Discover how these 13 neuro-plasticity actions can help you manage your Parkinson’s disease symptoms.
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WHAT ARE PARKINSON’S FREEZING GAIT SYMPTOMS?
Some people describe their Parkinson’s Disease freezing symptoms as
Like being stuck in mud
My feet are stuck to the floor
Someone has hit my pause button but I really want to go
I’m yelling at my legs to move and they won’t
It’s like my brain shuts down and yep – stuck
I’m in a fog
Fatigue, that’s my thing I feel so tired
I’m glued in!
WHAT DOES “FREEZING OF GAIT” LOOK LIKE IN DAILY LIFE (COMMON FEATURES)
If you’re scratching your head about what freezing of gait means, you’re not alone. In fact most health professionals need to “google it”.
When it comes to walking, some people living with PD experience this sense of being stuck, or “my feet are stuck to the floor” which describes the disrupted gait in patients living with PD.
Freezing Episode: These are brief or prolonged episodic phenomena of not being able able to step, or move your feet forward despite the mind being willing and having the conscious intention to walk.
Gait: Refers to the pattern of walking. There is an observable change in step length. This change in gait in parkinson’s disease is a cardinal sign of the disease. Small, shuffling and hallmark stooped posture is known as a festinating gait.
Whatever your experience of Freezing of gait (FoG), there are some common features of this gait pattern.
Firstly, FoG is defined as a “brief episodic absence or marked reduction of forward progression of the feet despite the intention to walk” (Giladi et al, 2000).
Freezing of gait is a major disabling motor impairment symptom that affects the daily quality of life of Parkinson’s disease (PD) patients.
FoG appears commonly at advanced or later stages of the disease experience: So with disease progression, the prevalence of FoG increases. It’s been reported that 81% of Parkinson’s disease patients experienced FOG after a disease duration of 20 years.
BUT a mild form can be seen in the early stages. The work of Prof. Alice Nieuwboer has presented modelling of freezing which is noted to affect speech and weight shifting between legs so you could say “not just walking can be a symptom”
Moreover, clinical features cited are: motor dysfunction, sleepiness, fatigue, and cognitive dysfunction
And this differs to what the patient reports such as postural instability and walking pattern (gait) difficulty.
About 38 percent of people living with PD fall each year. PD-related falls occur mostly when turning or changing directions and are often related to a freezing episode.
People who are living with Parkinson’s and experience Freezing of Gait will often report near misses, crash landing in chairs or minor falls.
It’s vital to be attentive to these events as a “fall” can be a significant safety and life threatening issue. A fall can result in a serious injury.
Please don’t dismiss the impact a fall can have.
A fall can have catastrophic consequences on a person’s independence, health and lifespan.
“Freezing of gait is one of the most debilitating symptoms of Parkinson’s disease and is an important contributor to falls, leading to it being a major cause of hospitalization and nursing home admissions.” (Sweeney et al, 2019)
“FOG in PD patients is the main cause of falling, fracture risk, and activities of daily living disability” (Okuma et al, 2018)
Discover how these 13 neuro-plasticity actions can help you manage your Parkinson’s disease symptoms.
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COMMON TRIGGERS OR CAUSES OF FREEZING OF GAIT
People who experience freezing may describe situations where they find themselves stuck, for example:
Narrow spaces or tapering corridors
A disruption to your walking pattern
Change direction: A change of direction can induce a freezing experience
Crowded places
Crowded rooms
Responding to unexpected events like being rushed or startled: Trying to get to the toilet on time
Changes in walking surfaces ( textures, patterns or there is a visible object, like a shower hob or door threshold)
Transitions between environments – breaks or lines in the walking pathway be they inside or out. This may be experienced in shopping centres with the electric sliding doors or escalators. On and off public transport
Increasing cognitive loads. So in this instance greater thinking whilst doing or as referred to as “dual tasking”
Changes in levodopa medication such as being in the medication “off phase”
You can appreciate that in the spacious clinic, with uniform floor surfaces it is often hard to detect freezing of gait.
