Parkinson’s Freezing Gait Treatment

Predictors Of Freezing: When Are People Living With Parkinsons Most Likely To Freeze

Freezing is common among Parkinsons patients, and is most often seen in those with long-standing symptoms.

A survey of 6,620 people living with Parkinsons 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.

A previous study in 2001 has also established

• 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 , and was not associated with the progression of rigidity .

A current study rigorously compared studies and found that strong evidence supports the following risk factors for freezing

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Passive Remote Patient Monitoring Of Physical Activity: Opal Actigraphy

In addition to active assessments, sponsors seek ways to capture continuous real-world patient activity measures via remote passive monitoring. Clarios Opal® actigraphy solution quantifies daily physical activity to complement QOL & ePRO data for any trial. Combining objective measurements from wearable sensors with qualitative ePRO creates a comprehensive picture. Data is collected passively from patients wearing a single Opal sensor on their wrist.

How To Deal With Freezing

The management of this symptom is based on physical therapy with rehabilitation oriented towards gait disorders. The use of sensory cues can be used to support this management and to limit freezing of gait.

It is recommended to practice regular physical activity, and to favor activities involving the mobilization of motor and rhythmic abilities .

Here are some tips recommended by the American Parkinson Disease Association for returning to walking during a freezing episode :

• Try to do another movement before moving on. For example, raise one arm, touch your head, point to the ceiling, then try to move again.

• Change direction, or move to the side before moving again.

• Visualize an object on the floor in front of you and try to walk on it.

• Take a step backward and then forward.

• Walk on the spot and then move forward.

• Point with your arm in the desired direction and move forward, insisting on swinging your arms.

• Tap the leg you want to move forward before starting the movement.

• Count “1, 2, 3” and move forward.

• Use a rhythmic sound to focus on the rhythm to restart and maintain a steady walk.

Technological solutions are being developed to offer rhythmic auditory stimulation at home. This technique can be useful to resume walking after a freezing and to limit its appearance in order to improve one’s overall gait.

The WALK medical device is based on this technique and it is possible to try this innovation at home.

To learn more, visit our website

RESILIENT INNOVATION

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Complex Exercises Reverse Gait Freezing In Parkinsons Disease Study

A challenging physical training program has helped reverse the symptom of gait freezing in study participants with Parkinsons disease, according to investigators from Brazil.

People with freezing of gait cannot move their feet forward despite the intention to walk, a problem that not only interferes with daily functioning but can lead to falls. Researchers at the University of São Paulo recently tested a 12-week exercise protocol that stimulates motor and cognitive skills at the same time.

The 32 study participants, who had stage 3 or 4 Parkinsons disease, performed adapted resistance training exercises that combined instability, weight lifting, motor coordination and cognitive demands. The exercises were done concurrently to create the complexity necessary to stimulate significant brain changes, explained doctoral candidate Carla da Silva Batista.

This demands considerable effort from the patient and confidence on the part of the trainer, who will invariably have to give patients some support so they dont fall, Batista said.

Significant functional improvements were found following the trial, including a 60% reduction in gait freezing and a 70% reduction in motor symptoms. Measurements of brain activity before and after the training program also showed changes in the brain regions linked to gait freezing, and enhanced brain activity and plasticity in the regions affected by Parkinsons disease, the researchers reported.

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What Can Be Done To Thaw One Out When Freezing Occurs

There are various cues and/or tricks that can be tried with your physical therapist to determine which cue will work best for you. Examples of such cues include:

• Visual cues: Provide feedback to through your eyes and visual system to provide you with a location to place your foot when stepping. Visual cues include: lasers on canes and U-step walkers, placing lines of tape on the floor, placing Xs of tape in a semi-circle in tight spaces, and stepping over the foot of the therapist while gait training.
• Auditory cues: We rely on feedback through our ears to establish a rhythm step to the beat. These cues come in the form of music, counting out loud 1,2, 3.., or using a metronome. There are also applications for smart phones that can provide sounds like a metronome that your therapist can demonstrate for you!

