showed that EFGT led to
superior improvement and retention compared to GT.
• Regarding single-task gait, only a significant assessment
effect was observed, confirmed by Tukey’s post-hoc
test, which showed that both groups improved gait
performance on this task.
CONCLUSION
• EFGT was found to be superior 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, showing that
despite automatic motor control dysfunctions
and cognitive deficiencies, performance of this
patient group on multiple tasks can be
improved.