作者：Deborah Brauser
出處：WebMD醫學新聞
January 28, 2010 — 根據德國一篇新的系統性回顧，相較於未接受運動治療的病患，跑步機訓練可以讓巴金森氏症(Parkinson's disease，PD)病患的步態參數改善更多。
事實上，訓練組的跨步長度、走路速度、走路距離等都有所改善。
德國Kreischa巴伐利亞歐洲私立醫院協會領導者科學研究中心的教授Jan Mehrholz醫師等人寫道，研究對象接受跑步機訓練不但有好處，副作用也罕見。
Mehrholz醫師在Medscape Neurology的訪問中表示，這是首度彙整此類PD治療方式之效果的系統性回顧，許多巴金森氏症病患希望改善他們的步態動作，希望走得更快，因為這些與他們的生活品質有強烈關係。
這篇研究登載於2010年第一期的考科藍實證醫學資料庫(Cochrane Database of Systematic Reviews)。
【一種非藥物的方式】
根據研究作者們表示，步態動作變緩的特徵是動作遲鈍緩慢，是與PD有關的主要動作異常之一。目前，通常未將運動整合到這些病患的治療處方中輔助傳統的藥物治療，以前的研究則是著眼在使用電子機械裝置，如跑步機，來協助步態復健。
Mehrholz醫師表示，小型試驗顯示有改善但是沒有定論，因此，我們嘗試進行系統性評估，希望提供有關這類治療方式的有力證據，而提出明確的建議。
Mehrholz醫師的團隊比較使用跑步機訓練和沒有使用跑步機訓練之PD病患的步態效果，以及前者的接受度和安全性，總共評估了來自Cochrane Library的8篇隨機控制與隨機控制交叉試驗、共203名病患(平均年紀為66. 25歲) 。他們分析走路速度、跨步長度、每分鐘的步伐次數(頻率)、走路距離等，以測量步態的改善。
Mehrholz醫師解釋，我們希望跑步機訓練作為非藥物方式可以獲得明顯的步態改善。
【頻率之外皆有所改善】
結果顯示，相較於其他組，接受跑步機訓練組的各種步態參數皆有所改善，除了頻率之外；而且這種訓練方式也不會增加病患退出的風險，這可以顯示病患的接受度。
表.跑步機訓練對於步態參數的效果
測量 | 差異(95% CI) | P 值 |
走路速度 (SMD) | 0.50 (0.17 - 0.84) | .003 |
跨步長度 (SMD) | 0.42 (0.00 - 0.84) | .05 |
走路距離 (MD), m | 358 (289 - 426) | <.0001 |
頻率 (MD) | 1.06 (-4.32 - 6.44) | .70 |
病患退出率 (RD) | -0.07 (-0.18 - 0.05) | .26 |
CI = 信心區間、MD = 平均差、RD = 相對風險差異、SMD = 標準平均差
研究作者寫道，跑步機訓練看來是安全且有效地改善PD病患之步態的方式，關鍵的是，使用這種復健方式的副作用和退出率都很低。
Mehrholz醫師指出，如果病患有因為PD的步態問題，即便很輕微，我們會建議使用跑步機來訓練動作，此外，使用跑步機的速度要比在平面快一些。
不過，研究作者警告，這些發現僅是根據8個小型研究而來，至於步態改善的持續度未知。後續研究應強調有關跑步機訓練的期間和頻率以及效果期間的問題，目前，還不清楚這些裝置是否可以運用到例行性的復健。
Mehrholz醫師報告指出，他的團隊希望可以從評估的這些試驗中對個別病患資料追蹤1年。
【令人鼓舞的結果 但是需要更多研究】
俄亥俄州克里夫蘭診所神經重建中心的Jay Alberts博士向Medscape Neurology表示，我認為研究者對現有文獻做了一個詳細且嚴密的總結。不過他未參與該研究，Alberts博士最近發表了一篇研究(由Medscape報導)評估固定式腳踏車對PD病患的效果。
Alberts博士表示，他們的結論認為跑步機訓練改善了步態的一些結果是令人鼓舞的，我也感到鼓舞，因為資料認為你可以透過一些行為介入，如跑步機訓練，來改變巴金森氏症病患的動作功能。
不過，他也警告，這些研究不代表此一領域不再需要更多研究，我們都知道，運動對我們有好處，但是我們需要更多研究，作者們強調的是，實際瞭解哪種類型的運動對PD病患有好處，也許是跑步機訓練，也許是固定式腳踏車，也許是強迫運動，也許是其他類型的介入方式，但是我認為，使用「運動對你有好處」這種概括式的聲明，會使神經動作與神經認知功能不佳的人受到忽視。
Alberts博士指出，但願本研究的結論可以讓人們警覺到我們需持續注意運動介入對步態、對姿勢穩定、上肢功能等的影響。
他指出，該研究所提，對於效果持續多久還不清楚，這是需適當處理的問題，我們希望發展可以長時間持續的介入方式，藥物和深部腦刺激的效果都未能長時間持續，因此，如果我們能發展出可以持續的行為介入方式，例如執行停止後4週，我認為就是成功了。
Alberts博士表示，為了讓運動和運動介入方式在未來「闖入神經科醫師的辦公室」，研究者需要顯示的是，他們可以在動作功能方面有全面的改善，顯示效果超過個人執行之特定任務的效果。
他結論指出，如果你可以整體地改變動作功能，這表示中心機轉為腦中有實際上的改變，這是全新的、令人興奮的方向，且不僅是巴金森氏症，也包括其他神經退化、甚至是神經認知異常。
德國的Klinik Bavaria Kreischa、德瑞斯登科技大學醫學院、SRH Fachhochschule Gera以及加州州立大學Long Beach分校資助本研。其中兩位研究作者、包括Mehrholz醫師，是納入分析之其中一篇研究的共同作者，他們未參與其評估。其他研究作者與Alberts博士皆宣告沒有相關財務關係。
Cochrane Database Syst Rev. 2010:第一期。