It happens in everyday life away from the clinic.
That’s why we offer in tele-therapy, in home and community consultations.
It allows us to assess the impact of PD in your life and to design personalised plans with the goal to help you live a more independent life.
Discover how these 13 neuro-plasticity actions can help you manage your Parkinson’s disease symptoms.
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WHY DOES FREEZING HAPPEN IN PARKINSON’S DISEASE?
It’s clear, anything to do with the brain is far from simple.
When it comes to the brain networks which controls your gait, yep you guessed it, it’s complex.
Your walking pattern relies on multiple connections and pathways between various parts of the brain.
Freezing of gait can be viewed like a good detective novel.
Movement is a dynamic activity. It adapts and responds to the world around us. As a result, there are a number of brain regions or “characters” implicated as being involved with Freezing of Gait in Parkinson’s Disease.
These brain areas are widely distributed and act in a synchronised and consistent manner.
You could say movement involves dynamic brain network coordination, and it’s this circuitry, this network behaviour, which appears to be affected and in the end gives rise to Parkinson’s freezing of gait (Lozano and Lipsman, 2013).
So, What Circuits Aren’t Working?
“Out of Sync” Limbic System and Cognition regulated by the basal ganglia as well as the supplementary motor area, cerebral cortex and more recently supraspinal locomotor network and being referred to a circuitopathy (Sawada et al, 2019., Pozzi et al, 2019)
Support to this “circuitopathy” is getting greater recognition by studies showing that FOG is correlated with limited dual-tasking ability and inability to “set-shift” attention among motor, limbic, and cognitive networks.
In addition, freezing can occur during speech, handwriting, and other actions aside from gait, suggesting that the dysfunction occurs in generalized neural networks not solely related to ambulation. (Bluett et al, 2018)
The limbic system is the part of the brain involved in our behavioural and emotional responses, especially when it comes to behaviours we need for survival: feeding, reproduction and caring for our young, and fight or flight responses (QLD Brain Institute)
So, Let’s Simplify This Complex of Freezing of Gait Brain Scenario
So, it appears Freezing of Gait involves disordered communication and processing of information between networks involving the:
front of the brain that plan and initiate movement
basal ganglia where the dopaminergic neurons that fine tune and exert control over movement
parts of the brainstem which again refine movement and support wakefulness
Yes, it’s a complex scenario involving a breakdown in brain circuitry and processing.
Therefore, the response to this situation requires a multi-pronged and personalised response.
PREDICTORS OF FREEZING: WHEN ARE PEOPLE LIVING WITH PARKINSON’S MOST LIKELY TO FREEZE?
Freezing is common among Parkinson’s patients, and is most often seen in those with long-standing symptoms.
A survey of 6,620 people living with Parkinson’s disease found that 47% reported experiencing freezing regularly. Further analysis of people who reported freezing showed
It was significantly associated with a longer disease duration and a more advanced stage of the disease.
Episodes were more likely in men than in women and
Finally, people who reported tremor as their main symptom were likely to also report freezing less frequently.
The results underline the necessity to develop appropriate countermeasures against this phenomenon, which is widely known to cause significant impairment of patients’ quality of life and – as our data also showed – may cause traffic accidents in licensed patients.
Risk factors associated with freezing where found to be at the early stages of the disease 1. the absence of tremor and 2. PD symptoms being mostly as a gait disorder early in the disease experience.
The development of freezing over the course of the illness was also strongly associated with the development of balance and speech problems and less so with the worsening of bradykinesia (slowed movement), and was not associated with the progression of rigidity (Giladi, N et al, 2001).
A current study rigorously compared studies and found that strong evidence supports the following risk factors for freezing
Gait disorders specifically having postural stability, and neuro-imaging which observes striatal (part of the brain) dopamine loss were found to be independent risk factors of FOG with consistent evidence. Combining the these two observant researchers accurately predicted Freezing 4 years later (Gao et al, 2020)
Not everyone can complete neuro-imaging and if anything you can take away here, is being attentive to balance and your walking patterns, especially reducing in step length.
