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Imbalzano G, Artusi CA, Ledda C, Montanaro E, Romagnolo A, Rizzone MG, Bozzali M, Lopiano L, Zibetti M. Effects of Continuous Dopaminergic Stimulation on Parkinson's Disease Gait: A Longitudinal Prospective Study with Levodopa Intestinal Gel Infusion. JOURNAL OF PARKINSON'S DISEASE 2024; 14:843-853. [PMID: 38728203 PMCID: PMC11191481 DOI: 10.3233/jpd-240003] [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: 03/27/2024] [Indexed: 05/12/2024]
Abstract
Background Gait issues, including reduced speed, stride length and freezing of gait (FoG), are disabling in advanced phases of Parkinson's disease (PD), and their treatment is challenging. Levodopa/carbidopa intestinal gel (LCIG) can improve these symptoms in PD patients with suboptimal control of motor fluctuations, but it is unclear if continuous dopaminergic stimulation can further improve gait issues, independently from reducing Off-time. Objective To analyze before (T0) and after 3 (T1) and 6 (T2) months of LCIG initiation: a) the objective improvement of gait and balance; b) the improvement of FoG severity; c) the improvement of motor complications and their correlation with changes in gait parameters and FoG severity. Methods This prospective, longitudinal 6-months study analyzed quantitative gait parameters using wearable inertial sensors, FoG with the New Freezing of Gait Questionnaire (NFoG-Q), and motor complications, as per the MDS-UPDRS part IV scores. Results Gait speed and stride length increased and duration of Timed up and Go and of sit-to-stand transition was significantly reduced comparing T0 with T2, but not between T0-T1. NFoG-Q score decreased significantly from 19.3±4.6 (T0) to 11.8±7.9 (T1) and 8.4±7.6 (T2) (T1-T0 p = 0.018; T2-T0 p < 0.001). Improvement of MDS-UPDRS-IV (T0-T2, p = 0.002, T0-T1 p = 0.024) was not correlated with improvement of gait parameters and NFoG-Q from T0 to T2. LEDD did not change significantly after LCIG initiation. Conclusion Continuous dopaminergic stimulation provided by LCIG infusion progressively ameliorates gait and alleviates FoG in PD patients over time, independently from improvement of motor fluctuations and without increase of daily dosage of dopaminergic therapy.
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Affiliation(s)
- Gabriele Imbalzano
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Claudia Ledda
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Elisa Montanaro
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Alberto Romagnolo
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Mario Giorgio Rizzone
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Marco Bozzali
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
| | - Maurizio Zibetti
- Department of Neuroscience “Rita Levi Montalcini”, University of Torino, Torino, Italy
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Torino, Italy
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Morales-Briceño H, Ha AD, Chiang HL, Tai Y, Chang FCF, Tsui DS, Griffith J, Galea D, Kim SD, Cruse B, Mahant N, Fung VSC. A single centre prospective study of three device-assisted therapies for Parkinson's disease. NPJ Parkinsons Dis 2023; 9:101. [PMID: 37386050 DOI: 10.1038/s41531-023-00525-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
Comparative studies assessing outcomes with the three device-assisted therapies could help to individualise treatment for patients living with Parkinson's disease. We designed a single-centre non-randomised prospective observational study assessing the quality of life (QoL), motor and non-motor outcomes at 6 and 12-months in patients treated with subcutaneous apomorphine continuous 16-hours infusion (APO), levodopa-carbidopa intestinal gel (LCIG) or subthalamic nucleus deep brain stimulation (STN-DBS). In this study, 66 patients were included (13 APO; 19 LCIG; 34 STN-DBS). At baseline, cognitive, non-motor and motor scores were significantly less severe in the STN-DBS group, whereas the LCIG group had a longer disease duration and higher non-motor scores. In the APO group, there were no statistically significant changes in non-motor, motor and QoL scales. The LCIG group had significant changes in QoL and motor scales that were significant after multiple comparison analysis at 6 and 12-months. The STN-DBS group showed improvement in QoL scores and non-motor and motor scores at 6 and 12-months after multiple comparison analysis. In this real-life prospective study, device-assisted therapies showed differences in their effects on QoL and motor and non-motor function at 12-months. However, there were also differences in baseline characteristics of the patient groups that were not based on pre-determined selection criteria. Differences in characteristics of patients offered and/or treatment with different device-assisted therapies may reflect within-centre biases that may, in turn, influence perceptions of treatment efficacy or outcomes. Treatment centres should be aware of this potential confounder when assessing and offering device-assisted treatment options to their patients and potential baseline differences need to be taken into consideration when comparing the results of non-randomised studies.
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Affiliation(s)
- Hugo Morales-Briceño
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia
| | - Ainhi D Ha
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia
| | - Han-Lin Chiang
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yicheng Tai
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Department of Neurology, E-DA Hospital/I-Shou University, No.1, Yida Rd., Yanchao Dist., Kaohsiung City, 824, Taiwan
| | - Florence C F Chang
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia
| | - David S Tsui
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Jane Griffith
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Donna Galea
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Samuel D Kim
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia
| | - Belinda Cruse
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Neil Mahant
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW, 2145, Australia.
- Sydney Medical School, University of Sydney, Sydney, NSW, 2145, Australia.
