Evidence for exercise on FOG in PD Moran Gilat PhD Department of - - PowerPoint PPT Presentation

Evidence for exercise on FOG in PD

Moran Gilat PhD

Department of Rehabilitation Sciences

Supported by European Commission Marie-Skłodowska Curie Actions Fellowship

Disclosures

• None

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Freezing of gait (FOG)

Common

• Episodic
• Worsening
• Disabling

Triggers

• Turning
• Narrow passages
• Gait initiation
• Dual-tasking

Schaafsma et al. 2009; Nutt et al. 2011; Ehgoetz Martens et al. 2014; Bohnen et al. 2014; Bekkers et al. 2018

Motor

• Gait variability
• Smaller steps
• Postural instability

Non-motor

• Executive dysfunction
• Sensory deficits
• Anxiety

Clinical

• Disease severity
• Worse in OFF
• Extra-nigral pathology

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Evolution of freezing

Gilat et al. 2020 in preparation; Bohnen et al. 2014; Peterson and Horak 2016; Gilat et al. 2019

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Why bother with PT?

Medications / DBS

No FOG Mild FOG Severe FOG

Physical Therapy

Does PT work?

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Research Questions

• 1. How much evidence is there on the effect of physical therapy for reducing FOG?
• Immediate effect
• Long term effect
• 2. What type of intervention should we offer PD with FOG?

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Physical therapy for FOG in PD1 FOG-specific

Aims

• Reduce FOG episodes
• Prepare for upcoming FOG

Examples

• Cueing
• Gait feedback
• Action observation
• Fall prevention

FOG-correlates

Aims

• Train (non-)motor correlates

→More resilience against FOG Examples

• Balance/Posture/APA
• Cognitive training
• Motor-Cognitive training

Generic exercise

Aims

•  Physical & Mental fitness2
•  Sleep quality3
•  Dopamine release striatum4
•  Motor symtom progression2,5

Examples

• Dancing
• Treadmill
• Aquatic exercise
• Conventional PT
• Etc.

1=Gilat et al. 2020 In prep; 2=Schootemeijer et al. 2020; 3=Cristini et al. 2020; 4=Sacheli et al. 2019; 5=van der Kolk et al. 2019

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FOG-specific example: Cueing

Nieuwboer et al. 2007; Fietzek et al. 2014; Spildooren et al. 2017; Ferraye et al. 2016; Ginis et al. 2017

χ Hypokinetic Gait and FOG in PD

“ “

Visual Cueing

• Stripes

χ+20% Auditory Cueing χ+20% Visual Cueing

• Laser shoe
• On demand

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FOG-specific example: Action Observation

Pelosin et al. 2010; 2018; Agosta et al. 2017; Mezzarobba et al. 2017

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FOG-correlates examples

Walton et al. 2018 King et al. 2020; Clerici et al. 2019; Silva-Baptista et al. 2020 Bekkers et al. 2020

Cognitive training Motor-Cognitive training

RED GREEN BLUE RED GREEN BLUE

. .

RED GREEN BLUE RED GREEN BLUE RED GREEN BLUE RED GREEN BLUE

Motor = Balance / Weight-shifting / Turning / Gait training

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Systematic Search

Databases

• PubMed
• EMBASE
• MEDLINE
• Web of Science
• Google Scholar
• Search conducted 3rd August 2020
• Screening and data extraction by two researchers

INCLUSION CRITERIA 1) RCT of training/exercise with FOG as an outcome 2) Training at least two days 3) N>10 4) Any language 5) Any date

Gilat et al. 2020 in preparation

PROSPERO Registration: 42019123882

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Meta-analysis

• RevMan (v5.3)

Analysis of final measures Contrasts: 1) Effect of any type of training/exercise

• Passive control
• Active control

1) Subgroup (Categories) 1) Long-term (follow-up) effect 2) Effect in freezers only FOG outcomes used (N)FOGQ FOG diary FOG-score FOG-ratio %FOG 43 1 4 MDS-UPDRS II MDS-UPDRS III 1 1 2 1

Gilat et al. 2020 in preparation

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1) Any training/exercise

* * *

42 studies Total 1838 PD patients

• 933 Intervention
• 905 Control

ES=-0.37 [-0.51, -0.22], p<0.00001, I2=52%

• 3 outliers

ES=-0.24 [-0.35, -0.14], p<0.00001, I2=9%

Gilat et al. 2020 in preparation

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1) Type of Control

Gilat et al. 2020 in preparation; Cosentino et al. 2019

ES=-0.20 [-0.32, -0.08], p<0.001, I2=0%

* *

Passive control ES=-0.30 [-0.49, -0.11], p=0.002, I2=30% Active control

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2) Subgroups: FOG-specific

12 studies Total 807 PD patients

• 403 Intervention
• 404 Control

ES=-0.35 [-0.56, -0.13], p<0.01, I2=45%

• 1 outlier

ES=-0.24 [-0.40, -0.07], p<0.01, I2=14%

*

Aimed at the alleviation of FOG episodes

Gilat et al. 2020 in preparation

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2) Subgroup: FOG-correlates

13 studies Total 422 PD patients

• 263 Intervention
• 159 Control

ES=-0.59 [-0.95, -0.24], p<0.01, I2=72%

• 1 outlier

ES=-0.40 [-0.64, -0.16], p<0.01, I2=36%

*

Aimed at the underlying correlates of FOG

Gilat et al. 2020 in preparation

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2) Subgroup: Generic Exercise

