2nd of April 2019
To freeze or not to freeze
Strategies to circumvent freezing
It happens to me regularly. Mental freezing. For example, I recently had to list as many animals as possible within a minute, and I really didn’t have a clue. I could retrieve their images, but in no way could I find their names. Confronting.
During my second attempt, I had an idea. What if I would start with animals with an A, then with a B and so on. And … it worked! I had managed to find a detour around my mental freeze. That really felt like a victory of my creativity.
I began to imagine that mental freezing could work just like freezing, one of the more familiar motor symptoms of advanced Parkinson’s. During a period of freezing your feet seem to be glued to the ground and you can no longer move forward. At least, not by using the automatic walking method that we have learned as a child. People with Parkinson’s disease lose dopamine neurons in an area of the brain where automated behavior is prescribed. To bypass freezing, patients must challenge their brains to find creative detours.
Immediately, I wondered how my colleague Parkinson patients deal with these kinds of challenges. If the road of habit has become a dead end street, what happens? Could we inspire each other with our attempts to find detours?
It is exactly this kind of inspiration that I found in an article by Jorik Nonnekes, Alice Nieuwboer, Evzen Ruzicka, Mark Hallet, Alfonso Fasano and Bas Bloem (1,2). They collected videos of patients who bypassed their freezing episode and supplemented the picture that emerged with literature research. These two strategies combined resulted in dozens of unique detours that I have visualised below. Via the Volkskrant of March 26, 2019 you can also watch a compilation video of the compensation strategies used.
7 Compensation categories
The creative detours differ per patient. Yet there also appear to be many similarities. The researchers were able to classify each strategy into one or more of the following seven categories. The underlying mechanisms use targeting, focusing attention on a specific aspect of walking and using ways to move that are less automated than our normal walking pattern.
The categories are explained in more detail below the illustration.
I. External cues
This strategy is the most visible and – perhaps partly because of its visibility – the best known. In 44% of the videos submitted, the patient used an external visual, auditory or somatosensory stimulus to focus and filter attention. Think of stepping over objects that are placed on the floor in a regular pattern, walking to the rhythm of the music and walking with weights on your shoes.
II. Internal cues
III. Changing balance requirements
With this strategy, patients change walking conditions to make it easier to move their weight from one leg to the other. Think of walking in water, making wider turns or using a so called walking bike.
IV. Altering the mental state
This strategy stimulates the alertness of a patient and helps to focus attention. In an extreme form, this strategy occurs in stress situations such as an earthquake or the burning of food on a stove. In such cases, a patient who is in a freezing episode can suddenly walk.
V. Motor imagery or action observation
During this strategy, the patient visualizes that he is walking or the patient is looking at someone else who is walking. In both cases, our mirror neurons are activated and that helps to get moving.
VI. New walking pattern
By using movement patterns that are less automated than the normal way of walking, a patient can bypass freezing. Think of making a cross pass, moving as if you were skating, walking sideways, climbing stairs and jumping.
VII. Alternatives to to normal walking
Patients using this strategy use other means than walking to move forward. Examples include cycling and skating.
The researchers postulate that, in addition to the mechanisms mentioned, there is also an overarching mechanism at work: increasing walking confidence. That turned out to be the case with a patient with laser shoes. The patient walked better even though the laser beam was switched off. He felt more secure by the simple fact that he – when necessary – cóuld turn on the laser.
The next step
In follow-up research, Jorik Nonnekes and colleagues want to find out if they can match the right strategy with the right patient (2). Not every detour works for every patient. In addition, a strategy can eventually lose its effect because the required brain cells die or because the strategy becomes too automated.
Why is this work important to me?
I am a newbie in the wonders of the world of Parkinson’s, but if something has become clear to me after a year with Parkinson’s diagnosis, it is that this disease requires a real retraining to become a “master in finding creative detours”. All tips and tricks that we can get from experienced Parkinson patients and practitioners are very welcome and very much needed!
I think it is wonderful that care providers and scientists – such as Jorik Nonnekes – collect these kinds of tips: after all, they see lots of patients.
In turn, I hope that my drawings will be helpful to Nonnekes and colleagues to transfer their collected work to all “new students in finding creative detours”. That would be motor imagery in action indeed!
(1) Nonnekes J, Růžička E, Nieuwboer A, Hallett M, Fasano A, Bloem BR (March 25, 2019). Compensation Strategies for Gait Impairments in Parkinson Disease: A Review. JAMA Neurol. Retrieved from doi:10.1001/jamaneurol.2019.0033
(2) Donders Institute (March 26, 2019). Walking ability in Parkinson patients improves with the clever use of self-discovered compensation strategies [News item]. Retrieved from https://www.ru.nl/donders/@1214118/walking-ability-parkinson-patients-improves-clever/