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Imbalzano G, Rinaldi D, Calandra-Buonaura G, Contin M, Amato F, Giannini G, Sambati L, Ledda C, Romagnolo A, Olmo G, Cortelli P, Zibetti M, Lopiano L, Artusi CA. How resistant are levodopa-resistant axial symptoms? Response of freezing, posture, and voice to increasing levodopa intestinal infusion rates in Parkinson disease. Eur J Neurol 2023; 30:96-106. [PMID: 36093563 PMCID: PMC10092343 DOI: 10.1111/ene.15558] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of freezing of gait (FoG) and other Parkinson disease (PD) axial symptoms is challenging. Systematic assessments of axial symptoms at progressively increasing levodopa doses are lacking. We sought to analyze the resistance to high levodopa doses of FoG, posture, speech, and altered gait features presenting in daily-ON therapeutic condition. METHODS We performed a pre-/postinterventional study including patients treated with levodopa/carbidopa intestinal gel infusion (LCIG) with disabling FoG in daily-ON condition. Patients were evaluated at their usual LCIG infusion rate (T1), and 1 h after 1.5× (T2) and 2× (T3) increase of the LCIG infusion rate by quantitative outcome measures. The number of FoG episodes (primary outcome), posture, speech, and gait features were objectively quantified during a standardized test by a blinded rater. Changes in motor symptoms, dyskinesia, and plasma levodopa concentrations were also analyzed. RESULTS We evaluated 16 patients with a mean age of 69 ± 9.4 years and treated with LCIG for a mean of 2.2 ± 2.1 years. FoG improved in 83.3% of patients by increasing the levodopa doses. The number of FoG episodes significantly decreased (mean = 2.3 at T1, 1.7 at T2, 1.2 at T3; p = 0.013). Posture and speech features did not show significant changes, whereas stride length (p = 0.049), turn duration (p = 0.001), and turn velocity (p = 0.024) significantly improved on doubling the levodopa infusion rate. CONCLUSIONS In a short-term evaluation, the increase of LCIG dose can improve "dopa-resistant" FoG and gait issues in most advanced PD patients with overall good control of motor symptoms in the absence of clinically significant dyskinesia.
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Affiliation(s)
- Gabriele Imbalzano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
| | - Domiziana Rinaldi
- Department of Neuroscience, Mental Health, and Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Giovanna Calandra-Buonaura
- Scientific Institute for Research and Health Care, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Manuela Contin
- Scientific Institute for Research and Health Care, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Federica Amato
- Department of Control and Computer Engineering, Polytechnic University of Turin, Turin, Italy
| | - Giulia Giannini
- Scientific Institute for Research and Health Care, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Luisa Sambati
- Scientific Institute for Research and Health Care, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Claudia Ledda
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
| | - Gabriella Olmo
- Department of Control and Computer Engineering, Polytechnic University of Turin, Turin, Italy
| | - Pietro Cortelli
- Scientific Institute for Research and Health Care, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,SC Neurologia 2U, AOU City of Health and Science, Turin, Italy
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Rota S, Urso D, van Wamelen DJ, Leta V, Boura I, Odin P, Espay AJ, Jenner P, Chaudhuri KR. Why do 'OFF' periods still occur during continuous drug delivery in Parkinson's disease? Transl Neurodegener 2022; 11:43. [PMID: 36229860 PMCID: PMC9558383 DOI: 10.1186/s40035-022-00317-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Continuous drug delivery (CDD) is used in moderately advanced and late-stage Parkinson’s disease (PD) to control motor and non-motor fluctuations (‘OFF’ periods). Transdermal rotigotine is indicated for early fluctuations, while subcutaneous apomorphine infusion and levodopa-carbidopa intestinal gel are utilised in advanced PD. All three strategies are considered examples of continuous dopaminergic stimulation achieved through CDD. A central premise of the CDD is to achieve stable control of the parkinsonian motor and non-motor states and avoid emergence of ‘OFF’ periods. However, data suggest that despite their efficacy in reducing the number and duration of ‘OFF’ periods, these strategies still do not prevent ‘OFF’ periods in the middle to late stages of PD, thus contradicting the widely held concepts of continuous drug delivery and continuous dopaminergic stimulation. Why these emergent ‘OFF’ periods still occur is unknown. In this review, we analyse the potential reasons for their persistence. The contribution of drug- and device-related involvement, and the problems related to site-specific drug delivery are analysed. We propose that changes in dopaminergic and non-dopaminergic mechanisms in the basal ganglia might render these persistent ‘OFF’ periods unresponsive to dopaminergic therapy delivered via CDD.
