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Herman T, Barer Y, Bitan M, Sobol S, Giladi N, Hausdorff JM. A meta-analysis identifies factors predicting the future development of freezing of gait in Parkinson's disease. NPJ Parkinsons Dis 2023; 9:158. [PMID: 38049430 PMCID: PMC10696025 DOI: 10.1038/s41531-023-00600-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 11/02/2023] [Indexed: 12/06/2023] Open
Abstract
Freezing of gait (FOG) is a debilitating problem that is common among many, but not all, people with Parkinson's disease (PD). Numerous attempts have been made at treating FOG to reduce its negative impact on fall risk, functional independence, and health-related quality of life. However, optimal treatment remains elusive. Observational studies have recently investigated factors that differ among patients with PD who later develop FOG, compared to those who do not. With prediction and prevention in mind, we conducted a systematic review and meta-analysis of publications through 31.12.2022 to identify risk factors. Studies were included if they used a cohort design, included patients with PD without FOG at baseline, data on possible FOG predictors were measured at baseline, and incident FOG was assessed at follow-up. 1068 original papers were identified, 38 met a-priori criteria, and 35 studies were included in the meta-analysis (n = 8973; mean follow-up: 4.1 ± 2.7 years). Factors significantly associated with a risk of incident FOG included: higher age at onset of PD, greater severity of motor symptoms, depression, anxiety, poorer cognitive status, and use of levodopa and COMT inhibitors. Most results were robust in four subgroup analyses. These findings indicate that changes associated with FOG incidence can be detected in a subset of patients with PD, sometimes as long as 12 years before FOG manifests, supporting the possibility of predicting FOG incidence. Intriguingly, some of these factors may be modifiable, suggesting that steps can be taken to lower the risk and possibly even prevent the future development of FOG.
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Affiliation(s)
- Talia Herman
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Barer
- Maccabitech, Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Michal Bitan
- School of Computer Science, The College of Management, Rishon LeZion, Israel
| | - Shani Sobol
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Giladi
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
- Department of Orthopedic Surgery and Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA.
- Department of Physical Therapy, Faculty of Medicine, Tel Aviv, Israel.
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Jansen JAF, Capato TTC, Darweesh SKL, Barbosa ER, Donders R, Bloem BR, Nonnekes J. Exploring the levodopa-paradox of freezing of gait in dopaminergic medication-naïve Parkinson's disease populations. NPJ Parkinsons Dis 2023; 9:130. [PMID: 37689706 PMCID: PMC10492797 DOI: 10.1038/s41531-023-00575-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/25/2023] [Indexed: 09/11/2023] Open
Abstract
The relationship between dopaminergic treatment and freezing of gait (FOG) in Parkinson's disease (PD) is complex: levodopa is the most effective symptomatic treatment for FOG, but long-term pulsatile levodopa treatment has also been linked to an increase in the occurrence of FOG. This concept, however, continues to be debated. Here, we compared the occurrence of FOG between a levodopa-naive PD cohort and a levodopa-treated cohort. Forty-nine treatment-naive patients and 150 levodopa-treated patients were included. The time since first motor symptoms was at least 5 years. Disease severity was assessed using the MDS-UPDRS part III. Occurrence of FOG was assessed subjectively (new freezing-of-gait-questionnaire) and objectively (rapid turns test and Timed Up-and-Go test). The presence of FOG was compared between the levodopa-treated and levodopa-naive groups using a chi-square test of homogeneity. We also performed a binomial Firth logistic regression with disease duration, disease severity, country of inclusion, location of measurement, and executive function as covariates. Subjective FOG was more common in the levodopa-treated cohort (n = 41, 27%) compared to the levodopa-naive cohort (n = 2, 4%, p < 0.001). The association between FOG and levodopa treatment remained after adjustment for covariates (OR = 6.04, 95%Cl [1.60, 33.44], p = 0.006). Objectively verified FOG was more common in the levodopa-treated cohort (n = 21, 14%) compared to the levodopa-naive cohort (n = 1, 2%, p = 0.02). We found an association between long-term pulsatile levodopa treatment and an increased occurrence of FOG. Future studies should further explore the role of nonphysiological stimulation of dopamine receptors in generating FOG, as a basis for possible prevention studies.
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Affiliation(s)
- Jamie A F Jansen
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Rehabilitation, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Tamine T C Capato
- University of São Paulo, Department of Neurology, Movement Disorders Center, São Paulo, Brazil
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Sirwan K L Darweesh
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Egberto R Barbosa
- University of São Paulo, Department of Neurology, Movement Disorders Center, São Paulo, Brazil
| | - Rogier Donders
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Jorik Nonnekes
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Rehabilitation, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands.
- Department of Rehabilitation, Sint Maartenskliniek, Ubbergen, The Netherlands.