Treadmill Training Improves Gait in Patients With Parkinson's Disease
By Deborah Brauser
Medscape Medical News
January 28, 2010 — Treadmill training can lead to more improved gait parameters for patients with Parkinson's disease (PD) than for those who do not participate in exercise treatment, according to a new systematic review from Germany.
In fact, the training group showed increases in stride length, walking speed, and walking distance.
"Acceptability of treadmill training for study participants was also good and adverse events were rare," write Jan Mehrholz, MPH, professor at the Leiter Wissenschaftliches Institut at the Private Europaische Medizinische Akademie der Klinik Bavaria in Kreischa, Germany, and colleagues.
In an interview with Medscape Neurology, Dr. Mehrholz said that this is the first systematic review with a pooled estimate on the effects of this type of PD therapy. "Many patients with Parkinson's want to improve their gait movement, want to go faster, and it's strongly related to their quality of life. Treadmill training is a promising option for them."
This study was published in the first 2010 issue of the Cochrane Database of Systematic Reviews.
A Nonpharmaceutical Approach
Gait hypokinesia, characterized by slowness of movement, is one of the primary movement disorders associated with PD, according to the study authors. Currently, exercise is often incorporated into treatment regimens for these patients as a useful complement to traditional drug therapies, and past studies have looked at using electromechanical devices, such as treadmills, to facilitate gait rehabilitation.
"Small trials have shown improvements but have been inconclusive," said Dr. Mehrholz. "Therefore, we were interested in a systematic evaluation [that provided] strong evidence about this type of therapy to give clear advice going forward."
His team sought to compare the effects of treadmill training vs no treadmill training on the gait of patients with PD, as well as its acceptability and safety, by evaluating data on 203 patients (mean age, 66.25 years) from 8 randomized controlled and randomized controlled crossover trials from the Cochrane Library. They measured gait improvement by analyzing walking speed, stride length, number of steps per minute (cadence), and walking distance.
"We hoped that treadmill training as a nonpharmaceutical approach would lead to clear improvements of gait," explained Dr. Mehrholz.
