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Introduction Parkinson's Disease (PD) is frequently associated with cognitive dysfunction ranging from Mild Cognitive Impairment (PD-MCI) to dementia. Few electrophysiological studies are available evaluating potential pathogenetic mechanisms linked to cognitive impairment in PD since its initial phases. The objective of the study is to analyze electrocortical networks related with cognitive decline in PD-MCI for identifying possible early electrophysiological markers of cognitive impairment in PD. Methods From the PaCoS (Parkinson's disease Cognitive impairment Study) cohort, a sample of 102 subjects including 46 PD-MCI and 56 PD with normal cognition (PD-NC) was selected based on the presence of a neuropsychological assessment and at least one EEG recording. EEG signal epochs were analysed using Independent Component Analysis LORETA and spectral analysis by computing the Power Spectral Density (PSD) of site-specific signal epochs. Results LORETA analysis revealed significant differences in PD-MCI patients compared to PD-NC, with a decreased network involving alpha activity over the occipital lobe, an increased network involving beta activity over the frontal lobe associated with a reduction over the parietal lobe, an increased network involving theta and delta activity over the frontal lobe and a reduction of networks involving theta and delta activity in the parietal lobe. Quantitative EEG analysis showed a significant decrease of alpha PSD over the occipital regions and an increase of delta PSD over the left temporal region in PD-MCI as compared to PD-NC. Conclusion Electrocortical abnormalities detected in PD-MCI patients may represent the instrumental counterpart of early cognitive decline in PD.

Aim of the study was to evaluate the possible relationship between Temperament traits and executive dysfunction in patients with Parkinson's disease (PD).Patients affected by PD diagnosed according to the UK Parkinson's disease Society Brain Bank criteria were enrolled in the study. Patients with a Mini Mental State Examination24 were excluded from the study. The Temperament and Character Inventory (TCI), a self-report questionnaire assessing the Harm Avoidance (HA), Novelty Seeking (NS) and Reward Dependence (RD) temperamental traits, has been performed. The executive functions were assessed with the Frontal Assessment Battery (FAB).Fifty PD patients (28 men and 22 women; mean age 59.1 ± 10.1 years) were enrolled. High HA (mean score 73.3 ± 24.7) and a low NS score (24.2 ± 18.7) were recorded. Fifteen (30%) patients presented a pathological FAB score (≤13.5). Patients with a pathological FAB score presented an HA score significantly higher than patients with normal FAB score (respectively 84.9 ± 13.7 versus 69.8 ± 26.9; p = 0.045). At the univariate analysis an association between high HA score and pathological FAB score was found (OR 3.85, 95%CI 1.06-13.9; p-value 0.040).Our study confirmed an association between executive disturbances and HA in PD patients, possibly related to a common impairment of the frontostriatal circuits.

Background In Parkinson's Disease (PD), effects of a cognitive training have been systematically evaluated only for cognitive and behavioral outcome measures, with mild to moderate effects. Despite the demonstrated interplay between cognition and gait, no studies have investigated the effect of cognitive rehabilitation protocols on gait in PD. Methods Patients affected by PD with freezing of gait were treated twice a week for six weeks with one hour sessions of computer-assisted training of attention ability and information processing tasks. Gait parameters were recorded at baseline, after six weeks and at three months. Results Seven patients completed the evaluations at six weeks, six patients at three months. We observed at six weeks a significant reduction in both legs cycle duration, with an increment in mean velocity and cadence. Bilateral cycle and step lengths increased even if not significantly. No significant differences in gait parameters were detected at three months with respect to the baseline. Conclusions This pilot study suggests that a computer-assisted rehabilitation protocol based on executive functions training could improve walking in PD patients with freezing of gait.