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Virmani T, Landes RD, Pillai L, Glover A, Larson-Prior L, Prior F, Factor SA. Gait Declines Differentially in, and Improves Prediction of, People with Parkinson's Disease Converting to a Freezing of Gait Phenotype. JOURNAL OF PARKINSON'S DISEASE 2023; 13:961-973. [PMID: 37522218 PMCID: PMC10578275 DOI: 10.3233/jpd-230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Freezing of gait (FOG) is a debilitating, variably expressed motor symptom in people with Parkinson's disease (PwPD) with limited treatments. OBJECTIVE To determine if the rate of progression in spatiotemporal gait parameters in people converting from a noFOG to a FOG phenotype (FOGConv) was faster than non-convertors, and determine if gait parameters can help predict this conversion. METHODS PwPD were objectively monitored longitudinally, approximately every 6 months. Non-motor assessments were performed at the initial visit. Steady-state gait in the levodopa ON-state was collected using a gait mat (Protokinetics) at each visit. The rate of progression in 8 spatiotemporal gait parameters was calculated. FOG convertors (FOGConv) were classified if they did not have FOG at initial visit and developed FOG at a subsequent visit. RESULTS Thirty freezers (FOG) and 30 non-freezers were monitored an average of 3.5 years, with 10 non-freezers developing FOG (FOGConv). FOGConv and FOG had faster decline in mean stride-length, swing-phase-percent, and increase in mean total-double-support percent, coefficient of variability (CV) foot-strike-length and CV swing-phase-percent than the remaining non-freezers (noFOG). On univariate modeling, progression rates of mean stride-length, stride-velocity, swing-phase-percent, total-double-support-percent and of CV swing-phase-percent had high discriminative power (AUC > 0.83) for classification of the FOGConv and noFOG groups. CONCLUSION FOGConv had a faster temporal decline in objectively quantified gait than noFOG, and progression rates of spatiotemporal gait parameters were more predictive of FOG phenotype conversion than initial (static) parameters Objectively monitoring gait in disease prediction models may help define FOG prone groups for testing putative treatments.
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Affiliation(s)
- Tuhin Virmani
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Reid D. Landes
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lakshmi Pillai
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aliyah Glover
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Linda Larson-Prior
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Fred Prior
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stewart A. Factor
- Jean and Paul Amos Parkinson’s Disease and Movement Disorder Program, Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Lewis S, Factor S, Giladi N, Nieuwboer A, Nutt J, Hallett M. Stepping up to meet the challenge of freezing of gait in Parkinson's disease. Transl Neurodegener 2022; 11:23. [PMID: 35490252 PMCID: PMC9057060 DOI: 10.1186/s40035-022-00298-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
There has been a growing appreciation for freezing of gait as a disabling symptom that causes a significant burden in Parkinson’s disease. Previous research has highlighted some of the key components that underlie the phenomenon, but these reductionist approaches have yet to lead to a paradigm shift resulting in the development of novel treatment strategies. Addressing this issue will require greater integration of multi-modal data with complex computational modeling, but there are a number of critical aspects that need to be considered before embarking on such an approach. This paper highlights where the field needs to address current gaps and shortcomings including the standardization of definitions and measurement, phenomenology and pathophysiology, as well as considering what available data exist and how future studies should be constructed to achieve the greatest potential to better understand and treat this devastating symptom.
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Affiliation(s)
- Simon Lewis
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Sydney, NSW, Australia.
| | - Stewart Factor
- Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University School of Medicine, Atlanta, GA, USA
| | - Nir Giladi
- Movement Disorders Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - John Nutt
- Movement Disorder Section, Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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Shackleford MR, Mishra V, Mari Z. Levodopa-Carbidopa Intestinal Gel may improve treatment-resistant freezing of gait in Parkinson’s disease. Clin Park Relat Disord 2022; 7:100148. [PMID: 35756075 PMCID: PMC9218161 DOI: 10.1016/j.prdoa.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/19/2022] [Accepted: 06/04/2022] [Indexed: 11/20/2022] Open
Abstract
Freezing of gait (FOG) in Parkinson’s Disease (PD) is difficult to control with oral levodopa. Levodopa-Carbidopa Intestinal Gel (LCIG) may be a therapeutic option for patients with FOG. This review examines the current literature on LCIG as a therapy for FOG.
Introduction Freezing of gait (FOG) is a highly disabling symptom in Parkinson’s Disease (PD) with varying degree of benefits from oral dopaminergic medications and several subtypes that present with different medication states (e.g., off FOG, on FOG, pseudo-on FOG, supra-on FOG). Levodopa-Carbidopa Intestinal Gel (LCIG) greately reduces the variability of cerebral dopamine replacement inherent to oral therapies by continuous levodopa intestinal infusion. While LCIG may be superior to oral therapy in its ability to treat motor fluctuations and minimize off-time, there is no consensus regarding the overall effectiveness of LCIG specifically for the treatment of FOG in PD patients. Methods A systematic literature review was conducted to understand the efficacy of LCIG to treat FOG in PD patients. A PubMed search was conducted using the search query “Intestinal AND (Levodopa OR L-dopa) AND Freezing of Gait AND Parkinson.” Additional eligibility criteria included articles written in English and currently published journal articles. Articles were excluded if they did not have a clinical design or if they did not yield reportable data on FOG. Results The literature search yielded 16 articles, of which 10 articles were included. Of the 10 studies included, there were 3 retrospective studies, 6 case reports or case series, and 1 open-label study. (n = 449 patients total and 318 FOG patients). Nine of the 10 studies concluded that LCIG has a favorable effect on FOG, though the metrics to evaluate benefits of LCIG on FOG varied among the articles. Conclusion LCIG may be an effective treatment for PD patients suffering from FOG including those with poor response to oral medication, likely because of its ability to maintain steadier dopamine levels. Further research is necessary on LCIG as a therapy for refractory FOG, with particular attention to the different subtypes of FOG.
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Affiliation(s)
- Melanie R. Shackleford
- Kirk Kerkorian School of Medicine at University of Nevada, 2040 W Charleston Blvd 3rd Floor, Las Vegas, NV 89102, United States
| | - Virendra Mishra
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Ave, Las Vegas, NV 89106, United States
| | - Zoltan Mari
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W Bonneville Ave, Las Vegas, NV 89106, United States
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Nonnekes J, Koehler P, Bloem BR. Freezing of Gait Before Levodopa. JOURNAL OF PARKINSON'S DISEASE 2021; 11:2093-2094. [PMID: 34511514 PMCID: PMC8673499 DOI: 10.3233/jpd-212933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jorik Nonnekes
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, Nijmegen, The Netherlands
| | - Peter Koehler
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Bastiaan R. Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
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