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Camargo CHF, Ferreira-Peruzzo SA, Ribas DIR, Franklin GL, Teive HAG. Imbalance and gait impairment in Parkinson's disease: discussing postural instability and ataxia. Neurol Sci 2024; 45:1377-1388. [PMID: 37985635 DOI: 10.1007/s10072-023-07205-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
Gait and balance difficulties pose significant clinical challenges in Parkinson's disease (PD). The impairment of physiological mechanisms responsible for maintaining natural orthostatism plays a central role in the pathophysiology of postural instability observed in PD. In addition to the well-known rigidity and abnormalities in muscles and joints, various brain regions involved in the regulation of posture, balance, and gait, such as the basal ganglia, cerebellum, and brainstem regions like the pontine peduncle nucleus, are affected in individuals with PD. The recognition of the cerebellum's role in PD has been increasingly acknowledged. Cortical areas and their connections are associated with freezing of gait, a type of frontal lobe ataxia commonly observed in PD. Furthermore, impairments in the peripheral nervous system, including those caused by levodopatherapy, can contribute to gait impairment and imbalance in PD patients. Consequently, individuals with PD may exhibit frontal ataxia, sensory ataxia, and even cerebellar ataxia as underlying causes of gait disturbances and imbalance, starting from the early stages of the disease. The complex interplay between dysfunctional brain regions, impaired cortical connections, and peripheral nervous system abnormalities contributes to the multifaceted nature of gait and balance difficulties in PD. Understanding the intricate mechanisms is crucial for the development of effective therapeutic approaches targeting these specific deficits in PD.
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Affiliation(s)
- Carlos Henrique F Camargo
- Neurological Diseases Group, Postgraduate Program in Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, 80060-900, Brazil.
| | - Silvia Aparecida Ferreira-Peruzzo
- Neurological Diseases Group, Postgraduate Program in Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, 80060-900, Brazil
- School of Health Sciences, Autonomous University of Brazil, Curitiba, Paraná, Brazil
| | - Danieli Isabel Romanovitch Ribas
- Neurological Diseases Group, Postgraduate Program in Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, 80060-900, Brazil
- School of Health Sciences, Autonomous University of Brazil, Curitiba, Paraná, Brazil
| | - Gustavo L Franklin
- School of Medicine, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil
| | - Hélio A G Teive
- Neurological Diseases Group, Postgraduate Program in Internal Medicine, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, 80060-900, Brazil
- Movement Disorders Unit, Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, Paraná, Brazil
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2
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Zoetewei D, Ginis P, Goris M, Gilat M, Herman T, Brozgol M, Thumm PC, Hausdorff JM, Nieuwboer A, D'Cruz N. Which Gait Tasks Produce Reliable Outcome Measures of Freezing of Gait in Parkinson's Disease? JOURNAL OF PARKINSON'S DISEASE 2024; 14:1163-1174. [PMID: 39121137 PMCID: PMC11380302 DOI: 10.3233/jpd-240134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Abstract
Background Measurement of freezing of gait (FOG) relies on the sensitivity and reliability of tasks to provoke FOG. It is currently unclear which tasks provide the best outcomes and how medication state plays into this. Objective To establish the sensitivity and test-retest reliability of various FOG-provoking tasks for presence and severity of FOG, with (ON) and without (OFF) dopaminergic medication. Methods FOG-presence and percentage time frozen (% TF) were derived from video annotations of a home-based FOG-provoking protocol performed in OFF and ON. This included: the four meter walk (4MW), Timed Up and Go (TUG) single (ST) and dual task (DT), 360° turns in ST and DT, a doorway condition, and a personalized condition. Sensitivity was tested at baseline in 63 definite freezers. Test-retest reliability was evaluated over 5 weeks in 26 freezers. Results Sensitivity and test-retest reliability were highest for 360° turns and higher in OFF than ON. Test-retest intra-class correlation coefficients of % TF varied between 0.63-0.90 in OFF and 0.18-0.87 in ON, and minimal detectable changes (MDCs) were high. The optimal protocol included TUG ST, 360° turns ST, 360° turns DT and a doorway condition, provoking FOG in all freezers in OFF and 91.9% in ON and this could be done reliably in 95.8% (OFF) and 84.0% (ON) of the sample. Combining OFF and ON further improved outcomes. Conclusions The highest sensitivity and reliability was achieved with a multi-trigger protocol performed in OFF + ON. However, the high MDCs for % TF underscore the need for further optimization of FOG measurement.
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Affiliation(s)
- Demi Zoetewei
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Pieter Ginis
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Maaike Goris
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Moran Gilat
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Talia Herman
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Marina Brozgol
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pablo Cornejo Thumm
- Center for the Study of Movement, Cognition, and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, 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 Physical Therapy, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rush Alzheimer's Disease Center and Department of Orthopedic Surgery, Rush University, Chicago, IL, USA
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Nicholas D'Cruz
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
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Marquez JS, Bartsch RP, Günther M, Hasan SMS, Koren O, Plotnik M, Bai O. Supplementary Motor Area Activity Differs in Parkinson's Disease with and without Freezing of Gait. PARKINSON'S DISEASE 2023; 2023:5033835. [PMID: 37701070 PMCID: PMC10495228 DOI: 10.1155/2023/5033835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 07/18/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023]
Abstract
The study aimed to investigate the neural changes that differentiate Parkinson's disease patients with freezing of gait and age-matched controls, using ambulatory electroencephalography event-related features. Compared to controls, definite freezers exhibited significantly less alpha desynchronization at the motor cortex about 300 ms before and after the start of overground walking and decreased low-beta desynchronization about 300 ms before and about 300 and 700 ms after walking onset. The late slope of motor potentials also differed in the sensory and motor areas between groups of controls, definite, and probable freezers. This difference was found both in preparation and during the execution of normal walking. The average frontal peak of motor potential was also found to be largely reduced in the definite freezers compared with the probable freezers and controls. These findings provide valuable insights into the underlying structures that are affected in patients with freezing of gait, which could be used to tailor drug development and personalize drug care for disease subtypes. In addition, the study's findings can help in the evaluation and validation of nonpharmacological therapies for patients with Parkinson's disease.
