What Is Freezing Of Gait And What Can I Do About It?
Do you ever feel like your feet are glued to the floor when you are trying to walk? If so you are likely experiencing what is known as freezing of gait. In this blog post we will discuss freezing of gait, why and when it may happen, and strategies to help manage and prevent freezing.
What is freezing of gait?
Freezing of gait is defined as a “brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk”.
What is festination?
This is different from Festination’s which is defined as involuntary gait where stride length is shorted and steps become progressively more rapid. An individual with festinating gait appears to be hurrying or shuffling along, and forward propulsion is decreased overall. The torso and lower extremities are often flexed.
Why do we freeze?
Not everyone that has Parkinson’s will develop freezing and the exact cause of freezing is not known. Freezing of gait is something that occurs over time and can occur in individuals with Parkinson’s as it progresses.
When looking at possible mechanics underlying freezing of gait, we have to look at the brain - specifically at the areas involved in locomotion or walking. The main regions exerting a critical role in locomotion are the reticular formation, mesencephalic locomotor region, basal ganglia, cerebellum, and cerebral cortex (supplementary motor and pre motor areas). Huh?! What you need to know is that all these regions of the brain communicate with each other to control voluntary movement, automaticity of movement, and movement initiation. While these areas of the brain are important for walking and movement, there are other factors involved in whether an individual with Parkinson’s freezes or does not. The relationship between motor, cognitive, and limbic (mood ) circuits in the brain are both competing and complementary. As dopaminergic neurons are depleted in those with Parkinson’s, concurrent processing of cognitive and/or limbic information during motor tasks can overload the information processing capacity within the basal ganglia. This interference between neural circuits in the brain is used to explain the phenomena that increasing cognitive load while performing a dual task can lead to the breakdown of locomotion.
The take away is freezing is likely caused by a combination of things! If you think about all of the things your brain is having to process throughout the day, it is quite a lot. In individuals with Parkinson’s, this can become even more challenging. If your brain is not able to do things as smoothly or as automatically, it can make walking and movement very difficult.
Other things that increase the likelihood of freezing:
Freezing of gait is significantly associated with the presence of dementia.
The severity of Parkinson’s progression was a significant contributing factor.
Notable association between freezing of gait and the presence of dyskinesia’s of early dystonia.
Early freezing of gait in early Parkinson’s is suggestive of atypical Parkinson’s.
When does freezing occur?
Freezing of gait can happen at any time, but often occurs with transitions of movement. Such as going from sitting to standing or static standing to walking. Other common triggers of freezing occur when you are walking through a doorway or turning or stepping from one type of surface to another (going from carpet to hardwood floors). Due to the complexity of walking as mentioned above, dual tasking (doing two things at once) and stopping or changing speed of walking are other likely triggers of freezing of gait. Bouts of freezing often occur during your “off” phase, when you are wearing down on your medication. With proper timing throughout the day, medication can decrease periods of freezing! This is why it is important to keep a thorough account of when you take your meds and when freezing bouts occur so you can speak to your neurologist about ways they can help optimize your overall level of function.
What to know about meds and freezing of gait?
Medication optimization can help reduce bouts of freezing!
“Off” related freezing of gait is improved by levodopa or entacapone treatment.
L-dopa can decrease duration of each freezing of gait episode as well as its frequency.
Only in the most advanced stages of Parkinson’s is freezing of gait resistant to treatment.
Dopamine agonists may produce freezing of gait.
MAO-B inhibitors decrease freezing of gait frequency or severity.
Why is freezing of gait worrisome?
About 38% percent of individuals living with Parkinson’s fall each year. Thee beginning and end of these bouts can be unpredictable. Often loved ones encourage the individual with Parkinson’s to push through bouts t of freezing. This can cause the individual to lose balance and fall. It is important to inform your health care team if you are having bouts of freezing. Your physician will likely want to know where in your medication cycle freezing is occurring and will refer you to Physical Therapy!
Why do therapists help?
The good news is that freezing of gait can be improved. However, it often takes a moderate to high dose of exercise and previously mentioned medication to greatly help! What do therapies focus on?
It is very comprehensive!
Physical – rigidity, bradykinesia, step length, gait speed, etc
Cognitive – spatial awareness, mild cognitive disorder/dementia, set shifting, etc
Emotional – anxiety, decreased confidence, etc
In addition to the above, you can work with your Physical Therapist to find tricks that work for you to stop freezing episodes and decrease risk of falls. Did you know that freezing does not only occur within the lower extremities, but can occur in the hands and affect speech as well? This is something that Occupational and Speech Therapy can help with! Decreasing freezing in the hands and speech will help drive the same pathways to decreased freezing when waking!
Quick strategies to overcome freezing of gait.
One of the most important things to remember is to NOT push through the bout of freezing. This will likely increase the freezing and as mentioned earlier can lead to falls. A helpful acronym to remember when a bout of freezing occurs are the 4 S’s
4 S’s
Stop – Don’t push through the bout of freezing
Stand tall – Once you have stopped freezing, stand tall with good posture
Shift weight – Perform a big weight shift from one leg to the other
Step big – Now take a BIG step and begin walking
Other ideas to try:
Imagine a line in front of you to step over to initiate walking once you have stopped
Count your steps as you are turning
If going through a doorway in your home, predict the number of steps it will take you to get through. Count and complete that number of steps
Turn by walking in a circle instead of pivoting
Sing or hum a song and step to the rhythm
Use a laser or the end of your cane as an object to step to or over
How can loved ones help?
Remain calm and do not push the individual to keep walking
Remind loved ones of the 4 S’s
If the individual can’t initiate movement, try placing a foot in front of the person as a physical object to step to or over to initiate walking
If the individual still can’t initiate movement, loved one’s can assist with weight shifting or encourage them to march or count
If freezing is occurring in or outside of the home, notify your physician and start Physical Therapy!
Sources:
Giladi N, Treves TA, Simon ES, Shabtai H, Orlov Y, Kandinov B, Paleacu D, Korczyn AD. Freezing of gait in patients with advanced Parkinson's disease. J Neural Transm (Vienna). 2001;108(1):53-61. doi: 10.1007/s007020170096. PMID: 11261746.
Giladi N. Medical treatment of freezing of gait. Mov Disord. 2008;23 Suppl 2:S482-8. doi: 10.1002/mds.21914. Erratum in: Mov Disord. 2008 Aug 15;23(11):1639-40. PMID: 18668620.
Morris ME, Iansek R, Galna B. Gait festination and freezing in Parkinson's disease: pathogenesis and rehabilitation. Mov Disord. 2008;23 Suppl 2:S451-60. doi: 10.1002/mds.21974. Erratum in: Mov Disord. 2008 Aug 15;23(11):1639-40. PMID: 18668618.
Witt K, Kalbe E, Erasmi R, Ebersbach G. Nichtmedikamentöse Therapieverfahren beim Morbus Parkinson [Nonpharmacological treatment procedures for Parkinson's disease]. Nervenarzt. 2017 Apr;88(4):383-390. German. doi: 10.1007/s00115-017-0298-y. PMID: 28251243.