Elsevier

The Lancet Neurology

Volume 14, Issue 7, July 2015, Pages 768-778
The Lancet Neurology

Personal View
Freezing of gait: a practical approach to management

https://doi.org/10.1016/S1474-4422(15)00041-1Get rights and content

Summary

Freezing of gait is a common and disabling symptom in patients with parkinsonism, characterised by sudden and brief episodes of inability to produce effective forward stepping. These episodes typically occur during gait initiation or turning. Treatment is important because freezing of gait is a major risk factor for falls in parkinsonism, and a source of disability to patients. Various treatment approaches exist, including pharmacological and surgical options, as well as physiotherapy and occupational therapy, but evidence is inconclusive for many approaches, and clear treatment protocols are not available. To address this gap, we review medical and non-medical treatment strategies for freezing of gait and present a practical algorithm for the management of this disorder, based on a combination of evidence, when available, and clinical experience of the authors. Further research is needed to formally establish the merits of our proposed treatment protocol.

Introduction

Freezing of gait is a common and incapacitating symptom that occurs in patients with Parkinson's disease, and even more frequently in patients with most forms of atypical parkinsonism. Additionally, freezing of gait can occur in isolation in patients with primary progressive freezing of gait; this disorder is often a prelude to later development of progressive supranuclear palsy (PSP) or another tauopathy. In Parkinson's disease, freezing of gait is associated with disease severity,1 although it can be seen early in the course of the disease. However, if freezing of gait is (one of) the first presenting signs, atypical forms of parkinsonism should be suspected.2 Freezing is not restricted to gait, and can occur in alternating repetitive movements of the fingers3, 4 and during speech.5 Whether these other motor blocks have the same pathophysiological substrate as freezing of gait is unclear.

Freezing of gait is characterised clinically by sudden, fairly brief episodes of inability to produce effective forward stepping that typically occur during gait initiation or turning while walking.6, 7 These gait blocks greatly interfere with daily life. Importantly, freezing of gait is now recognised as one of the main risk factors for falls (because, during walking, the trunk keeps moving while the feet become stuck).8 This risk is compounded by the fact that freezing of gait often co-occurs with substantial balance problems9 and cognitive (mainly frontal executive) deficits.10

Treatment of freezing of gait is perceived by clinicians as a very challenging task. The need for a treatment protocol with a clear decision algorithm is widely acknowledged, but such a protocol does not exist. In this Personal View, we provide an overview of the medical and non-medical management of freezing of gait, including use of drugs and surgical approaches, non-pharmacological therapies, and treatment of comorbidities. We first discuss the need for careful history taking and clinical assessment to accurately diagnose freezing of gait and to assess its (subjective) severity; we then present an algorithm for the practical management of freezing of gait. All recommended interventions are based on evidence when available (classified according to their level of evidence in table 1). Otherwise, our recommendations reflect practice-based evidence supported by our clinical experience.

Section snippets

History taking and clinical assessment

Several papers provide a detailed description of both history taking and clinical provocation of freezing of gait;47, 48 here, we provide a brief summary. Simply asking the patient whether freezing has occurred is usually insufficient to identify whether or not freezing of gait is present. Instead, we recommend asking whether the patient has ever experienced the characteristic feeling of the feet being glued or pasted to the floor, or being stuck to the floor, as if attracted by an invisible

Treatment of mild freezing of gait

The first step in our treatment algorithm (figure) is to decide whether or not freezing of gait is troublesome to the patient. Troublesome is operationally defined here as interfering with the patient's mobility or quality of life—eg, when freezing of gait is associated with social embarrassment or fear of falling, or actually leads to (near) falls. For some patients, and certainly in early stages of development, freezing of gait can be mild and not interfere with daily function. Importantly,

Treatment of troublesome freezing of gait

For patients with troublesome freezing of gait, management consists of three pillars: medical treatment (drugs and deep-brain stimulation); non-pharmacological therapies; and assessment and treatment of comorbidities.

Treatment of comorbidities

The presence of various comorbid disorders (panel) can negatively affect freezing of gait, and these should be treated when possible. As mentioned before, treatment of cognition with cholinesterase inhibitors rarely has a strong beneficial effect on freezing of gait. In our experience, depression and anxiety are better treatment targets than cognition. Anxiety is common in patients with freezing of gait, both as a trigger for freezing of gait events (eg, in crowded places, or during

Freezing of gait in atypical parkinsonism

Owing to a paucity of well designed clinical trials, the extent to which freezing of gait in patients with atypical parkinsonism improves with dopaminergic medication is unclear. Our experience suggests that a trial of adequately dosed levodopa is justified. High doses of levodopa are often needed to achieve some benefit. Additionally, amantadine could be considered in patients with PSP, because improved scores on freezing of gait questionnaires have been reported after treatment with

Conclusions and future directions

We hope that, pending further evidence, this practical algorithm will support clinicians in their management of freezing of gait in daily clinical practice. However, the level of evidence underlying several steps in our treatment algorithm is limited, and further investigation is needed. Randomised clinical trials are needed that include freezing of gait not just as one of many outcomes, but rather as the primary outcome. These future studies should include patients with dopamine-responsive,

Search strategy and selection criteria

We searched PubMed for relevant articles published in English from database inception to April 1, 2015. Potential papers were identified with the terms “freezing of gait”, “Parkinson's”, “parkinsonism”, and “treatment”. Selected articles were also obtained from the reference lists of papers identified by the PubMed search and from searches of the authors' own files. Relevant studies were classified by level of evidence; studies with the highest level of evidence are reported for each treatment

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