In a recent webinar, Maria Allen led the way in unpacking the challenges faced by those experiencing Freezing of Gait (FOG).
Maria Allen is a physical therapist and a leading expert on Parkinson’s Disease. She is also LSVT BIG certified, PWR certified, and acts as an instructor for many of these courses.
In this presentation, Maria uncovered what causes freezing, the different types of freezing symptoms, why this affects people with Parkinson’s, and how cueing technology could help people with Parkinson’s overcome freezing episodes.
Take a look below at some of the key pieces of information to come out of the webinar.
What is Freezing of Gait (FoG)?
Freezing is the temporary, involuntary inability to move. We think mostly of freezing in relation to gait or walking, but it can also happen with speech and arm movement. Freezing in Parkinson's disease is not only Freezing of Gait (also known as Parkinsonian gait). It can affect other parts of function as well. It's a prevalent symptom in people with Parkinson's disease. Up to 70% of people with Parkinson's disease regularly fall, which is one of the problems related to freezing and freezing episodes. This sudden and brief episode of inability to produce effective forward stepping is freezing of gait.
Why is this a problem for people with Parkinson's disease?
Freezing episodes can be very unpredictable. They are major risk factors for falls, which leads to hospitalizations. This also leads to many comorbidities, problems, and a decline in health and function, and it's a major source of disability. It affects independence and quality of life for people with Parkinson's disease. If you have freezing episodes, it makes it much harder to go out in public and participate in some of those normal daily activities of living.
What might be the experience of FoG for people with Parkinson’s?
There are different ways to talk about freezing. As with everything else with Parkinson's disease, everybody with Parkinson's disease has a different presentation, a different set of symptoms, and different problems. The saying, ‘if you've met one person with Parkinson's disease, you've met one person with Parkinson's disease’ is accurate. It's more of a combination of symptoms, but everybody's freezing is a little bit different.
For some people, that's this alternating trembling leg movements, so your legs just start trembling and get a shaky feeling. For some people, it's just that festination or those tiny steps. For some people, it's an absolute just they can't move. They're stuck, or frozen, feeling like they're glued to the ground. No movement is called akinesia or absence of movement.
What are the triggers of FoG?
Underlying symptoms and triggers that seem to be leading to those freezing episodes may include motor impairments, posture, slow movements, stiffness, rigidity, and the inability to move well. Anxiety can also be a massive trigger for a freezing episode in stressful situations.
Other triggers may be due to attentional impairments, which can be experienced when completing a dual-task. We call this set switching. This is anytime your brain has to do more than one thing at a time. Sustained attention is part of that problem set.
What causes freezing in people with Parkinson’s?
The cause is unclear and very complex. We know there are some motor impairments and cognitive problems. However, there's a whole combination of different things that seem to cause freezing—some of the underlying causes have to do with the basal ganglia system and the lack of dopamine.
Parkinson's disease is a complex, progressive, neurodegenerative disease. It involves the basal ganglia, which sits in your midbrain. What happens is, you lose these dopamine-producing nerve cells. Dopamine acts as a neurotransmitter to help regulate your body's movement. Typically, by the time you are diagnosed with Parkinson’s, about 50% to 60% of those dopamine-producing neurons are already dead. This, usually, is a process that happens five, six, or more years before you start having some symptoms.
Why is dopamine so important?
Dopamine is a chemical and neurotransmitter that plays a role in your brain’s essential functions, not just movement. It also works as part of your reward-based system, some of your memory, and your thinking strategies. It's a vital chemical in your brain and provides a way for your brain cells to communicate.
When you begin to move, the initiation of that movement starts in the outer part of the brain, in the motor cortex. Then it gets processed in the basal ganglia. That's a lot of information that gets processed in the basal ganglia, including actual movement and your sensation of movement, your proprioception of knowing where you are in space and how you're moving. All of that gets processed through the basal ganglia. That's why dopamine and the basal ganglia are so important for movement.
What should I do if I am experiencing a freezing episode, and how can I prevent myself from falling?
My favorite strategy to overcome a freezing episode or when you feel a freeze coming on is just to stop, stand up tall, sigh or take that deep breath, shift that weight side to side, and then start over with that big step. That 5S strategy is what to do if you get frozen.
We're going to stop. You mustn’t try to keep going. That's one of the reasons people fall a lot. Once their feet have stopped and the message from their brain is just not getting in, and they are continuing to try to go, it typically only makes that freeze worse and can often lead to the fall. That's a simple strategy that you can use at any point in time.
My other favorite strategy is a step prediction strategy, which works by preventing freezing. If you start with that nice tall posture, get that head up, and look ahead to where you're going to go, and planning in your head how many steps it's going to take you to get across the room or the next obstacle. The goal would be to say, "Okay. I can do that in 10 steps." That intentional movement focuses on your movement. You're trying to reach that goal in that number of steps. It typically will improve gait, and most people can do that. Most people will get there within a close number. If they say, "I'm going to get there in 10," maybe they get there in 11 or 12, or perhaps it's eight or nine, but people can use that strategy pretty effectively.
What are the ways you can manage or treat FoG?
There's no cure for FoG, and it's one of those symptoms of Parkinson's that we have to figure out how to manage. There are various medication options, as well as different types of therapy options. All physical therapists, occupational therapists, and speech therapists can have things to work with you to help you with your freezing. External cueing devices that have been successfully proven to help reduce and overcome freezing episodes. Internal cueing strategies that can help. As well, there's cognitive training and internal cueing strategy that can help. Some studies have also shown evidence that deep brain stimulation (brain surgery) can help.
What are some other ways FoG can be managed?
Compensatory strategies can be used to manage FoG by modifying the environment. Clearing pathways and reducing clutter makes a big difference. Freezing episodes are much more common in a smaller setting or a cluttered environment, so simply making sure you have space can make a significant difference.
Exercise and fitness are also considered some of the best treatments for people with Parkinson’s. Exercise does need to be both aerobic. This means you should be exercising at a higher level than you think you can exercise and pushing yourself past your we call it a self-selected effort. Being able to get that aerobic exercise helps your brain function better.
How can De Oro’s external cueing device NexStride help?
External cueing devices that use visual targets or laser lines have been proven to help prevent and overcome freezing episodes. The NexStride device has a visual target, which is a green laser line. This laser is fully adjustable and can be mounted on different devices, including a walker, cane, or walking pole, depending on what you need. Additionally, NexStride also has an auditory cue that similarly acts as an external cue. The metronome helps you keep moving in time to a certain beat per minute.
Studies of NexStride show that when these cues are used together, there is a 69% reduction in the time you're frozen. There is also a 43% reduction of total freezing episodes and a 40% reduction in falls. This can be a great tool to assist you in preventing and overcoming FoG.