How can walking and freezing be improved in Parkinson's disease?

Why does Parkinson's change the way people walk?

Parkinson's disease reduces dopamine in the part of the brain that helps movements run automatically and at the right size. As a result, steps become smaller and slower, arm swing reduces, the posture bends forward and turning takes several small steps. Some people start to hurry with short, shuffling steps, called festination, as if chasing their centre of gravity.

Walking also becomes less automatic, so it needs more attention. Talking, carrying something or thinking about a problem while walking can make steps shorter and increase the risk of freezing or falling.

What is freezing of gait?

Freezing is a brief, sudden inability to move the feet forward despite trying. It often happens when starting to walk, turning, approaching a doorway or a narrow space, in a crowded place, or when rushed or anxious. It usually lasts a few seconds but can lead to falls because the upper body continues forward.

Freezing can be related to medication wearing off, when it tends to improve with a dose adjustment, or it can occur even when other symptoms are well controlled. Keeping a diary of when freezing happens in relation to doses helps the neurologist decide whether medication changes may help.

Which physiotherapy strategies help?

UK guidance recommends referral to a physiotherapist with experience of Parkinson's for people with balance or motor problems 1. Physiotherapy approaches include cueing, large-amplitude movement training, treadmill and walking practice, strength and balance exercise and training in how to turn and get up from the floor. A Cochrane review found benefits across a range of techniques, but not enough evidence to say one is better than another 2.

Cues give the brain an external signal that bypasses the faulty automatic system. Visual cues include stepping over lines or tape on the floor or a laser line projected by a walking aid. Auditory cues include walking to a metronome or music with a steady beat. Attention cues include thinking 'big step' before moving. Many people find one type works better for them than others.

How can you get moving again during a freeze?

Stop trying to push forward, stand up tall and shift weight from one foot to the other before stepping. Then take a deliberate large first step, possibly over an imagined line or to a counted rhythm. Turning in a wide arc rather than pivoting on the spot reduces freezing during turns.

Carers can help by giving a calm verbal cue, placing a foot in front as a target to step over, or counting a rhythm. Pulling the person forward usually makes things worse and increases the risk of a fall.

What changes at home reduce freezing and falls?

Removing clutter, rugs and narrow gaps between furniture reduces common triggers. Strips of contrasting tape on the floor at doorways and in the kitchen can act as permanent visual cues. Good lighting, grab rails in the bathroom and a chair with arms to push up from all make daily movement safer.

Falls are a major concern in Parkinson's, and fall prevention guidance recommends individual assessment of risk factors such as balance, medication, low blood pressure on standing, vision and home hazards 3. Standing up slowly and sitting for a moment on the edge of the bed helps if blood pressure drops on standing.

When should the treatment plan be reviewed?

A review is worth requesting when walking changes noticeably over weeks, freezing becomes more frequent, falls start or increase, or medication seems to wear off before the next dose. Involuntary writhing movements, called dyskinesia, can also affect balance and may mean doses need adjusting.

Physiotherapy is most useful when it is repeated as needs change rather than offered once. Occupational therapy can add strategies for dressing, turning in bed and moving around the kitchen, and speech and language therapy helps when voice or swallowing changes. Coordinating these with the neurologist keeps medication and rehabilitation working together 1.

Does exercise slow Parkinson's disease?

Exercise has not been proven to slow the underlying disease, but regular activity improves fitness, strength, balance, walking speed and confidence, and many people report better mood and sleep. Exercise sessions are often most productive when medication is working well.

A mix of aerobic exercise, strengthening, balance training and practice of daily movements is typical. Programmes should progress gradually and be reviewed as the condition changes. Group classes designed for people with Parkinson's can help with motivation and social contact.

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