Publication: Parkinson hastalarında solunum kas eğitimi: postüral stabilite ve denge, mobilite, günlük yaşam aktiviteleri ve solunum kas kuvveti arasındaki ilişkinin araştırılması / Respiratory muscle training in patients with parkinson's disease: investigation of the relationship between postural stability and balance, mobility, daily living activities and respiratory muscle strength
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SAFRAN, ertuğrul
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GÜRSES, Hülya Nilgün
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Parkinson hastalığı (PH), Alzheimer hastalığını takiben en sık görülen ikinci nörodejeneratif hastalıktır. Etiyolojisi hala net olarak bilinmese de bireyin genetik ve çevresel etmenlere bağlı olarak hastalık riski taşıyabileceği, beynin ilgili bölgelerinde ilerleyici nöron dejenerasyonu neticesinde oluşabileceği düşünülen bir hastalıktır. Substansia nigrada yoğunlaşmış halde bulunan dopamin hücrelerinin üretilemez hale gelmesiyle birlikte görülen motor belirtiler ve bunlara ek olarak non-motor belirtiler de görülmektedir. En yaygın motor belirtiler; tremor, rijidite, akinezi ve postüral instabilitedir. Ayrıca mortalite ve morbiditelerin gelişmesine yol açabilecek solunumsal problemler de görülmektedir. Literatüre bakıldığında PH'lı kişilerde yapılan çalışmalarda, denge çalışmaları ön plandadır. Nörodejeneratif hastalıklarda yapılan solunum kas eğitimi çalışmalarının hem nitelik hem de nicelik olarak yetersiz düzeyde olduğu görülmektedir. PH'da solunum kas eğitimi (SKE)'nin denge üzerine etkisini inceleyen çalışmaya da rastlanmadı. Bu çalışma ile PH'lı hastalarda dengeyle ilişki olan parametreleri incelemek ve denge eğitimine ek olarak verilen SKE'nin postüral stabilite, denge, mobilite, solunum fonksiyonları, solunum kas kuvveti, günlük yaşam aktiviteleri ve yaşam kaliteleri üzerine etkisini araştırmak amaçlandı. Çalışma kapsamında kriterlere uygun, Modifiye Hoehn & Yahr'a (MHY) göre evre 1-3 arasında, 60 ile 85 yaş aralığında 30 PH'lı hasta randomize edilerek deney ve kontrol gruplarına ayrıldı. Tüm hastalara, solunum fonksiyon testi (SFT), solunum kas gücü ölçümü, Biodex Balance System® cihazı ile postural stabilite, stabilite limitleri testleri uygulandı. Tüm hastaların günlük yaşam aktiviteleri; mobilite; yaşam kalitesi ve hastalık dereceleri sırasıyla barthel indeksi (Bİ); rivermead mobilite indeksi (RMİ); Nottingham sağlık profili (NSP) ve birleşik parkinson hastalık derecelendirme ölçeği (BPHDÖ) ile değerlendirildi. Kontrol grubuna, 8 hafta süre ile, haftada 1 gün gözetimli 2 gün ev egzersizi olmak üzere toplam 3 seans denge eğitimi verildi. Deney grubuna ise denge eğitimine ek SKE; günde 2 kez 15'şer dakika olmak zere Threshold IMT® cihazı ile inspiratuar kas eğitimi (İKE) şeklinde verildi. Cihaz, ağız içi basınç aletiyle ölçülen maksimum inspiratuar basıncın (MIP) %30'u şiddetine ayarlandı. Öğrenmenin etkisini kaldırma adına kontrol grubuna da her hafta ağız içi basınç ölçümü yapıldı. Tüm ölçümler 8 haftanın sonunda tekrar yapıldı. Veri analizi için SPSS v.20 programı kullanıldı. Dengenin bağımsız belirleyicilerinin tespit edilebilmesi için lineer regresyon analizi yapıldı. Verilerin dağılım özelliklerine göre de grup içi karşılaştırmalarda Paired Sample T-test ya da Wilcoxon testi; gruplar arası karşılaştırmalarda ise Independent Samples T-test ya da Mann Whitney U testi kullanıldı. Değerler arasındaki ilişkiye ise Pearson ya da Spearman korelasyon analiz yöntemiyle bakıldı. Tüm analizler için anlamlılık düzeyi p<0.05 olarak kabul edildi. Yapılan regresyon analizi sonucunda, BPHDÖ, Bİ ve RMİ değerlerinin ise sırasıyla % 33 (p:0,001), %22 (p:0,008) ve % 21'lik (p:0,010) varyans değerleriyle postüral stabilitenin bağımsız belirleyicileri olduğu görüldü. NSP, MIP, maksimum ekspiratuar basınç (MEP), PEF, tanı süresi ve beden kitle indeksi (BKİ) değerlerinin herhangi bir postüral stabilite ve denge skorunun bağımsız belirleyici olmadığı görüldü (p>0.05). Sekiz haftalık tedavi sonrasında her iki grupta da MEP ve postüral stabilite değerlerinde anlamlı gelişme görüldü (p<0.05). Stabilite limitleri ve MIP değerlerinde ise yalnızca deney grubunda anlamlı gelişme görüldü (p<0.05). Her iki grupta da MEP, zorlu vital kapasite (FVC), zorlu ekspiratuar volüm 1. saniye (FEV1) değerlerinde meydana gelen değişimler ele alındığında gruplar arasında anlamlı farklılık yoktu (p>0.05). MIP ve PEF değerlerinde meydana gelen değişimlere bakıldığında ise deney grubunda meydana gelen değer artışı kontrol grubuna göre anlamlı şekilde daha yüksekti (p<0.05). Her iki grupta da tedavi öncesine kıyasla RMI, BI ve NSP değerlerinde anlamlı bir artış görülmedi (p>0.05). BPHDÖ skorlarında ise her iki grupta da tedavi öncesine kıyasla anlamlı gelişme vardı (p<0.05). BPHDÖ, RMİ, Bİ ve NSP skorlarında gruplar arasında anlamlı bir farklılık yoktu (p>0.05). Tedavi öncesi tüm olgular üzerinden yapılan korelasyon analizinde postüral stabilite değerinin HY, BPHDÖ, RMİ ve Bİ ölçek skorları ile anlamlı ilişkisi saptanmıştır (p<0.05). MIP değerinin MHY ve BPHDÖ değerleriyle anlamlı ilişkisi vardı (p<0.05). BPHDÖ'nün RMİ ve MHY ile; RMİ'nin de BI ve NSP skorları ile anlamlı ilişkisi vardı (p<0.05). Literatürde SKE ve dengenin ayrı ayrı PH'lı hastalarda etkili olduğu gösterilmiştir. Çalışmamız ile literature paralel bir şekilde bu iki eğitimden de verim alındığı görüldü. Fakat denge eğitimine ek verilen SKE'nin yalnızca denge eğitimine oranla dengeyi ve solunum kas kuvvetini artırmada daha etkili olduğu sonucuna ulaşıldı. Hastalarda, tek başına medikal tedavi yeterli olmadığı için semptomları azaltma ve yaşam kalitesini arttırma adına rutin olarak verilen denge eğitimlerinin yanında mutlaka solunum eğitimlerinin de verilmesi gerekliliği görülmüştür.