Contains fulltext : 220586.pdf (Publisher’s version ) (Open Access) The need to perform multiple tasks more or less simultaneously is a common occurrence during walking in daily life. Performing tasks simultaneously typically impacts task performance negatively. Hypothetically, such dual-task costs may be explained by a lowered state of preparation due to competition for attentional resources, or alternatively, by a 'bottleneck' in response initiation. Here, we investigated both hypotheses by comparing 'StartReact' effects during a manual squeezing task under single-task (when seated) and dual-task (when walking) conditions. StartReact is the acceleration of reaction times by a startling stimulation (a startling acoustic stimulus was applied in 25% of trials), attributed to the startling stimulus directly releasing a pre-prepared movement. If dual-task costs are due to a lowered state of preparation, we expected trials both with and without an accompanying startling stimulus to be delayed compared to the single-task condition, whereas we expected only trials without a startling stimulus to be delayed if a bottleneck in response initiation would underlie dual-task costs. Reaction times of the manual squeezing task in the flexor digitorum superficialis and extensor carpi radialis muscle were significantly delayed (approx. 20 ms) when walking compared to the seated position. A startling acoustic stimulus significantly decreased reaction times of the squeezing task (approx. 60 ms) both when walking and sitting. Dual-task costs during walking are, therefore, likely the result of lowered task preparation because of competition for attentional resources.

Postural instability is a symptom of disorders like ear diseases, high blood pressure, diabetes, psychiatric disorders, and neurodegenerative diseases like Parkinson and one of the main causes of falls. A continuous monitoring of the patient’s postural stability while performing the daily activities would be of strategic interest for the doctors to gain continuous information on the user pathology or its progression. This article focuses on the experimental assessment of a wearable inertial device aimed at the continuous monitoring of the user’s postural sway, which exploits a novel postural sway classification algorithm providing a classification index. Two performance keys have been proposed: 1) to assess the postural sway monitoring strategy and 2) to rate the reliability of the classification outcome. Experiments reported in this article have been performed involving “healthy” users miming typical instability dynamics under the supervision of the neurologists. In the case of study addressed through this article, a full classification success has been obtained with an overall reliability of about 70%.

Background: In a precedent paper, we validated part IV of the Unified Parkinson’s Disease Rating Scale (UPDRS) for detecting motor fluctuations in Parkinson’s Disease (PD) patients using a 12-h Waking-Day Motor Assessment (WDMA) as gold standard, showing a high sensitivity (> 80%) and a lower specificity (< 45%). The aim of this study was to validate the Movement Disorder Society-UPDRS (MDS-UPDRS) part IV, especially items 4.3 and 4.5, using the same methodology. Methods: PD patients attending the Movement Disorders Clinic at the University Hospital in Catania were consecutively enrolled in the study. A diurnal WDMA was performed to detect motor fluctuations. At each time interval, the motor impairment was evaluated using the motor section of the MDS-UPDRS. Presence or absence of motor fluctuations and the type of motor fluctuation were assessed by four blinded expert raters in movement disorders, by evaluating the graphical representations of the WDMA. We evaluated sensitivity and specificity together with 95% Confidence Interval (CI) of items 4.3 and 4.5, using WDMA as gold standard. Results: We estimated for item 4.3 of the MDS-UPDRS a sensitivity of 74.3% (95% CI 56.7–87.5) and a specificity of 70.6% (95% CI 44–89.7), while for item 4.5, a sensitivity of 67.9% (95% CI 47.6–84.1) and a specificity of 66.7% (95% CI 44.7–84.4). Conclusions: The present showed a higher specificity level for MDS-UPDRS with respect to the UPDRS, while a slightly lower sensitivity mainly for predictable OFF.

In Parkinson's disease (PD), the identification of instrumental biomarkers is crucial to evaluate disease susceptibility and motor stage. We evaluated self-similarity of electrocortical activity as expression of brain signal complexity in untreated PD, to investigate its possible role as a neurophysiological biomarker. We analyzed the data of 34 untreated PD subjects and 18 group-matched controls who underwent standardized electroencephalography. A Welch's periodogram was applied to site-specific electroencephalographic signal epochs. To investigate self-similarity of electrocortical activity, the power law exponent β was computed for each selected coordinate. In both PD subjects and controls, β values at each coordinate increased with an antero-posterior gradient, changing from values around one in fronto-temporal sites to values around two among parieto-occipital sites. PD subjects presented overall lower β values among different sites compared to controls, with significant differences for the left fronto-temporal sites. Our findings suggest an increased level of fronto-temporal neuronal organization in untreated PD. We hypothesize a possible role of β as a neurophysiological biomarker for early untreated PD.