WILL MEDICATION HELP WITH FREEZING OF GAIT EPISODES?
In a study of 593 patients living with PD found that 325 (54.3%) experienced freezing (freezers) of whom 200 (61.6%) experienced FOG only during medication off state (off-freezers), 6 people (1.8%) experienced FOG only during on state (when medication is active) and 119 (36.6%) either in on and off states or independently of dopaminergic response-related symptoms (onoff-freezers).
Overall, the key findings of the study showed that
When comparing freezers vs non-freezers, freezers tend to have been living with PD for longer so they had a more advanced stage of PD, as well as, more advanced disease and greater disability.
Freezers also more frequently reported medication wearing-off and experienced worse quality of life.
Comparing onoff-freezers with off-freezers, they tend to be older, more severely disabled, less likely to experience wearing-off, treated with lower levodopa equivalent daily dose and with poorer cognitive performance.
In short, there is a trend to observe freezing of gait n later stages of the disease state, however those who experience FOG in both On and Off medication states are likely the result, according the researchers, to be under medicated (Amboni et al, 2015)
TIP: If you’re experience Freezing in both medication ON and OFF states be sure to speak with your doctor regarding your current medication regime.
OH NO, I’M FREEZING! WHAT THE HECK SHOULD I DO NOW?
There are a number of factors that can contribute to freezing of your gait.
First up we need to map out what they are.
FIRSTLY,TAKE THIS FREEZING OF GAIT QUESTIONNAIRE:
IDENTIFY WHAT ARE YOUR TRIGGERS
Am I Freezing? Is This Freezing?
Most questionnaires, or clinical assessments of people living with PD which checks for freezing will commonly observe a person performing a number of walking actions.
So, to do this ask yourself how is your movement performance in the following areas, do you have had problems with:
Being able to perform turns about furniture or obstacles
Getting into or out of a lift?
Moving over changes in floor surfaces, patterns or thresholds
Being able stop on command, like when some says – look out for that xxxxx ( obstacle)
Moving in and around narrow or cluttered passages,
Moving in crowded or public spaces
Able to walk and do another task at the same time, like walking and talking at the same time or braking and talking whilst driving? This is often referred to dual motor-tasking such as carrying a tray.
Walking when under pressure to get a task down, or when there is a lot on your mind like worry or being anxious.
Managing your balance whilst walking and doing daily activities?
Take a moment and consider your experiences here against this list.
Do you have any symptoms?
Do these symptoms they all the time, sometimes, occasionally or not at all?
Connecting with a physiotherapist or occupational therapist maybe of help, and our suggestion is to do this early rather than later as the risk of having a fall increases when living with PD and Freezing.
Here’s a list of common factors that may add up to freezing episode happening more often.
HERE’S WHAT IS POSSIBLY AMPLIFYING YOUR FREEZING EPISODE
Medication Cycle Consistency
Your medication, for example, levodopa will go up and down depending on when you taken it, how well your body leverages it and the stage of your PD.
Taking your medication on a regular basis helps you understand your PD symptoms.
Let me explain, if you’re consistent with your medication, it’s one factor you can control for.
With your investigator hat on you can map out what else is happening other than the medication
Fine tuning your medication may be also indicated if it is not aligned to the way you’re wanting to live your life.
Being under medicated is a common culprit in a person’s experience of freezing of gait episodes.
You’d appreciate a complex brain network problem is rarely solved by just medication alone.
Ramping up your dopaminergic medication like carbidopa/levodopa are only part of the equation, some people even report Freezing when ON. So it happens even when people are flush with their medication.
Anxiety (Mental Health) and Freezing of Gait
Marten’s and associates showed in 2014 anxiety is an important mechanism underlying freezing of gait and suggests that increasing limbic “load” (i.e. anxiety) leads to increased freezing of gait and step-to-step variability. (Remember brain changes in the limbic system are associated with FoG. )
Sleep Quality
Having a nourishing sleep needs to be up there as the same as a nutritious meal.
Fatigue is strongly associated with freezing of gait episodes.
Not only that, consistent sleep patterns support our cognitive skills of attention, memory, arousal as well as mood.
Nutrition, Hydration and Gut Health
A diet which supports your tummy motility ( the ability to move food through your bowels) can help avoid some of the associated complications of PD such as constipation.
Being consistent with a Mediterranean diet may also be positive step.
The problem with nutrition research to date is that there is a lack of quality and depth.
The recommended approach is to work with a skilled Dietician or Nutritionist to help provide you with a personalized plan.
Increasing Stiffness
It’s fairly consistent for people living with PD that slowed movement, stiff muscles and a stopping posture are commonly reported.
However, freezing is something outside the above “cardinal cluster” of symptoms and doesn’t affect everyone.
The common culprit to freezing is the medication cycle. Whilst freezing can occur whilst ON your medication it is more commonly reported on the OFF cycle.
Off” periods are times when Parkinson’s disease (PD) medication, namely levodopa, is not working optimally. (Michael J Fox Foundation )
Inconsistency or Lack of Exercise Program
Are you challenging your movement patterns and elevating your heart rate on a regular basis?
I’ll often speak about the imaginary fence line and giving up territory or PD.
The less we challenge this boundary which are your personal limits, the more likely you’re to give up movement independence.
That’s why it’s important to maintain an active exercise and movement routine on a regular basis.
WHAT SHOULD YOUR FREEZING OF GAIT TREATMENT STRATEGY LOOK LIKE?
Keeping in mind your triggers a personalised approach may include one or more of the following.
Here’s 13 Freezing of Gait Tips To Help You Get Moving Again
1.Keep your movements BIG – Scale Matters.
Slowness of movements (Bradykinesia) is one of the cardinal symptoms of Parkinson’s disease. The sequence effect is a feature observed with Bradykinesia in which there is decline in amplitude and speed of repeated movements (e.g. walking and wand writing).
So, as a person commences movement there is relative scale and as person continues with the movement it gets smaller and smaller. It is a major cause of disability in Parkinson’s disease.
Medication has had mixed results with this feature of PD though external prompts have shown to be beneficial (Tinaz, et al., 2016).
Like a bank account, movement appears to have an energetic cost and as a person progress in a movement, there is less and less available.
Dopamine supporting medication allows the trigger for movement but appears to not maintain the vigor and size of movement according to research.
What To Do:
Aim to make over exaggerated movements, such as Big steps and Big arm swings. It’s a way to retrain the muscles and slow down the progression of hypokinesia, the increasingly smaller, more shuffling movements that happen with Parkinson’s.
2. Develop the mindful skills to walk with purpose and with intent.
Using therapy programs to practice these skills there are emerging positive results using interventions like:
treadmill training
obstacle aquatic training – a form of hydrotherapy
slackline training
walk bicycle
The findings of a large meta-analysis suggest that it’s a combination of approaches which are needed as “in clinic” exercises have a short term carry over. Meaning more sustained activities as well as in home work is needed as well. (Cosentino et al, 2019)
3. Develop your “circuit breaker” toolkit.
Rather than trying to “bust through” the freezing, consider moving an alternative part of your body to “circuit break” the frozen movement. This may include:
Move another limb finger, move your gaze.
Take a deep breath in and shorter breath out.
Auditory or visual cues also can be used as well and covered later in this list
4. Pick a Destination
A point of focus, like a boat charting a course through difficult waters, map a path to get to your intended destination . This may be about the home for example. You want to get form the loving to that bathroom but you need to go through the kitchen to get there. Pick a visual target that leap fogs you to the next visual destination.
5. Verbal Cue and Prime yourself to GO!
This can be a countdown methods 3-2-1 GO! Please note the GO! is a LOUD and POWERFUL internal command you give yourself.
6. Leverage Assistive Technology
Tools like BEATS Medical have promise to help keep a movement rhythm. That said you can start with no cost items like, singing, get a song with a beat to cue you into the movement you want.