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Affiliation(s)
- J. Sebastian Marquez
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida, USA
| | - Ronny P. Bartsch
- Department of Physics, Bar-Ilan University, Ramat Gan 5290002, Israel
| | | | - S. M. Shafiul Hasan
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida, USA
| | - Or Koren
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Israel
| | - Meir Plotnik
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Israel
- Department of Physiology and Pharmacology, School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Ou Bai
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida, USA
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4
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Colletta K, Kletzel S, Hirsch M, Wegen EV, Gross M, Walker S, Devos H. Practical Strategies for Managing Freezing of Gait at Home for People Living With Parkinson Disease. Arch Phys Med Rehabil 2023; 104:1551-1555. [PMID: 37661126 DOI: 10.1016/j.apmr.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 09/05/2023]
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Li H, Gao M, Chen Z, Zhou Z, Li W, Zhang X, Jiang X, Luo L, Li F, Wang G, Zhang Y, Huang X, Zhu J, Fan S, Wu X, Huang C. Hordenine improves Parkinsonian-like motor deficits in mice and nematodes by activating dopamine D2 receptor-mediated signaling. Phytother Res 2023; 37:3296-3308. [PMID: 36883794 DOI: 10.1002/ptr.7790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
Parkinson's disease (PD) is a chronic neurodegenerative disease characterized by selective loss of dopaminergic neurons in the substantia nigra pars compacta (SNpc) and the striatum, leading to dopamine (DA) deficiency in the striatum and typical motor symptoms. A small molecule as a dietary supplement for PD would be ideal for practical reasons. Hordenine (HOR) is a phenolic phytochemical marketed as a dietary supplement found in cereals and germinated barley, as well as in beer, a widely consumed beverage. This study was aimed to identify HOR as a dopamine D2 receptor (DRD2) agonist in living cells, and investigate the alleviative effect and mechanism of HOR on PD-like motor deficits in mice and nematodes. Our results firstly showed that HOR is an agonist of DRD2, but not DRD1, in living cells. Moreover, HOR could improve the locomotor dysfunction, gait, and postural imbalance in MPTP- or 6-OHDA-induced mice or Caenorhabditis elegans, and prevent α-synuclein accumulation via the DRD2 pathway in C. elegans. Our results suggested that HOR could activate DRD2 to attenuate the PD-like motor deficits, and provide scientific evidence for the safety and reliability of HOR as a dietary supplement.
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Affiliation(s)
- Hongli Li
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Min Gao
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ziyu Chen
- Shanghai Key Laboratory of Compound Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhenyu Zhou
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wei Li
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Physiology, and Institute for Brain Sciences, School of Life Sciences, Nanjing University, Nanjing, China
| | - Xiaoyang Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Physiology, and Institute for Brain Sciences, School of Life Sciences, Nanjing University, Nanjing, China
| | - Xi Jiang
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lingling Luo
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fei Li
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Gaorui Wang
- Shanghai Key Laboratory of Compound Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yu Zhang
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China
| | - Xingxu Huang
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China
| | - Jingning Zhu
- State Key Laboratory of Pharmaceutical Biotechnology, Department of Physiology, and Institute for Brain Sciences, School of Life Sciences, Nanjing University, Nanjing, China
| | - Shengjie Fan
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaojun Wu
- Shanghai Key Laboratory of Compound Chinese Medicines, Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Cheng Huang
- Drug Discovery Laboratory, School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Kehnemouyi YM, Petrucci MN, Wilkins KB, Melbourne JA, Bronte-Stewart HM. The Sequence Effect Worsens Over Time in Parkinson's Disease and Responds to Open and Closed-Loop Subthalamic Nucleus Deep Brain Stimulation. JOURNAL OF PARKINSON'S DISEASE 2023:JPD223368. [PMID: 37125563 DOI: 10.3233/jpd-223368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND The sequence effect is the progressive deterioration in speech, limb movement, and gait that leads to an inability to communicate, manipulate objects, or walk without freezing of gait. Many studies have demonstrated a lack of improvement of the sequence effect from dopaminergic medication, however few studies have studied the metric over time or investigated the effect of open-loop deep brain stimulation in people with Parkinson's disease (PD). OBJECTIVE To investigate whether the sequence effect worsens over time and/or is improved on clinical (open-loop) deep brain stimulation (DBS). METHODS Twenty-one people with PD with bilateral subthalamic nucleus (STN) DBS performed thirty seconds of instrumented repetitive wrist flexion extension and the MDS-UPDRS III off therapy, prior to activation of DBS and every six months for up to three years. A sub-cohort of ten people performed the task during randomized presentations of different intensities of STN DBS. RESULTS The sequence effect was highly correlated with the overall MDS-UPDRS III score and the bradykinesia sub-score and worsened over three years. Increasing intensities of STN open-loop DBS improved the sequence effect and one subject demonstrated improvement on both open-loop and closed-loop DBS. CONCLUSION Sequence effect in limb bradykinesia worsened over time off therapy due to disease progression but improved on open-loop DBS. These results demonstrate that DBS is a useful treatment of the debilitating effects of the sequence effect in limb bradykinesia and upon further investigation closed-loop DBS may offer added improvement.
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Affiliation(s)
- Yasmine M Kehnemouyi
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA, USA
- Stanford University School of Engineering, Department of Bioengineering, Stanford, CA, USA
| | - Matthew N Petrucci
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA, USA
- Stanford University School of Engineering, Department of Bioengineering, Stanford, CA, USA
| | - Kevin B Wilkins
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA, USA
| | - Jillian A Melbourne
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA, USA
| | - Helen M Bronte-Stewart
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA, USA
- Stanford University School of Medicine, Department of Neurosurgery, Stanford, CA, USA
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7
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Yang N, Sang S, Peng T, Hu W, Wang J, Bai R, Lu H. Impact of GBA variants on longitudinal freezing of gait progression in early Parkinson's disease. J Neurol 2023; 270:2756-2764. [PMID: 36790548 DOI: 10.1007/s00415-023-11612-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Freezing of gait (FOG) is a common disabling gait disturbance among patients with Parkinson's disease (PD), but the influence of genetic variants on the incidence of FOG has been poorly studied to date. OBJECTIVES We aimed to evaluate the association of GBA variants with the risk of FOG development in a large early PD cohort. METHODS This study included 371 early PD patients from the Parkinson's Progression Markers Initiative (PPMI) who were divided into a GBA variant carrier group (GBA-PD group, n = 44) and an idiopathic PD group without GBA variants (iPD group, n = 327). They were followed up for up to 5 years to examine the progression of FOG. The cumulative incidence of FOG and risk factors for FOG were assessed using Kaplan‒Meier and Cox regression analyses. RESULTS At baseline, the GBA-PD group had lower CSF β-amyloid 1-42 (Aβ42) levels and more severe motor and nonmotor symptoms than the iPD group. During the 5-year follow-up, the GBA-PD group had a higher incidence of FOG than the iPD group, and the FOG progression rate was related to GBA variant severity. In the multivariable Cox model without CSF Aβ42, GBA variants were significant predictors of future FOG, and the association remained significant after adding CSF Aβ42 to the model. In the subgroup analyses, the effect of GBA variants was not observed in the "low-level" group. However, in the "high-level" group, GBA variants independently increased the risk of FOG, and this association was stronger than the association with CSF Aβ42. CONCLUSION GBA variants are novel genetic risk factors for future FOG development in early PD patients. This association seemed to be mediated by both Aβ-dependent pathways and Aβ-independent pathways.
