Why do people with Parkinson’s freeze?
Some people are more prone to freezing than others. It tends to occur with increased frequency as Parkinson’s progresses and appears to be linked to long-term use of levodopa. It can be experienced by people who do not take levodopa, so it is not simply a side effect of medication.
Whatever the cause, not everyone with Parkinson’s will experience freezing and it is impossible to accurately predict those who will. Freezing seems to be more prevalent in those whose initial symptoms included gait problems, and less prevalent in people who initially present with tremor.
The exact cause of freezing is unclear, but it is thought to occur when there is an interruption to a familiar or automatic sequence of movements. During walking, freezing is mainly observed when:
- you are walking towards doorways, chairs or around obstacles
- you are turning or changing direction, especially in a small space
- you are distracted by another task when you are walking
- you are in places that are crowded, cluttered or have highly patterned flooring
- the ‘flow’ of your walking is interrupted by an object, by someone talking, or if you begin to concentrate on something else. All of these will stop you from being able to keep a rhythm going
- your medication isn’t working very well
- you’re in a group situation or in conversation.
Usually the length our steps changes when we walk from smooth to uneven ground, or from open to narrow spaces. But people with Parkinson’s won’t always react in the same way to these things. For some people with Parkinson’s, changes in stride length and speed are not made automatically as they are in other people. You may be able to walk without a problem on uneven surfaces, but may freeze when the floor is smoother or has a patterned surface. Or, the opposite might happen. You may find your walking pattern gets out of control and your steps get smaller and smaller or you speed up as you walk.
Is freezing related to the intake of dopaminergic medication?
Some people with Parkinson’s have ‘on’ and ‘off’ periods, when they switch from being able to move when their medication level is higher (on) to being unable to move without difficulty when their medication level is low (off). Many people notice that freezing is worse when their medication level is low, when they are ‘off’. But freezing is not the same as being ‘on’ or ‘off’.
Treatment and management
There are a lot of things you can do to help yourself but there are also experienced professionals who can support you.
The most important factor in treating freezing is to establish whether or not it responds to standard Parkinson’s medications. Freezing that occurs during ‘off ’ periods, when medication is not working well, often responds well to adjustments in the timing and dosage of medications. Always discuss any changes to medication with your doctor, or Parkinson’s nurse if you have one.
Freezing that is not related to ‘off’ periods and occurs during ‘on’ periods does not generally respond well to standard Parkinson’s medications or adjustments to their timing or dosage. For some people reducing the amount they take of a dopamine medication may make freezing less likely during ‘on’ periods but this can also make ‘wearing off’ symptoms worse.
Research carried out on the medication selegeline (Eldepry® and Zelapar® ) provided indirect evidence that people who take it may be less likely to develop freezing problems, but there is no direct strong evidence that selegeline is an effective treatment.
An occupational therapist will be able to help you maintain as much independence as possible in your everyday life. He or she will be able to assess your home and daily routine then to recommend ways of adapting your home to avoid episodes of freezing, or overcome them if they occur. For example, moving furniture may widen narrow spaces that trigger freezing, or lines on the floor to step over in doorways may be helpful. They can also advise on techniques to reduce anxiety which can trigger freezing episodes, and on the most suitable footwear for you.
See also: Occupational Therapy.
A physiotherapist can teach techniques to avoid freezing and will recommend strategies to deal with it if it does occur. They can also advise on the most suitable footwear to minimise freezing and on walking aids – some are not recommended for people with Parkinson’s and can increase the likelihood of freezing.
Parkinson’s can affect your posture and balance so a physiotherapist will suggest techniques and exercises to improve these so there is less chance of falling forward if you freeze. They will help you learn how to do two things at once whilst remaining focussed on walking so you are less likely to freeze. This is particularly important in unfamiliar or crowded places where your mind needs to stay in control of your movements.
See also: Physiotherapy and Falls.
It is important for anyone with Parkinson’s to maintain sufficient exercise levels. A physiotherapist can advice you on a suitable form of exercise.
If other interventions do not help, deep brain stimulation (DBS) can be effective in treating freezing episodes in some, but not all, people with Parkinson’s.
How can I help myself?
Freezing in public places can be upsetting, embarrassing and even frightening. You may feel tempted to avoid situations that are more likely to make you freeze – crowded rooms, narrow entrances etc – but this may not always be practical. Social activities are important to quality of life and overall wellbeing so it is important to find out what strategies work best for you to prevent or overcome freezing. This will mean that you can continue to do things you enjoy.
The first thing to remember if you think you are about to freeze is to stop moving so that you have time to think about your balance. Stay calm and don’t rush. You can then think about your next movement and plan how to carry it out before you actually move. Following these simple steps will allow you to put in place the strategies you have learned to overcome freezing and will reduce the risk of falling.
If you experience frequent freezing your doctor may suggest that you keep a medication or ‘wearing off’ diary to help establish what might be causing these episodes. By keeping a diary you can record the timing, duration and frequency of freezing episodes, as well as the timing and dosage of each medication, which can help your doctor in adjusting medication to try to overcome freezing problems. For a sample diary and information on keeping one, see Keeping a diary.
If you find that you freeze in busy places such as shops or public places you may find the following strategy helpful:
- Pause - stop safely to one side for a moment. Stay calm
- Look - looking ahead for obstacles such as people or trolleys, and observing quieter routes, will make your journey much easier and will therefore reduce the likelihood of freezing
- Plan - plan the next part of your route section by section to your destination
- Proceed – only move off once you have completed all these steps.
