Freezing when walking is observed in Parkinson’s disease, secondary parkinsonism, less often detected in vascular disorders, hydrocephalus, multisystem atrophy and torsion dystonia. In the elderly, it is sometimes an isolated symptom. It can be expressed in motor blocks during movement or inability to start moving. The cause is determined according to the anamnesis, the results of neurological examination, EEG, rheoencephalography, MRI and CT. Treatment includes dopaminergic drugs, levodopa drugs, surgical interventions.
Freezing when walking or freezing dysbasia are recurring episodes of inability to start or continue moving. They can be absolute (complete inability to move) or partial (steps of no more than a few centimeters in length or trampling on the spot). In the second case, the patient’s legs practically do not move, and the body moves forward, which sometimes leads to falls. Partial freezes also include trembling of the legs during the start or continuation of walking.
The symptom in most cases appears when trying to switch from one mode to another (the beginning of walking) or the need to change the motor program: when passing through a doorway or a narrow corridor, turns, stepping over obstacles, reaching a chair. Sometimes the external cause of solidification is not revealed, the patient freezes out of the blue when moving in a straight line.
Freezing is provoked by an additional load on the brain (an attempt to make arithmetic calculations or formulate an answer to a question without stopping walking), staying in the same territory with a large number of other people, the need to perform a certain action for a limited time (cross the road to a green light).
Rhythmic sound stimulation, visual landmarks, emotional experiences and climbing stairs, on the contrary, temporarily reduce the severity and frequency of the development of freezing dysbasia. The onset of the symptom is often accompanied by a loss of synergy of movements, an increase in instability when standing and walking. Solidification can occur not only when walking, but also when self-service, writing or talking.
Causes of freezing when walking
Pathology is manifested by four main motor disorders: trembling, asymmetric muscle rigidity, hypokinesia (slowness and decrease in the number of movements, a decrease in their speed and amplitude), postural disorders. Stiffening when walking appears on average 5 years after the manifestation of the disease, more often observed in elderly patients.
The frequency and duration of episodes of freezing dysbasia increases with the progression of Parkinson’s disease. There is no clear correlation with the severity of other motor disorders, but there is a link with the severity of speech disorders, anxiety and depressive disorders. In severe cases, the patient cannot start moving without assistance.
It is a polyethological condition, differs from Parkinson’s disease by a faster increase in symptoms and symmetry of motor disorders. The clinical picture is quite variable, it may not include all the symptoms characteristic of Parkinson’s disease. Possible combination with other cerebral manifestations: atactic gait, cerebellar syndrome, early intellectual decline. Freezing when walking and other signs of secondary parkinsonism are provoked by the following pathologies:
- Traumatic brain injuries: single severe (compression or bruising of the brain) and repeated light (multiple concussions) TBI.
- Infectious diseases: encephalitis, herpes, measles, mumps, HIV.
- Toxic effects: poisoning with methanol, prussic acid, carbon monoxide, heavy metals, manganese intoxication when using synthetic drugs.
- Degenerative pathologies of the central nervous system: multiple sclerosis, progressive supranuclear paralysis, dementia with Lewy bodies, Wilson’s disease.
- Brain hypoxia: after attempted strangulation, clinical death, severe acute respiratory disorders caused by diseases and injuries.
Freezing when walking is characteristic of vascular parkinsonism – one of the variants of secondary Parkinsonism caused by acute and chronic disorders of cerebral circulation. The cause of the pathology is ischemic and hemorrhagic strokes, chronic cerebral ischemia due to cerebral atherosclerosis, arterial hypertension, SLE, vascular amyloidosis, cerebral vasculitis, nodular periarteritis.
Typical features of this form of Parkinsonism are subacute course, symmetry of disorders, predominance of motor disorders in the lower extremities, early development of postural instability. The gait is stiff, shuffling, slow, small steps alternate with freezes. Facial expressions are poor, gestures are stingy or absent. Vascular dementia is possible.
Most cases of drug-induced parkinsonism are associated with the use of neuroleptics. Less often, pathology develops during treatment with metoclopramide, sympatholytics, anticonvulsants, calcium antagonists, and some antidepressants. The disease, as a rule, debuts within 3 months from the start of drug therapy, is more often detected in elderly patients, people with a hereditary predisposition who are at risk (HIV, depression, strokes and a history of TBI).
There is a predominance of hypokinesia, a high probability of freezing when walking. Other motor disorders may not be pronounced or poorly expressed. Withdrawal of the drug in most patients entails a gradual regression of symptoms. Sometimes the phenomena of Parkinsonism persist. Some patients develop Parkinson’s disease after a few years.
