Beck EN, Ehgoetz Martens KA, Almeida QJ.
Freezing of gait in Parkinson’s Disease: an overload problem?
PLoS ONE 2015;10(12):e0144986

Abstract
Freezing of gait (FOG) is arguably the most severe symptom associated with Parkinson’s disease (PD), and often occurs while performing dual tasks or approaching narrowed and cluttered spaces. While it is well known that visual cues alleviate FOG, it is not clear if this effect may be the result of cognitive or sensorimotor mechanisms. Nevertheless, the role of vision may be a critical link that might allow us to disentangle this question. Gaze behaviour has yet to be carefully investigated while freezers approach narrow spaces, thus the overall objective of this study was to explore the interaction between cognitive and sensory-perceptual influences on FOG.

In experiment #1, if cognitive load is the underlying factor leading to FOG, then one might expect that a dual-task would elicit FOG episodes even in the presence of visual cues, since the load on attention would interfere with utilization of visual cues. Alternatively, if visual cues alleviate gait despite performance of a dual-task, then it may be more probable that sensory mechanisms are at play. In compliment to this, the aim of experiment#2 was to further challenge the sensory systems, by removing vision of the lowerlimbs and thereby forcing participants to rely on other forms of sensory feedback rather than vision while walking toward the narrow space.

Spatiotemporal aspects of gait, percentage of gaze fixation frequency and duration, as well as skin conductance levels were measured in freezers and non-freezers across both experiments.

Results from experiment#1 indicated that although freezers and non-freezers both walked with worse gait while performing the dual-task, in freezers, gait was relieved by visual cues regardless of whether the cognitive demands of the dual-task were present. At baseline and while dual-tasking, freezers demonstrated a gaze behaviour that neglected the doorway and instead focused primarily on the pathway, a strategy that non-freezers adopted only when performing the dual-task. Interestingly, with the combination of visual cues and dual-task, freezers increased the frequency and duration of fixations toward the doorway, compared to non-freezers. These results suggest that although increasing demand on attention does significantly deteriorate gait in freezers, an increase in cognitive demand is not exclusively responsible for freezing (since visual cues were able to overcome any interference elicited by the dual-task).

When vision of the lower limbs was removed in experiment#2, only the freezers’ gait was affected. However, when visual cues were present, freezers’ gait improved regardless of the dualtask. This gait behaviour was accompanied by greater amount of time spent looking at the visual cues irrespective of the dual-task. Since removing vision of the lower-limbs hindered gait even under low attentional demand, restricted sensory feedback may be an important factor to the mechanisms underlying FOG.

Our opinion

This is one of the first study to explore the interaction between the cognitive and sensory-perceptual influences on FOG in PD using both gait analysis, gaze behaviour, and skin conductance. The protocol, that associates also the use of black tape striped lines placed on top of the walkway, walking through a narrow doorway and dual-tasking, generates an uncommon and interesting work, and proves that the creativity should be more often a feature of interest in protocols.