Dan Keller 0:08
Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research—the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow.
Problems with walking, known as gait disturbances, are common in Parkinson's disease. Slowness of movement, shuffling, and inability to turn and stiffness are some of the common disturbances. One problem that is especially troubling is freezing of gait, where a person with Parkinson's feels that their feet are stuck to the floor and is therefore unable to move. Fortunately, there are ways to help alleviate this problem, from medication adjustment to rehabilitation to some devices that can help facilitate movement. In this episode, I spoke with Dr. Jay Nutt of the Oregon Health and Science University in Portland when we both were at a Parkinson's and movement disorders conference in Hong Kong. He described the problem of freezing of gait, offers remedies, and shares what may be coming along. I guess, first of all, what is it? How does it manifest?
Dr. Jay Nutt 1:42
Well, freezing of gait is an inability to begin to walk and sometimes to continue walking. And the person who has this often feels as though their feet are frozen or glued to the floor. And the episodes can be very brief, a couple seconds. For some patients, they can last longer. They tend to occur with starting to walk, as somebody, for example, stands up from a chair and is unable to begin to walk. It often happens when people turn that they get stuck and can't complete a turn. And very typically, it happens as people pass through doorways. The worst situation are patients who are waiting for an elevator and the elevator door opens and they can't move forward to get on the elevator.
Dan Keller 2:32
Does everyone have freezing of gait, or when does it occur in the course of the disease?
Dr. Jay Nutt 2:38
First off, we should go back and sort of say freezing of gait is very typical of Parkinson's disease. But it's not just Parkinson's disease. There are some of the Parkinson's-plus syndromes, such as progressive supranuclear palsy or multiple system atrophy, that also have freezing. And occasionally there are people who have many small strokes in the brain that can develop freezing, or normal pressure hydrocephalus can sometimes be associated with freezing of gait. But it's most typical for just the run-of-the-mill Parkinson's disease. It does not occur early in the disease. For the common forms of Parkinson's disease, it may occur early with progressive supranuclear palsy, so it's generally five to 10 years after people have had Parkinson's disease that they may develop it.
Dan Keller 3:30
Can it be dangerous? Does it occur in situations where you really ought to be able to move? And does it have a relationship to balance problems?
Dr. Jay Nutt 3:42
Yes, it does, and yes, it can be a real problem. So if you have trouble moving around like that, and you have these freezing episodes, it may be hard to do your activities of daily living around the house. Particularly, it is a problem if you try to leave the home and go places, and people are often afraid to go in the public because that often will really bring out the problems with freezing. Freezing often causes falls. People will fall forward on their knees and hands, and they break wrists. But they also fall with other things, such as turning, and then they can fall on their hip, break hips, and so forth. So yes, freezing of gait is a serious problem.
Dan Keller 4:29
What can be done about it?
Dr. Jay Nutt 4:32
Well, there are several things that can happen. First off, freezing of gait most commonly occurs when the levodopa is not working. So this is at the end of a dose cycle. And if that is what is happening, then you can try to adjust the levodopa to have fewer "off" periods—that is when the medicine is not working during the day. Deep brain stimulation is generally not helpful for this problem, but the most common thing that we use is physical therapy. And physical therapy works with methods of trying to help people start stepping. I saw a patient this week who uses a metronome that clicks every approximately second, a second and a half, and this really helps her with stepping when she is walking. Other tricks that will help is sometimes putting masking tape on the floor at places that are a problem with freezing, and the person can use the masking tape as a target to step on or to step over to start walking. To navigate in crowded places like the kitchen or the bathroom, using a walker oftentimes is really helpful, as it seems to somehow free up the person to walk better.
Dan Keller 5:50
I've even heard of walkers with a little laser pointer on them that puts a spot on the floor.
Dr. Jay Nutt 5:56
That's exactly right. That's like the masking tape. So the walker has a laser beam generally, and you can train the person to either step on the beam or to step over the beam to help with walking.
Dan Keller 6:10
What about exercise? Is regular exercise a help?
Dr. Jay Nutt 6:15
Regular exercise, by the time freezing is developed, is probably not particularly helpful. We think that exercising and working on agility before freezing appears may delay the appearance of freezing.
Dan Keller 6:33
What about other movement kind of things, like dance or boxing? Do they fall in the same category as the exercise?
