Iniciação do andar e doença de Parkinson: influência da presença de um obstáculo, da tarefa cognitiva e da informação sensorial
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2021-08-17
Autores
Simieli, Lucas
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Universidade Estadual Paulista (Unesp)
Resumo
A dificuldade na iniciação da marcha é recorrente em pacientes com doença de Parkinson (DP). A ausência de ajustes posturais antecipatórios (APAs) que ocorrem antes do início do movimento de andar são as principais causas de dificuldades nesta população e está relacionada com os sinais e sintomas comuns na DP como acinesia e instabilidade postural. O aumento na complexidade motora e na demanda cognitiva e sensorial pode prejudicar ainda mais a iniciação do andar de pacientes com DP. Assim, este estudo tem como objetivo investigar o efeito da presença de obstáculo, da tarefa dupla e da restrição sensorial durante o início do andar em pacientes com DP. Para isso, uma sequência quatro estudos foram desenvolvidos. No primeiro estudo foi realizada uma revisão sistemática com objetivo de determinar as mudanças nos parâmetros de centro de pressão, APAs e espaço-temporais durante a iniciação da marcha de pacientes com DP. Os estudos posteriores tiveram como objetivo verificar o efeito da presença do obstáculo de diferentes alturas na iniciação do andar, de analisar a influência da carga cognitiva e de determinar a contribuição da informação visual e proprioceptiva na iniciação do andar com e sem a presença do obstáculo em pacientes com DP. Em cada estudo participarão entre 13 e 15 pacientes com DP e o mesmo número idosos neurologicamente sadios. Todos os participantes foram avaliados cognitivamente, sendo que os pacientes com DP ainda foram avaliados clinicamente. Os resultados da revisão sistemática ilustram a importância do estudo da iniciação do andar, uma vez que o grupo DP apresenta dificuldades em iniciar o primeiro passo, diminuindo o número de APA para realizar esse início de forma mais segura e eficiente. Ainda, revelou que pouco se sabe sobre a influência de tarefa duplas durante essa fase, sendo poucas as evidências, mas que já indicam a dificuldade ainda maior do grupo DP em lidar com duas ou mais tarefas durante essa etapa do andar. Nosso estudo sobre altura do obstáculo mostrou uma característica interessante sobre os APA: o grupo DP mantém os parâmetros dos APA praticamente inalterados, independente da altura. Os ajustes para iniciar a tarefa com obstáculo são, majoritariamente, nos ajustes espaço temporais (comprimento, largura, duração e velocidade do passo). Os dados dos estudos 3 e 4, somam aos achados do estudo 2, evidenciando a robustez dos dados dos APAs. Ou seja, indivíduos com DP conservam os APA durante o início do andar em ambientes mais complexos, modificando parâmetros espaço-temporais do andar. Ainda, quando a visão dos membros inferiores é bloqueada, os parâmetros espaço-temporais sofrem mais ajustes, corroborando com a literatura sobre a necessidade de informação visual maior para indivíduos com doença de Parkinson. Dessa forma, é possível afirmar que pessoas com DP apresentam dificuldades na iniciação do andar, de modo que os APA são menores e mais lentos quando comparados a idosos sem DP. Entretanto, esses parâmetros são pouco modificáveis, elucidando a robustez que o sistema carrega para modifica-los de acordo com a tarefa.