Not every cue works for every patient! But it is important to consult with your PT to find which one will help you.

References:Lohnes CA, Earhart GM. The impact of attentional, auditory, and combined cues on walking during single and cognitive dual tasks in Parkinson disease. Gait and Posture 33 478-483.

Plotnik M, Giladi N, Balash Y, Peretz C, Hausdorff J. Is freezing of gait in Parkinsons Disease Related to Asymmetric Motor Function? Annals of Neurology. Vol 57 No 5, May 2005

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

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.

Heres a list of common factors that may add up to freezing episode happening more often.

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What Does It Look Like

Parkinsonian gait is one of several motor symptoms that are the hallmarks of Parkinsons disease, including slowness of movement and tremors. Motor symptoms in Parkinsons disease come from a lack of control over movements and difficulty initiating muscle movements.

The exact features of Parkinsonian gait can differ from person to person, but there are some very common features that most people have. These include:

• taking small, shuffling steps
• moving more slowly than expected for your age
• festinating, or when your strides become quicker and shorter than normal, which can make it look like youre hurrying
• taking jerky steps
• moving your arms less when walking
• falling frequently
• freezing of gait

People with Parkinsons disease can sometimes lose the ability to pick up their feet, which makes them stuck in place. Freezing of gait can be triggered by environmental factors, such as walking through a narrow doorway, changing directions, or walking through a crowd. It can also be triggered by emotions, especially anxiety or feeling rushed.

Freezing of gait can happen anytime. However, it often occurs when you stand up. You might find that youre unable to pick up your feet and start moving.

So What Circuits Arent 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
• 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.
• 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

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Subthalamic Oscillatory Activity And Connectivity During Gait Freezing

To investigate the role of the STN neural activity in gait freezing we compared the STN oscillations between walking and ongoing freezing episodes. We first studied power changes in low frequency and in the -frequency band of the two STN and did not find any differences during gait freezing in comparison to walking . We also assessed the duration of -burst and did not find a difference between walking and gait freezing . We finally investigated the subthalamic interhemispheric coupling in the -band and showed an increase of -coupling followed by a reduction in the synchronization between the two STN during gait freezing. However, this change did not reach statistical significance .

Clinical Molecular Imaging And Biomechanical Data

Detailed demographic and clinical data are listed in . All subjects showed a sustained improvement from DBS , which was similar to the benchmark positive response from levodopa . This further supports the correct placement of the electrodes that were used for the recording of the STN neural activity.

In comparison with healthy controls, all patients showed a significant bilateral reduction of striatal DAT binding, with one hemisphere more dopamine-depleted than the opposite one . The average asymmetry index of the striatum was 27 . The H was contralateral to the clinically most impaired body side in each patient. The individual values of striatal DAT binding were previously reported for all patients except Patient nwk01 .

Biomechanics measurements showed reduced stride length and maximal velocity in subjects with Parkinsons disease with respect to healthy control subjects . All five subjects suffering from FOG showed gait freezing episodes during the study . We recorded 14 freezing episodes , clinically and biomechanically defined. All freezing episodes occurred while approaching a door .

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What Freezing Is Like For My Dad

Like many Parkinsons patients, my dad notices that he usually only freezes when hes not on his medication. It usually happens while hes moving through doors: When you pivot youre worried about losing your balance. Thats why we shuffle our feet and take baby steps initially. Once Im moving Im fine, he says.

Since hes worried about maintaining balance while navigating, its possible that theres a connection between fear and freezing. Continuous motion seems to bypass the risk of freezing, while shifting motion types can present challenges.

Future Of Freezing Of Gait Treatments

Various research approaches may transform how freezing of gait is treated in the future. Cognitive training strategies are being studied to determine if they improve freezing of gait. Another approach is the development of wearable technology systems that can detect an imminent freeze and then automatically deploy a sensory cue. Novel deep brain stimulation targets are also being developed as a method of controlling freezing of gait.

