2 years ago

An interview with Dr Jojo Kwok on ‘Managing freezing of gait in Parkinson's disease: a systematic review and network meta-analysis’

Dr Jojo Kwok




This content is part of the Research in Practice in Mental Health series of interviews with scientists, focusing on how their research work can have impact on medical practice. Click here to follow 'Research in Practice in Mental Health' - for free - on Researcher for more great interviews.


Please give us a brief introduction to who you are, where you work, and what your focus is.

I'm Dr Jojo Kwok, an Assistant Professor at the School of Nursing at the University of Hong Kong. I am a registered nurse and a certified yoga instructor. I'm also a council member of the Hong Kong Parkinson's disease foundation and I advocate a behavioural approach to improve holistic wellbeing. My research focuses on chronic illness care, gerontology, mental health, and behavioural medicine with a special emphasis on Parkinson's disease (PD). My ongoing research projects include the effects and the mechanism of individual mindfulness techniques in people with PD. In 2019, our team has initiated the first mindfulness yoga clinical trial in PD, which concluded that mindfulness yoga is an effective, safe, and superior mind-body treatment option for stress and motor rehabilitation for PD patients. And the research findings have been published in international leading journals such as JAMA neurology and featured as impactful news in both local and international mass media, including the World Health and Radio Television Hong Kong.

 

Specifically, about the research paper, just tell us a little bit about it and why this topic is so important.

This paper adopts a systematic review and network meta-analysis approach to compare the effectiveness of different behavioural interventions for managing freezing of gait in patients with Parkinson's disease. Freezing of gait is one of the most frustrating, disabling gait disorders affecting over 80% of PD patients. It's categorized by sudden short and temporary episodes of inability to move the feet forward, despite the intention to walk. In a sense, your feet are stuck to the floor. But the torso still carries a forward momentum, which frequently leads to a fall and injuries. Pathophysiology underlying freezing of gait is multifaceted. Common triggers include motor aspect, the dysregulates stepping mechanism, and lower motor contributions including anxiety, stress and cognitive decline. During the disease progression, freezing occurs more frequently and shows more resistance to dopaminergic medications. So, a complementary behavioural approach is often adopted so as to minimize the freezing episodes, as well as training the patient to unfreeze themselves in a safe condition. 

In clinical and research settings, a wide range of behavioural modalities have been developed and applied to target different triggers of freezing, e.g., gait training, external cueing, dual-task training and motor imaginary techniques, and so on. The research questions remain on what are the most effective and optimal behavioural modalities to reduce the freezing of gait symptoms in patients daily living and how strong the evidence is. Although there are many trials testing individual treatment modalities, existing reviews were limited to a pairwise comparison of a subset of these treatments. In this review, we took a network meta-analysis approach to examine the comparative effect and treatment ranking possibilities of all existing behavioural strategies for freezing of gait management and such information will help to support evidence-based research directions and recommendations regarding effective freezing of gait management for patients with PD.

 

What is your connection between your research and medical practice? How do you hope your work will have an impact on therapies, treatments and patient outcomes in the future?

The existing clinical pathway of PD care prioritizes functional rehabilitation, and exercise is a key component for people with Parkinson's disease. The optimal prescription of behavioural intervention and exercise needs to be specific and effective, as well as feasible and easy to be implemented into patients' daily living and this research paper provides evidence regarding the treatment choices and the recommended dosage. The findings conclude that obstacle training, gait training on the treadmill, general exercise, action observation training, and even conventional physiotherapy demonstrate immediate real-life benefits in reducing freezing of gait among patients with mild to moderate PD, and these findings also suggest that intervention with high-complexity motor tasks may help to strengthen both motor and cognitive reservoirs, which are more likely to be useful to minimize the impact of freezing in patients daily living. 

Our work helps to inform the clinical pathways for symptom management and wellness promotion for PD patients. It also hints at future research directions. Future trials should use both subjective and objective outcome measures to capture the freezing of gait episodes, and its consequence, as well as implementation strategies to promote sustainability of the intervention in long run. And as a council member of the Hong Kong Parkinson's disease Foundation, we host regular public seminars and educational talks to promote public awareness, holistic rehabilitation, also capacity building for people living with PD, their caregivers, and the health care providers.

 

And then finally, where could your work lead you next and what is your dream outcome or your ultimate aim?

This work is inspired by our previous clinical trial of mindfulness yoga for Parkinson's disease, in which mindfulness yoga was pioneered as a rehabilitation tool for resilient training to manage psychological distress in PD patients. From the process evaluation, it surprised us that many of the PD participants verbalized the merit of mindful walking in minimizing the severity and impact of freezing of gait in their daily life. This feedback probed us to further study the potential mechanisms and effects of mindfulness techniques on freezing of gait management. Hence, we conducted this review to have a better and more comprehensive understanding of the evidence of all behavioural interventions for freezing of gait. We have integrated the findings to develop a MY-PACE programme, which stands for Mindfulness Yoga, Practice Awareness through Cognitive Exercise, and this programme incorporates different mindfulness techniques to address the potential triggers of freezing of gait including stress, motor dysfunction, and impaired attention and cognition. We have received funding from the Research Council of Hong Kong to initiate a full-scale randomised control trial of this programme, and we are now recruiting participants to examine the effects of the MY-PACE programme on freezing of gait. Since Parkinson's disease is chronic and degenerative in nature, focusing on the symptoms alone can lead to frustration and sometimes disappointment because sometimes symptoms represent disability and vulnerabilities. Holistic care should extend beyond symptom management. Ultimately, we hope to establish a holistic, transcending care model for PD rehabilitation, covering pragmatic symptom management, as well as psycho-spiritual wellness to empower the patient to live well with Parkinson's disease.


You can read and discover Dr. Jojo Kwok’s research here.

Managing freezing of gait in Parkinson's disease: a systematic review and network meta-analysis is published in Springer Nature.

Photo Credits: Twitter

Disclaimer: This is a transcript of a video conversation. You can listen to the recording on Researcher.

 

Publisher URL: https://link.springer.com/article/10.1007/s00415-022-11031-z

DOI: 7211.28974.ace8226d-4c71-4f6b-8d2d-2268c047b3ff.1656418283

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