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Affiliation(s)
- Nannan Yang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Shushan Sang
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Tao Peng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Wentao Hu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jingtao Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Rong Bai
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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Krüger M, Lux V. Failure of motor function-A Developmental Embodiment Research perspective on the systemic effects of stress. Front Hum Neurosci 2023; 17:1083200. [PMID: 36875241 PMCID: PMC9977814 DOI: 10.3389/fnhum.2023.1083200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/26/2023] [Indexed: 02/18/2023] Open
Abstract
Humans are capable to skillfully perform a huge variety of complex movements seemingly effortless and to flexibly adjust movement execution to ever-changing environmental conditions, often without apparent differences in the movement outcome. This impressive ability has sparked scientific interest in the mechanisms underlying movement execution for decades. In this perspective article, we argue that investigating the processes and mechanisms leading to failure of motor functions is a fruitful approach to advance the field of human motor neuroscience and beyond. The study of failure of motor function in specific populations (patient groups, skilled experts) has already provided tremendous insight in the systemic characteristics and multi-level functional dependencies of movement execution. However, particularly the transient failure of function in everyday motor actions remains a blind spot. Coming from the perspective of Developmental Embodiment Research, we argue that the integration of a developmental embodiment and lifespan perspective with existing systemic and multi-level methodological approaches of failure of function analyses provides an integrative, interdisciplinary framework, which will allow us to overcome this shortcoming. We further suggest that stress-induced failure of motor function situations might represent a promising starting point for this endeavor. Identifying the involved cross-level functional dependencies of acute and chronic stress on transient and persistent motor functioning would further advance our knowledge on the mechanisms underlying movement execution, and would allow to identify targets for intervention and prevention across the whole spectrum of motor function and failure.
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Affiliation(s)
- Melanie Krüger
- Institute of Sports Science, Faculty of Humanities, Leibniz University Hannover, Hannover, Germany
| | - Vanessa Lux
- Department of Genetic Psychology, Ruhr University Bochum, Bochum, Germany
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Karimi F, Almeida Q, Jiang N. Large-scale frontoparietal theta, alpha, and beta phase synchronization: A set of EEG differential characteristics for freezing of gait in Parkinson's disease? Front Aging Neurosci 2022; 14:988037. [PMID: 36389071 PMCID: PMC9643859 DOI: 10.3389/fnagi.2022.988037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/03/2022] [Indexed: 08/18/2023] Open
Abstract
Freezing of gait (FOG) is a complex gait disturbance in Parkinson's disease (PD), during which the patient is not able to effectively initiate gait or continue walking. The mystery of the FOG phenomenon is still unsolved. Recent studies have revealed abnormalities in cortical activities associated with FOG, which highlights the importance of cortical and cortical-subcortical network dysfunction in PD patients with FOG. In this paper, phase-locking value (PLV) of eight frequency sub-bands between 0.05 Hz and 35 Hz over frontal, motor, and parietal areas [during an ankle dorsiflexion (ADF) task] is used to investigate EEG phase synchronization. PLV was investigated over both superficial and deeper networks by analyzing EEG signals preprocessed with and without Surface Laplacian (SL) spatial filter. Four groups of participants were included: PD patients with severe FOG (N = 5, 5 males), PD patients with mild FOG (N = 7, 6 males), PD patients without FOG (N = 14, 13 males), and healthy age-matched controls (N = 13, 10 males). Fifteen trials were recorded from each participant. At superficial layers, frontoparietal theta phase synchrony was a unique feature present in PD with FOG groups. At deeper networks, significant dominance of interhemispheric frontoparietal alpha phase synchrony in PD with FOG, in contrast to beta phase synchrony in PD without FOG, was identified. Alpha phase synchrony was more distributed in PD with severe FOG, with higher levels of frontoparietal alpha phase synchrony. In addition to FOG-related abnormalities in PLV analysis, phase-amplitude coupling (PAC) analysis was also performed on frequency bands with PLV abnormalities. PAC analysis revealed abnormal coupling between theta and low beta frequency bands in PD with severe FOG at the superficial layers over frontal areas. At deeper networks, theta and alpha frequency bands show high PAC over parietal areas in PD with severe FOG. Alpha and low beta also presented PAC over frontal areas in PD groups with FOG. The results introduced significant phase synchrony differences between PD with and without FOG and provided important insight into a possible unified underlying mechanism for FOG. These results thus suggest that PLV and PAC can potentially be used as EEG-based biomarkers for FOG.
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Affiliation(s)
- Fatemeh Karimi
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Quincy Almeida
- Movement Disorders Research and Rehabilitation Consortium, Department of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Ning Jiang
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Manufacturing, Sichuan University, Chengdu, China
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Mostile G, Fasano A, Zappia M. Parkinsonism in idiopathic normal pressure hydrocephalus: is it time for defining a clinical tetrad? Neurol Sci 2022; 43:5201-5205. [PMID: 35648268 PMCID: PMC9385815 DOI: 10.1007/s10072-022-06119-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 11/02/2022]
Abstract
Abstract
Background
Association between parkinsonism and idiopathic normal pressure hydrocephalus (iNPH) still remains debated. There is already plenty of evidences in the literature suggesting that this clinical sign can be considered as an integral part of the clinical spectrum of iNPH patients.
Methods
We reviewed the possible pitfalls in the core clinical definition of iNPH based on available international diagnostic criteria, phenomenology of parkinsonism in iNPH, and neuroimaging supporting the presence of parkinsonism in iNPH.
Conclusions
We argue that the diagnostic definition of the iNPH “triad” should be possibly reconsidered as a “tetrad” also including parkinsonism.
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Hu H, Xiao D, Rhodin H, Murphy TH. Towards a Visualizable, De-identified Synthetic Biomarker of Human Movement Disorders. JOURNAL OF PARKINSON'S DISEASE 2022; 1:2085-2096. [PMID: 36057831 PMCID: PMC10473142 DOI: 10.3233/jpd-223351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 12/15/2022]
Abstract
Human motion analysis has been a common thread across modern and early medicine. While medicine evolves, analysis of movement disorders is mostly based on clinical presentation and trained observers making subjective assessments using clinical rating scales. Currently, the field of computer vision has seen exponential growth and successful medical applications. While this has been the case, neurology, for the most part, has not embraced digital movement analysis. There are many reasons for this including: the limited size of labeled datasets, accuracy and nontransparent nature of neural networks, and potential legal and ethical concerns. We hypothesize that a number of opportunities are made available by advancements in computer vision that will enable digitization of human form, movements, and will represent them synthetically in 3D. Representing human movements within synthetic body models will potentially pave the way towards objective standardized digital movement disorder diagnosis and building sharable open-source datasets from such processed videos. We provide a perspective of this emerging field and describe how clinicians and computer scientists can navigate this new space. Such digital movement capturing methods will be important for both machine learning-based diagnosis and computer vision-aided clinical assessment. It would also supplement face-to-face clinical visits and be used for longitudinal monitoring and remote diagnosis.