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Affiliation(s)
- Silvia Rota
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. .,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK. .,Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Daniele Urso
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Centre for Neurodegenerative Diseases and the Aging Brain, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro, "Pia Fondazione Cardinale G. Panico", 73039, Tricase, Italy
| | - Daniel J van Wamelen
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK.,Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Valentina Leta
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Iro Boura
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,School of Medicine, University of Crete, Crete, Greece.,Department of Neurology, University Hospital of Heraklion, Crete, Greece
| | - Per Odin
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alberto J Espay
- University of Cincinnati Gardner Neuroscience Institute, Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Peter Jenner
- Institute of Pharmaceutical Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
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5
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Freezing of gait: overview on etiology, treatment, and future directions. Neurol Sci 2022; 43:1627-1639. [DOI: 10.1007/s10072-021-05796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022]
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6
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Viljaharju V, Mertsalmi T, Pauls KAM, Koivu M, Eerola-Rautio J, Udd M, Pekkonen E. Single-Center Study of 103 Consecutive Parkinson's Disease Patients with Levodopa-Carbidopa Intestinal Gel. Mov Disord Clin Pract 2022; 9:60-68. [PMID: 35005066 DOI: 10.1002/mdc3.13361] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/13/2021] [Accepted: 09/29/2021] [Indexed: 11/06/2022] Open
Abstract
Background Levodopa-carbidopa intestinal gel (LCIG) effectively reduces off time and dyskinesia and increases on time in advanced Parkinson's disease (PD). However, patients with LCIG-infusion experience frequent complications and some discontinue treatment early on. Objectives The objectives of this study were to find predictive factors for early dropout from the LCIG infusion, analyze the treatment burden on the tertiary health care system, and explore changes in medication during the LCIG treatment. Methods LCIG-infusion was administrated to 103 patients between July 2006 and May 2020 at the Helsinki University Hospital, accumulating 350 years of follow-up data. We evaluated, retrospectively, changes in medication during treatment, discontinuation of the infusion, and adverse events from the patient records. Results Living alone was a predictive factor for early dropout (OR = 3.88; 95% CI = 1.03-14.66; P = 0.045). The treatment burden on the tertiary health care system increased after the initiation of LCIG infusion mostly because of common complications related to the infusion system (median change of in- and out-patient visits +1, P = 0.03). Mean levodopa equivalent daily dose (LEDD) rose from baseline to 6 months (1246.7 vs. 1684.9, P = 0.001) and stabilized thereafter. Patients commonly switched from "polypharmacy" to "LCIG-only" or "LCIG + oral levodopa" medication-groups during long-term treatment. Conclusions Recurrent complications related to the infusion system increase the treatment burden on tertiary healthcare system after the initiation of LCIG-infusion. Most patients continue long-term with the infusion. Few patients discontinue infusion during the first year after initiation and living alone appears to be a risk factor for this outcome.
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Affiliation(s)
- Vili Viljaharju
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Tuomas Mertsalmi
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - K Amande M Pauls
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Maija Koivu
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Johanna Eerola-Rautio
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Marianne Udd
- Department of Gastroenterological Surgery Helsinki University Hospital Helsinki Finland
| | - Eero Pekkonen
- Department of Neurology Helsinki University Hospital Helsinki Finland.,Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
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7
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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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8
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Personalized Medicine in Parkinson's Disease: New Options for Advanced Treatments. J Pers Med 2021; 11:jpm11070650. [PMID: 34357117 PMCID: PMC8303729 DOI: 10.3390/jpm11070650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/29/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
Parkinson’s disease (PD) presents varying motor and non-motor features in each patient owing to their different backgrounds, such as age, gender, genetics, and environmental factors. Furthermore, in the advanced stages, troublesome symptoms vary between patients due to motor and non-motor complications. The treatment of PD has made great progress over recent decades and has directly contributed to an improvement in patients’ quality of life, especially through the progression of advanced treatment. Deep brain stimulation, radiofrequency, MR–guided focused ultrasound, gamma knife, levodopa-carbidopa intestinal gel, and apomorphine are now used in the clinical setting for this disease. With multiple treatment options currently available for all stages of PD, we here discuss the most recent options for advanced treatment, including cell therapy in advanced PD, from the perspective of personalized medicine.
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Antonini A, Odin P, Pahwa R, Aldred J, Alobaidi A, Jalundhwala YJ, Kukreja P, Bergmann L, Inguva S, Bao Y, Chaudhuri KR. The Long-Term Impact of Levodopa/Carbidopa Intestinal Gel on 'Off'-time in Patients with Advanced Parkinson's Disease: A Systematic Review. Adv Ther 2021; 38:2854-2890. [PMID: 34018146 PMCID: PMC8189983 DOI: 10.1007/s12325-021-01747-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/08/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Levodopa/carbidopa intestinal gel (LCIG; carbidopa/levodopa enteral suspension) has been widely used and studied for the treatment of motor fluctuations in levodopa-responsive patients with advanced Parkinson's disease (PD) when other treatments have not given satisfactory results. Reduction in 'off'-time is a common primary endpoint in studies of LCIG, and it is important to assess the durability of this response. This systematic literature review was conducted to qualitatively summarise the data on the long-term effects of LCIG therapy on 'off'-time. METHODS Studies were identified by searching PubMed, EMBASE and Ovid on 30 September 2019. Studies were included if they reported on patients with PD, had a sample size of ≥ 10, LCIG was an active intervention and 'off'-time was reported for ≥ 12 months after initiation of LCIG treatment. Randomised clinical trials, retrospective and prospective observational studies, and other interventional studies were included for selection. Data were collected on: 'off'-time (at pre-specified time periods and the end of follow-up), study characteristics, Unified Parkinson's Disease Rating Scale (UPDRS) II, III and IV total scores, dyskinesia duration, quality of life scores, non-motor symptoms and safety outcomes. RESULTS Twenty-seven studies were included in this review. The improvement in 'off'-time observed shortly after initiating LCIG was maintained and was statistically significant at the end of follow-up in 24 of 27 studies. 'Off'-time was reduced from baseline to end of follow-up by 38-84% and was accompanied by a clinically meaningful improvement in quality of life. Stratified analysis of 'off'-time demonstrated mean relative reductions of 47-82% at 3-6 months and up to 83% reduction at 3-5 years of follow-up. Most studies reported significant improvements in activities of daily living and motor complications. Most frequent adverse events were related to the procedure or the device. CONCLUSION In one of the largest qualitative syntheses of published LCIG studies, LCIG treatment was observed to provide a durable effect in reducing 'off'-time. INFOGRAPHIC Video Abstract.