16 studies Total 1838 PD patients

• 267 Intervention
• 242 Control

ES=-0.20 [-0.39, -0.01], p=0.04, I2=11%

• 1 outlier

ES=-0.14 [-0.32, 0.04], p=0.80, I2=0%

*

Generic exercises

Gilat et al. 2020 in preparation

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2) Subgroups: Effect sizes

Gilat et al. 2020 in preparation

FOG specific FOG correlates Generic exercise ES=-0.24, p<0.01 ES=-0.40, p<0.01 ES=-0.14, p=0.80

Effective Not effective

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Model for PT

Gilat et al. 2020 in preparation

• C
• B
• A

No FOG Occasional FOG

• Frequent

FOG

Disease duration

Present Future

Generic Excercise FOG Correlates FOG Specific

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3) long-term effect

15 studies Total 520 PD patients

• 257 Intervention
• 263 Control

Follow-up 1-6 months ES=-0.16 [-0.36, 0.03], p=0.10, I2=16%

• 1 outliers

ES=-0.08 [-0.27, 0.10], p=0.36, I2=0% Without exercise: ES=-0.09, p=0.11

Gilat et al. 2020 in preparation *

8w 8w 4w 4w 4w 4w 4w 4w 12w 24w 12w 4w 4w 24w 24w Retention period Category 2 2 1 2 1 2 3 3 3 2 1 1 1 2 1 20

3) long-term effect

Our meta-analysis:

• All trials (n=14) → p=0.36
• FOG related (n=12) → p=0.11

Cosentino et al. (2019)1

• Exercise (n=2) → p=0.93
• PT (n=8) → p<0.001
• Action observation (n=4) → p=0.02
• Cueing (n=2) → p=0.78
• Treadmill / Aquatic

1=Cosentino et al. 2019; 2=Nieuwboer et al. 2004; 3=D’Cruz et al. 2020

Retention possible, but impaired in freezers2 → Target these patients EARLY2 → In future, target those at risk for FOG3

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Early start and long-term engagement

Not self-evident in this population: Predictors of poor adherence1

• FOG
• Falls
• Mental health (anxiety & depression)
• Cognitive decline
• Pain
• Lack of exercise partner2

1 = Allen et al. 2015; 2 = Zaman et al. 2019

Multidisciplinary care Predictors of good adherence1

• Prior experience with exercise

Start EARLY

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Early start and long-term engagement

Good news: Increasing variety of FOG-based interventions on offer → Currently low availability, but rising → Supervision needed → Consider Group classes1

1=King et al. 2015 1 2 3 4 5 6 7 8 ‘11-12 ‘13-14 ‘15-16 ‘17-18 ‘19-20 publication year

N studies

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Limitation 1

Not all RCT’s were directly aimed at FOG, with many also including non-freezers 14 studies Total 1838 PD patients

• 314 Intervention
• 296 Control

ES=-0.53 [-0.87, -0.18], p=0.002, I2=73%

• 1 outlier

ES=-0.32 [-0.55, -0.09], p=0.007, I2=38% Freezers only

*

Category 2 1

1 2 1 2 1 1 1 2 2 1 2 1 24

Gilat et al. 2020 in preparation

Limitation 2

Use of the N(FOGQ) as an outcome

1=Hulzinga et al. 2020; 2=Gilat 2020

+ Easy and quick to use

• Subjective scale → recollection bias
• Minimal detectable change ~10 points!1

2 Download for FREE at → morangilat.com

A: Layout

• f

the ‘FOG-scoring’ template B: Example

• f

the

• utput

Fully automated IMU at-home assessment (N)FOGQ FOG diary FOG ratio FOG score %FOG video UPDRS single item

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TAKE HOME MESSAGE

➢ Exercise is very important, but FOG reduction not to be expected ➢ At FOG onset, offer PT targeting motor- and non-motor correlates to increase resilience ➢ When FOG becomes frequent, offer FOG-specific PT interventions to reduce its impact  Start EARLY  Ensure supervision and consider group-classes  PD with FOG will need extra motivation and follow-up

✓ Targeted PT has a significant effect on the impact of FOG in PD!

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Thank you

moran.gilat@kuleuven.be

Questions?