BACKGROUND AND PURPOSE Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) may share similar clinical findings and tests to distinguish between the two disorders could be useful. We evaluated the blink reflex and R2 blink reflex recovery cycle (R2BRRC), determining diagnostic sensitivity, specificity and positive and negative predictive value of R2BRRC in differentiating patients with PSP from those with CBS. METHODS This was a prospective data collection study investigating blink reflex and R2BRRC at interstimulus intervals (ISIs) of 100, 150, 200, 300, 400, 500 and 750 ms in 12 patients with PSP, eight patients with CBS and 10 controls. RESULTS Patients with PSP have earlier recruitment of R2BRRC as compared with patients with CBS (ISI: 100 ms, P = 0.002; 150 ms, P < 0.001; 200 ms, P < 0.001; 300 ms, P = 0.02) and controls (ISI: 100 ms, P < 0.001; 150 ms, P < 0.001; 200 ms, P < 0.001; 300 ms, P = 0.004). The presence of an early recovery of the R2 differentiated PSP from CBS with a specificity and sensitivity of 87.5% and 91.7%, respectively. CONCLUSIONS The R2BRRC curve might be considered to be a useful tool in differentiating patients with PSP from those with CBS.

The pull test (PT) is a common practice to assess the postural instability of patients with Parkinson’s disease. Postural instability is a serious issue for elderly and people with neurological disease, which can cause falls. The implementation of the PT consists in observing the user response after providing a tug to the patients’ shoulders, in order to displace the center of gravity from its neutral position. The validity of the test can be compromised by a nonstandard backward tug provided to the patient. The solution proposed in this paper consists of a low-cost multisensor system allowing an instrumented estimation of the input solicitation. Moreover, the system provides supplementary information on the user postural stability, by means of a set of features extracted from the user stabilogram. A wide set of experiments have been performed to assess the system capability to provide a rough classification between stable and unstable behaviors. Results obtained demonstrate the validity of the approach proposed, with very low rates of false positive and false negative.

The pull test (PT) is a common maneuver used by neurologist to assess the postural instability of patients with iatrogenic forms or Parkinson's disease. Postural instability is one of the main causes of the incident of falls in elderly and people with neurological disease. The pull test (PT) consists in observing the user response after providing a tug to the patients' shoulders, in order to displace the center of gravity from its neutral position. With a nonstandard backward tug, the validity of the test can be seriously compromised; this problem became more serious when the test must be supplied to the same patient alter a given period of time to assess the time evolution of the disease. In this paper is presented a preliminary analysis on the usability of pressure sensing elements, connected in a matrix 4×4, for the pull strength evaluation. A static characterization has been carried out in order to assess the measurement range along with its uncertainty band (experimentally found). Results obtained demonstrate a good force measurement range (0.242 Kg–0.642 Kg), measured in a single sensing element.

Contains fulltext : 154274.pdf (Publisher’s version ) (Closed access) BACKGROUND: Previous studies reported a preserved ability to cycle in freezers, creating opportunities for restoring mobility and independence. However, use of a bicycle is not always feasible. Here, we investigated the effectiveness of a "walk-bicycle" in reducing freezing of gait (FOG). METHODS: Eighteen Parkinson patients with FOG performed the following tasks, each four times, with and without the walk-bicycle: (1) normal walking; (2) walking with small steps, at normal speed; (3) walking with small steps, as rapidly as possible. RESULTS: Seven patients showed FOG during walking without the walk-bicycle. In those patients, the walk-bicycle afforded a 12% reduction of time frozen (p = 0.026). In 11 patients no FOG was observed during walking without the walk-bicycle. Two of them showed FOG when using the walk-bicycle. CONCLUSIONS: The walk-bicycle may help to reduce FOG in some patients, but not in all. Future studies need to evaluate its usefulness in a home environment. 01 juli 2015