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Affiliation(s)
- Angelo Antonini
- Parkinson and Movement Disorders Unit, Center for Rare Neurological Diseases (ERN-RND), Department of Neurosciences, University of Padova, Padua, Italy.
| | - Per Odin
- Division of Neurology, Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, USA
| | - Jason Aldred
- Selkirk Neurology and Inland Northwest Neurological, Spokane, WA, USA
| | - Ali Alobaidi
- AbbVie Inc., North Chicago, USA
- University of Illinois at Chicago, Chicago, USA
| | | | | | | | - Sushmitha Inguva
- Center for Pharmaceutical Marketing and Management, University of Mississippi, University, Oxford, USA
| | | | - K Ray Chaudhuri
- King's College London, and Parkinson's Foundation International Centre of Excellence, King's College Hospital, London, UK
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10
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Tsunemi T, Oyama G, Saiki S, Hatano T, Fukae J, Shimo Y, Hattori N. Intrajejunal Infusion of Levodopa/Carbidopa for Advanced Parkinson's Disease: A Systematic Review. Mov Disord 2021; 36:1759-1771. [PMID: 33899262 PMCID: PMC9290931 DOI: 10.1002/mds.28595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/18/2021] [Accepted: 03/05/2021] [Indexed: 02/01/2023] Open
Abstract
Advanced Parkinson's disease is inconsistently defined, and evidence is lacking in relation to device‐aided therapies. To update existing reviews of intrajejunal infusion of levodopa/carbidopa (LCIG), we performed a literature search for relevant articles (to November 3, 2020) using PubMed supplemented by hand searching. Retrieved articles were categorized by relevance to identified research questions, including motor complications and symptoms; nonmotor symptoms; functioning, quality of life, and caregiver burden; optimal timing of treatment initiation and administration duration; discontinuation; and complications. Most eligible studies (n = 56) were open‐label, observational studies including relatively small patient numbers. LCIG consistently reduces OFF time and increased ON time without troublesome dyskinesia with varying effects regarding ON time with troublesome dyskinesia and the possibility of diphasic dyskinesia. More recent evidence provides some increased support for the benefits of LCIG in relation to nonmotor symptoms, quality of life, activities of daily living, and reduced caregiver burden. Patient age does not appear to significantly impact the effectiveness of LCIG. Discontinuation rates with LCIG (~17%–26%) commonly relate to device‐related issues, although the ability to easily discontinue LCIG may represent a potential benefit. LCIG may be a favorable option for patients with advanced Parkinson's disease who show predominant nonmotor symptoms and vulnerability to complications of other advanced therapy modalities. Larger, well‐controlled studies, including precise investigation of cost effectiveness, would further assist treatment selection. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Taiji Tsunemi
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Genko Oyama
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Neurodegenerative and Demented Disorders, Juntendo University School of Medicine, Tokyo, Japan.,Home Medical Care System Based on Information and Communications Technology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shinji Saiki
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Taku Hatano
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Neurodegenerative and Demented Disorders, Juntendo University School of Medicine, Tokyo, Japan
| | - Jiro Fukae
- Department of Neurology, Juntendo Nerima Hospital, Tokyo, Japan
| | - Yasushi Shimo
- Department of Neurology, Juntendo Nerima Hospital, Tokyo, Japan.,Research and Therapeutics for Movement Disorders, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Neurodegenerative and Demented Disorders, Juntendo University School of Medicine, Tokyo, Japan.,Home Medical Care System Based on Information and Communications Technology, Juntendo University School of Medicine, Tokyo, Japan.,Research and Therapeutics for Movement Disorders, Juntendo University School of Medicine, Tokyo, Japan
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11
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Freezing of Gait in Parkinson's Disease: Risk Factors, Their Interactions, and Associated Nonmotor Symptoms. PARKINSONS DISEASE 2021; 2021:8857204. [PMID: 33505652 PMCID: PMC7815408 DOI: 10.1155/2021/8857204] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/22/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
Background Freezing of gait (FOG) is a debilitating and incompletely understood symptom in Parkinson's disease (PD). Objective To determine the principal clinical factors predisposing to FOG in PD, their interactions, and associated nonmotor symptoms. Methods 164 PD subjects were assessed in a cross-sectional retrospective study, using the MDS-UPDRS scale, MMSE, and Clinical Dementia Rating Scale. Clinical factors associated with FOG were determined using univariate analysis and nominal logistic regression. Receiver operating characteristic curves were computed, to obtain measures of sensitivity and specificity of predictors of FOG. Subgroups of patients with FOG were compared with those without FOG, based on defining aspects of their clinical phenotype. Results Relative to non-FOG patients, those with FOG had a longer disease duration, higher PIGD and balance-gait score, higher LED, and more motor complications (p < 0.0001) and were more likely to exhibit urinary dysfunction (p < 0.0003), cognitive impairment, hallucinations, and psychosis (p=0.003). The balance-gait score and motor complications, at their optimum cutoff values, together predicted FOG with 86% accuracy. Interactions were noted between cognitive dysfunction and both the Bal-Gait score and motor complication status, cognitive impairment or dementia increasing the likelihood of FOG in subjects without motor complications (p=0.0009), but not in those with motor complications. Conclusions Both disease and treatment-related factors, notably LED, influence the risk of FOG in PD, with a selective influence of cognitive dysfunction in patients with balance-gait disorder but not in those with motor fluctuations. These findings may help to inform clinical management and highlight distinct subgroups of patients with PD-FOG, which are likely to differ in their network pathophysiology.