Difficulty in gait initiation is recurrent in people with Parkinson's disease (PD). The absence of anticipatory postural adjustments (APAs) that occur before the beginning of walking is the main cause of difficulties in this population and is related to common signs and symptoms in PD, such as akinesia and postural instability. The increase in motor complexity and cognitive and sensory demand can further impair gait initiation in PD patients. Thus, this study aims to investigate the effect of the presence of obstacles, dualtask, and sensory restriction during the beginning of walking in people with PD. For this, a sequence of four studies was developed. In the first study, a systematic review was performed to determine changes in the center of pressure, APAs, and spatiotemporal parameters during gait initiation in PD patients. Further studies aimed to verify the effect of the presence of the obstacle of different heights on gait initiation, to analyze the influence of cognitive load, and to determine the contribution of visual and proprioceptive information in gait initiation with and without the presence of the obstacle in PD patients. Between 13 and 15 patients with PD and the same number of neurologically healthy elderly people participated in each study. All participants were cognitively evaluated, and patients with PD were clinically evaluated either. The results of the systematic review illustrate the importance of studying the initiation of walking, since the PD group has difficulties in performing the first step, reducing the number of APAs to perform this initiation more safely and efficiently compared to people without PD. Furthermore, it revealed that little is known about the influence of dual tasks during this phase, with little evidence, but that already indicates the even greater difficulty of the PD group in dealing with two or more tasks during this stage of walking. Our study on the height of the obstacle showed an interesting characteristic about the APA: the DP group maintains the parameters of the APA practically unchanged, regardless of the height. The adjustments to start the task with an obstacle are, mostly, in the spatiotemporal parameters (step length, width, duration, and velocity). Data from studies 3 and 4 add to the findings from study 2, showing the robustness of data from the APAs. In other words, individuals with PD changing APAs during only gait initiation in more complex environments, modifying the spatiotemporal parameters of gait in most of cases (easier tasks). Moreover, when the vision of the lower limbs is blocked, the spatiotemporal parameters were even more affected, demanding further adjustments. These results corroborate with the literature on the need for greater visual information for individuals with Parkinson's disease. Thus, it is possible to state that people with PD have difficulties in starting to walk so that the APAs are smaller and slower when compared to elderly people without PD. However, these parameters are dependent of task difficulty, elucidating the robustness that the system loads to modify them according to the task, doing all changes on spatiotemporal parameters to perform the task.
Difficulty in gait initiation is recurrent in people with Parkinson's disease (PD). The absence of anticipatory postural adjustments (APAs) that occur before the beginning of walking is the main cause of difficulties in this population and is related to common signs and symptoms in PD, such as akinesia and postural instability. The increase in motor complexity and cognitive and sensory demand can further impair gait initiation in PD patients. Thus, this study aims to investigate the effect of the presence of obstacles, dualtask, and sensory restriction during the beginning of walking in people with PD. For this, a sequence of four studies was developed. In the first study, a systematic review was performed to determine changes in the center of pressure, APAs, and spatiotemporal parameters during gait initiation in PD patients. Further studies aimed to verify the effect of the presence of the obstacle of different heights on gait initiation, to analyze the influence of cognitive load, and to determine the contribution of visual and proprioceptive information in gait initiation with and without the presence of the obstacle in PD patients. Between 13 and 15 patients with PD and the same number of neurologically healthy elderly people participated in each study. All participants were cognitively evaluated, and patients with PD were clinically evaluated either. The results of the systematic review illustrate the importance of studying the initiation of walking, since the PD group has difficulties in performing the first step, reducing the number of APAs to perform this initiation more safely and efficiently compared to people without PD. Furthermore, it revealed that little is known about the influence of dual tasks during this phase, with little evidence, but that already indicates the even greater difficulty of the PD group in dealing with two or more tasks during this stage of walking. Our study on the height of the obstacle showed an interesting characteristic about the APA: the DP group maintains the parameters of the APA practically unchanged, regardless of the height. The adjustments to start the task with an obstacle are, mostly, in the spatiotemporal parameters (step length, width, duration, and velocity). Data from studies 3 and 4 add to the findings from study 2, showing the robustness of data from the APAs. In other words, individuals with PD changing APAs during only gait initiation in more complex environments, modifying the spatiotemporal parameters of gait in most of cases (easier tasks). Moreover, when the vision of the lower limbs is blocked, the spatiotemporal parameters were even more affected, demanding further adjustments. These results corroborate with the literature on the need for greater visual information for individuals with Parkinson's disease. Thus, it is possible to state that people with PD have difficulties in starting to walk so that the APAs are smaller and slower when compared to elderly people without PD. However, these parameters are dependent of task difficulty, elucidating the robustness that the system loads to modify them according to the task, doing all changes on spatiotemporal parameters to perform the task.
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Palavras-chave
Gait initiation, Parkinson's disease, Cognition, Complex environment