Improvements in All Outcomes but Cadence
Results showed that the group receiving treadmill training had improvements in all gait parameter measurements except for cadence compared with those in the other group. The training also did not increase the risk of patients dropping out, signalling patient acceptability.
Table. Treadmill Training Effects on Gait Parameters
| Measure | Differences (95% CI) | P Value |
| Walking speed (SMD) | 0.50 (0.17 to 0.84) | .003 |
| Stride length (SMD) | 0.42 (0.00 to 0.84) | .05 |
| Walking distance (MD), m | 358 (289 to 426) | <.0001 |
| Cadence (MD) | 1.06 (?4.32 to 6.44) | .70 |
| Patient dropout rate (RD) | ?0.07 (?0.18 to 0.05) | .26 |
CI = confidence interval, MD = mean difference, RD = relative risk difference, SMD = standard mean difference
"Treadmill training appears to be a safe and effective way of improving gait in patients with [PD]," the study authors write. "Crucially, we saw very few adverse effects or drop outs ... given this type of rehabilitation therapy."
"If patients have gait problems due to [PD], even if they are very small, we would [recommend] using treadmills to train the movement," added Dr. Mehrholz. "Additionally, one should use higher treadmill speeds than usually used on the ground."
However, the study authors caution that these findings are based on only 8 small studies, and the persistence of the gait improvements is unknown. "Further research should address specific questions about duration of effect and frequency and duration of treadmill training. [For now], it is not clear if such devices should be applied in routine rehabilitation."
Dr. Mehrholz reported that his team hopes to follow up in 1 year on the individual patient data from the trials evaluated.
Encouraging Results, but More Studies Needed
"I thought [the investigators] did a detailed and meticulous job of summarizing the existing literature that is out there," said Jay Alberts, PhD, from the Center for Neurological Restoration at the Cleveland Clinic in Ohio, to
Medscape Neurology. Although he was not involved with this study, Dr. Alberts recently presented a
study (reported by
Medscape) evaluating the effects of stationary bicycle use on patients with PD.
"Their conclusions in regards to treadmill training improving certain aspects of gait are encouraging," said Dr. Alberts. "I'm also encouraged that the data suggests that you can change motor function in a Parkinson's patient through some type of behavioral intervention, such as treadmill training."
However, he cautioned that these results shouldn't suggest that more studies aren't needed in this area. "We all know that exercise is good for us but we need more studies, and the authors stressed that, to really understand what types of exercise are good for individuals with [PD]. Maybe it's treadmill training, maybe it's stationary cycling, maybe it's forced exercise, maybe it's other types of interventions. But I think using the blanket statement that just says 'exercise is good for you' leaves people with neuromotor and neurocognitive dysfunction out in the cold, if you will."
"Hopefully, the conclusions from this study will keep people aware that we need to keep looking at exercise interventions on gait, as well as on postural stability, upper extremity function, and such," Dr. Alberts added.
He noted that the study's comments on not knowing how long the effects last should be kept in perspective. "Although we do want to develop interventions that are long-lasting, the effects of medications and the effects of deep brain stimulation are not long-lasting. So if we can develop a behavioral intervention that only lasts, say, 4 weeks after they stop doing it, I think that's a success."
Dr. Alberts said that in order to "break into the neurologists' offices" in terms of exercise and exercise interventions in the future, researchers will need to show that they can induce global improvements in motor functioning — and show that the effects go beyond the specific tasks that the individuals are practicing.
"If you can change motor function globally, it then points towards a central mechanism that may actually be changing the brain, and that is a whole new, exciting direction that isn't restricted to Parkinson's but includes other neurodegenerative and even neurocognitive disorders," he concluded.
This study was funded by the Klinik Bavaria Kreischa, the Faculty of Medicine at the Technical University of Dresden, and the SRH Fachhochschule Gera — all in Germany — and by the
California State University in Long Beach. Although 2 of the study authors, including Dr. Mehrholz, were coauthors of one of the trials included in the analysis, they did not participate in its assessment. The other study authors and Dr. Alberts have disclosed no relevant financial relationships.
Cochrane Database Syst Rev. 2010:Issue 1.
