I am a slow walker but I never walk backwards. Those who walk with God ALWAYS reach their destination.”- unknown
When I was in New York not long ago, I got a call from a dear friend to come help because she was ‘stuck.’ She was literally trapped both in the room and in her body, because when we have PD for whatever reason our bodies stop responding to our brain which is yelling….MOVE!
Fortunately, I was able to get into her room but she was stuck in the narrow hallway barely letting me stand next to her. Having many years of practice as a neurologist, I knew how to get her moving. I placed my arm around her arm and I told her now we will count together and move the right leg forward on one, like bicycling when you have momentum of someone else moving body mirrors image and can propel forward. The counting and beat also helps to move.
One of the biggest frustrations for people suffering with PD as disease advances is the inability to keep walking at will- the so call “motor block ” or “freezing phenomena” is the number one cause of falls in PD patients. Freezing which is said to occur in up to 30% of patients with PD. This problem happens suddenly and unexpectedly particularly when walking – it is as if glue has been applied to the body especially feet which get stubbornly stuck to whatever surface its own. Speech, eyes and writing are also affected. Although, this phenomenon is a sign of advanced disease occasionally it can be seen in early stages of PD in those who go untreated; this a excellent reason to start medication early.
So what causes this dreaded phenomenon?
Reason for this is unknown; but some believe that the brain fails to automatically adjust to changes in stride. This is more prevalent in those of us who have non- tremor dominant PD (i.e. more rigidity and gait problems from the onset of disease); those of us with prominent tremors -do not experience this problem as much.
Since the brain can’t react quickly or accommodate for changes in altitude, elevation, and spatial differences like walking on uneven ground, moving from one patterned floor to another, or walking through narrow hallways, or navigating small spaces, the individual has to make conscious decisions as to how to react and change stride in order to navigate; thus causing hesitation rather than automatic response. Freezing then is brought about by interruption of continuous movement. Freezing is worst with stress, and anxiety, walking in crowed places, upon reaching a target and suddenly having to stop, or turning in corners or confined spaces.
How do we treat?
Everyone is different.
The main thing is to first discover whether this pattern of walking or lack thereof is related to an “off” state. Does it occur with other symptoms such as rigidity, slowness, or tremors?
If so, then adjusting medications can help greatly to reduce this problem; especially the addition of such medications as Eldepryl and Zelpar which have been shown in studies to improve freezing. I have had good personal experience in decreasing freezing and other gait problems such as festination, very short labored steps, and over all improved mobility with the use of Azilect another MAO-B inhibitor as well. DBS usually tends to make gait and freezing worst in my own experience. In the literature, however, there is mention of a few cases where freezing improved after stimulation implant. I must caution that this is NOT the norm and that whatever improvement some might have noted I personally believe is due to correction of a patients primarily “off” state via DBS.
Other treatment modalities:
Physical therapy is of the out most importance to instruct patients in safety and teach a few tricks in order to move around home with greater ease.
Physical therapist love the use of blue tape as a visual transition aid on the floor. Parkinson’s patients often have ‘freezing’ episodes and require some visual aid to help them transition from one room to another when crossing doorways. I recommend placing a colored line-such as a piece of blue tape(any color will do), on the floor on the transition points that connect one room to another to allow easy flow and preventing you from getting stuck as you amble from room to room.
No carpets in the living areas. Best to have wood floors or tile with slippery surfaces to decrease friction while ambulating and allow for greater mobility within the home. (wear shoes with slippery soles).
Visual cues are extremely important because they provide feedback to allow you to determine where to place your feet. Types of visual cues include:
- lasers on canes
- U -walkers
- horizontal lines on the floor
- placing an X with tape in a semi-circle in small or tight spaces
- lasers at the tips of shoes (new technology still being tested)
- stepping over the foot of the therapist or care partner to initiate gait.
Auditory cues are just as important- to provide hearing signals to allow patients to step to the rhythm or beat of the music or sound. Some of the preferred music to walk to is marching music, or counting 1,2,3.. which is what I did with my friend along with my visual cues. Other auditory cues can be achieved by the use of a metronome which can be up-loaded for free on a smart phone. In the works there is a ‘movement sensor device’ prototype being developed in Spain. This system is designed to activate acoustic stimuli to allow the patient to walk better when it senses difficulty in motor movements.