Laser-shoe: The laser-shoe is equipped with a line-generating laser activated through the loading of the body weight onto the switch upon heel contact during the gait cycle. (Gao et al, 2020). Side Note: We’ve not seen these but they sound great, don’t they?
7. STOP! Take The Pressure Off
When you get stuck, STOP, Pause, Reset GO. Too often we see people battling it out. The lack of movement “fine tuning” power means there’s a great fire hydrant pouring commands into your movement networks and nothing happens. Stopping is key the rest follows a natural order.
8. Establish a home or work environment which is “Freezing Resistant Sanctuary”
Attend to the home hazards which trigger your freezing of gait is one part of a holistic management plan (Nonnekes et al, 2015)
9. Plan Your Day
So, in more advanced cases plan your day around the likelihood of your symptoms raising their head. You’ll likely know of the impact and timing of this. For example, it may mean a two walking aids of choice to cover your bases.
10. Place An Object In Front Of You
One strategy is to visualise an object to step over.
As counter intuitive as this sounds some people respond to the visual stimuli to promote the movement pattern.
There is an emphasis on stepping over which can shift your weight from your toes ( this can exacerbate the freezing) to the whole of the foot.
This is the principle of the laser lights. Either attached to a cane, on a walker or a small laser pointer that you hold in your hand. You have to step over the light or step to the light.
The challenge that we encounter with the aids is that they promote the stooped posture and reduce your scale of movement as most folk underestimate their capacity for bigger movement
11. Your Neurologist May Recommend Deep Brain Stimulation.
A paper presented by Kim and colleagues, 2019 suggest subthalamic nucleus deep brain stimulation (STN DBS) is effective against freezing of gait in Parkinson’s disease.
However, a limitation of their paper was their finding that DBS appeared to only affect a person’s experience of FoG in Off – medication state.
No doubt a conversation with your neurologist is needed when discussing major treatment options. An assessment of the pros and cons for your personal situation will guide you to being informed about the right treatment course.
Gao and colleagues have compiled a comprehensive review of DBS in their article.
12. Cognitive “Brain” Training
Walton and colleagues in 2018 showed a novel cognitive training program over 14 session which targeted brain skills of attention and speed of processing as having positive benefits to freezing of gait when ON as well as increased cognitive endurance.
13. PLUS: Mitigate the threats to achieving and sustaining a healthy lifestyle.
Maintain healthy nutrition, sleep, mood, social relationships and exercise. In this article “Break The Cycle of Parkinson’s Disease” we summarize the role of diet and Parkinson’s disease.
Discover how these 13 neuro-plasticity actions can help you manage your Parkinson’s disease symptoms.
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ASSISTIVE TECHNOLOGY (AIDS) TO HELP WITH FREEZING OF GAIT
There are many walkers on the market, basically a simple metal frame which may be supported by stoppers, slides or wheels.
Walking stick with visual cueing aid/ technology
U Step walker: a wheeled walking aid with visual cueing technology
Beats Medical: auditory “personalised” metronome like tool
THERAPIST WHO CAN HELP WITH FREEZING OF GAIT
A physical therapist or commonly known as physiotherapist who’s skilled in working with people living with movement or gait disorders will be a great member of your team!
As mentioned a lot triggers for Freezing of Gait episodes happen outside the clinic.
Having an occupational therapist come to your home, community or workplace offers you a clinical perspective with a deeply pragmatic focus.
The Occupational Therapy Blog is a news and health promotion initiative. It by no means aims to be a source of medical or therapeutic advice. We enjoy sharing information and will attempt to curate it as best we can. You’d appreciate we like to lighten our blog articles which often tackles very serious issues. It’s our way of sharing. The information contained on this blog is not intended to be a substitute for professional advice, or intervention. Always seek the advice of your GP or qualified therapist with any questions you may have regarding your personal situation. Never substitute or delay seeking professional advice because of information you’ve read on this website.