Objectives To provide a quantitative estimation of motor fluctuations in PD through a 12-h Waking-day Motor Assessment (WDMA) and to develop new WDMA-based tools, the Motor Fluctuation Indices. Methods Two independent samples of PD patients (exploratory population N = 51, testing population N = 109) were examined. Patients underwent a WDMA using the Unified Parkinson's Disease Rating Scale (UPDRS) and were classified as either having or not having motor fluctuations. To quantify motor fluctuations, the Worsening Index (WI), the Mean Fluctuation Index (MFI) and the Coefficient of Variation (CV) were computed. The optimal cut-off for each index distinguishing patients with or without fluctuations was calculated on the exploratory population. Cut-offs’ accuracy was then verified in the testing population. Results Optimal cut-off scores to differentiate stable patients from fluctuating ones were 8.3 for WI, 5 for MFI and 12.9 for CV. Sensitivity and a specificity were 91.2% (95%CI: 85.9 to 96.5) and 87.8% (95%CI: 81.7 to 93.9) for WI; 75% (95%CI: 66.9 to 83.1) and 90.2% (95%CI: 84.7 to 95.8) for MFI; 69.1% (95%CI: 60.4 to 77.8) and 95.1% (95%CI: 91.1 to 99.2) for CV. Patients with a larger magnitude of fluctuation had higher values for all three indices, whereas patients with multiple daily fluctuations presented only higher WI values. Conclusions WDMA-derived Motor Fluctuation Indices may represent reliable tools for evaluating and quantifying the severity of motor fluctuations in PD patients. Even if WDMA is a time-consuming procedure, the detection of Motor Fluctuation Indices could be helpful in assessing therapeutic efficacy on motor fluctuations.

Postural instability is one of the symptoms of Parkinson's disease which can cause falls with possible unpleasant consequences. Two main tests, the Timed Up and Go and the Pull Test, are typically performed by physicians to assess the postural instability of patients. Such tests require on purpose structured laboratory equipped with expensive monitoring systems. Moreover, in the case of Pull test, the validity of the tests can be compromised by the nonstandard backward tug provided to the patient. The solution proposed in this paper consists of a low cost multisensor system and a methodology which allows to implement an objective estimation of the input solicitation as well as the assessment and classification of the user response. Different parameters (10) presented in the literature for the sake of the postural instability evaluation were investigated, in case of Pull Test, with a large set of experiments (59) in order to extract a set of features useful for the classification between stable and unstable behavior. Results obtained demonstrated the feasibility of the methodology proposed.

Contrafatto D, Mostile G, Nicoletti A, Dibilio V, Raciti L, Lanzafame S, Luca A, Distefano A, Zappia M. [123I]FP-CIT-SPECT asymmetry index to differentiate Parkinson’s disease from vascular parkinsonism. Acta Neurol Scand: 2012: 126: 12–16. © 2011 John Wiley & Sons A/S. Objectives – Differential diagnosis between vascular parkinsonism (VP) and Parkinson’s Disease (PD) is often difficult, due to the overlap in clinical presentation and the lack of specificity at neuroimaging. Aim of the study was to identify a possible reliable marker at SPECT imaging useful to distinguish the two conditions. Material and methods – We studied 20 PD, 20 VP and 20 essential tremor (ET) patients as control group, who had undergone a cerebral [123I] FP-CIT SPECT. A semiquantitative analysis was performed on DaTSCAN SPECT imaging and to establish the degree of asymmetry of the ligand uptake the Striatal Asymmetry Index (SAI) was used. Results – The binding of the ligand in the most affected side resulted significantly lower in VP than in ET patients but higher compared to PD patients. SAI was significantly higher in PD compared to VP (P

Introduction aim of the study was to evaluate the presence of the Obsessive Compulsive Personality Disorder (OCPeD) in Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP) and Essential Tremor (ET) and in a group of healthy subjects. Methods patients affected by MSA, PSP and ET diagnosed according to currently accepted diagnostic criteria and a group of healthy controls were enrolled in the study. Patients with cognitive impairment were excluded from the study. The Structured Clinical Interview for Personality Disorders-II (SCID-II) has been performed to evaluate the presence of personality disorders (PeDs). The diagnosis of OCPeD was confirmed by a psychiatric interview. Results fifteen MSA patients (8 men and 7 women; aged 62.9 ± 7.6 years), 14 PSP patients (8 men and 6 women; aged 69.8 ± 4.4 years), 16 ET patients (10 men and 6 women; aged 70.4 ± 6.4 years) and 20 healthy subjects (10 men and 10 women; aged 65.5 ± 6.0 years) were enrolled. OCPeD was recorded in 5 (35.7%) PSP patients, 2 (13.3%) MSA patients, 2 (12.5%) ET patient and 2 (10%) controls. Conclusion a low frequency of OCPeD, close to those recorded in healthy subjects, was recorded in both MSA and ET patients. Conversely an higher frequency of OCPeD, similar to PD was found among PSP patients, supporting the possibility of an impairment of common basal ganglia network possibly involving the orbito-frontal circuits.