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Affiliation(s)
- Hao Hu
- University of British Columbia, Department of Psychiatry, Kinsmen Laboratory of Neurological Research, Detwiller Pavilion, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Dongsheng Xiao
- University of British Columbia, Department of Psychiatry, Kinsmen Laboratory of Neurological Research, Detwiller Pavilion, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Helge Rhodin
- Department of Computer Science, University of British Columbia, Vancouver, BC, Canada
| | - Timothy H. Murphy
- University of British Columbia, Department of Psychiatry, Kinsmen Laboratory of Neurological Research, Detwiller Pavilion, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Fathipour-Azar Z, Azad A, Akbarfahimi M, Behzadipour S, Taghizadeh G. Symmetric and asymmetric bimanual coordination and freezing of gait in Parkinsonian patients in drug phases. Ann N Y Acad Sci 2022; 1511:244-261. [PMID: 35194819 DOI: 10.1111/nyas.14759] [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: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Freezing of gait (FOG) is a debilitating symptom in patients with Parkinson's disease (PD), which may be associated with motor control impairments in tasks other than gait. This study aimed to examine whether symmetric and asymmetric bimanual coordination is impaired in PD with FOG (PD +FOG) patients and whether dual-task and drug phases may affect bimanual coordination in these patients. Twenty PD +FOG patients, 20 PD patients without FOG (PD -FOG) performed symmetric and asymmetric functional bimanual tasks (reach to and pick up a box and open a drawer to press a pushbutton inside it, respectively) under single-task and dual-task conditions. PD patients were evaluated during on- and off-drug phases. Kinematic and coordination measures were calculated for each task. PD +FOG patients demonstrated exacerbated impairments of bimanual coordination while performing goal-directed bimanual tasks, which was more evident in the asymmetric bimanual task and under dual-task conditions, highlighting the need for rehabilitation interventions for bimanual tasks that include different cognitive loads in these patients. Interestingly, 25% and 5% of participants in the PD +FOG and -FOG groups developed upper limb freezing 2 years later, respectively. This study aimed to examine whether symmetric and asymmetric bimanual coordination is impaired in Parkinson's disease with freezing of gait (PD +FOG) patients and whether dual-task and drug phases may affect bimanual coordination in these patients. PD +FOG patients demonstrated exacerbated impairment of bimanual coordination while performing goal-directed bimanual tasks, highlighting the need for rehabilitation interventions for bimanual tasks that include different cognitive loads in these patients.
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Affiliation(s)
- Zeinab Fathipour-Azar
- Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Akram Azad
- Rehabilitation Research Center, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Malahat Akbarfahimi
- Rehabilitation Research Center, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Behzadipour
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran.,Djavad Mowafaghian Research Center for Intelligent Neuro-rehabilitation Technologies, Tehran, Iran
| | - Ghorban Taghizadeh
- Rehabilitation Research Center, Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
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13
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Rösch AD, Taub E, Gschwandtner U, Fuhr P. Evaluating a Speech-Specific and a Computerized Step-Training-Specific Rhythmic Intervention in Parkinson's Disease: A Cross-Over, Multi-Arms Parallel Study. FRONTIERS IN REHABILITATION SCIENCES 2022; 2:783259. [PMID: 36188780 PMCID: PMC9397933 DOI: 10.3389/fresc.2021.783259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
Background: Recent studies suggest movements of speech and gait in patients with Parkinson's Disease (PD) are impaired by a common underlying rhythmic dysfunction. If this being the case, motor deficits in speech and gait should equally benefit from rhythmic interventions regardless of whether it is a speech-specific or step-training-specific approach. Objective: In this intervention trial, we studied the effects of two rhythmic interventions on speech and gait. These rhythmic intervention programs are similar in terms of intensity and frequency (i.e., 3x per week, 45 min-long sessions for 4 weeks in total), but differ regarding therapeutic approach (rhythmic speech vs. rhythmic balance-mobility training). Methods: This study is a cross-over, parallel multi-arms, single blind intervention trial, in which PD patients treated with rhythmic speech-language therapy (rSLT; N = 16), rhythmic balance-mobility training (rBMT; N = 10), or no therapy (NT; N = 18) were compared to healthy controls (HC; N = 17; matched by age, sex, and education: p > 0.82). Velocity and cadence in speech and gait were evaluated at baseline (BL), 4 weeks (4W-T1), and 6 months (6M-T2) and correlated. Results: Parameters in speech and gait (i.e., speaking and walking velocity, as well as speech rhythm with gait cadence) were positively correlated across groups (p < 0.01). Statistical analyses involved repeated measures ANOVA across groups and time, as well as independent and one-samples t-tests for within groups analyses. Statistical analyses were amplified using Reliable Change (RC) and Reliable Change Indexes (RCI) to calculate true clinically significant changes due to the treatment on a patient individual level. Rhythmic intervention groups improved across variables and time (total Mean Difference: 3.07 [SD 1.8]; 95% CI 0.2–11.36]) compared to the NT group, whose performance declined significantly at 6 months (p < 0.01). HC outperformed rBMT and NT groups across variables and time (p < 0.001); the rSLT performed similarly to HC at 4 weeks and 6 months in speech rhythm and respiration. Conclusions: Speech and gait deficits in PD may share a common mechanism in the underlying cortical circuits. Further, rSLT was more beneficial to dysrhythmic PD patients than rBMT, likely because of the nature of the rhythmic cue.
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Affiliation(s)
- Anne Dorothée Rösch
- Department of Clinical Neurophysiology/Neurology, Hospital of the University of Basel, Basel, Switzerland
| | - Ethan Taub
- Department of Neurosurgery, Hospital of the University of Basel, Basel, Switzerland
| | - Ute Gschwandtner
- Department of Clinical Neurophysiology/Neurology, Hospital of the University of Basel, Basel, Switzerland
- *Correspondence: Ute Gschwandtner
| | - Peter Fuhr
- Department of Clinical Neurophysiology/Neurology, Hospital of the University of Basel, Basel, Switzerland
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14
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Putortì A, Corrado M, Avenali M, Martinelli D, Allena M, Cristina S, Grillo V, Martinis L, Tamburin S, Serrao M, Pisani A, Tassorelli C, De Icco R. The Effects of Intensive Neurorehabilitation on Sequence Effect in Parkinson's Disease Patients With and Without Freezing of Gait. Front Neurol 2021; 12:723468. [PMID: 34557151 PMCID: PMC8453149 DOI: 10.3389/fneur.2021.723468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The sequence effect (SE), defined as a reduction in amplitude of repetitive movements, is a common clinical feature of Parkinson's disease (PD) and is supposed to be a major contributor to freezing of gait (FOG). During walking, SE manifests as a step-by-step reduction in step length when approaching a turning point or gait destination, resulting in the so-called destination sequence effect (dSE). Previous studies explored the therapeutic effects of several strategies on SE, but none of them evaluated the role of an intensive rehabilitative program. Objectives: Here we aim to study the effects of a 4-week rehabilitative program on dSE in patients with PD with and without FOG. Methods: Forty-three patients (30 males, 70.6 ± 7.5 years old) with idiopathic PD were enrolled. The subjects were divided into two groups: patients with (PD + FOG, n = 23) and without FOG (PD - FOG, n = 20). All patients underwent a standardized 4-week intensive rehabilitation in-hospital program. At hospital admission (T0) and discharge (T1), all subjects were evaluated with an inertial gait analysis for dSE recording. Results: At T0, the dSE was more negative in the PD + FOG group (-0.80 ± 0.6) when compared to the PD - FOG group (-0.39 ± 0.3) (p = 0.007), even when controlling for several clinical and demographic features. At T1, the dSE was reduced in the overall study population (p = 0.001), with a more pronounced improvement in the PD + FOG group (T0: -0.80 ± 0.6; T1: -0.23 ± 0.4) when compared to the PD - FOG group (T0: -0.39 ± 0.3; T1: -0.22 ± 0.5) (p = 0.012). At T1, we described in the overall study population an improvement in speed, cadence, stride duration, and stride length (p = 0.001 for all variables). Conclusions: dSE is a core feature of PD gait dysfunction, specifically in patients with FOG. A 4-week intensive rehabilitative program improved dSE in PD patients, exerting a more notable beneficial effect in the PD + FOG group.
