Understanding Freezing of Gait in Parkinson's Disease: Strategies and Considerations

Definition of Freezing in Parkinson's Disease

Freezing of gait (FOG) is a common and debilitating symptom in Parkinson's disease (PD) characterized by a sudden, temporary inability to move the feet forward despite the intention to walk. Patients often describe it as feeling as if their feet are glued to the ground, which can occur during initiation of movement, turning, or navigating through narrow spaces. The exact mechanisms underlying FOG are not fully understood, but it is thought to be associated with dysfunctions in the brain's motor control circuits, particularly in the basal ganglia (Giladi & Nieuwboer, 2008).

Triggers and Exacerbating Factors

FOG can be triggered or exacerbated by various factors, including dual-tasking, anxiety, stress, and specific environmental contexts. Notably, engaging in dual tasks—simultaneously performing a motor task while carrying out a cognitive task—can significantly increase the likelihood of freezing episodes. This is likely due to the added cognitive load interfering with motor control processes (Lewis & Barker, 2009) .

Another critical aspect is the timing of these episodes. Freezing often becomes more prevalent or severe later in the day, particularly during nighttime. This phenomenon may be related to medication wearing off, fatigue, or circadian fluctuations in motor and cognitive function (Yogev-Seligmann et al., 2012).

Strategies to Manage Freezing of Gait

1. Cueing Techniques External cues, such as visual or auditory signals, can help overcome FOG. Visual cues like floor markings (e.g., lines or tiles) can provide a visual guide, encouraging step initiation (Nieuwboer et al., 2007). Auditory cues, such as rhythmic sounds or music, can help synchronize steps and reduce the freezing episodes (McIntosh et al., 1997). Portable devices that deliver rhythmic auditory stimulation have shown promise in assisting patients with PD in managing FOG (Nieuwboer et al., 2007).

   
   

2. Cognitive Strategies Cognitive strategies involve mental techniques to overcome freezing. For example, patients can use self-instruction, mentally rehearsing the movement before attempting it. Breaking down movements into smaller, more manageable steps can also be effective. In addition, focusing on a specific target or using a mental imagery technique to visualize walking without interruption can help reduce freezing episodes (Almeida & Lebold, 2010).

   
   

3. Occupational Therapy, Physical Therapy and Exercise Regular occupational therapy, physical therapy and exercise tailored to the individual's needs can improve overall mobility and reduce FOG. Strength training, balance exercises, and flexibility training are crucial components. Dual task training, often under the supervision of a occupational therapist or physical therapist, can specifically target freezing episodes by practicing walking in different contexts and improving body mechanics (Dibble et al., 2006).

   
   

4. Dual-Task Training Since dual-tasking can exacerbate FOG, practicing dual-task training under controlled conditions can help patients develop better strategies to manage the increased cognitive load. This training involves practicing motor and cognitive tasks simultaneously to improve the ability to handle complex situations in daily life (Rochester et al., 2007).

   
   

5. Medication Management Optimizing PD medication regimens is crucial, as FOG can be more prevalent during "off" periods when the effects of medication wear off. Adjusting medication timing, dosage, or type can help maintain more consistent motor function and reduce the frequency of freezing episodes (Fasano et al., 2015).

   
   

6. Environmental Modifications Modifying the environment to minimize obstacles and reduce the complexity of movement paths can help. This includes clearing clutter, using contrasting colors to highlight steps or thresholds, and ensuring adequate lighting, especially at night, to reduce visual perceptual difficulties (Mancini & Horak, 2010).

Conclusion

Freezing of gait is a complex and multifaceted symptom of Parkinson's disease that requires a comprehensive management approach. By employing a combination of cueing techniques, cognitive strategies, physical therapy, dual-task training, medication adjustments, environmental modifications, and side stepping, patients can improve their mobility and reduce the impact of FOG on their daily lives. Ongoing research continues to explore new interventions and therapies to better understand and manage this challenging aspect of PD.

References

1. Giladi, N., & Nieuwboer, A. (2008). Understanding and treating freezing of gait in Parkinsonism, proposed working definition, and setting the stage. Movement Disorders, 23(Suppl 2), S423-S425.

2. Lewis, S. J., & Barker, R. A. (2009). A pathophysiological model of freezing of gait in Parkinson's disease. Parkinsonism & Related Disorders, 15(5), 333-338.

3. Yogev-Seligmann, G., Hausdorff, J. M., & Giladi, N. (2012). The role of executive function and attention in gait. Movement Disorders, 27(9), 1072-1080.

4. Almeida, Q. J., & Lebold, C. A. (2010). Freezing of gait in Parkinson's disease: A perceptual cause for a motor impairment? Journal of Neurology, Neurosurgery & Psychiatry, 81(5), 512-518.

5. Nieuwboer, A., Kwakkel, G., Rochester, L., Jones, D., van Wegen, E., Willems, A. M., ... & Lim, I. (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.

6. McIntosh, G. C., Brown, S. H., Rice, R. R., & Thaut, M. H. (1997). Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease. Journal of Neurology, Neurosurgery & Psychiatry, 62(1), 22-26.

7. Mancini, M., & Horak, F. B. (2010). The relevance of clinical balance assessment tools to differentiate balance deficits. European Journal of Physical and Rehabilitation Medicine, 46(2), 239-248.

8. Dibble, L. E., Hale, T. F., Marcus, R. L., Droge, J., Gerber, J. P., & LaStayo, P. C. (2006). High-intensity resistance training amplifies muscle hypertrophy and functional gains in persons with Parkinson's disease. Movement Disorders, 21(9), 1444-1452.

9. Rochester, L., Nieuwboer, A., Baker, K., Hetherington, V., Willems, A. M., Chavret, F., ... & Kwakkel, G. (2007). The attentional cost of external rhythmical cues and their impact on gait in Parkinson's disease: Effect of cue modality and task complexity. Journal of Neural Transmission, 114(10), 1243-1248.

10. Fasano, A., Laganiere, S. E., Lam, S., & Munhoz, R. P. (2015). The treatment of freezing of gait in Parkinson's disease: Turning to the less common options. Movement Disorders, 30(12), 1531-1540.

11. Shine, J. M., Naismith, S. L., & Lewis, S. J. (2011). The pathophysiological mechanisms underlying freezing of gait in Parkinson's disease. Journal of Clinical Neuroscience, 18(7), 909-914.

This article provides an overview of freezing of gait in Parkinson's disease, highlighting the importance of a multidisciplinary approach to managing this challenging symptom.