Description
Thesis (Doctoral)--Bezmialem Vakıf University, Department of Cardiopulmonary Physiotherapy and Rehabilitation, Istanbul, 2020
Parkinson's disease (PD) is recognized as the second most common neurodegenerative disorder after Alzheimer's disease. Although the etiology is still unknown, it is thought that the individual may carry a risk of disease due to genetic and environmental factors and that it may occur as a result of progressive neuron degeneration in related regions of the brain. Motor symptoms are seen with the inability to produce dopamine cells, which are concentrated in the Substance nigra, as well as non-motor symptoms. The most common motor symptoms; tremor, rigidity, akinesia and postural instability. There are also respiratory problems that may lead to the development of mortality and morbidity. When the databases examined, balance studies are in the foreground in the studies conducted in people with PD. Respiratory muscle training studies conducted with neurodegenerative populations are inadequate both in quality and quantity. There was no study examining the effect of respiratory muscle training (RMT) on balance in PD. The aim of this study was to investigate the parameters related to balance in patients with PD and to investigate the effect of RMT in addition to balance training on postural stability, balance, mobility, respiratory functions, respiratory muscle strength, daily living activities and quality of life. According to inclusion criteria, Modified Hoehn & Yahr grade 1-3, thirty individual aged between 60-85 who are diagnosed with PD were randomised into experimental or control group. Pulmonary function test (PFT), respiratory muscle strentgth assessment, postural stability, limits of stability tests in Biodex Balance System® were applied to all patients. Barthel index (BI), rivermead mobility index (RMI), nottigham healt profile (NHP), unified parkinson's disease rating scale (UPDRS) were used for the evaluation of daily living activities, mobility, quality of life and disease severity, respectively. The control group received a total of 3 sessions of balance training for 8 weeks, 1 day per week supervised and 2 days home exercise. In addition to the balance training, SKE for the experimental group; it was given as an inspiratory muscle training (IMT) with Threshold IMT® device for 15 minutes, 2 times a day. The device is set to 30% of the maximum inspiratory pressure (MIP) measured by the mouth pressure device. In order to remove the effect of learning, the control group also received mouth pressure measurements every week. All assessments were repeated at the end of the eighth week. Data was analyzed using SPSS v.20. For analyzing the independent predictors of the balance, linear regression analysis was conducted on thirty subjects. Paired Sample T-test or Wilcoxon Test was used for in-group comparisons and Independent Samples T-tes or Mann Whitney U test was used for between-groups comparisons depending on the distribution properties of the data. The relationship between the values was analyzed by Pearson or Spearman correlation analysis method. The results were considered significant with P-values <0,05. As a result of the regression analysis, it was seen that the values of UPDRS, BI and RMI were independent predictors of postural stability with 33% (p: 0.001), 22% (p:0.008) and 21% (p:0.010) variance values, respectively. NSP, PEF, MIP, maximum expiratory pressure (MEP), diagnosing time and body mass index (BMI) values were not independent predictors of any postural stability and balance score (p>0.05). MEP and postural stability values were significantly improved in both groups after 8 weeks of treatment (p<0.05). Stability limits and MIP values were significantly improved only in the experimental group (p<0.05). When the changes in forced vital capacity (FVC) and forced expiratory volume 1 second (FEV1) values were considered in both groups, there was no significant difference between the groups (p> 0.05). When the changes in MIP, MEP and PEF values were examined, the increase in the value of the experimental group was significantly higher than the control group (p<0.05). There was no significant increase in RMI, BI and NSP values in both groups compared to pretreatment (p>0.05). There were significant improvement in UPDRS scores in both groups compared to pretreatment (p<0.05). There were no significant differences between the groups in terms of BPRS, RMI, BI and NSP scores (p>0.05). Correlation analysis of all cases before treatment showed a significant correlations of postural stability value to MHY, UPDRS, RMI and BI scale scores (p<0.05). There were significant relations of MIP to MHY and UPDRS (p<0.05). There were significant relations of UPDRS to RMI and MHY and also relations of RMI to BI and NSP scores (p<0.05). Many studies showed that RMT and balance trainings are effective in patients with PD, separately. In parallel with the literature, it was seen that the efficiency of these two trainings was obtained. However, it was concluded that RMT, which was added to balance training, was more effective in increasing balance and respiratory muscle strength compared to balance training alone. Since medical treatment alone was not sufficient, it was seen that in addition to routine balance trainings, respiratory muscle training should be given in order to increase balance, respiratory muscle strength, reduce symptoms and improve quality of life.
