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|LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 3 | Page : 646-647
Primary progressive freezing gait: Report of five cases
Sunitha Robert, Robert Mathew
Department of Neurology, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Tamil Nadu, India
|Date of Web Publication||9-May-2017|
Department of Neurology, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Robert S, Mathew R. Primary progressive freezing gait: Report of five cases. Neurol India 2017;65:646-7
Primary progressive freezing gait (PPFG) is a neurodegenerative atypical Parkinson syndrome, which begins with start hesitation or ignition failure, causes gait freezing during the first 3 years, and subsequently results in postural instability and falls. It is often accompanied by bradykinesia and rigidity and is unresponsive to dopaminergic medications.
We report five patients fulfilling the diagnostic criteria for PPFG. There were four male and one female patients with their age ranging from 62 to 84 years and the duration of illness ranging from 2 to 7 years. They had start hesitation, gait freezing, postural instability, mild bradykinesia, and rigidity. Most of the patients required support to walk. One patient was wheelchair bound. They were given high doses of levodopa, with no significant improvement. Magnetic resonance imaging (MRI) of the brain was done in three patients, computed tomography (CT) of the brain in two patients, and additional cervical MRI in one patient. None had ventricular dilatation or infarcts. Two representative patients are described here.
The first patient, a 62-year old lady, developed start hesitation, slow gait, en bloc turns with poor balance, although she had no difficulty in moving her legs while in bed or sitting. There was no tremor or stiffness of legs, bladder symptoms or cognitive impairment. She was given up to 600 mg of levodopa per day with no significant response. MRI brain showed mild diffuse atrophy. Seven years after the onset of her illness, she had subtle symmetric bradykinesia, severe gait freezing, and walked with support of a person, with no tremors or oculomotor signs.
The second patient, a 63-year-old diabetic gentleman, presented with 4-year history of gait initiation difficulty and poor balance. He had normal oculomotor movements, mild rigidity and bradykinesia, gait freezing, and severe postural instability. CT brain and MRI cervical spine were normal.
PPFG was defined by Nir Giladi as an episodic inability (lasting seconds) to generate effective stepping in the absence of any known cause other than Parkinsonism More Details or higher level gait disorders. It is most commonly experienced during turning and step initiation but also when faced with spatial constraint, stress, and distraction. Focused attention and external stimuli (cues) can overcome the episode. The most common feature associated with PPFG is the unique subjective feeling of feet getting glued to the ground.
The strongest provocative factor for PPFG is turning (turning hesitation). Freezing is also common at the initiation of gait (start hesitation), when passing through a narrow space (tight quarters hesitation), or immediately before reaching a destination (destination hesitation). Time pressure to execute walking, as in attempting to cross before a traffic signal changes, also worsens PPFG. Providing marching commands similar to that given to a soldier or giving visual stimuli such as stepping over objects, such as another person's foot, floor patterns, specially designed walking sticks with extensions near the foot, which the patient can cross over, are some techniques to overcome freezing.
PPFG is a distinct clinical entity and is probably underdiagnosed in our part of the country. Despite its heterogeneous nature, this diagnosis definitely has its own clinical relevance, especially in predicting natural history and prognosis.
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Conflicts of interest
There are no conflicts of interest.
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