When the legs freeze – the motor symptom “Freezing of Gait”

If you are a person affected by it, you may already know: You walk around your home and want to turn into another room. Suddenly, however, nothing works at all. The steps become smaller and smaller, you finally come to a complete standstill and suddenly can’t move even an inch forward. Some patients also describe that although they are still able to take small steps in place, they still cannot move from the spot. A feeling of being frozen occurs. This state can last for different lengths of time – from a few minutes up to half an hour or even longer.

Most often, this symptom occurs when affected persons start walking (like a kind of start inhibition at the gait initiation), make turns, pass through narrow passages like doors, carry out dual tasks (like talking while walking), or try to reach a specific destination. In the literature, this symptom is called “Freezing of Gait (FOG)” and, along with postural instability, is one of the most noticeable signs of Parkinson’s disease.

Management of FOG through attention training and other exercises

Patients, therapists, and studies include and describe various exercises and methods to influence freezing of gait. These include directing your attention to your walking. Even if the symptom is not yet noticeable, you should consciously draw attention to your own steps. This can delay, or ideally even prevent, FOG.

If FOG has already set in, there are also measures and options to counteract freezing at the moment of immobility. There are also exercises that, if done regularly, can gradually reduce the frequency of freezing attacks.

Attention during walking

It all starts with introspection – perhaps the critical locations in the house are already known, or there are familiar paths where FOG tends to occur? Many patients also report certain times of day when FOG is more likely to occur, or they have been able to identify a correlation with their medication regimen. All of these things – once they are known – can improve FOG management and better prepare you for FOG each time.

If you feel that you are about to experience a freezing episode and may have difficulty walking, try to take larger and more rhythmic steps and try to lift your knees higher than normal. Especially when turning in a different direction, make sure that the steps are executed very specifically. By attentively and consciously setting each step, FOG can thus be reduced.

Regular gait training

Patients with Parkinson’s disease report – and there is also strong evidence in the literature – that gait training can positively influence FOG. We would like to present some of these suggestions and show you how you can use them to design your training and to improve your gait pattern.

Define a specific walking distance and try walking it in different ways:

Variant 1: Take large steps forward and then backward.

Variant 2: When walking, make sure the track is evenly spaced.

Variant 3: Walk and raise knees high with each step.

Variant 4: Take large sideways steps in both directions.

You can increase the influence of the exercises by also ensuring your arms move evenly while walking; that is, the arms swing back and forth in opposite directions – similar to two pendulums.

Tips for gait training

• During gait training, make sure to be in a safe environment. Before you start, make sure everything is out of the way so there is no risk of falling or injury.
• Don’t strain yourself. First, choose a distance that you can easily manage that won’t leave you out of breath. With time and practice, you can gradually increase the walking distance. If necessary, you can also use aids such as walking sticks for your own safety.
• If you have little space in your home, remember that you can also walk in circles while performing the exercises. In any case, the gait/walk should remain rhythmic and smooth.
• Don’t be afraid to ask your therapist for support as well. He or she can work with you to develop a personalized gait training program that is completely tailored to your individual needs.

“Cueing”- giving a clear impulse

“Cueing” refers to an impulse that helps to stay in gait rhythm or to break free from the feeling of being “frozen in place.” This stimulus can be not only auditory or visual, but also tactile. It can be set either by yourself or with the use of various tools.

Auditory cueing

Set an impulse in the above exercises by…

… counting along loudly and rhythmically.

… singing a rhythmic song.

Make use of various tools for auditory cueing. You can put on headphones and have the song or rhythm played to you. Try different versions and methods and find out whether it is more effective for you to count by yourself or to use headphones to help you. Some patients even manage to free themselves from the immobility that has already set in by counting out loud.

Visual cueing

In addition to acoustic stimuli, there is also visual cueing, in which a visual stimulus is given. In practice, it looks like this:

Variant 1: Select and define distances on your walking route that you want to reach.

Variant 2: Depending on the possibility, lines can be marked on the floor with the help of adhesive tape, across which you want to step each time.

Variant 3: Another option is special adaptations you can put on your walking sticks that project a laser strip in front of your feet on the floor, across which you want to step. It is best to ask your therapist, who can help you obtain one.

Tactile cueing

Tactile cueing involves a touch stimulus in the form of a light rhythmic tap on the thighs while walking – this can positively influence the flow of movement. There are also devices that can be attached to the legs that prompt walking via a vibration pulse.

Treadmill training

Treadmill training also has several benefits for patients with Parkinson’s disease. You are independent of wind and weather and can therefore train regularly. While swinging your arms during walking is recommended, the handrails allow you to practice in a safe way, as you can hold on to them at any time. There is a wide range of treadmill models for home use. However, those who don’t want to invest in a home treadmill, can alternatively use one as part of a gym subscription or exercise therapy. Research has shown that regular treadmill training can counteract freezing. This type of exercise seems to have a positive effect after just a few weeks. But here, too, you should first seek advice from an expert: The treating therapist will be happy to explain the correct operation and appropriate settings of the device to you.

A diagnosis of Parkinson’s disease and the symptoms that accompany it can often severely limit patients’ lives. However, proper exercises and a regular exercise routine can help regain confidence and self-determination in everyday life, thus improving quality of life.

Literature:

DGNR – Deutsche Gesellschaft für Neurorehabilitation e.V. (n.d.). 2017, from http://www.dgnr.de/ 

Ginis, P., Nackaerts, E., Nieuwboer, A., & Heremans, E. (2018). Cueing for people with Parkinson’s disease with freezing of gait: A narrative review of the state-of-theart and novel perspectives. Annals of Physical and Rehabilitation Medicine, 61(6), 407–413.

Gómez-González, J., Martín-Cashttps://doi.org/10.1016/j.rehab.2017.08.002as, P., & Cano-de-la-Cuerda, R. (2019). Effects of auditory cues on gait initiation and turning in patients with Parkinson’s disease. Neurología (English Edition), 34(6), 396–407.

Nieuwboer, A., Kwakkel, G., Rochester, L., Jones, D., van Wegen, E., Willems, A. M., Chavret, F., Hetherington, V., Baker, K., & 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.