Gait Training in Parkinson’s Disease: Freezing of Gait and Rhythmic Cueing

For a person with Parkinson’s disease, what troubles daily life most is often not tremor but the feet not obeying: walking turns into small shuffling steps, speeds up and cannot stop, or the feet seem stuck to the floor and cannot move. The root of these gait problems is damage to the basal ganglia deep in the brain, which loses the ability to produce a steady walking rhythm automatically.

Fortunately, the key to gait training is not strength but a different route. Physiotherapy uses external auditory and visual cues (cueing) to bypass the failing basal ganglia and borrow the conscious pathway of the cerebral cortex to take each step. Based on clinical evidence, this article examines the causes of freezing of gait, why rhythmic cueing works, and the research results on treadmill and dual task training. It also states frankly a fact that is often overlooked: the benefit of cueing training fades once practice stops, so patients need to use portable tools and keep practising, and to see gait management as a long-term effort.

Features of Parkinsonian gait: shuffling, festinating and freezing

As the disease progresses, patients gradually show a characteristic Parkinsonian gait, which not only limits mobility but also raises the risk of falling greatly. Clinically the three most common patterns, which are linked to one another, are:

Behind these clinical features there are traces to follow. Nieuwboer and colleagues (2004), using electromyography, found that before an episode of freezing, the tibialis anterior and gastrocnemius muscles of the lower leg already show premature abnormal timing and reduced amplitude, which leads to inadequate push-off, slower steps and finally a breakdown of the whole walking movement. In other words, freezing of gait does not strike without warning. It is a gradual loss of order, which also explains why an external rhythm given in good time can set the steps going again.

What freezing of gait is

Freezing of gait (FOG) is one of the most troublesome symptoms of Parkinson’s disease and one of those most likely to cause falls. Patients often describe the feeling as the feet being stuck to the ground or the feet not obeying: the mind wants to move forward, but the legs will not move. This is very common. Giladi and colleagues (2001) studied 172 late-stage patients with Parkinson’s disease, and 91 of them (about 53%) said they had experienced freezing of gait, with the severity of the disease (Hoehn and Yahr stage in the off-medication state) the factor most closely linked to it.

Situations that easily trigger freezing of gait

Knowing what triggers freezing makes it possible to plan ahead and reduce the chance of an episode. The common triggers fall roughly into three kinds:

The principle and use of external cueing

External cueing is one of the most effective ways to improve Parkinsonian gait. The principle behind it is in fact simple: Parkinson’s disease damages the “automatic” rhythm control function of the basal ganglia, but the pathway of conscious control in the cerebral cortex remains intact. A steady external beat or a line on the floor gives the brain an external time or space reference, and switches the walking pattern from automatic control to conscious control, so bypassing the blocked neural circuit.

This approach does not rest on the clinical experience of individual therapists alone but has a large body of research data behind it. The systematic review and pooled analysis by Ghai and colleagues (2018) covered 50 studies and 1,892 participants in all and confirmed that auditory cueing has a positive effect on walking speed and stride length, and a negative effect on cadence. This means it can both lengthen the stride and slow a cadence that is too fast, and the results of the studies were quite consistent.

How rhythmic auditory cueing (RAS) is done

Rhythmic auditory stimulation (RAS) is the most widely studied gait training strategy with the most evidence. In the study by Thaut and colleagues (1996), after 3 weeks of RAS gait training, patients improved more clearly in walking speed, stride length and cadence than a control group who set their own pace (extra gain between the groups: walking speed +25%, stride length +12%, cadence +10%). In actual training, the following steps can be followed in order:

1. 1
   Measure the baseline

   First measure the patient’s cadence when walking naturally as usual (how many steps a minute).
2. 2
   Set the beat

   Set the metronome speed to about 5 to 10% faster than the usual cadence.
3. 3
   Practise in step with it

   First step on the spot to the beat, and only start to walk forward once the rhythm is steady.
4. 4
   Adjust step by step

   Where it is safe, slowly speed up the beat and make the practice harder.

