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Parkinson's disease (PD) is a chronic degenerative disease of the nervous system.
Its main clinical features are resting tremor, muscle rigidity, and motor retardation
.
Postural instability and abnormal gait (PIGD) often occur in the middle and late stages of PD.
Among them, postural instability is mainly manifested as trunk tilt, spinal deformation and abnormal body stability; gait abnormalities mainly include flustered gait, frozen gait (FOG) and Other manifestations include changes in stride length, reduced stride length, changes in walking rhythm, and dysfunction in performing dual tasks
.
At present, it is believed that the appearance of FOG is a sign of Parkinson's disease entering the middle and late stages, which can cause frequent falls, injuries and even severe fractures in patients, which is one of the reasons that increase the burden of disease and seriously threaten the quality of life of patients
.
In order to improve the level of diagnosis and treatment of FOG, give full play to the advantages of drugs, non-drug treatments and their combined therapies, and better guide the clinical practice of PD in China, combined with the clinical experience of experts, after many discussions and repeated condensing, this expert consensus has been formed
.
Frozen Gait Classification The 2010 Washington DC Symposium defined FOG as "short, sudden cessation, or significant reduction in an attempt to walk or in the process of moving forward
.
"
The common classifications are as follows: (1) According to the classification of dopamine responsiveness ➤ Dopamine responsive type: freezing mainly during the off period, which is caused by the loss of dopaminergic neurons in the central nervous system, and responds well to dopaminergic drug treatment.
This type is the most Common; ➤Dopamine-inducible type: freezing during the opening period is mainly related to drug induction, and the effect of dopaminergic drugs is poor; ➤dopamine-resistant type: freezing gait occurs in both the opening and closing phases, and is composed of non-dopaminergic brain tissue Due to injury, non-dopaminergic medication may be effective
.
(2) Classification according to clinical characteristics ➤In-situ tremor type: alternating tremor of both legs (knee joints) after overcoming the walking block; ➤Small steps drag the foot forward type; ➤Completely incapable of movement: limbs and trunk cannot move , This item is relatively rare, but the most well-known
.
Frozen gait diagnosis and evaluation (1) There is currently no unified diagnostic criteria for the diagnosis of FOG in patients with Parkinson's disease, mainly based on its clinical characteristics: ➤Go forward without leaving the ground or just rubbing the ground with the tip of the foot or toe; ➤Bilateral The lower legs tremble alternately, with a frequency of 3～8 Hz; ➤In FOG, the pace is increased or the walking rhythm is increased, while the step length is decreased; ➤When freezing occurs, the subjective feeling is that the feet are "sticky" to the floor; ➤The patient has visual impairment during walking Changes in the form of objects, or the ground in front, or walking in a narrow or crowded area, and being suddenly pushed or pulled or frightened during walking can all induce gait freezing; FOG can often be relieved by a variety of prompts; FOG can be asymmetric , Mainly affects one foot, or is more likely to appear when turning in a certain direction
.
(2) Evaluation ①PIGD scale: the assessment content is postural stability and gait, used to determine the type of gait/stability disorder, and the evaluation method is strict; ②The simple balance assessment system test (mini-BESTest): mainly for gait Assessment of gait and postural stability; ③Dynamic gait index and functional gait evaluation: verification and assessment of gait dynamic balance scale; ④Frozen gait questionnaire (FOG-Q): effective and quantitative description of freezing and gait disorders Monitoring tools; ⑤6min walking test and 10m walking test: Simple and short time-consuming for walking speed measurement; ⑥Functional reach test: gait stability detection is quick and simple; ⑦Timed standing-walking test: standing up, walking, turning stability Sexual evaluation is a representative tool for evaluating PD; ⑧Pull test (PT): UPDRS-an important indicator of postural stability evaluation, but the operation of the examiner has a certain influence on the result; ⑨Assistant wearable device evaluation Parameters: The auxiliary wearable device can record the posture and gait movement parameters of the FOG patient from the objective data of the electronic sensor, and obtain the characteristics of the patient's FOG through the analysis of the computer software, and predict the risk of the patient's fall
.
Treatment of frozen gait (1) Recommendations for drug therapy: Rasagiline can be used as an adjuvant therapy for FOG (A2 level of evidence)
.
PD patients who have received STN deep brain stimulation (DBS) but still have FOG can try 1 mg·kg-1·d-1 methylphenidate (level A2 evidence)
.