Dr. Jay Nutt 6:39
I think they do. I mean, they help with agility and hopefully will help with preventing freezing from appearing. Now, you might ask, "What about the future?" And there are a number of things that are being considered. There are other targets that are being tried for deep brain stimulation; for example, stimulating in the brainstem, in a nucleus called the pedunculopontine nucleus, has been proposed as a treatment. And this has been tried in a few centers in the world, but the results are inconclusive at this point whether that helps. Another type of stimulation has been actually stimulating the spinal cord, and this is stimulating as is done sometimes to treat chronic pain. So patients will be stimulated on the back of the dorsal part of the spinal cord, or the back part of the spinal cord. And this, in some people's experience, has been helpful for treating freezing of gait. I think there will be other techniques that will develop. It may be that working out a method of feedback so that you can detect when freezing is about to begin and give some sort of stimulation, such as a metronome or perhaps vibration to a limb, will help with freezing. There have been some shoes recently that have been developed that have laser beams in them that seem to help with some patients in reducing freezing. So I think there are a lot of different strategies that are being experimented with, and I think our therapy will be better within the next few years managing this very difficult syndrome.
Dan Keller 8:24
Considering there's work looking at vibratory stimulus, and as you mentioned, stimulating the spinal cord in the dorsal area, does that imply that there's some sort of sensory deficit here, that you can apply some modalities to that? That there's a feedback and sensation that causes the problem at all?
Dr. Jay Nutt 8:49
I'm not sure I'd say that, but part of what happens with sensory stimuli—because they certainly will both precipitate freezing. That is, something laying on the floor may cause freezing, opening the door or passing through a door; it's a visual stimulus that causes freezing. At the same time, sensory stimuli will also help with freezing—the tape on the floor to step over and the metronome. So sensory stimuli can both precipitate freezing, and if used in the right way, can help with freezing. Stimulating the spinal cord may be sending information back up sensory tracks to the brain and somehow alerts the brain or stops abnormal oscillations in the brain. And we're particularly worried about what are called beta frequency oscillations in the brain cause freezing, and so we don't know for sure, but these are things that are being explored currently.
Dan Keller 9:52
If visual stimuli can precipitate this sort of thing, what about hallucinations? Do they also count as visual stimuli?
Dr. Jay Nutt 10:02
They do, but I'm not sure that hallucinations and freezing are really put together. They're both problems, but I don't know that they're related.
Dan Keller 10:15
If people can use some of these techniques to overcome freezing—stepping over a piece of masking tape on the floor, or a laser beam, or things like that—it implies or says that the body still can walk. So it seems that some part of the brain is taking over for the lower areas. I've heard that the frontal lobes, the thinking part of the brain, compensates. How does that figure into dual tasks, if you get distracted or you have a mental thing to do at the same time? Is that a problem for freezing?
Dr. Jay Nutt 10:49
Okay, very good observation, Dan. So what happens with freezing is automatic walking seems to be blocked. And generally, when we walk, we don't think about walking. We just think about we're going to go from point A to point B. What happens with freezing is that mechanism is somehow disrupted, and then walking becomes very directed and is controlled by the higher centers in the brain where it's voluntary. So, for example, patients may not be able to step, but they may be able to pretend to kick something, and some people will try and kick their cane, or they will try and step over the handle of the cane. So it's taking movements from automatic to very voluntary stepping.
Dan Keller 11:41
Are there certain questions that someone could ask their neurologist if they're having these problems, or how do they express it?
Dr. Jay Nutt 11:50
I think that neurologists will be tuned in to freezing and the problems with freezing, and so if the patient says that they have trouble starting to walk sometimes, or they have trouble passing through doorways, turning—and particularly turning is where freezing comes out—that the neurologist will pick up on that. Hopefully they will look at their medication dosing and see whether that's the problem, and they will generally refer them to physical therapy that will work with the person on developing strategies to overcome freezing.
Dan Keller 12:28
Very good. I appreciate it. Thanks. For more information on gait disturbances, including freezing of gait, visit our PD library at parkinson.org/library and search "falls and freezing." You'll find fact sheets, webinars, and podcast episodes addressing the problem and exercise and physical therapy, in addition to the spinal cord stimulation that Dr. Nutt mentioned. You can also find an expert briefing on gait, balance, and falls by Dr. Fay Horak on parkinson.org/eb, as well as our podcast episode 18 in this series featuring Dr. Soterios A. Parashos titled "Stall the Fall."
As always, our PD Information Specialists can answer questions and provide information in English or Spanish about this topic or anything else having to do with Parkinson's. You can reach them at 1-800-4PD-INFO. For questions about the topics discussed today, or if you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback. If you have enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts or wherever you get your podcasts. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life. Today, to that end, we'll be bringing you a new episode in this podcast series every other week. Until then, for more information and resources, visit parkinson.org or call our toll-free helpline at 1-800-4PD-INFO, that's 1-800-473-4636. Thank you for listening.