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12
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Paolone G. From the Gut to the Brain and Back: Therapeutic Approaches for the Treatment of Network Dysfunction in Parkinson's Disease. Front Neurol 2020; 11:557928. [PMID: 33117258 PMCID: PMC7575743 DOI: 10.3389/fneur.2020.557928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/04/2020] [Indexed: 12/16/2022] Open
Abstract
Parkinson's disease (PD) is a complex, multisystem, progressive, degenerative disorder characterized by severe, debilitating motor dysfunction, cognitive impairments, and mood disorders. Although preclinical research has traditionally focused on the motor deficits resulting from the loss of nigrostriatal dopaminergic neurons, up to two thirds of PD patients present separate and distinct behavioral changes. Loss of basal forebrain cholinergic neurons occurs as early as the loss of dopaminergic cells and contributes to the cognitive decline in PD. In addition, attentional deficits can limit posture control and movement efficacy caused by dopaminergic cell loss. Complicating the picture further is intracellular α-synuclein accumulation beginning in the enteric nervous system and diffusing to the substantia nigra through the dorsal motor neurons of the vagus nerve. It seems that α-synuclein's role is that of mediating dopamine synthesis, storage, and release, and its function has not been completely understood. Treating a complex, multistage network disorder, such as PD, likely requires a multipronged approach. Here, we describe a few approaches that could be used alone or perhaps in combination to achieve a greater mosaic of behavioral benefit. These include (1) using encapsulated, genetically modified cells as delivery vehicles for administering neuroprotective trophic factors, such as GDNF, in a direct and sustained means to the brain; (2) immunotherapeutic interventions, such as vaccination or the use of monoclonal antibodies against aggregated, pathological α-synuclein; (3) the continuous infusion of levodopa-carbidopa through an intestinal gel pad to attenuate the loss of dopaminergic function and manage the motor and non-motor complications in PD patients; and (4) specific rehabilitation treatment programs for drug-refractory motor complications.
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Affiliation(s)
- Giovanna Paolone
- Department of Diagnostic and Public Health - Section of Pharmacology, University of Verona, Verona, Italy
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13
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Intestinal Levodopa/Carbidopa Infusion as a Therapeutic Option for Unresponsive Freezing of Gait after Deep Brain Stimulation in Parkinson's Disease. PARKINSONS DISEASE 2020; 2020:1627264. [PMID: 32509261 PMCID: PMC7244984 DOI: 10.1155/2020/1627264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/04/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022]
Abstract
Background Treatment of freezing of gait (FOG) is always challenging because of its unpredictable nature and multifactorial physiopathology. Intestinal levodopa infusion has been proposed in recent years as a valuable option for its improvement. FOG in Parkinson's disease (PD) can appear after deep brain stimulation in patients who never had gait symptoms. Objective To study the effects of intestinal levodopa/carbidopa infusion in unresponsive-FOG that appears in PD patients treated with subthalamic nucleus deep brain stimulation. Methods We retrospectively collected and analyzed demographic, clinical, and therapeutic data from five PD patients treated with subthalamic nucleus stimulation who developed unresponsive-FOG and received intestinal levodopa/carbidopa infusion as an alternative therapy. FOG was measured based on scores in item 14 of the Unified Parkinson's Disease Rating Scale before and after intestinal levodopa infusion. Results Administration of intestinal levodopa caused improvement of FOG in the “ON” state in four patients (80%) by 2 or more points in item 14 of the Unified Parkinson's Disease Rating Scale. The improvement was maintained for at least 12 months. Conclusions Intestinal levodopa infusion may be a valuable therapeutic option for unresponsive-FOG developed after subthalamic nucleus deep brain stimulation.