APDA invests in research that may lead to new treatments for the gait disorders of PD. Here are some examples:

Christopher Bishop, PhD, at Binghamton University in Binghamton, NY, is studying an area of the brainstem known as the pedunculopontine nucleus, which plays a key role in movement and wakefulness. It has been an experimental DBS target for relief of freezing of gait and PD-related gait disorders with mixed results. Dr. Bishop is probing the specific functions of this key brain area to determine how they impact PD symptoms.

Aasef Shaikh, MD, PhD, at Cleveland VA Medical Center, University Hospitals Cleveland, and Case Western Reserve University in Cleveland, OH, is studying the complex interactions of various neurologic systems, their effects on gait and balance in PD, and how they can be modified by DBS. The systems that Dr. Shaikh studies include vision, eye movements, the inner ear/vestibular system, and proprioception.

Tips and takeaways

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Trouble Moving Or Walking

Weight Management

People without Parkinson’s disease do not think about their walking. Their arms naturally swing, and their feet naturally land on the heels with each step. They can walk and talk and carry bags, purses and plates of food without difficulty.

Individuals with PD tend to lose their automatic movements. Especially as Parkinsons advances, it may bring with it a variety of symptoms that are uncommon in early stages, such as problems with walking and poor balance . Feet begin to shuffle and performing two tasks at once becomes more difficult. Turning becomes challenging, often leading to a freezing episode and sometimes a fall.

So Lets 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, its a complex scenario involving a breakdown in brain circuitry and processing.

Therefore, the response to this situation requires a multi-pronged and personalised response.

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Tips To Get Moving Again

When you get stuck, these tricks from the National Parkinson Foundation can help:

• Be aware of freezing triggers and prepare strategies in advance.
• Shift the weight of your body from one leg to another.
• Listen to music and step with the rhythm.
• Hum, sing, or count.
• Imagine a line to step over or focus on a target on the floor to step on.
• Use a mobile laser device to create a line in front of you to step over.
• Turn by walking half a circle instead of by a pivot turn.

Therapist Who Can Help With Freezing Of Gait

A physical therapist or commonly known as physiotherapist whos 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 role of occupational therapy and Parkinsons disease is to help people live better with their PD symptoms.

You can expect from an occupational therapist services which focus on

• Home audit and design solutions
• Assistive technology for Parkinsons Disease
• Lifestyle prescription
• Tailored activity recommendations to support movement diversity and other goals
• Cognitive strategies for Freezing of Gait
• Caregiver education and training to assist people living with advanced PD who experience freezing of Gait.

If theres a key takeaway to close this article on Freezing of Gait and what to do about its this:

Freezing in Parkinsons is a highly complex brain circuitry pathology which requires a multi-pronged and personalised approach.

If youd like to explore strategies for your personal situation please do not hesitate to contact us at Occupational Therapy Brisbane today.

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Cerebellar Transcranial Ultrasound Stimulation To Alleviate Freezing Of Gait In Parkinsons Disease

Treatments to help people with Parkinsons whose gait freezes when they walk or pass through doorways have so far had limited success.

To restore peoples independence and freedom of movement, Dr. Jean-Francois Nankoo, a post-doctoral fellow at Torontos University Health Network, is trying a new approach.

Hes using low-intensity sound waves from an ultrasound machine to target the cerebellum, an area of the brain that appears to be involved in freezing.

The cerebellum tends towards being a corrector of movement, says Nankoo. We think that in those people , this area of the cerebellum is increasing its activity, trying to correct some sort of malfunction.

Nankoo believes the focused ultrasound waves will give the target cells an extra boost to help unfreeze peoples gait.

To test his theory, Nankoo will place a small, portable ultrasound on the back of the heads of people who experience freezing of gait. Hell stimulate the cerebellum for one to two minutes.

After the painless procedure, Nankoo will measure peoples gait as they walk around, charting any improvement in freezing.

If Nankoos treatment successfully unblocks freezing of gait, even for a short period of time, his research will span larger clinical trials. Hell then go on to investigate how long the sound wave stimulation should last, and how frequently it must be re-applied.

Eventually, he hopes researchers could create a small, portable ultrasound for treatment in doctors offices or even at home.