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Affiliation(s)
- Alessia Putortì
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Michele Corrado
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Micol Avenali
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Daniele Martinelli
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Marta Allena
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Silvano Cristina
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Valentina Grillo
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Luca Martinis
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Public Health, Experimental Medicine and Forensic Science, University of Pavia, Pavia, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome Sapienza, Latina, Italy
- Movement Analysis Laboratory, Policlinico Italia, Rome, Italy
| | - Antonio Pisani
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Cristina Tassorelli
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Roberto De Icco
- Movement Analysis Research Unit, IRCCS Mondino Foundation, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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15
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Poor sleep quality is associated with cognitive, mobility, and anxiety disability that underlie freezing of gait in Parkinson's disease. Gait Posture 2021; 85:157-163. [PMID: 33578308 DOI: 10.1016/j.gaitpost.2021.01.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Individuals with Parkinson's disease (PD) who report freezing of gait (FOG) have poorer sleep quality than those without FOG. Cognitive, anxiety, and mobility disability are components of the FOG phenotype, however, no study has investigated if poor sleep quality is associated with all three components that underlie FOG in PD. RESEARCH QUESTION Are there associations among sleep quality and all three components of the FOG phenotype? METHODS Forty and 39 individuals with and without FOG (PD + FOG and PD-FOG), respectively, and 31 age-matched healthy controls (HC) participated in this study. Self-reported FOG (new-FOG questionnaire-NFOGQ), sleep quality (Pittsburgh Sleep Quality Index-PSQI), cognitive function (Montreal Cognitive Assessment-MoCA), anxiety (subscale from Hospital Anxiety and Depression Scale-HADS-A), and mobility (timed-up-and-go test-TUG) were assessed. RESULTS AND SIGNIFICANCE PSQI scores were correlated with the scores of NFOGQ, MoCA, HADS-A, and TUG time in PD + FOG (P ≤ 0.0038). The multiple regression analysis identified the PSQI scores as the only predictor of the variance of the NFOGQ scores (R2 = 0.46, P < .0001). The variance in the PSQI scores were explained (69 %) by MoCA scores, NFOGQ scores, TUG time, and HADS-A scores (P ≤ 0.05). Although PD + FOG had a higher disease severity compared to PD-FOG (P < 0.001), disease severity did not enter in the regression model to explain PSQI scores and NFOGQ scores. We also observed associations of PSQI scores with the MoCA scores and TUG time for HC (P ≤ 0.0038), whereas there was no association between PSQI scores and any variable in PD-FOG (P > 0.05). Finally, PD + FOG presented worse scores of PSQI, MoCA, HADS-A, and TUG time than PD-FOG and HC (P < 0.05). Thus, poor sleep quality is associated with FOG and all three components that underlie FOG, regardless of the disease severity. Therefore, treatments useful to decrease FOG should be targeted to ameliorate sleep quality, cognition, anxiety, and mobility.
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16
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Nobleza CMN, Siddiqui M, Shah PV, Balani P, Lopez AR, Khan S. The Relationship of Rapid Eye Movement Sleep Behavior Disorder and Freezing of Gait in Parkinson's Disease. Cureus 2020; 12:e12385. [PMID: 33532150 PMCID: PMC7846434 DOI: 10.7759/cureus.12385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rapid eye movement sleep behavior disorder (RBD) contributes to injury due to the alteration of the expected atonia during rapid eye movement (REM) sleep. It occurs before the overt signs of Parkinson's disease (PD). The co-expression of PD and RBD is characterized by non-tremor predominant subtype and higher incidence of freezing. Freezing of gait (FOG) is a debilitating symptom seen in PD patients that lead to falls. While this phenomenon is understood poorly, the involvement of the pedunculopontine nucleus (PPN) and the neural circuits that control locomotion and gait have been examined. This network has also the same control for REM sleep and arousal. The close relationship between PD and RBD and FOG's consequences has led us to explore the relationship between RBD and PD with FOG. This review provides an overview of the neural connections that control gait, locomotion, and REM sleep. The neural changes were seen in PD with FOG and RBD, and sensory and motor changes observed in these two diseases. The functional neuroanatomy that controls REM sleep, arousal, and locomotion overlap significantly with multiple neural circuits affected in RBD and PD with FOG. Visual perception dysfunction and motor symptoms that primarily affect gait initiation are common to both patients with RBD and FOG in PD, leading to freezing episodes. Prospective studies should be conducted to elucidate the relationship of RBD and PD with FOG subtype and find innovative treatment approaches and diagnostic tools for PD with FOG.
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Affiliation(s)
- Chelsea Mae N Nobleza
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mariah Siddiqui
- Neurology, St. George's University, True Blue, GRD.,Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Parth V Shah
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prachi Balani
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Angel R Lopez
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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17
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Marquez JS, Hasan SMS, Siddiquee MR, Luca CC, Mishra VR, Mari Z, Bai O. Neural Correlates of Freezing of Gait in Parkinson's Disease: An Electrophysiology Mini-Review. Front Neurol 2020; 11:571086. [PMID: 33240199 PMCID: PMC7683766 DOI: 10.3389/fneur.2020.571086] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022] Open
Abstract
Freezing of gait (FoG) is a disabling symptom characterized as a brief inability to step or by short steps, which occurs when initiating gait or while turning, affecting over half the population with advanced Parkinson's disease (PD). Several non-competing hypotheses have been proposed to explain the pathophysiology and mechanism behind FoG. Yet, due to the complexity of FoG and the lack of a complete understanding of its mechanism, no clear consensus has been reached on the best treatment options. Moreover, most studies that aim to explore neural biomarkers of FoG have been limited to semi-static or imagined paradigms. One of the biggest unmet needs in the field is the identification of reliable biomarkers that can be construed from real walking scenarios to guide better treatments and validate medical and therapeutic interventions. Advances in neural electrophysiology exploration, including EEG and DBS, will allow for pathophysiology research on more real-to-life scenarios for better FoG biomarker identification and validation. The major aim of this review is to highlight the most up-to-date studies that explain the mechanisms underlying FoG through electrophysiology explorations. The latest methodological approaches used in the neurophysiological study of FoG are summarized, and potential future research directions are discussed.