Parkinson's disease (PD) is recognized as the second most common neurodegenerative disorder after Alzheimer's disease. Although the etiology is still unknown, it is thought that the individual may carry a risk of disease due to genetic and environmental factors and that it may occur as a result of progressive neuron degeneration in related regions of the brain. Motor symptoms are seen with the inability to produce dopamine cells, which are concentrated in the Substance nigra, as well as non-motor symptoms. The most common motor symptoms; tremor, rigidity, akinesia and postural instability. There are also respiratory problems that may lead to the development of mortality and morbidity. When the databases examined, balance studies are in the foreground in the studies conducted in people with PD. Respiratory muscle training studies conducted with neurodegenerative populations are inadequate both in quality and quantity. There was no study examining the effect of respiratory muscle training (RMT) on balance in PD. The aim of this study was to investigate the parameters related to balance in patients with PD and to investigate the effect of RMT in addition to balance training on postural stability, balance, mobility, respiratory functions, respiratory muscle strength, daily living activities and quality of life. According to inclusion criteria, Modified Hoehn & Yahr grade 1-3, thirty individual aged between 60-85 who are diagnosed with PD were randomised into experimental or control group. Pulmonary function test (PFT), respiratory muscle strentgth assessment, postural stability, limits of stability tests in Biodex Balance System® were applied to all patients. Barthel index (BI), rivermead mobility index (RMI), nottigham healt profile (NHP), unified parkinson's disease rating scale (UPDRS) were used for the evaluation of daily living activities, mobility, quality of life and disease severity, respectively. The control group received a total of 3 sessions of balance training for 8 weeks, 1 day per week supervised and 2 days home exercise. In addition to the balance training, SKE for the experimental group; it was given as an inspiratory muscle training (IMT) with Threshold IMT® device for 15 minutes, 2 times a day. The device is set to 30% of the maximum inspiratory pressure (MIP) measured by the mouth pressure device. In order to remove the effect of learning, the control group also received mouth pressure measurements every week. All assessments were repeated at the end of the eighth week. Data was analyzed using SPSS v.20. For analyzing the independent predictors of the balance, linear regression analysis was conducted on thirty subjects. Paired Sample T-test or Wilcoxon Test was used for in-group comparisons and Independent Samples T-tes or Mann Whitney U test was used for between-groups comparisons depending on the distribution properties of the data. The relationship between the values was analyzed by Pearson or Spearman correlation analysis method. The results were considered significant with P-values <0,05. As a result of the regression analysis, it was seen that the values of UPDRS, BI and RMI were independent predictors of postural stability with 33% (p: 0.001), 22% (p:0.008) and 21% (p:0.010) variance values, respectively. NSP, PEF, MIP, maximum expiratory pressure (MEP), diagnosing time and body mass index (BMI) values were not independent predictors of any postural stability and balance score (p>0.05). MEP and postural stability values were significantly improved in both groups after 8 weeks of treatment (p<0.05). Stability limits and MIP values were significantly improved only in the experimental group (p<0.05). When the changes in forced vital capacity (FVC) and forced expiratory volume 1 second (FEV1) values were considered in both groups, there was no significant difference between the groups (p> 0.05). When the changes in MIP, MEP and PEF values were examined, the increase in the value of the experimental group was significantly higher than the control group (p<0.05). There was no significant increase in RMI, BI and NSP values in both groups compared to pretreatment (p>0.05). There were significant improvement in UPDRS scores in both groups compared to pretreatment (p<0.05). There were no significant differences between the groups in terms of BPRS, RMI, BI and NSP scores (p>0.05). Correlation analysis of all cases before treatment showed a significant correlations of postural stability value to MHY, UPDRS, RMI and BI scale scores (p<0.05). There were significant relations of MIP to MHY and UPDRS (p<0.05). There were significant relations of UPDRS to RMI and MHY and also relations of RMI to BI and NSP scores (p<0.05). Many studies showed that RMT and balance trainings are effective in patients with PD, separately. In parallel with the literature, it was seen that the efficiency of these two trainings was obtained. However, it was concluded that RMT, which was added to balance training, was more effective in increasing balance and respiratory muscle strength compared to balance training alone. Since medical treatment alone was not sufficient, it was seen that in addition to routine balance trainings, respiratory muscle training should be given in order to increase balance, respiratory muscle strength, reduce symptoms and improve quality of life.