Contains fulltext : 167738.PDF (Publisher’s version ) (Open Access) INTRODUCTION: StartReact is the acceleration of reaction time by a startling acoustic stimulus (SAS). The SAS is thought to release a pre-prepared motor program. Here, we investigated whether the StartReact effect is applicable to the very first trial in a series of repeated unpractised single-joint movements. METHODS: Twenty healthy young subjects were instructed to perform a rapid ankle dorsiflexion movement in response to an imperative stimulus. Participants were divided in two groups of ten. Both groups performed 17 trials. In one group a SAS (116 dB) was given in the first trial, whereas the other group received a non-startling sound (70 dB) as the first imperative stimulus. In the remaining 16 trials, the SAS was given as the imperative stimulus in 25% of the trials in both groups. The same measurement was repeated one week later, but with the first-trial stimuli counterbalanced between groups. RESULTS: When a SAS was given in the very first trial, participants had significantly shorter onset latencies compared to first-trial responses to a non-startling stimulus. Succeeding trials were significantly faster compared to the first trial, both for trials with and without a SAS. However, the difference between the first and succeeding trials was significantly larger for responses to a non-startling stimulus compared to responses triggered by a SAS. SAS-induced acceleration in the first trial of the second session was similar to that in succeeding trials of session 1. DISCUSSION: The present results confirm that the StartReact phenomenon also applies to movements that have not yet been practiced in the experimental context. The excessive SAS-induced acceleration in the very first trial may be due to the absence of integration of novel context-specific information with the existing motor memory for movement execution. Our findings demonstrate that StartReact enables a rapid release of motor programs in the very first trial also without previous practice, which might provide a behavioural advantage in situations that require a rapid response to a potentially threatening environmental stimulus. 11 p.

Introduction The UPDRS-IV represents the most common screening tool to assess motor fluctuations in patients with PD despite the lack of a clinimetric validation. Objectives We evaluated sensitivity and specificity of UPDRS-IV using a 12-h waking-day motor assessment as the gold standard. Methods We consecutively enrolled PD patients who underwent a 12-h waking-day motor assessment in the study. Patients were clinically evaluated every 2 h for 12 h using the UPDRS-III. Motor scores were reported as a line graph and six blinded raters classified patients as having or not having motor fluctuations. The UPDRS-IV was used in order to assess the presence of predictable and unpredictable motor fluctuations according to items 36–38. Results Sixty two PD patients were enrolled in the study. According to the raters' evaluations, 39 (62.9%) were classified as having motor fluctuations, while according to the UPDRS-IV 47 (75.8%) presented a motor fluctuation giving a sensitivity of 87.2% (95%CI 72.6–95.7) and a specificity of 43.5% (95%CI 23.2–65.5). Conclusion Our study results confirm the high level of sensitivity with a lower level of specificity of UPDRS-IV to screen motor fluctuations in PD patients.

Background and purpose A population-based case−control study in the city of Catania, Sicily, was carried out to determine restless legs syndrome (RLS) prevalence and its association with multiple sclerosis (MS). Methods Patients were randomly selected from a cohort of MS patients resident in the study area and a group of age and sex matched controls was enrolled from the general population. RLS was diagnosed according to the International Restless Legs Syndrome Study Group criteria. Results In total, 152 MS patients and 431 controls were included in the study. A significantly higher prevalence of RLS amongst MS patients (14.5%) compared with controls (6.0%) was detected, corresponding to an almost threefold increased risk (odds ratio 2.7, 95% confidence interval 1.4–5.0) of developing RLS. Spinal cord lesions in MS patients were associated with a higher risk of RLS (odds ratio 3.7, 95% confidence interval 1.1–13.5). Conclusion RLS was strongly associated with MS, with a significantly higher risk in patients presenting spinal cord lesions.

Background In Parkinson's disease (PD), different topographically defined cortical-subcortical oscillatory networks have been implicated in motor program dysfunction. Few studies have focused on clinical correlates of cortical activity asymmetry using quantitative electroencephalography. Methods We retrospectively selected N = 34 l -dopa naive PD subjects who had undergone standardized electroencephalography. We selected N = 18 subjects group-matched by age, sex and hand dominance with normal electroencephalography and no parkinsonism and/or cognitive decline as controls. A Welch's periodogram was applied to electroencephalographic signal epochs recorded from homologous pairs of electrodes over each hemisphere. An index of lateralization was then obtained as the absolute value of the electroencephalographic asymmetry index, computed by subtracting left from right-sided log power spectral density for each homologous site and frequency band. A standardized l -dopa acute challenge test was performed on all PD subjects to compute short-duration response magnitude. Results In mid/lateral frontal regions higher index of lateralization for the beta band (p = 0.015) and lower index of lateralization for the theta band (p = 0.036) were found in PD subjects as compared to controls. Both parameters correlated with Hoehn-Yahr staging (beta: r = 0.428, p = 0.012; theta: r = −0.464, p = 0.006). In occipital region lower index of lateralization for the alpha band was found in PD correlating with l -dopa short-duration response magnitude (r = 0.456; p = 0.007). Conclusions Lateralization of frontal cortex beta electroencephalographic activity is associated with clinical disability. Occipital cortex alpha activity may relate to l -dopa responsiveness in untreated PD subjects.

IntroductionAutosomal recessive spastic ataxia of Charlevoix-Saguenay(ARSACS) is a neurodegenerative disorder characterized byearly-onsetspasticataxia,dysarthria,nystagmus,distalmusclewasting, peripheral neuropathy, finger and foot deformities,andhypermyelinationofretinalnervefibers[1].Brainimagingoften reveals cerebellar hemispheres and superior vermis atro-phy,spinal cordatrophy, and linearhypointensitiesofthepons[2].Thegene SACS responsible fortheARSACSwasmappedto chromosome 13q11 [3] and consists in one gigantic andeight smaller upstream exons [4]. We report a novel SACSmutation in a Sicilian family with ARSACS phenotype.MethodsClinical StudyA woman, aged 36 years, was referred to our hospital forevaluation of ataxia. She was born from non-consanguineousparentsandearlymotormilestoneswerenormal.Elevenmem-bers of the family were studied. Informed consent wasobtained from all family members involved.Molecular StudyGenomic DNA of the patient and relatives was extractedfrom blood lymphocytes using standard procedure. We per-formed sequence analysis of the transcript of the SACS gene(NM_014363.4) that comprises nine exons. The nine codingexons, including the gigantic exon described previously, aswell as flanking intronic sequences of the SACS gene werepolymerase chain reaction (PCR)-amplified from genomicDNA by using 37 primer pairs. Primer sequences and am-plificationparameters are available onrequest. Purified PCRproducts (Wizard SV Gel and PCR Clean-Up System,Promega Corporation 2800 Woods Hollow Road Madison,WI 53711-5399 USA) were directly sequenced on anABI3130 automated sequencer (Applied Biosystems, FosterCity, CA, USA). In addition, mutation analysis was per-formed in patient’s parents and siblings to confirm the

Contains fulltext : 168134.pdf (Publisher’s version ) (Open Access) Parkinson's disease (PD) patients likely use attentional strategies to compensate for their gait deficits, which increases the cognitive challenge of walking. The interplay between cognitive functions and gait can be investigated by evaluating the subject's attendance to a secondary task during walking. We hypothesized that the ability to attend to a secondary task decreases during challenging walking conditions in PD, particularly during freezing of gait (FOG)-episodes. Twenty-nine PD patients and 14 age-matched controls performed a simple reaction task that involved squeezing a ball as fast as possible in response to an auditory stimulus. Participants performed this reaction task during four conditions: (1) walking at preferred speed; (2) walking with short steps at preferred speed; (3) walking with short steps, as rapidly as possible; (4) making rapid full turns. We used surface electromyography to determine reaction times, and a pressure sensor located within the ball to determine movement onset. Reaction times of PD patients were slower (on average by 42 ms) compared to controls, regardless of the walking task. In both groups, reaction times were significantly longer during the turning condition compared to all other conditions. FOG-episodes were most often seen during the turning condition. In PD patients, reaction times were significantly longer during FOG-episodes compared to trials without FOG. Our results suggest that turning requires more attentional resources than other walking tasks. The observation of delayed reaction times during FOG-episodes compared to trials without FOG suggests that freezers use additional resources to overcome their FOG-episodes.