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14
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Gao C, Liu J, Tan Y, Chen S. Freezing of gait in Parkinson's disease: pathophysiology, risk factors and treatments. Transl Neurodegener 2020; 9:12. [PMID: 32322387 PMCID: PMC7161193 DOI: 10.1186/s40035-020-00191-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background Freezing of gait (FOG) is a common, disabling symptom of Parkinson's disease (PD), but the mechanisms and treatments of FOG remain great challenges for clinicians and researchers. The main focus of this review is to summarize the possible mechanisms underlying FOG, the risk factors for screening and predicting the onset of FOG, and the clinical trials involving various therapeutic strategies. In addition, the limitations and recommendations for future research design are also discussed. Main body In the mechanism section, we briefly introduced the physiological process of gait control and hypotheses about the mechanism of FOG. In the risk factor section, gait disorders, PIGD phenotype, lower striatal DAT uptake were found to be independent risk factors of FOG with consistent evidence. In the treatment section, we summarized the clinical trials of pharmacological and non-pharmacological treatments. Despite the limited effectiveness of current medications for FOG, especially levodopa resistant FOG, there were some drugs that showed promise such as istradefylline and rasagiline. Non-pharmacological treatments encompass invasive brain and spinal cord stimulation, noninvasive repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) and vagus nerve stimulation (VNS), and physiotherapeutic approaches including cues and other training strategies. Several novel therapeutic strategies seem to be effective, such as rTMS over supplementary motor area (SMA), dual-site DBS, spinal cord stimulation (SCS) and VNS. Of physiotherapy, wearable cueing devices seem to be generally effective and promising. Conclusion FOG model hypotheses are helpful for better understanding and characterizing FOG and they provide clues for further research exploration. Several risk factors of FOG have been identified, but need combinatorial optimization for predicting FOG more precisely. Although firm conclusions cannot be drawn on therapeutic efficacy, the literature suggested that some therapeutic strategies showed promise.
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Affiliation(s)
- Chao Gao
- 1Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Liu
- 1Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuyan Tan
- 1Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shengdi Chen
- 1Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2Co-innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province China
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15
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The TANDEM investigation: efficacy and tolerability of levodopa-carbidopa intestinal gel in (LCIG) advanced Parkinson's disease patients. J Neural Transm (Vienna) 2020; 127:881-891. [PMID: 32212015 DOI: 10.1007/s00702-020-02175-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 01/18/2023]
Abstract
The TANDEM investigation was carried out in 17 Italian Movement Disorder centers on behalf of a joint initiative of neurologist members of the Italian Academy for Parkinson's disease and Movement Disorders (LIMPE-DISMOV Academy) and gastroenterologist members of the Italian Society of Digestive Endoscopy (SIED) to evaluate the efficacy and tolerability of levodopa-carbidopa intestinal gel (LCIG) in patients with advanced Parkinson's disease (PD) in routine medical care. Motor scores in "ON" and OFF" state (UPDRS-III), complications of therapy (UPDRS-IV), activities of daily living, sleep disorders and quality of life were evaluated at baseline and at two follow-up assessments (FUV1 and FUV2) within the initial 12-month LCIG treatment. In 159 patients (55% males) with a mean age of 69.1 ± 6.6 years and a diagnosis of PD since 13.6 ± 5.5 years, the UPDRS-III total score (in "OFF") decreased from baseline (45.8 ± 13.2) to FUV1 (41.0 ± 17.4; p < 0.001) and FUV2 (40.5 ± 15.5; p < 0.001), the UPDRS-IV total score decreased from baseline (8.8 ± 2.9) to FUV1 (5.1 ± 3.4; p < 0.001) and FUV2 (5.5 ± 3.2; p < 0.001). The percentage of patients exhibiting freezing, dystonia, gait/walking disturbances, falls, pain and sleep disorders was significantly reduced. Twenty-eight device complications were reported and 11 (6.9%) patients prematurely terminated the study. LCIG after 12-month treatment led to sustained improvement of time spent in "OFF", complications of therapy, PD-associated symptoms and sleep disorders. LCIG tolerability was consistent with the established safety profile of LCIG.
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16
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Fabbri M, Pongmala C, Artusi CA, Imbalzano G, Romagnolo A, Lopiano L, Zibetti M. Video analysis of long-term effects of levodopa-carbidopa intestinal gel on gait and posture in advanced Parkinson's disease. Neurol Sci 2020; 41:1927-1930. [PMID: 32172404 DOI: 10.1007/s10072-020-04319-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 02/28/2020] [Indexed: 11/25/2022]
Abstract
Gait and posture parameters of ten advanced Parkinson's disease (PD) patients were assessed before and after starting levodopa-carbidopa intestinal gel (LCIG) treatment by means of both objective video analysis and clinical assessment. After 3 years of treatment, gait and posture remained stable. A slower gait velocity at baseline significantly correlates with a higher axial and motor severity at follow-up. This pilot study suggests that validated video analysis software may support the clinical assessment of axial signs in PD patients who are candidates for device-aided therapies.
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Affiliation(s)
- Margherita Fabbri
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy.,Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Chatkaew Pongmala
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Via Cherasco 15, 10124, Turin, Italy.