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Affiliation(s)
- J. Sebastian Marquez
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, United States
| | - S. M. Shafiul Hasan
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, United States
| | - Masudur R. Siddiquee
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, United States
| | - Corneliu C. Luca
- Department of Neurology, University of Miami Hospital, Miami, FL, United States
| | - Virendra R. Mishra
- Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV, United States
| | - Zoltan Mari
- Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas, NV, United States
| | - Ou Bai
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, United States
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18
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Gonzalez-Latapi P, Bhowmick SS, Saranza G, Fox SH. Non-Dopaminergic Treatments for Motor Control in Parkinson's Disease: An Update. CNS Drugs 2020; 34:1025-1044. [PMID: 32785890 DOI: 10.1007/s40263-020-00754-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Glutamatergic, noradrenergic, serotonergic, and cholinergic systems play a critical role in the basal ganglia circuitry. Targeting these non-dopaminergic receptors remains a focus of ongoing research to improve Parkinson's disease (PD) motor symptoms, without the potential side effects of dopamine replacement therapy. This review updates advancements in non-dopaminergic treatments for motor control in PD since 2013. To date, no non-dopaminergic selective drug has shown significant long-term efficacy as monotherapy in PD. The largest area of development in non-dopaminergic targets has been for motor complications of dopamine replacement therapy (motor fluctuations and dyskinesia). For treatment of motor fluctuations, safinamide, zonisamide, and istradefylline are currently approved, and novel glutamatergic and serotonergic drugs are in development. Long-acting formulations of amantadine are approved for treating dyskinesia. Several non-dopaminergic drugs have failed to show anti-dyskinetic efficacy, while some are still in development. Non-dopaminergic targets are also being pursued to treat specific motor symptoms of PD. For example, CX-8998 (a calcium channel modulator) is being evaluated for PD tremor and rivastigmine may improve gait dysfunction in PD. Drug repurposing continues to be a key strategy for non-dopaminergic targets in PD, but the field needs to increase discovery and availability of such drugs.
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Affiliation(s)
- Paulina Gonzalez-Latapi
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, Department of Medicine, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Suvorit Subhas Bhowmick
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, Department of Medicine, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Gerard Saranza
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, Department of Medicine, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Susan H Fox
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Division of Neurology, Department of Medicine, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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19
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Cao SS, Yuan XZ, Wang SH, Taximaimaiti R, Wang XP. Transverse Strips Instead of Wearable Laser Lights Alleviate the Sequence Effect Toward a Destination in Parkinson's Disease Patients With Freezing of Gait. Front Neurol 2020; 11:838. [PMID: 32903360 PMCID: PMC7434927 DOI: 10.3389/fneur.2020.00838] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The sequence effect (SE), referring to step-to-step reduction in amplitude, is considered to lead to freezing of gait (FOG) in Parkinson's disease (PD). Visual cues may alleviate SE and help reduce freezing episodes. FOG patients show significant SE prior to turning or toward a doorway, but the SE toward a destination has not been clearly studied. Objectives: To examine the SE when approaching a destination in PD patients with FOG, and to further explore the effects of different types of visual cues on destination SE. Methods: Thirty-five PD patients were divided into a freezing (PD+FOG, n = 15) group and a non-freezing (PD-FOG, n = 20) group. Walking trials were tested under three conditions, including without cues (no-cue condition), with wearable laser lights (laser condition), and with transverse strips placed on the floor (strip condition). Kinematic data was recorded by a portable Inertial Measurement Unit (IMU) system. The destination SE and some key gait parameters were evaluated. Results: The PD+FOG group showed greater destination SE in the no-cue and laser conditions when compared to the PD-FOG group. There were no significant differences in the strip condition when comparing destination SE of the two groups. The destination SE was alleviated only by using the transverse strips on the floor. In contrast, transverse strips and wearable laser lights could increase the step length. Conclusions: The significant destination SE may explain why FOG patients are prone to freezing when heading toward their destination. Visual cues using transverse strips on the floor may be a more effective strategy for FOG rehabilitation in PD patients.
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Affiliation(s)
- Shan-Shan Cao
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang-Zhen Yuan
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu-Hong Wang
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Reyisha Taximaimaiti
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Ping Wang
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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20
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Strigaro G, Barbero P, Pizzamiglio C, Magistrelli L, Gori B, Comi C, Varrasi C, Cantello R. Cortical visuomotor interactions in Freezing of Gait: A TMS approach. Neurophysiol Clin 2020; 50:205-212. [PMID: 32354665 DOI: 10.1016/j.neucli.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/10/2020] [Accepted: 04/10/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Altered cortical visuomotor integration has been involved in the pathophysiology of freezing of gait (FoG) in parkinsonism. The aim of this study was to assess the connections between the primary visual (V1) and motor (M1) areas with a paired-pulse, twin-coil transcranial magnetic stimulation (TMS) technique in patients with FoG. METHODS Twelve Parkinson's disease (PD) patients suffering from levodopa-responsive-FoG (off-FoG) were compared with 12 PD patients without FoG and 12 healthy subjects of similar age/sex. In the "off" condition, visuomotor connections (VMCs) were assessed bilaterally. A conditioning stimulus over the V1 phosphene hotspot was followed at interstimulus intervals (ISIs) of 18 and 40ms by a test stimulus over M1, to elicit motor evoked potentials (MEPs) in the contralateral first dorsal interosseous muscle. RESULTS Significant (P<0.01), bilateral effects due to VMCs were detected in all three groups, consisting of a MEP suppression at ISI 18 and 40ms. However, in PD patients with FoG, the MEP suppression was significantly (P<0.05) enhanced, both at ISI 18-40ms, in comparison with the other two groups. The phenomenon was limited to the right hemisphere. CONCLUSIONS PD patients with FoG showed an excessive inhibitory response of the right M1 to inputs travelling from V1 at given ISIs. Right-sided alterations of the cortical visuomotor integration may contribute to the pathophysiology of FoG.