Levodopa is the drug of choice for the treatment of FOG in Parkinson's disease (level B evidence)
.
Rotigotine transdermal patch treatment can significantly improve FOG (level B evidence)
.
SSRIs (paroxetine or escitalopram) or SNRIs (duloxetine) significantly improved FOG (level B evidence)
.
Galantamine treatment is effective in improving FOG (level B evidence), droxidopa plus entacapone has been shown to be effective in improving FOG (level B evidence), but the evidence on whether droxidopa alone can improve FOG is inconsistent (C Level of evidence)
.
LCIG, selegiline, and ittraphylline are effective in treating FOG (level C evidence); dopamine receptor agonists increase the risk of FOG (level D evidence).
Doctors are prescribing dopamine receptor agonists to PD patients with FOG Should be cautious
.
No improvement in FOG after treatment with the acetylcholinesterase inhibitor ricaplastine (A2 level of evidence) has been found, and there is no strong evidence that oral amantadine can improve FOG (level C evidence)
.
(2) Recommendations for surgical treatment: STN-DBS improves dopamine-responsive and dopamine-inducible FOG (level C recommendation), and the nucleus of the foot and pontine (PPN)-DBS has different conclusions (level C recommendation); the medial globus pallidus (GPI) -DBS still needs further research; subthalamic nucleus (STN)-DBS has no improvement on dopamine-resistant FOG (level C recommendation)
.
(3) Recommendations for physical and rehabilitation therapy: rTMS improves dopamine-responsive and dopamine-induced FOG (level C recommendation).
Whether spinal cord stimulation (SCS) is effective for various types of FOG still needs to be explored; assisting wearable devices to improve dopamine-responsive FOG And dopamine-inducible FOG (level B recommendation), may be effective for dopamine-resistant FOG (level C recommendation); rehabilitation therapy improves dopamine-responsive and dopamine-inducible FOG (level D recommendation), and may be effective for dopamine-resistant FOG (D Level recommendation)
.
Yimaitong compiled from: Cao Xuebing, Tang Beisha, Liu Zhenguo.
Expert consensus on diagnosis and treatment of Parkinson’s disease frozen gait with Chinese and Western medicine (2021)[J].
Stroke and Neurological Diseases,2021,28(05):599-604.
Its main clinical features are resting tremor, muscle rigidity, and motor retardation
.
Postural instability and abnormal gait (PIGD) often occur in the middle and late stages of PD.
Among them, postural instability is mainly manifested as trunk tilt, spinal deformation and abnormal body stability; gait abnormalities mainly include flustered gait, frozen gait (FOG) and Other manifestations include changes in stride length, reduced stride length, changes in walking rhythm, and dysfunction in performing dual tasks
.
At present, it is believed that the appearance of FOG is a sign of Parkinson's disease entering the middle and late stages, which can cause frequent falls, injuries and even severe fractures in patients, which is one of the reasons that increase the burden of disease and seriously threaten the quality of life of patients
.
In order to improve the level of diagnosis and treatment of FOG, give full play to the advantages of drugs, non-drug treatments and their combined therapies, and better guide the clinical practice of PD in China, combined with the clinical experience of experts, after many discussions and repeated condensing, this expert consensus has been formed
.
Frozen Gait Classification The 2010 Washington DC Symposium defined FOG as "short, sudden cessation, or significant reduction in an attempt to walk or in the process of moving forward
.
"
The common classifications are as follows: (1) According to the classification of dopamine responsiveness ➤ Dopamine responsive type: freezing mainly during the off period, which is caused by the loss of dopaminergic neurons in the central nervous system, and responds well to dopaminergic drug treatment.
This type is the most Common; ➤Dopamine-inducible type: freezing during the opening period is mainly related to drug induction, and the effect of dopaminergic drugs is poor; ➤dopamine-resistant type: freezing gait occurs in both the opening and closing phases, and is composed of non-dopaminergic brain tissue Due to injury, non-dopaminergic medication may be effective
.
(2) Classification according to clinical characteristics ➤In-situ tremor type: alternating tremor of both legs (knee joints) after overcoming the walking block; ➤Small steps drag the foot forward type; ➤Completely incapable of movement: limbs and trunk cannot move , This item is relatively rare, but the most well-known
.