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17
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Delgado-Alvarado M, Marano M, Santurtún A, Urtiaga-Gallano A, Tordesillas-Gutierrez D, Infante J. Nonpharmacological, nonsurgical treatments for freezing of gait in Parkinson's disease: A systematic review. Mov Disord 2019; 35:204-214. [PMID: 31769904 DOI: 10.1002/mds.27913] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/20/2019] [Accepted: 09/27/2019] [Indexed: 01/12/2023] Open
Abstract
Freezing of gait is a disabling phenomenon that appears in a substantial number of Parkinson's disease (PD) patients as the disease evolves. It is considered to be one of the most relevant contributing factors to worsening of quality of life. Current pharmacological or surgical treatment options have limited efficacy. Thus, alternative nonpharmacological/nonsurgical approaches have emerged in recent years in an attempt to improve quality of life in PD. This systematic review summarizes studies of such therapies over the past 5 years. Thirty-five studies were evaluated by use of a qualitative evaluation, while the methodological quality was assessed using validated tools. According to our results, there appear to be two broad categories of nonpharmacological therapies: those that seek a long-lasting benefit and those that aim to achieve a transient effect to overcome the freezing of gait episode. Among the former, it is possible to differentiate between "passive" therapies, which include transcranial magnetic stimulation or transcranial direct current stimulation, and "active" therapies, which are based on different cognitive or physical training programs. Finally, "transient effect" therapies use different types of cues, such as visual, auditory, or proprioceptive stimuli, to attempt to shift the patient's habitual motor control to a goal-directed one. In conclusion, a broad spectrum of nonpharmacological/nonsurgical approaches for freezing of gait has emerged in recent years with promising results. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Manuel Delgado-Alvarado
- Neurology Department, Sierrallana Hospital, Torrelavega, Spain.,Psychiatry Research Area, IDIVAL, University Hospital Marqués de Valdecilla, Santander, Spain.,Biomedical Research Networking Center for Mental Health (CIBERSAM), Madrid, Spain
| | - Massimo Marano
- Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, Rome, Italy
| | - Ana Santurtún
- Unit of Legal Medicine, Department of Physiology and Pharmacology, University of Cantabria, Santander, Spain
| | | | - Diana Tordesillas-Gutierrez
- Biomedical Research Networking Center for Mental Health (CIBERSAM), Madrid, Spain.,Neuroimaging Unit, Technological Facilities, Valdecilla Biomedical Research Institute IDIVAL, Santander, Spain
| | - Jon Infante
- Neurology Service, University Hospital Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain.,Centro de investigación en red de enfermedades neurodegenerativas (CIBERNED), Madrid, Spain
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18
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Artusi CA, Balestrino R, Imbalzano G, Bortolani S, Montanaro E, Tuttobene S, Fabbri M, Zibetti M, Lopiano L. Beyond 10 years of levodopa intestinal infusion experience: Analysis of mortality and its predictors. Parkinsonism Relat Disord 2019; 76:98-103. [PMID: 31610986 DOI: 10.1016/j.parkreldis.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 09/15/2019] [Accepted: 10/05/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Although levodopa/carbidopa intestinal infusion (LCIG) proved a sustained efficacy on Parkinson's disease (PD) motor fluctuations, there is a lack of studies on mortality of LCIG patients. In this study, we aimed at analyzing mortality and its predictors in a cohort of 105 PD patients treated with LCIG for over 10 years. METHODS The death rate, death causes, mortality predictors, and serious adverse events (SAEs) were analyzed. A Cox regression model was used to estimate the influence of several demographic and clinical factors on mortality, and a binary logistic regression to evaluate the association between SAEs number and mortality. Kaplan-Meier and Log-rank test was used for a survival comparison between patients with an early drop-out (within 3 years since LCIG start) and patients continuing LCIG. RESULTS Ninety-eight advanced PD patients treated with LCIG were included. During follow-up, 34.7% of patients died at a mean age of 74.7 years, with a mean survival time of 4.6 years since LCIG start and 18 years since PD onset. The only predictor of mortality identified was the Mini Mental State Examination score at LCIG start (p:0.034). A total of 222 SAEs occurred in 87.9% of LCIG patients. The number of SAEs did not correlate with the mortality of LCIG patients (p:0.370). No survival difference exists between early drop-out patients and those continuing LCIG (p:0.341). CONCLUSION Our findings do not indicate an association between SAEs or LCIG treatment duration and mortality and highlight the importance of cognitive alterations as a mortality predictor of LCIG patients.
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Affiliation(s)
- Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy.
| | - Roberta Balestrino
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Sara Bortolani
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Elisa Montanaro
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Sara Tuttobene
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Margherita Fabbri
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
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19
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Fabbri M, Pongmala C, Artusi CA, Romagnolo A, Rizzone MG, Zibetti M, Lopiano L. Long-term effect of levodopa-carbidopa intestinal gel on axial signs in Parkinson's disease. Acta Neurol Scand 2019; 140:157-161. [PMID: 31025312 DOI: 10.1111/ane.13110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/24/2019] [Accepted: 04/22/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have suggested that levodopa-carbidopa intestinal gel (LCIG) may have a benefit on Parkinson's disease (PD) axial signs. AIMS OF THE STUDY To investigate the long-term effect of LCIG on axial signs and the related prognostic factors. METHODS A retrospective study on 49 PD patients treated with LCIG. Axial signs as per the Unified Parkinson Disease Rating Scale axial score (AS), Hoehn and Yahr (H&Y) scale, and levodopa equivalent daily dose (LEDD) were assessed at baseline (before starting LCIG treatment) and at the last follow-up (FU). RESULTS After 47.6 ± 30 months of treatment, total AS deteriorated while motor complications still improved, in spite of a significant LEDD/Kg increment. When adjusted for LCIG treatment duration, a higher AS and freezing of gait severity at FU were predicted by a baseline lower response to l-dopa and higher H&Y (P < 0.01) and they were related to a lower independency in activity of daily life at FU (P < 0.001). Single axial items remain stable up to one year and postural instability up to four years. CONCLUSION Baseline disease severity and the magnitude of l-dopa response predict axial signs' severity after around four years of LCIG treatment, with consequent implication on patients' functional independence.