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Affiliation(s)
- Gionata Strigaro
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy.
| | - Paolo Barbero
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Chiara Pizzamiglio
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Luca Magistrelli
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Benedetta Gori
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Cristoforo Comi
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Claudia Varrasi
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
| | - Roberto Cantello
- Department of Translational Medicine, Section of Neurology, University of Piemonte Orientale and "Maggiore della Carità" University Hospital, Novara, Italy
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21
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Bologna M, Paparella G, Fasano A, Hallett M, Berardelli A. Evolving concepts on bradykinesia. Brain 2020; 143:727-750. [PMID: 31834375 PMCID: PMC8205506 DOI: 10.1093/brain/awz344] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/02/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022] Open
Abstract
Bradykinesia is one of the cardinal motor symptoms of Parkinson's disease and other parkinsonisms. The various clinical aspects related to bradykinesia and the pathophysiological mechanisms underlying bradykinesia are, however, still unclear. In this article, we review clinical and experimental studies on bradykinesia performed in patients with Parkinson's disease and atypical parkinsonism. We also review studies on animal experiments dealing with pathophysiological aspects of the parkinsonian state. In Parkinson's disease, bradykinesia is characterized by slowness, the reduced amplitude of movement, and sequence effect. These features are also present in atypical parkinsonisms, but the sequence effect is not common. Levodopa therapy improves bradykinesia, but treatment variably affects the bradykinesia features and does not significantly modify the sequence effect. Findings from animal and patients demonstrate the role of the basal ganglia and other interconnected structures, such as the primary motor cortex and cerebellum, as well as the contribution of abnormal sensorimotor processing. Bradykinesia should be interpreted as arising from network dysfunction. A better understanding of bradykinesia pathophysiology will serve as the new starting point for clinical and experimental purposes.
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Affiliation(s)
- Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Italy
- IRCCS Neuromed, Pozzilli (IS), Italy
| | | | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Italy
- IRCCS Neuromed, Pozzilli (IS), Italy
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22
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Yuda E, Yoshida Y, Ueda N, Kaneko I, Miura Y, Hayano J. Effects of aging on foot pedal responses to visual stimuli. J Physiol Anthropol 2020; 39:3. [PMID: 32059744 PMCID: PMC7023820 DOI: 10.1186/s40101-020-0213-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Car accidents due to unexpected forward or backward runaway by older drivers are a serious social problem. Although the cause of these accidents is often attributed to stepping on the accelerator instead of the brake, it is difficult to induce such pedal application errors systematically with usual drive simulators. We developed a simple personal computer system that induces the pedal errors, and investigate the effects of age on the error behaviors. METHODS The system consisted of a laptop computer and a three-pedal foot mouse. It measured response time, accuracy, and flexibility of pedal operation to visual stimuli. The system displayed two open circles on the computer display, lighting one of the circles in a random order and interval. Subjects were instructed to press the foot pedal with their right foot as quickly as possible when the circle was lit; the ipsilateral pedal to the lit circle in a parallel mode and the contralateral pedal in a cross mode. When the correct pedal was pressed, the light went off immediately, but when the wrong pedal was pressed, the buzzer sounded and the light remained on until the correct pedal was pressed. During a 6-min trial, the mode was switched between parallel and cross every 2 min. During the cross mode, a cross mark appears on the display. The pedal responses were evaluated in 52 subjects divided into young (20-29 years), middle-aged (30-64 years), and older (65-84 years) groups. Additionally, the repeatability of the pedal response characteristic indicators was examined in 14 subjects who performed this test twice. RESULTS The mean response time was 95 ms (17%) longer in the older group than in the young group. More characteristically, however, the older group showed 2.1 times more frequent pedal errors, fell into long hesitations (response freezing > 3 s) 16 times more often, and took 1.8 times longer period to correct the wrong pedal than the young groups. The indicators of pedal response characteristics showed within-individual repeatability to the extent that can identify the age-dependent changes. CONCLUSIONS Hesitations and extended error correction time can be associated with increased crash risk due to unexpected runaway by older drivers. The system we have developed may help to uncover and evaluate physiological characteristics related to crash risk in the elderly population.
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Affiliation(s)
- Emi Yuda
- Tohoku University Graduate School of Engineering, Aoba 6-6-05 Aramaki Aoba-ku, Sendai, 980-8759, Japan
| | - Yutaka Yoshida
- Nagoya City University Graduate School of Design and Architecture, Kita Chikusa 2-1-10 Chikusa-ku, Nagoya, 464-0083, Japan
| | - Norihiro Ueda
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan
| | - Itaru Kaneko
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yutaka Miura
- Shigakkan University, 55 Nakoyama, Yokonemachi, Obu, Aichi, 474-8651, Japan
| | - Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan.
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23
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The Therapeutic Effect of Nordic Walking on Freezing of Gait in Parkinson's Disease: A Pilot Study. PARKINSONS DISEASE 2019; 2019:3846279. [PMID: 32089815 PMCID: PMC7024088 DOI: 10.1155/2019/3846279] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/27/2019] [Accepted: 12/05/2019] [Indexed: 11/17/2022]
Abstract
Introduction. The effectiveness of the currently utilized therapies for FoG is limited. Several studies demonstrated a beneficial impact of Nordic walking (NW) on several gait parameters in Parkinson's disease, but only one paper reported reduction of freezing. Research Question. In the present study, the question is whether NW is an effective therapeutic intervention in FoG.
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24
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Freezing of Gait can persist after an acute levodopa challenge in Parkinson's disease. NPJ PARKINSONS DISEASE 2019; 5:25. [PMID: 31799377 PMCID: PMC6874572 DOI: 10.1038/s41531-019-0099-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/31/2019] [Indexed: 02/01/2023]
Abstract
Study objectives included testing whether presumed levodopa-unresponsive freezing of gait (FOG) in Parkinson's disease (PD) actually persists in the presence of adequate dopaminergic dosing and to investigate whether the presence of other parkinsonian features and their responsiveness to therapy varies across patients without FOG (NO-FOG), with levodopa-responsive FOG (OFF-FOG), and with levodopa-unresponsive FOG (ONOFF-FOG). Fifty-five PD patients completed levodopa challenges after >12-h OFF with supratherapeutic doses of dopaminergic medications. Observed responses in FOG, measured with MDS-UPDRS-III during the patient reported full "ON", were used to classify them as NO-FOG, OFF-FOG, or ONOFF-FOG. Serum levodopa levels were measured. Only those with ≥20% improvement in MDS-UPDRS-III score were included in analyses. Levodopa challenge was sufficient to bring about a full "ON" state with ≥20% improvement in 45 patients. Levodopa-equivalent-dose utilized was 142 ± 56% of patients' typical morning doses. Overall, 19/45 patients exhibited FOG in the full "ON" state (ONOFF-FOG), 11 were classified as OFF-FOG, and 15 NO-FOG. Linear mixed models revealed a highly significant association between serum levodopa level and total MDS-UPDRS-III score that was similar across groups. The ONOFF-FOG group exhibited significantly higher New-FOG-questionnaire and MDS-UPDRS-II scores compared to the OFF-FOG group. Among MDS-UPDRS-III subdomains significant effects of group (highest in ONOFF-FOG) were identified for other axial parkinsonian features. We found that FOG can persist in the full "ON" state brought about by ample dopaminergic dosing in PD. Other axial measures can also be levodopa-unresponsive among those with ONOFF-FOG only. These data provide evidence that ONOFF-FOG is distinct from responsive freezing.
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25
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Demrozi F, Bacchin R, Tamburin S, Cristani M, Pravadelli G. Toward a Wearable System for Predicting Freezing of Gait in People Affected by Parkinson's Disease. IEEE J Biomed Health Inform 2019; 24:2444-2451. [PMID: 31715577 DOI: 10.1109/jbhi.2019.2952618] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Some wearable solutions exploiting on-body acceleration sensors have been proposed to recognize Freezing of Gait (FoG) in people affected by Parkinson Disease (PD). Once a FoG event is detected, these systems generate a sequence of rhythmic stimuli to allow the patient restarting the gait. While these solutions are effective in detecting FoG events, they are unable to predict FoG to prevent its occurrence. This paper fills in the gap by presenting a machine learning-based approach that classifies accelerometer data from PD patients, recognizing a pre-FOG phase to further anticipate FoG occurrence in advance. Gait was monitored by three tri-axial accelerometer sensors worn on the back, hip and ankle. Gait features were then extracted from the accelerometer's raw data through data windowing and non-linear dimensionality reduction. A k-nearest neighbor algorithm (k-NN) was used to classify gait in three classes of events: pre-FoG, no-FoG and FoG. The accuracy of the proposed solution was compared to state-of-the-art approaches. Our study showed that: (i) we achieved performances overcoming the state-of-the-art approaches in terms of FoG detection, (ii) we were able, for the very first time in the literature, to predict FoG by identifying the pre-FoG events with an average sensitivity and specificity of, respectively, 94.1% and 97.1%, and (iii) our algorithm can be executed on resource-constrained devices. Future applications include the implementation on a mobile device, and the administration of rhythmic stimuli by a wearable device to help the patient overcome the FoG.
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26
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Santos-García D, de Deus Fonticoba T, Suárez Castro E, Aneiros Díaz A, Paz González JM, Feal Panceiras MJ, García Sancho C, Jesús S, Mir P, Aguilar M, Pastor P, Hernández Vara J, de Fábregues-Boixar O, Puente V, Crespo Cuevas A, González-Aramburu I, Infante J, Carrillo Padilla F, Pueyo M, Escalante S, Bernardo N, Solano B, Cots Foraster A, Martinez-Martin P. High ultrasensitive serum C-reactive protein may be related to freezing of gait in Parkinson's disease patients. J Neural Transm (Vienna) 2019; 126:1599-1608. [PMID: 31673927 DOI: 10.1007/s00702-019-02096-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/14/2019] [Indexed: 12/21/2022]
Abstract
C-reactive protein (CRP) is a biomarker of systemic inflammation that has been linked to accelerated decline in walking speed in older adults. The aim of the present study was to compare the CRP levels of PD patients with vs patients without freezing of gait (FOG). Patients and controls participating in the COPPADIS-2015 study that performed blood extraction for determining molecular serum biomarkers were included. Patients with FOG were identified as those with a score of 1 or greater on item-3 of the Freezing of Gait Questionnaire (FOG-Q). Immunoassay was used for determining ultrasensitive CRP (US-CRP) level (mg/dL). In the PD group (n = 225; 61.8 ± 9.5 years old, 61.8% males), 32% of the patients presented FOG but none in the control group (n = 65; 60.3 ± 6.1 years old, 56.9% males) (p < 0.0001). Differences in US-CRP level were significant in patients with FOG vs patients without FOG and vs controls (0.31 ± 0.52 vs 0.16 ± 0.21 vs 0.21 ± 0.22; p = 0.04). Significant differences were also observed between patients with vs without FOG (p = 0.001) but not between patients and controls (p = 0.163). US-CRP level was related to FOG (OR = 4.369; 95% CI 1.105-17.275; p = 0.036) along with H&Y (OR = 2.974; 95% CI 1.113-7.943; p = 0.030) and non-motor symptoms burden (NMSS total score; OR = 1.017; 95% CI 1.005-1.029; p = 0.006) after adjusting for age, gender, disease duration, equivalent daily levodopa dose, number of non-antiparkinsonian drugs per day, motor fluctuations, cognition, motor phenotype, and chronic use of anti-inflammatory drugs. The present study suggests that serum US-CRP level is related to FOG in PD patients. Inflammation could be linked to FOG development.
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Affiliation(s)
- Diego Santos-García
- Section of Neurology, CHUAC, Complejo Hospitalario Universitario de A Coruña, A Coruña, HUAC, C/As Xubias 84, 15006, A Coruña, Spain.
| | - T de Deus Fonticoba
- Hospital Arquitecto Marcide y Hospital Naval, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - E Suárez Castro
- Hospital Arquitecto Marcide y Hospital Naval, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - A Aneiros Díaz
- Hospital Arquitecto Marcide y Hospital Naval, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J M Paz González
- Section of Neurology, CHUAC, Complejo Hospitalario Universitario de A Coruña, A Coruña, HUAC, C/As Xubias 84, 15006, A Coruña, Spain
| | - M J Feal Panceiras
- Section of Neurology, CHUAC, Complejo Hospitalario Universitario de A Coruña, A Coruña, HUAC, C/As Xubias 84, 15006, A Coruña, Spain
| | - C García Sancho
- Section of Neurology, CHUAC, Complejo Hospitalario Universitario de A Coruña, A Coruña, HUAC, C/As Xubias 84, 15006, A Coruña, Spain
| | - S Jesús
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Universidad de Sevilla/CSIC, Seville, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - P Mir
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Universidad de Sevilla/CSIC, Seville, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
| | - M Aguilar
- Hospital Universitari Mutua de Terrassa, Terrassa, Barcelona, Spain
| | - P Pastor
- Hospital Universitari Mutua de Terrassa, Terrassa, Barcelona, Spain
| | | | | | - V Puente
- Hospital del Mar, Barcelona, Spain
| | | | - I González-Aramburu
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Infante
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - F Carrillo Padilla
- Hospital Universitario de Canarias, San Cristóbal de la Laguna, Santa Cruz de Tenerife, Spain
| | - M Pueyo
- Hospital Universitario de Canarias, San Cristóbal de la Laguna, Santa Cruz de Tenerife, Spain
| | - S Escalante
- Hospital de Tortosa Verge de la Cinta (HTVC), Tortosa, Tarragona, Spain
| | - N Bernardo
- Hospital de Tortosa Verge de la Cinta (HTVC), Tortosa, Tarragona, Spain
| | - B Solano
- Institut d'Assistència Sanitària (IAS), Instituí Cátala de la Salud, Girona, Spain
| | - A Cots Foraster
- Institut d'Assistència Sanitària (IAS), Instituí Cátala de la Salud, Girona, Spain
| | - P Martinez-Martin
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
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