A genetically determined disease that develops at the age of less than 20-25 years. It is characterized by symmetry of motor disorders, muscle rigidity, tremor and hypokinesia. Postural instability is less pronounced than in primary parkinsonism. Solidification is complemented by shuffling gait, small steps, lack of friendly hand movements while walking. The symptoms of juvenile parkinsonism decrease in the morning and increase in the evening.
Primary freezing dysbasia
In elderly people (over 60 years old), solidification is sometimes detected as the only isolated symptom, not accompanied by other neurological disorders. The degree of the disorder ranges from single smoothed episodes to pronounced disorders with loss of the ability to walk independently. Gait changes gradually progress, therapy with antiparkinsonian agents is ineffective.
Other causes of freezing when walking include the following diseases and pathological conditions:
- Hydrocephalus. The symptom is detected with normotensive hydrocephalus, combined with urinary incontinence and signs of dementia. The steps are disproportionate, the walking is unbalanced, unstable, irregular, the movements of the arms, legs and trunk are poorly coordinated with each other.
- Multisystem atrophy. Signs of parkinsonism are detected in 60% of patients, are noted already in the initial stage of the disease, supplemented by cerebellar and autonomic disorders.
- Torsion dystonia. Pathology accompanied by tonic muscle contractions and the adoption of unusual poses. Freezing in abnormal poses is observed in patients with a generalized form, supplemented by rocking, pretentious gait.
Neurologists are engaged in establishing the causes of the development of congestions when walking. Recognition of Parkinson’s disease and its differentiation with various variants of secondary Parkinsonism in accordance with established criteria (asymmetry of manifestations, rest tremor, progressive course, high effectiveness of levodopa treatment) is of great importance. The following diagnostic procedures are prescribed for the final distinction of the type of disease, the establishment of the etiology of secondary Parkinsonism:
- Electroencephalography. It is performed to assess the functional state of the brain after strokes, TBI, in the presence of chronic circulatory disorders, toxic effects, and other factors that can provoke secondary parkinsonism.
- Rheoencephalography. It is indicative of vascular disorders: dyscirculatory encephalopathies, atherosclerosis, hypertension, chronic cerebral circulatory insufficiency, conditions after TBI and strokes.
- CT scan of the brain. It is recommended for confirmation of hydrocephalus, stroke, atherosclerosis, differential diagnosis of Parkinson’s disease with Alzheimer’s disease.
- MRI of the brain. The most informative technique that allows you to detect foci of degeneration, differentiate volumetric processes, identify the expansion of the ventricles of the brain in hydrocephalus, determine the prevalence and localization of the affected area in strokes.
- Consultations of specialists. To confirm changes in the fundus characteristic of hydrocephalus, Kaiser-Fleischer rings in Wilson’s disease, patients are referred to an ophthalmologist. In case of mental disorders, a psychiatrist’s consultation is prescribed.
Treatment of freezing when walking
Treatment tactics are determined taking into account the nature (primary or secondary) and severity of Parkinsonism. Medicines of the following groups are used:
- Dopaminergic drugs. Dopamine receptor agonists, selective MAO inhibitors, amantadine. Stimulate synthesis and release, inhibit the breakdown and reverse absorption of dopamine. Effective in the early stages. They allow you to reduce the dose of levodopa drugs or delay the start of administration.
- Levodopa preparations. They can be assigned in isolation. To prevent the “on-off” effect, the need for a gradual increase in the dose of the drug and the progression of side effects, treatment with a combined agent with entacapone or additional use of a COMT inhibitor is possible.
- Other means. Detoxification is indicated for patients with toxic damage to the nervous system, neurometabolic therapy is indicated for patients with posthypoxic, postinfectious and posttraumatic changes. In case of circulatory disorders, vascular preparations are required.
Drug therapy is supplemented with physical therapy and massage to reduce muscle rigidity, improve motor functions, preserve the ability to self-care and self-movement. In conditions after brain hypoxia, oxygen therapy is performed.
The tactics of surgical treatment is determined by the cause of freezing during walking:
- Parkinson’s disease: deep brain stimulation, electrical stimulation of the pale globe, pallidotomy, destruction of the thalamus nucleus.
- Vascular diseases: occlusion of aneurysms, thrombolysis, reconstruction of arteries, formation of vascular anastomoses.
- Hydrocephalus: ventriculoperitoneal and ventriculoatrial bypass surgery, endoscopic ventriculocysternostomy of the bottom of the III ventricle.