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Managing freezing of gait in Parkinson’s disease: a systematic review and network meta-analysis

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A Correction to this article was published on 05 April 2022

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Abstract

Background

Freezing of gait (FOG) is one of the most disabling gait disorders affecting 80% of patients with Parkinson’s disease (PD). Clinical guidelines recommend a behavioral approach for gait rehabilitation, but there is a wide diversity of behavioral modalities.

Objective

The objective of this network meta-analysis was to compare the effectiveness of different behavioral interventions for FOG management in PD patients.

Methods

Six databases were searched for randomized controlled trials of behavioral interventions for FOG management among PD patients from 1990 to December 2021. Bayesian network meta-analysis was used to combine both direct and indirect trial evidence on treatment effectiveness, while the surface under the cumulative ranking (SUCRA) score was used to estimate the ranked probability of intervention effectiveness.

Results

Forty-six studies were included in the qualitative synthesis. Among, 36 studies (1454 patients) of 72 interventions or control conditions (12 classes) were included in the network meta-analysis, with a mean intervention period of 10.3 weeks. After adjusting for the moderating effect of baseline FOG severity, obstacle training [SMD −2.1; 95% credible interval (Crl): −3.3, −0.86], gait training with treadmill (SMD −1.2; 95% Crl: −2.0, −0.34), action observation training (SMD −1.0; 95% Crl: −1.9, −0.14), conventional physiotherapy (SMD −0.70; 95% Crl: −1.3, −0.12) and general exercise (SMD −0.64; 95% Crl: −1.2, −0.11) demonstrated significant improvement on immediate FOG severity compared to usual care. The SUCRA rankings suggest that obstacle training, gait training on treadmill and general exercises are most likely to reduce FOG severity.

Conclusion

Obstacle training, gait training on treadmill, general exercises, action observation training and conventional physiotherapy demonstrated immediate real-life benefits on FOG symptoms among patients with mild–moderate PD. With the promising findings, the sustained effects of high complexity motor training combined with attentional/cognitive strategy should be further explored. Future trials with rigorous research designs using both subjective and objective outcome measures, long-term follow-up and cost-effective analysis are warranted to establish effective behavioral strategies for FOG management.

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Acknowledgments

The authors would like to extend our sincere gratitude and appreciation to our research assistants, Ms. Charis Ann Lai and Ms. Yuki Shum, for their dedicated assistance and contribution to this research paper. We would also like to thank the reviewers at the Journal of Neurology for their critical comments and valuable feedback that has much improved the paper.

Funding

This project was supported by the Seed Funding for Basic Research, The University of Hong Kong (201910159193).

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Authors and Affiliations

  1. School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, People’s Republic of China

    Jojo Yan Yan Kwok, Robert Smith, Lily Man Lee Chan, Daniel Yee Tak Fong, Edmond Pui Hang Choi, Kris Yuet Wan Lok & Jung Jae Lee

  2. School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK

    Leo Chun Chung Lam

  3. Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, People’s Republic of China

    Man Auyeung

  4. Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands

    Bastiaan R. Bloem

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  1. Jojo Yan Yan Kwok
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  2. Robert Smith
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Contributions

Dr. Kwok had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JK: conceptualization (lead); data curation (lead); methodology (lead); writing—original draft preparation (lead); writing—review and editing (lead); funding acquisition (lead); project administration (lead). RS: conceptualization (eqal); data curation (equal); formal analysis (lead); methodology (equal); writing—original draft preparation (equal); writing—review and editing (equal); project administration (equal). LC: data curation (lead); methodology (equal); writing—original draft preparation (equal); writing—review and editing (equal). LL: data curation (equal). DF: conceptualization (eqal); methodology (equal); writing—review and editing (equal); project administration (equal); supervision (lead). EC: Writing—review and editing (supporting). KL: writing—review and editing (supporting). JJL: writing—review and editing (supporting). MA: conceptualization (supporting); methodology (supporting). BB: writing—review and editing (supporting); supervision (supporting).

Corresponding author

Correspondence to Jojo Yan Yan Kwok.

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Conflicts of interest

The authors declare that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Kwok, Fong, Choi, Lok and Lee have received funding support as principal investigators of the Seed Funding for Basic Research, the University of Hong Kong, Research Grants Councils and the Food and Health Bureau from Hong Kong, respectively. Bloem has a consultancy role with respect to Michael J Fox Foundation, and is the secretary-elect of the International Parkinson and Movement Disorder Society. The views expressed are those of the author(s) and not necessarily those of funding/professional bodies and non-governmental organization.

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The original online version of this article was revised: Modifications have been made in the Affiliation, text, reference section and supplementary material. Full information regarding the corrections made can be found in the erratum/correction for this article.

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Kwok, J.Y.Y., Smith, R., Chan, L.M.L. et al. Managing freezing of gait in Parkinson’s disease: a systematic review and network meta-analysis. J Neurol 269, 3310–3324 (2022). https://doi.org/10.1007/s00415-022-11031-z

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