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Affiliation(s)
- Margherita Fabbri
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
- Faculty of Medicine Instituto de Medicina Molecular, University of Lisbon Lisbon Portugal
| | - Chatkaew Pongmala
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
| | - Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
| | | | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini" University of Torino Turin Italy
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20
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Motor and non-motor outcomes in patients with advanced Parkinson's disease treated with levodopa/carbidopa intestinal gel: final results of the GREENFIELD observational study. J Neurol 2019; 266:2164-2176. [PMID: 31134377 PMCID: PMC6687881 DOI: 10.1007/s00415-019-09337-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/03/2022]
Abstract
Introduction The GREENFIELD observational study assessed the effect of levodopa/carbidopa intestinal gel (LCIG) on motor and non-motor symptoms, and the related impact on patient quality of life and caregiver burden up to 8 years. Methods Final results of a large Italian cohort of patients who started LCIG in routine care between 2007 and 2014 are presented. Comparison between baseline (before LCIG) and follow-up visits on yearly basis (visit 2/3) is reported. Primary endpoint was Unified Parkinson’s Disease Rating Scale (UPDRS-IV) Item 39; secondary endpoints were UPDRS I and II, dyskinesia items, PD Quality of Life Questionnaire-39, Parkinson’s Disease Sleep Scale-2, Gait and Falls Questionnaire, Questionnaire on Impulsive Disorders, and Relative Stress Scale. Results Overall, 145 patients from 14 centers were assessed with a mean time since LCIG start of 2.8 ± 1.7 years at visit 2. The mean UPDRS-IV item 39 score showed significant reductions compared to baseline (mean score 2.0 ± 0.81) at visit 2 (mean score 0.9 ± 0.69; − 55%; p < 0.001) and at visit 3 (mean score 1.0 ± 0.75; − 50%; p < 0.001). At visit 3, significant reductions were observed for dyskinesia duration score (− 28%; p < 0.001), dyskinesia disability (− 40%; p < 0.001), and painful dyskinesia (− 50%; p < 0.001). Overall, 40 (27.6%) patients experienced 49 serious adverse events which were considered related to PEG/J procedure or to device in 16.3% of the cases. Conclusions The results of this study support the long-term efficacy of LCIG on PD symptoms as well as on activities of daily living. The adverse events were consistent with the established LCIG safety profile. Electronic supplementary material The online version of this article (10.1007/s00415-019-09337-6) contains supplementary material, which is available to authorized users.
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21
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Freezing of gait: Promising avenues for future treatment. Parkinsonism Relat Disord 2018; 52:7-16. [PMID: 29550375 DOI: 10.1016/j.parkreldis.2018.03.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 02/19/2018] [Accepted: 03/10/2018] [Indexed: 01/17/2023]
Abstract
Freezing of gait is a devastating symptom of Parkinson's disease and other forms of parkinsonism. It poses a major burden on both patients and their families, as freezing often leads to falls, fall-related injuries and a loss of independence. Treating freezing of gait is difficult for a variety of reasons: it has a paroxysmal and unpredictable nature; a multifaceted pathophysiology, with an interplay between motor elements (disturbed stepping mechanisms) and non-motor elements (cognitive decline, anxiety); and a complex (and likely heterogeneous) underlying neural substrate, involving multiple failing neural networks. In recent years, advances in translational neuroscience have offered new insights into the pathophysiology underlying freezing. Furthermore, the mechanisms behind the effectiveness of available treatments (or lack thereof) are better understood. Driven by these concepts, researchers and clinicians have begun to improve currently available treatment options, and develop new and better treatment methods. Here, we evaluate the range of pharmacological (i.e. closed-looped approaches), surgical (i.e. multi-target and adaptive deep brain and spinal cord stimulation) and behavioural (i.e. biofeedback and cueing on demand) treatment options that are under development, and propose novel avenues that are likely to play a crucial role in the clinical management of freezing of gait in the near future. The outcomes of this review suggest that the successful future management of freezing of gait will require individualized treatments that can be implemented in an on-demand manner in response to imminent freezing. With this review we hope to guide much-needed advances in treating this devastating symptom of Parkinson's disease.
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22
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Abstract
Parkinson disease (PD) is a complex, multisystem disorder with both neurologic and systemic nonmotor manifestations. It is neurodegenerative in nature in which disordered balance, gait, and falls are universal problems that can be present at initial diagnosis, and which progress over time. Freezing of gait is a particularly debilitating feature of PD that becomes more prevalent over time with disease progression, being present in approximately 7% after 2 years of disease and 28% after 5 years. Approximately 60% of people with PD fall each year, with around 70% of fallers falling recurrently, and some recurrent fallers falling multiple times per week. Many risk factors for falls in people with PD have been identified; these include a history of falls, freezing of gait, and abnormalities in measures of balance, leg muscle strength, mobility, cognition, and fear of falling. Therapies for improving physical function and mobility include levodopa, cholinesterase inhibitors, methylphenidate, deep-brain stimulation, cuing for freezing of gait, and exercise. This chapter reviews the clinical, pathologic, and physiologic correlates of gait disturbance and falls in PD, as well as the evidence for medical and nonmedical interventions.
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Affiliation(s)
- Samuel D Kim
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Natalie E Allen
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Department of Neurology, Westmead Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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