This was November’s Journal Club article. Seeing as how November is effectively over in a few short, I figured I had better hurry up and share it with ya’ll!
First of all, a definition of freezing of gait (FoG) was in order: a “‘brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk.'” So this is where the steps get short and shuffling. Which makes me think of this song EVERYTIME: *EVERYDAY I’M SHUFFLIN’!*
You will never be able to see FoG and not break out in song and dance every again. *BWAHAHA*
*cough* Yes, so anyway, back to FoG…
There are 3 ways to determine if someone has FoG including: observation, self-report or EMG of muscular trembling all related to activities that usually elicit FoG including: turning in place, short/rapid steps, negotiating narrow areas or in perceived floor depth changes such as color changes or thresholds. Levadopa and deep brain stimulation do not adequately address FoG (although I will say that a change in meds and a charge of the deep brain stimulator has worked WONDERS on FoG for my patients before, it is never completely eliminated by either in my observations). Currently we use compensatory strategies– visual and verbal cues– to get those feet moving. But one must have the prerequisite cognitive capacities to recall those strategies and utilize them. Enter: Parkinsonian dementia and all those compensatory strategies go out the window.
But is there a restorative method? That’s what this article is interested in and why I am so excited to share it with you!
First they discussed the bits of cognition that are required to successfully maneuver oneself on foot in the community and the theories which encompass them. I’ve always found theory rather boring, so I’ll leave a visual representation of them and if you’re dying to know more, please read the article. Actually, just read it anyway.
So the main bits that are problematic and thus where we need to focus our treatment include: inhibition (“deliberately inhibiting dominant, automatic, or proponent responses when appropriate”), executive control (“resolving conﬂict among responses”), shifting (“shifting back and forth between multiple tasks”), selective attention (“ability to intentionally focus attention on one source of information while excluding irrelevant information”), switching attention (“alternation of the focus of attention between 2 different tasks or sources of information”), and divided attention (“ability to complete 2 different attention-demanding tasks at the same time”). All of that in addition to visuospatial function. Those definitions are all fine and dandy, but what does that look like in the clinic?
First you have to able to test all these things, so you know where your patient’s difficulty lies. There is a huge table of tests and descriptions that pretty much takes up an entire page in the article. Never fear, I have got some resource links ready!
Some of those you can use as outcome measures too, because they use time or another quantifiable way to measure progress.
With the Stimulus-Response Compatibility Test, you’ll just need to make a set of arrow cards in Word. I did it and that’s not hard.
Here’s an example of a Matrix Reasoning Test. You’ll need to purchase these.
Ditto, Block Design Task.
Same goes for Judgement of Line Orientation Task
For the Rey-Osterrieth Complex Figure Task my understanding is that you can use any complex, non-sense figure to memorize and re-draw. However, here’s an example of a “complex figure.”
The Dual Task Test is easy. Can the person walk and talk or count backwards by 5s from 93 or name animals that start with the letter “B” at the same time?
The Clock Drawing Test is simple too. You’ll just need a 4″ circle on which to draw the time at 10 minutes past 11 o’clock.
I could not find anything on the Switching Task nor the Macworth’s Sustained Attention Task. It looked like you need some computer software to do either of those, so not free or easy to make. *womp, womp*
Now for the fun part: treatment.
For attentional deficits, you can throw in secondary cognitive tasks in addition to the exercises to get at dual tasking. For switching attention, you can make a real life Trail Making Test and have the patient walk between the letters and numbers. Boxing (with verbal and visual cues) and obstacle course are good in here too. There’s also an app for this! It’s called Clock Yourself. It’s a dual task + exercise app for all ages created by our very own Aussie physio, Meggen Lowry. The app really is good stuff and cheap enough that you could ask your patients to download it for an HEP.
For inhibition the boxing comes into play again which conflicting verbal and visual cues. Lunges are also recommended in a similar manner. A real life Stroop Test is also mentioned– have printed color words in a different color and with cues have the patient step onto the cued either written color word or actual color.
For visuospatial deficits, practicing those trigger areas, like thresholds, doorways, narrow spaces, changes in color/pattern on floor can go well. Practicing in virtual reality may be beneficial as well.
All right! Go out there, get creative and let’s try some restorative methods on freezing of gait!