A Randomized, Controlled Trial of Exercise for Parkinsonian Individuals With Freezing of Gait

Silva‐Batista, Carla; Lima‐Pardini, Andrea Cristina de; Nucci, Mariana Penteado; Coelho, Daniel Boari; Batista, Alana X.; Piemonte, Maria Elisa Pimentel; Barbosa, Egberto Reis; Teixeira, Luís Augusto; Corcos, Daniel M.; Amaro, Edson; Horak, Fay B.; Ugrinowitsch, Carlos

doi:10.1002/mds.28128

Cited by 43 publications

(65 citation statements)

References 60 publications

(117 reference statements)

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“…The ARTIT‐FOG was conducted between June 2018 and April 2019. Importantly, the gait automaticity and attentional set‐shifting are secondary outcomes as they represent a subset of the outcomes of the ARTIT‐FOG 23 …”

Section: Methodsmentioning

confidence: 99%

“…DTC, a measure of relative change between dual‐task trial relative to a single‐task trial, was considered as a proxy of gait automaticity. On the third day, individuals performed an event‐related fMRI protocol that simulated the step initiation to assess the CLR activation (blood oxygenation level dependent [BOLD]) as previously published 23 . See Appendix S1 for a detailed description of the assessments.…”

Section: Methodsmentioning

confidence: 99%

“…Details of the image acquisition and processing of brain activation have been previously published 23 but are also detailed in the Appendix S1. Briefly, images were obtained using a 3.0 T magnetic resonance system (Achieva, Philips Medical Imaging Best, Eindhoven, The Netherlands), 32‐channel head coil (80 mT/m gradient maximum amplitude).…”

Section: Methodsmentioning

confidence: 99%

“…In this sense, ARTI may have an effect on gait automaticity because of increased CLR activation. Thus, we hypothesize that previously published 23 changes in CLR activation would be associated with changes in gait automaticity following ARTI.…”

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confidence: 87%

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The Adapted Resistance Training with Instability Randomized Controlled Trial for Gait Automaticity

et al. 2020

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Background Deficits in the cerebellar locomotor region (CLR) have been associated with loss of gait automaticity in individuals with freezing of gait in Parkinson's disease (freezers); however, exercise interventions that restore gait automaticity in freezers are lacking. We evaluated the effects of the adapted resistance training with instability ([ARTI] complex exercises) compared with traditional motor rehabilitation (without complex exercises) on gait automaticity and attentional set‐shifting. We also verified associations between gait automaticity change and CLR activation change previously published. Methods Freezers were randomized either to the experimental group (ARTI, n = 17) or to the active control group (traditional motor rehabilitation, n = 15). Both training groups performed exercises 3 times a week for 12 weeks. Gait automaticity (dual‐task and dual‐task cost [DTC] on gait speed and stride length), single‐task gait speed and stride length, attentional set‐shifting (time between Trail Making Test parts B and A), and CLR activation during a functional magnetic resonance imaging protocol of simulated step initiation task were evaluated before and after interventions. Results Both training groups improved gait parameters in single task (P < 0.05), but ARTI was more effective than traditional motor rehabilitation in improving DTC on gait speed, DTC on stride length, dual‐task stride length, and CLR activation (P < 0.05). Changes in CLR activation were associated with changes in DTC on stride length (r = 0.68, P = 0.002) following ARTI. Only ARTI improved attentional set‐shifting at posttraining (P < 0.05). Conclusions ARTI restores gait automaticity and improves attentional set‐shifting in freezers attributed to the usage of exercises with high motor complexity. © 2020 International Parkinson and Movement Disorder Society

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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confidence: 87%

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The Adapted Resistance Training with Instability Randomized Controlled Trial for Gait Automaticity

et al. 2020

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“…NFOGQ and 18 secondary outcomes are listed in the trial registration. In this paper, 6 we reported the primary and specific secondary outcomes directly associated with our FOG-related hypotheses (motor symptoms, anticipatory postural adjustments, cognitive inhibition, quality of life, and locomotor-area brain activation).…”

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Reply to: ‘Letter to the Editor on “A Randomized Controlled Trial of Exercise for Parkinsonian Individuals With Freezing of Gait”’

et al. 2020

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Both groups contained a select group of unusually severe freezers based on NFOG-Q scores at baseline (TMR, 22.3 AE 6.0; ARTI, 21.6 AE 5.7), some of whom must have had FOG episodes lasting >30 seconds. 2 Moreover, the Hoehn and Yahr stages in both groups ranged from 3 to 4, indicating a moderate to severe degree of postural instability. Considering this severe level of disability, our concern relates to the requirements and feasibility of the ARTI intervention in such an extremely fall-prone cohort. Patients were asked to perform high-level balance exercises, that is, weighted lunges and squats on unstable surfaces, which could lead to falls and should therefore not translate to self-administration without expert supervision. Notably, adherence rates were exceptionally high (100% for 612 ARTI sessions) and adverse events scarce for such high-risk activities, although it remains unclear how these were monitored. The primary outcome was the New Freezing of Gait Questionnaire (NFOG-Q). Recent work comparing consecutive measurements in 2 independent PD populations without intervention showed that the NFOG-Q has a minimal detectable change (MDC) of 9.95 points. 3 This is larger than the reported effect of ARTI (4.7 points). The authors did not refer to this work, but calculated the MDC using pre-and postassessments of their own active control intervention (2.7 points). Thus, although the ARTI intervention seemed to significantly improve several outcomes, the conclusion that the intervention effectively reduced FOG is likely confounded by test-retest error. Furthermore, the FOG ratio, an objective measure of FOG severity, strongly deteriorated in controls (12.8 preintervention vs 20.9 postintervention), which is unexpected during this brief trial duration (3 months), particularly because controls received an active intervention. This unexplained worsening in controls may have inflated the effect of the ARTI intervention on this outcome. Also, participants had abnormal FOG-ratio values (average of 20.9), whereas they were ON medication, which is much higher than those reported in patients OFF medication in the initial FOG-ratio validation article (0-13). 4 Inconsistencies also exist between the trial registration and the reported outcome measures, including those for gait, balance, and fMRI analyses, hinting toward selective reporting. Further, the statistical analyses did not account for baseline performance, although the TMR group seemed to have scored worse on multiple metrics. Last, the original trial registration targeted a sample of n = 32 (albeit without power calculation), but it is unclear why the investigators proceeded to include n = 40. Given these issues, we caution the clinical interpretation of this article. PD patients with FOG typically have severe balance impairment, which greatly amplifies their fall risk. 5 The described intervention seems hazardous, based on images provided in the supplementary material, whereas the efficacy for reducing FOG appears uncertain. Therefore, we believe that caution and f...

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Physical exercise for people with Parkinson’s disease: a systematic review and network meta-analysis

Ernst

Folkerts

Gollan

et al. 2023

Cochrane Database of Systematic Reviews

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A Randomized, Controlled Trial of Exercise for Parkinsonian Individuals With Freezing of Gait

Cited by 43 publications

References 60 publications

The Adapted Resistance Training with Instability Randomized Controlled Trial for Gait Automaticity

The Adapted Resistance Training with Instability Randomized Controlled Trial for Gait Automaticity

Reply to: ‘Letter to the Editor on “A Randomized Controlled Trial of Exercise for Parkinsonian Individuals With Freezing of Gait”’

Physical exercise for people with Parkinson’s disease: a systematic review and network meta-analysis

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