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Understanding Freezing in Parkinson's Disease
Freezing in Parkinson’s disease (PD) is a temporary and involuntary inability to move that can affect both walking (freezing of gait or FOG) and upper limb movements (freezing of reaching). Episodes are particularly common during transitions, such as starting or stopping movement, turning, or navigating obstacles, and can feel as though the body is "stuck" despite the intent to move. Small, quick, asymmetrical steps often exacerbate freezing episodes (Nieuwboer et al., 2007).
Why Freezing Happens
Freezing is influenced by a complex interplay of physiological, cognitive, and emotional factors:
Physiological Mechanisms:
Dysfunction in the basal ganglia and dopamine depletion impair the brain’s ability to generate and regulate smooth motor sequences (Lewis & Barker, 2009).
Altered connections between the motor cortex and other brain areas, such as the prefrontal cortex, hinder movement planning and execution (Giladi & Nieuwboer, 2008).
Cognitive Contributions:
Dual-Tasking: Divided attention can worsen freezing by overloading the brain’s processing capacity, as demonstrated in studies where participants were asked to walk while performing a cognitive task (Plotnik et al., 2011).
Transitions: Situations that demand a shift in motor activity, like turning or stepping through a doorway, require additional cognitive resources and are common triggers for freezing.
Emotional Factors: High levels of anxiety, frustration, or fear during freezing episodes intensify the freeze, creating a vicious cycle (Ehgoetz Martens et al., 2014).
Preventative Strategies
Both physical and occupational therapy emphasize interventions to reduce the frequency and severity of freezing episodes by focusing on motor control, movement adaptability, and cognitive strategies:
Improve Movement Symmetry: Encourage patients to practice taking bigger, more symmetrical steps to prevent freezing episodes caused by small, quick, or uneven movements.
Dual-Task Training: Practice motor tasks in dual-task scenarios, such as walking while talking or manipulating objects, to improve cognitive-motor integration.
Environmental Manipulation: Simulate real-life scenarios to enhance movement adaptability and build confidence.
Cueing Techniques:
Auditory cues, such as metronomes or rhythmic music, have been shown to reduce freezing severity (Ginis et al., 2017).
Visual cues, like laser pointers or floor markings, can help guide movement.
Tactile cues, such as a light touch on the shoulders, can provide grounding.
Agility Training: Use obstacle courses to challenge the mind and body, enhancing coordination and adaptability.
Strategies During Freezing Episodes
When freezing occurs, these techniques can help break the freeze and restore movement:
Pause and Recenter:
Stop and stand still. Take a deep breath to reduce emotional tension, which perpetuates freezing (Ehgoetz Martens et al., 2014).
Ground yourself by visualizing stability and calmness.
Use External Cues:
Rock back and forth gently to create momentum.
Use verbal cues like "1-2-3, go!" or think of marching with exaggerated steps.
Step over or around an object, such as a line on the floor or a laser beam.
Adjust Movements:
For turning, avoid small pivots; instead, take wider arcs to maintain balance and movement.
If rigidity overlaps with freezing, stretch stiff joints regularly to enhance mobility.
Utilize Assistive Tools:
Rhythmic devices like a U-Step walker’s metronome can provide auditory cues.
Smartphone apps with rhythmic beats or metronome functions can achieve similar results.
Arm Freezing Solutions:
Use the unaffected arm to manually move the frozen arm to encourage motion.
Research Evidence
A study by Ginis et al. (2017) demonstrated that auditory cues, such as rhythmic music or metronomes, significantly improved step length and reduced freezing duration. Similarly, Nieuwboer et al. (2007) found that visual floor markers helped participants with Parkinson’s navigate challenging environments with fewer freezing episodes. These findings highlight the importance of cueing and task-specific training as part of a comprehensive therapy plan.
References
Ehgoetz Martens, K. A., Pieruccini-Faria, F., & Almeida, Q. J. (2014). Could anxiety contribute to freezing of gait in Parkinson's disease? The Journal of Neurology, Neurosurgery & Psychiatry, 85(8), 828–834. https://doi.org/10.1136/jnnp-2013-306635
Ginis, P., Nieuwboer, A., Dorfman, M., & Hausdorff, J. M. (2017). Cueing for freezing of gait in Parkinson’s disease: A narrative review. Journal of Neurology, 264(8), 1678–1686. https://doi.org/10.1007/s00415-017-8517-7
Giladi, N., & Nieuwboer, A. (2008). Understanding and treating freezing of gait in Parkinsonism, proposed working definition, and diagnostic criteria. Movement Disorders, 23(S2), S423–S425. https://doi.org/10.1002/mds.21927
Lewis, S. J., & Barker, R. A. (2009). Understanding the dopaminergic deficits in Parkinson’s disease: Insights into potential treatment strategies. Journal of Neurology, Neurosurgery & Psychiatry, 80(3), 277–286. https://doi.org/10.1136/jnnp.2008.157370
Nieuwboer, A., Rochester, L., Herman, T., Vandenberghe, W., Emil, G., & Thomaes, T. (2007). Cueing training in the home improves gait-related mobility in Parkinson’s disease: The RESCUE trial. Journal of Neurology, Neurosurgery & Psychiatry, 78(2), 134–140. https://doi.org/10.1136/jnnp.200X.00034
Plotnik, M., Giladi, N., & Hausdorff, J. M. (2011). Bilateral coordination of walking and freezing of gait in Parkinson’s disease. The European Journal of Neuroscience, 33(1), 197–204. https://doi.org/10.1111/j.1460-9568.2010.07508.x
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