Frozen gait diagnosis and evaluation (1) There is currently no unified diagnostic criteria for the diagnosis of FOG in patients with Parkinson's disease, mainly based on its clinical characteristics: ➤Go forward without leaving the ground or just rubbing the ground with the tip of the foot or toe; ➤Bilateral The lower legs tremble alternately, with a frequency of 3～8 Hz; ➤In FOG, the pace is increased or the walking rhythm is increased, while the step length is decreased; ➤When freezing occurs, the subjective feeling is that the feet are "sticky" to the floor; ➤The patient has visual impairment during walking Changes in the form of objects, or the ground in front, or walking in a narrow or crowded area, and being suddenly pushed or pulled or frightened during walking can all induce gait freezing; FOG can often be relieved by a variety of prompts; FOG can be asymmetric , Mainly affects one foot, or is more likely to appear when turning in a certain direction
.
(2) Evaluation ①PIGD scale: the assessment content is postural stability and gait, used to determine the type of gait/stability disorder, and the evaluation method is strict; ②The simple balance assessment system test (mini-BESTest): mainly for gait Assessment of gait and postural stability; ③Dynamic gait index and functional gait evaluation: verification and assessment of gait dynamic balance scale; ④Frozen gait questionnaire (FOG-Q): effective and quantitative description of freezing and gait disorders Monitoring tools; ⑤6min walking test and 10m walking test: Simple and short time-consuming for walking speed measurement; ⑥Functional reach test: gait stability detection is quick and simple; ⑦Timed standing-walking test: standing up, walking, turning stability Sexual evaluation is a representative tool for evaluating PD; ⑧Pull test (PT): UPDRS-an important indicator of postural stability evaluation, but the operation of the examiner has a certain influence on the result; ⑨Assistant wearable device evaluation Parameters: The auxiliary wearable device can record the posture and gait movement parameters of the FOG patient from the objective data of the electronic sensor, and obtain the characteristics of the patient's FOG through the analysis of the computer software, and predict the risk of the patient's fall
.
Treatment of frozen gait (1) Recommendations for drug therapy: Rasagiline can be used as an adjuvant therapy for FOG (A2 level of evidence)
.
PD patients who have received STN deep brain stimulation (DBS) but still have FOG can try 1 mg·kg-1·d-1 methylphenidate (level A2 evidence)
.
Levodopa is the drug of choice for the treatment of FOG in Parkinson's disease (level B evidence)
.
Rotigotine transdermal patch treatment can significantly improve FOG (level B evidence)
.
SSRIs (paroxetine or escitalopram) or SNRIs (duloxetine) significantly improved FOG (level B evidence)
.
Galantamine treatment is effective in improving FOG (level B evidence), droxidopa plus entacapone has been shown to be effective in improving FOG (level B evidence), but the evidence on whether droxidopa alone can improve FOG is inconsistent (C Level of evidence)
.
LCIG, selegiline, and ittraphylline are effective in treating FOG (level C evidence); dopamine receptor agonists increase the risk of FOG (level D evidence).
Doctors are prescribing dopamine receptor agonists to PD patients with FOG Should be cautious
.
No improvement in FOG after treatment with the acetylcholinesterase inhibitor ricaplastine (A2 level of evidence) has been found, and there is no strong evidence that oral amantadine can improve FOG (level C evidence)
.
(2) Recommendations for surgical treatment: STN-DBS improves dopamine-responsive and dopamine-inducible FOG (level C recommendation), and the nucleus of the foot and pontine (PPN)-DBS has different conclusions (level C recommendation); the medial globus pallidus (GPI) -DBS still needs further research; subthalamic nucleus (STN)-DBS has no improvement on dopamine-resistant FOG (level C recommendation)
.
(3) Recommendations for physical and rehabilitation therapy: rTMS improves dopamine-responsive and dopamine-induced FOG (level C recommendation).
Whether spinal cord stimulation (SCS) is effective for various types of FOG still needs to be explored; assisting wearable devices to improve dopamine-responsive FOG And dopamine-inducible FOG (level B recommendation), may be effective for dopamine-resistant FOG (level C recommendation); rehabilitation therapy improves dopamine-responsive and dopamine-inducible FOG (level D recommendation), and may be effective for dopamine-resistant FOG (D Level recommendation)
.
Yimaitong compiled from: Cao Xuebing, Tang Beisha, Liu Zhenguo.
Expert consensus on diagnosis and treatment of Parkinson’s disease frozen gait with Chinese and Western medicine (2021)[J].
Stroke and Neurological Diseases,2021,28(05):599-604.