Remember that freezing can happen at any time so it is important to take great care when out near roads or when swimming, for example. If you are prone to freezing make sure you have someone with you at such times.
The risk of freezing is also increased by anxiety. If you do freeze and fall you may become even more anxious so it becomes a vicious circle. It is therefore important to try to find or develop strategies to help you overcome freezing as you will then feel more confident in dealing with it and feel calmer when it occurs.
Strategies or tricks that help with freezing are very individual and what works for one person may not work for another. You will therefore need to try different approaches but once you find something that works, use it to restart your walking or even to avoid freezing in the first place. Remember that something that works now may become less effective over time, or visa versa. These tricks will not make freezing disappear but you will feel more confident in your ability to control it.
The cues below can be used to help you to concentrate so that it is easier to keep your feet moving at a steady, even pace. Such cues give information about the length and number of steps you take and use a part of the brain which is not affected by Parkinson’s. A physiotherapist or occupational therapist will be able to advise on appropriate cues for your situation. The video clips may help you discover and develop new strategies of your own.
- Lines on the ground or on the edges of steps will prompt you to step over and reduce the risk of freezing, for example when approaching a doorway. - see our video - Coping Strategies: overcoming freezing when approaching a doorway.
- A line or several lines of tape across a threshold can help you to focus and step through a doorway. Any sticky tape can be used provided that it is in a contrasting colour to the floor. The tape may get worn and scuffed so will need to be replaced from time to time.
- A physiotherapist will be able to advise on the best space between lines but generally strips of approximately 40 to 60 cm length should be stuck approximately 35 to 50 cm apart through a doorway if the flooring pattern is the same on both sides. If the pattern is different on both sides then a single strip across the join should suffice. On a bend or corner, similar length strips should radiate out in a fan shape. It is not important whether you step on or off the tape.
- Some patterned carpets, and the cracks between tiles or paving stones, can act as cues and help to focus attention on the quality of your walking and keep the step size regular. But look out for any rugs or mats which seem to cause you to freeze, such as patterned bathmats, and move them out of your normal path to see if this helps.
- You may find it useful to use a small torch or laser pointer to project onto the floor ahead. This acts as a visual cue to walk to meet the pool of light on the floor.
- Try looking through a doorway or focussing on a point beyond, rather than looking directly at the doorway itself.
- If you freeze and someone is with you they can help by putting their foot in front of yours for you to carefully step over (make sure you raise your foot as you do so to avoid tripping) and start walking again - see our video - Coping Strategies: stepping to overcome freezing.
Rhythmical or auditory cues
- A steady beat from a metronome or suitable music can help. The rhythm should be a comfortable pace, the beat prompting you to lift your feet and step.
- Decide which foot you want to step forward with then try saying, either silently or aloud, a phrase such as ‘one, two, three, step’, ‘one, two, one, two’, or ‘left, right, left, right’, or keep counting up to 10. If said in a firm, rhythmical tone this can cue the feet to walk forwards. This can be particularly helpful when approaching a spot where you often freeze. The rhythm, if started early, may prevent freezing, or it may prevent the shorter, more shuffling pace that often occurs just before a freezing episode.
- Develop a trigger word such as ‘go’, ‘step’ or ‘march’ to re-start your walking.
- Try closing your eyes to take the first step, making sure it is safe to do so, then open your eyes to continue walking.
- Hum a tune or download music with a good beat onto an MP3 player to keep your walking pattern going. Remember though that you should not use your MP3 in busy places where you should listen for traffic.
- The cue timing can be varied according to where you are, for example you will probably walk faster when outside, and slower in your home. See our video - Coping Strategies: overcoming freezing by counting 1 and our video - Overcoming freezing by counting 2.
- A physiotherapist or occupational therapist may be able to advise on mini metronomes or similar devices that can be clipped onto clothing so can be taken with you anywhere.
Attentional strategies – use your imagination
- Try rehearsing certain movements in your mind and focus on the sequence. For example, concentrate on putting your heel down firmly on the ground as your foot makes contact to help step evenly, or imagine a line to step over to help you negotiate narrow entrances. Attentional strategies require concentration though which can be difficult if there are external distractions. They work because thinking about moving and rehearsing a sequence uses the same part of the brain as when you actually move. See our video - Coping Strategies: managing small steps (Festination) or imagining a line to step over might help you to negotiate narrow entrances.
The weight shift method
- When you freeze, gently shift your weight onto the other leg, rather than trying to move forward. This will allow you to move forward on your other leg. Gently rocking your head and shoulders from side to side may help you achieve this shift in weight.
- It may help to step or stamp your feet from side to side, especially if freezing when opening doors is a problem for you. This might help you maintain a stepping movement until the door is open and passable.
- ‘Start hesitation’, or difficulty in starting an action, may be overcome by imagining or replaying in your mind the detailed sequences of an action, making sure that you complete the sequence in your mind. Only when you have done this without problem should you try to start the movement, perhaps counting ‘three, two, one’ before you follow the actions you have run through in your mind. This technique is sometimes known as mental rehearsal and is often used by musicians or athletes to improve their performance. It works because the imagined sequences use the same part of the brain as the actual movements, so the ‘rehearsal’ prepares the brain for the ‘performance’.
For more information on various cueing strategies see Coping Strategies - Tips & Tricks.
Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information: