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Comparison Between Forward and Backward Gait Retraining for Mobility in Individuals with Mild to Moderate Parkinson’S Disease

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Comparison Between Forward and Backward Gait Retraining for Mobility in Individuals with Mild to Moderate Parkinson’S Disease COMPARISON BETWEEN FORWARD AND BACKWARD GAIT RETRAINING FOR MOBILITY IN INDIVIDUALS WITH MILD TO MODERATE PARKINSON’S DISEASE by Roné Grobbelaar Article-format MSc Thesis presented in partial fulfilment of the requirements for the degree of Master of Science in the Faculty of Education at Stellenbosch University Supervisor: Dr Karen Welman Co-supervisor: Prof Ranel Venter March 2017 Stellenbosch University https://scholar.sun.ac.za Declaration By submitting this thesis electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof (save to the extent explicitly otherwise stated), that reproduction and publication thereof by Stellenbosch University will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining any qualification. March 2017 Copyright © 2017 Stellenbosch University All rights reserved i Stellenbosch University https://scholar.sun.ac.za ABSTRACT Background Dysfunctional gait and transitional movements are the most disabling features of Parkinson‟s disease (PD) and often relates to falls. Due to executive dysfunction in PD, dual tasking (DT) is detrimental to already impaired mobility parameters. Backwards walking (BW) might be a useful training alternative to improve aberrant PD gait and transitional movements to consequently improve the quality of complex, multi-directional daily activities, which most often involve DT. Over ground BW gait retraining has shown to be beneficial for neurological gait rehabilitation; however, has not yet been investigated in PD. Training in complex, novel tasks may induce enhanced cortical activity for movement preparation that is beyond training in automatic tasks. Purpose This study aimed to compare the effect of an eight-week forward and backwards gait retraining program on gait parameters, postural transitions and turning in PD individuals as well as the related percentage DT interference (%DTC). Methods This randomized controlled trial was performed as a staggered design in the Western Cape. Twenty-nine PD individuals (34.5% women) with disease severity of 38.1±12.3 (Movement Disorder Society – Unified Parkinson‟s Disease Rating Scale; UPDRS III) were randomly assigned into a forward (FWG) or backward (BWG) walking group by means of concealed, simple randomization (1:1 ratio). The FWG included 14 participants (aged: 70±11 years; Hoehn and Yahr (H&Y): 2.7±0.5; disease duration: 7±6 years) and was compared to 15 participants of similar age (72±6 years), H&Y (2.7±0.9) and disease duration (5±3 years) in the BWG. Groups performed a 24-session (3x/week for eight weeks) over ground gait retraining program of the same tasks in opposite directions. Descriptive measures at baseline included body mass index, experiences of daily living (UPDRS II), global cognition (Montreal Cognitive Assessment), depression (Patient Health Questionnaire-9) and freezing status (Freezing of Gait Questionnaire). Participants completed an instrumented (APDM®) 10m-Walk (i10mWT), a Five-times-Sit-to- Stand (i5xSTS) and Timed-Up-and-Go (iTUG) test under both single task (ST) and DT (cognitive, arrhythmic) conditions before and after the intervention. Participants were blinded to the primary outcome measures, which were selected gait variables (i10mWT), sit-to-stand (i5xSTS) and stand-to-sit (iTUG) transitions as well as turning variables (iTUG), together with %DTC of each variable. Secondary outcome measures included functional capacity (FC, Six- ii Stellenbosch University https://scholar.sun.ac.za Minute-Walk test), balance confidence (Activity-specific Balance Confidence scale) and disease related quality of life (Parkinson‟s Disease Questionnaire-39; PDQ-39). Results Both groups improved ST walking velocity (FWG: p=0.04, d=0.35; BWG: p<0.01, d=0.57), ST turning velocity (FWG: p=0.04, d=0.28; BWG: p=0.05, d=0.28), FC (FWG: d=0.82; BWG: d=1.06; p<0.01) and MDS-UPDRS III scores (FWG: p=0.02, d=0.45; BWG: p=0.03, d=0.62). Additionally, the BWG improved individual PDQ-39 domains (p=0.01, d=0.41), i10mWTST time (p<0.01, d=0.45), gait cycle time (p=0.01, d=0.00), stride length (SL; p=0.02, d=0.39) and cadence (p<0.01, d=0.67); however worsened SL variability (p=0.04, d=0.83) under ST conditions. The BWG also improved %DTC for percentage double support (%DS) variability (p=0.05, d=0.57); however deteriorated %DTC for %DS (p=0.05, d=0.45) and swing time gait asymmetry (p=0.02, d=0.61). The FWG improved UPDRS II scores (p=0.03, d=0.44), i5xSTSST duration (p<0.01, d=0.52), iTUG duration (ST: p<0.01, d=0.71; DT: p=0.02, d=0.54), turning angle (ST: p=0.02, d=0.52; DT: p=0.01, d=0.62) and %DTC for SL (p=0.02, d=0.67). Conclusion Both FW and BW over ground gait retraining can be beneficial for PD mobility. Even though most outcomes are training direction specific, findings illustrates that the ability to learn remains intact in mild to moderate PD. Considering that both interventions yielded individual benefits, BW should not replace, but rather be added to a FW gait retraining program. Albeit FW can be a beneficial non-pharmacological method to improve mobility aspects, BW is an interesting alternative for rehabilitative purposes in mild to moderate PD. iii Stellenbosch University https://scholar.sun.ac.za OPSOMMING Agtergrond Disfunksionele loopgang en oorgangsbewegings is die mees belemmerende kenmerke van Parkinson se siekte (PD) en hou dikwels verband met valrisiko. Te danke aan verswakte uitvoerende funksie in PD, word mobiliteit verder belemmer wanneer ʼn dubbele-taak (DT) bygevoeg word. Agteruit loop (BW) kan 'n nuttige alternatief vir rehabilitasie van abnormale loopgang en oorgang bewegings in PD wees. Sodoende, kan die gehalte van komplekse, multi- rigting daaglikse aktiwiteite, wat meestal DT insluit, verbeter word. Voorheen is getoon dat inoefening van bogrondse BW vir loopgang in neurologiese kondisies voordelig kan wees, maar is egter nog nie in PD ondersoek nie. In vergelyking met inoefening van ʼn bekende, outomatiese taak, kan inoefening van ʼn komplekse, nuwe taak verbeterde kortikale aktiwiteit vir voorbereiding van beweging veroorsaak. Doel Die doel van hierdie studie was om 'n agt-weke vorentoe en agtertoe loopgang inoefeningsprogram in PD individue te vergelyk ten opsigte van loopgang veranderlikes, posturale oorgangsbewegings en draai vermoëns sowel as die verwante invloed van ʼn DT (%DTC) op hierdie veranderlikes. Metodes Hierdie studie is as 'n gespreide ontwerp in die Wes-Kaap uitgevoer, waar groepe, insluitend ʼn kontrole groep, lukraak verdeel was. Nege-en-twintig PD individue (34,5% vroue) met siekte ernstigheidsgraad van 38.1 ± 12.3 (Movement Disorder Society – Unified Parkinson‟s Disease Rating Scale; UPDRS III) is ewekansig verdeel in 'n vorentoe (FWG) of agtertoe (BWG) loop groep deur middel van versteekte, eenvoudige randomisering (1: 1-verhouding). Die FWG het 14 deelnemers (ouderdom: 70±11 jaar; Hoehn en Yahr (H&Y): 2.7±0.5; siekte duur: 7 ± 6 jaar) ingesluit en is met 15 deelnemers van dieselfde ouderdom (72±6 jaar), H&Y (2.7±0.9) en siekte duur (5 ± 3 jaar) in die BWG vergelyk. Groepe het 'n 24-sessie (3x / week vir agt weke) bogrondse loopgang inoefeningsprogram, van dieselfde take in teenoorgestelde rigtings, gevolg. Beskrywende veranderlikes by basislyn het liggaamsmassa-indeks, ervarings van die daaglikse lewe (UPDRS II), globale kognisie (Montreal Cognitive Assessment), depressie (Patient Health Questionnaire-9) en vries-status (Freezing of Gait Questionnaire) ingesluit. Deelnemers het 'n instrumentele (APDM®) 10m-Stap (i10mWT), 'n Vyf-Keer-Sit-tot-Staan (i5xSTS) en Staan-Op- en-Gaan (iTUG) toets onder beide enkel-taak (ST) en DT (kognitiewe, aritmiese) toestande voor iv Stellenbosch University https://scholar.sun.ac.za en na die intervensie voltooi. Deelnemers was geblind teen die primêre uitkomsveranderlikes, wat loopgang (i10mWT), sit-tot-staan (i5xSTS) en staan-tot-sit (iTUG) bewegings sowel as draai veranderlikes (iTUG) insluit, tesame met %DTC van elke veranderlike. Sekondêre uitkomsveranderlikes het funksionele kapasiteit (Ses-Minute-Stap toets), balans selfvertroue (Activity-specific Balance Confidence skaal) en siekte-verwante kwaliteit van lewe (Parkinson‟s Disease Questionnaire-39; PDQ-39) ingesluit. Resultate Beide groepe het ST loopgang spoed (FWG: p=0.04, d=0.35; BWG: p<0.01, d=0.57), ST draai spoed (FWG: p=0.04, d=0.28; BWG: p=0.05, d=0.28), funksionele kapasiteit (FWG: d=0.82; BWG: d=1.06; p<0.01) en MDS-UPDRS III tellings (FWG: p=0.02, d=0.45; BWG: p=0.03, d=0.62) verbeter. Addisioneel het die BWG individuele PDQ-39 domeine (p=0.01, d=0.41), i10mWTST tyd (p<0.01, d=0.45), loopgang siklus tyd (p=0.01, d=0.00), tree lengte (SL; p=0.02, d=0.39) en tree frekwensie (p<0.01, d=0.67) verbeter, maar egter SL variasie (p=0.04, d=0.83) onder ST toestande verswak. Die BWG het ook %DTC vir persentasie dubbel-ondersteuning (%DS) variasie (p=0.05, d=0.57) verbeter, maar egter %DTC vir %DS (p=0.05, d=0.45) en swaai-tyd loopgangasimmetrie (p=0.02, d=0.61) verswak. Die FWG het UPDRS II tellings (p=0.03, d=0.44), i5xSTSST tyd (p<0.01, d=0.52), iTUG tyd (ST: p<0.01, d=0.71; DT: p=0.02, d=0.54), draai hoek (ST: p=0.02, d=0.52; DT: p=0.01, d=0.62) en %DTC vir SL (p=0.02; d=0.67) verbeter. Afsluiting Beide vorentoe en agteruit bogrondse loopgang inoefening kan voordelig vir mobiliteit in PD wees.
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