Understand FoG in PD: Behavioral Physiology and Clinical Application

Understand Freezing of Gait in Parkinson's Disease: Behavioral Physiology and Clinical Application

The overall goals of this proposed study are to investigate the behavioral and neurophysiological mechanisms of patients with Parkinson's disease (PD) experiencing freezing of gait (FoG). More specifically, we aim to determine the behavioral changes in context-dependency and changes in corticomotor excitability associated with FoG.

Study Overview

• Status: Unknown
• Conditions: Parkinson Disease; Freezing of Gait
• Intervention / Treatment: Behavioral: Clinical evaluations

Detailed Description

Background: Freezing of gait (FoG) is a debilitating symptom for patients with Parkinson's disease (PD). FoG not only impairs walking but also significantly increase fall risks and decrease quality of life for patients with PD. Despite the critical consequences, the mechanisms associated with this phenomenon are not well understood.

Clinically, FoG often occurs when individuals with PD are approaching a narrow pathway or crossing a busy street. This observation leads to the hypothesis that FoG is associated with context-dependent motor performance, a phenomenon that an individual demonstrate poorer performance if the learned motor task is carried out in an unfamiliar context. Whether the occurrence of freezing episodes is a result of context-dependency has not been systematically investigated. Moreover, the changes in corticomotor excitability associated with FoG have not been well-established.

Objectives: The objectives of this proposal are to understand the behavioral and neurophysiological mechanisms of FoG. The specific aim is to examine the behavioral changes in context-dependency and changes in corticomotor excitability associated with FoG.

Methods: a total of 70 participants, including PD patients with FoG, PD patients without FoG, and age-matched non-disabled adults, will be recruited. The participants will undergo behavioral and neurophysiological examinations. Behavioral evaluations will include context-dependent motor performance, FoG, disease severity, and walking and balance functions. Transcranial magnetic stimulation and electroencephalogram will be used to measure corticomotor excitability of the participants. Analysis of variance (ANOVA) and regression analysis will be performed to compare and determine the relationship between FoG, behavioral outcomes, and corticomotor excitability. Statistical significance level is set at p < 0.05.

• Study Type: Interventional
• Enrollment (Anticipated): 70
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Taiwan
  • Taipei, Taiwan, 100
    • Recruiting
    • National Taiwan University Hospital
    • Contact: Ya-Yun Lee, PHD; Phone Number: 02-33668155; Email: yayunlee@ntu.edu.tw

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion criteria:

• Individuals with Parkinson's disease
• Healthy control subjects

Exclusion criteria:

• unable to follow the instructions
• have other neurological diseases other than PD
• have pacemaker implanted in their body
• have a history of seizure
• have a family history of epilepsy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: SCREENING
• Allocation: RANDOMIZED
• Interventional Model: FACTORIAL
• Masking: SINGLE

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: PD+FoG; PD patients with FoG	Behavioral: Clinical evaluations; Participants will receive clinical evaluations, and practice the finger sequence task used to assess context-dependency along with EEG assessment. On the second day, the participants will receive the TMS assessment.
ACTIVE_COMPARATOR: PD-FoG; PD patients without FoG	Behavioral: Clinical evaluations; Participants will receive clinical evaluations, and practice the finger sequence task used to assess context-dependency along with EEG assessment. On the second day, the participants will receive the TMS assessment.
ACTIVE_COMPARATOR: Control; age-matched non-disabled adults	Behavioral: Clinical evaluations; Participants will receive clinical evaluations, and practice the finger sequence task used to assess context-dependency along with EEG assessment. On the second day, the participants will receive the TMS assessment.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
New Freezing of Gait Questionnaire (NFOG-Q)	The New Freezing of Gait Questionnaire (NFOG-Q) will be used to evaluate the freezing frequency and severity of the patients with PD. It composes of 3 parts; in the first part, a video clip will be shown to the participants with PD and help to classify whether an individual is a freezer or non-freezer. The second and third part of the questionnaire is designed for freezers only. PartⅡassesses the severity of FoG according to the frequency and duration of the freezing episodes, while PartⅢevaluates the impact of freezing on daily activities, such as walking. The reliability and internal consistency of the NFOG-Q have been well-established for patients with PD (Nieuwboer et al., 2009).	30 mins
Context-dependent behavior	A modified finger sequence task is specifically designed to evaluate context-dependent behavior for patients with PD. The participants will be instructed to put their index and middle fingers of both hands on a designated location of an enlarged key-board. The participants will first practice the three sequences for a total of 324 practice trials on the first day. Ten minutes and 24 hours after practice, to control for the medication status, the participants will be tested under the SAME and SWITCH conditions.With these 2 testing conditions, we will be able to calculate a variable called Switch Cost, which is the performance difference between the SWTICH and the SAME conditions normalized by the SAME condition [100% * (SWITCH - SAME)/SAME]. The Switch Cost will be used as an indicator of context-dependency.	40 mins

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Unified Parkinson's Disease Rating Scale (UPDRS)	The UPDRS contains 4 sections, and PartIIIwill be used in this study to evaluate the motor disturbances of patients with PD. Excellent internal consistency and validity has been established for UPDRS (Goetz et al., 2008).	30 mins
Montreal Cognitive Assessment (MoCA)	The MoCA evaluates several cognitive domains, including visuospatial processing, naming, short-term memory, digit forward and backward span, verbal fluency, abstract concept, counting, and orientation. The MoCA has been found to be a valid and reliable tool to screen for cognitive dysfunctions in patients with PD (Gill, Freshman, Blender, & Ravina, 2008).	10 mins
The Stroop Color-Word test	The Stroop Color-Word test involves congruent and incongruent conditions.The goal of the participants is to read out the ink color of the word, but not the color word name itself, as accurately and as soon as possible (Dubois et al., 2007; Ridley, Johnson, & Braisted, 1978).	5 mins
10-Meter Walk Test (10MWT)	10MWT assesses the walking ability of the participants. The participants will be instructed to walk in their comfortable walking speed and their fastest walking speed for 10 meters. Gait speed, stride length, and cadence will be calculated.	5 mins
The Timed Up and Go (TUG) test	The TUG evaluates the balance ability of the participants. The participants will be seated on a comfortable chair with hip and knee flexed at 90 Upon a 'Go' signal, the participants will stand up from the chair, walk 3 meters, turn around, and sit back down to the chair. The time to complete the procedure will be measured.	5 mins
The Parkinson's Disease Questionnaire(PDQ-39)	The PDQ-39 specifically assess quality of life in patients with PD. PDQ-39 contains 39 questions embedded in 8 different domains. PDQ-39 has now become the most widely accepted and reliable measure to determine the overall health status for patients with PD (Jenkinson, Peto, Fitzpatrick, Greenhall, & Hyman, 1995).	10 mins
Transcranial magnetic stimulation	To compare the neurophysiological characteristics of PD patients with FoG, PD patients without FoG, and non-disabled adults, a TMS device (The Magstim Company Ltd, Whitland, UK) will be used. TMS outcomes will include resting motor threshold (RMT), motor evoked potentials (MEPs), cortical silent period (CSP), short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and intracortical facilitation (ICF).	45 mins
Electroencephalogram (EEG)	While performing the modified finger sequence task, the electroencephalogram (EEG) will be used to monitor and record brain activity. Comparisons will be made between the first block of practice, last block of practice, and the two testing conditions.	40 mins
The short FoG and festination assessment score	The short FoG and festination assessment score, developed by Ziegler and colleagues (2010), will be used to clinically assess freezing and festination episodes over a short time course. The participants will initially sit on a chair for 30 seconds, then they will be instructed to stand up and walk to a floor mark with 40 radius and make 360 turn clockwise and counter-clockwise. Then, the participants will walk through a door, turn around and walk back to the chair. The participants will be required to walk in a fast but safe speed. This evaluation approach has been demonstrated to be feasible and reliable for assessing the severity of freezing and festination.	20 mins

Collaborators and Investigators

• Sponsor: National Taiwan University Hospital
• Collaborators: Ministry of Science and Technology, Taiwan

Study record dates

Study Major Dates

• Study Start: December 1, 2016
• Primary Completion (ANTICIPATED): December 1, 2019
• Study Completion (ANTICIPATED): December 1, 2019

Study Registration Dates

• First Submitted: December 6, 2016
• First Submitted That Met QC Criteria: December 6, 2016
• First Posted (ESTIMATE): December 8, 2016

Study Record Updates

• Last Update Posted (ESTIMATE): December 8, 2016
• Last Update Submitted That Met QC Criteria: December 6, 2016
• Last Verified: December 1, 2016

More Information

Terms related to this study

• Keywords: Parkinson's disease; freezing of gait; transcranial magnetic stimulation; visual cues; context-dependency
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Parkinsonian Disorders; Basal Ganglia Diseases; Movement Disorders; Synucleinopathies; Neurodegenerative Diseases; Parkinson Disease
• Other Study ID Numbers: 201606057RINA