Auditory cueing tools that can be used at home:

• A metronome app on a phone—Free and easy to carry, and the number of beats a minute can be set precisely
• Music with a steady rhythm—For example a march, which has a clear beat and a very steady rhythm
• Counting aloud in the mind—Silently counting “1-2-1-2” in the mind, which needs no tool
• A caregiver’s count—A family member beside the patient calls “one, two, one, two” to set the rhythm of walking

Visual cueing: floor lines and laser canes

Besides auditory cueing, visual cueing works too, and it suits patients who often freeze at a fixed place (such as a bedroom doorway) especially well. The method is to provide a clear visual target on the floor to guide the brain to lift the leg consciously and step over. The pooled analysis by Spaulding and colleagues (2013) found that visual cueing significantly lengthens the stride (Hedges g=0.554). Common tools include a horizontal line or coloured tape stuck on the floor, and a cane fitted with a laser projector, which can project a line on the floor ahead at any time and is especially handy when going out.

How the effect of cueing changes after practice stops

Most promotion in the community does not mention this point, but it must be told honestly here. The RESCUE trial (Nieuwboer 2007), a representative study of cueing training at home, recruited 153 patients and found that after 3 weeks of training, patients showed slight improvement in walking-related activity ability, walking speed, stride length, severity of freezing and balance (p<0.01). However, 6 weeks after training stopped, these gains had clearly faded.

Large-amplitude movement training (LSVT BIG): Think BIG, Move BIG

Because of slowness of movement, people with Parkinson’s disease often make every movement smaller without realising it, yet feel subjectively that their movements are of normal size. LSVT BIG is a high-intensity training designed specifically for Parkinson’s disease, with the core idea of “Think BIG, Move BIG”: by deliberately enlarging movements and recalibrating body sense, it counters the tendency for movements to shrink. The standard course is 4 sessions a week for 4 weeks.

To carry the large-amplitude idea into gait training, the key is to take deliberately big steps, land heel first, lift the feet high to avoid dragging, and at the same time swing the arms widely front and back with coordination between opposite sides. Forming a habit of consciously taking big steps is the most direct way of dealing with shuffling.

Clinical evidence on treadmill training

A treadmill provides a steady and continuous walking rhythm and is a reasonable choice for gait training, but its real effect must be understood objectively. According to the conclusions of the Cochrane review (Mehrholz 2016), treadmill training helps to improve walking speed and stride length, although the certainty of the evidence and its scope are still limited.

Safety and research results of dual task walking

“Is a person more likely to fall when talking while walking?” is a question many patients and families have. Earlier thinking leaned towards avoiding doing two things at once, but newer clinical evidence has overturned this one-size-fits-all idea. The DUALITY trial (Strouwen 2017) recruited 121 patients and found that, whether the dual task was trained “integrated” or “separately”, patients’ walking speed under dual task conditions improved significantly, the benefit lasted through the 12-week follow-up, and the risk of falling did not rise significantly (p=0.84).

Turning safely and stepping over obstacles

For a person with Parkinson’s disease, turning is one of the high-risk movements for falls. Mastering the right technique greatly lowers the risk of falling.

Stepping over obstacles also needs technique. The most common tripping hazards at home are door thresholds, cables on the floor, carpet edges and uneven floors. When meeting an obstacle, stop first and look carefully, deliberately lift the leg to step over the obstacle, go slowly one step at a time, and hold on to the wall for support if needed. Besides practising stepping over, clearing obstacles from the home matters just as much. It is advisable to remove unnecessary thresholds, secure cables properly, lay non-slip mats and keep walkways clear at all times.

A home gait training programme

Since the effect of cueing training fades once practice stops (RESCUE), consistent practice at home is the key to keeping gait steady and making sure the training dose is enough. Cochrane evidence (Tomlinson 2012) also shows that, compared with no intervention, physiotherapy clearly improves gait measures such as walking speed in the short term, and keeping these gains depends on the small things done every day. The daily practice that physiotherapists often recommend in home exercise therapy is below (it takes about 20 to 30 minutes):

Frequently asked questions