Objective: We aimed to search the literature for a potential association between freezing of gait (FOG) with cueing and dystonia with sensory tricks in Parkinson’s Disease (PD).

Background: FOG poses a major burden on PD patients and its treatment is quite difficult due to unresponsiveness to dopaminergic medications, and its pathophysiology is yet to be understood.
FOG is a sudden inability to initiate or continue gait, described by patients as “feet stuck to the floor”, of a paroxysmal nature with triggers and alleviating cues. Sensory cueing is often quoted as being very helpful in FOG.
On the other hand, sensory tricks work as suppressors of a dystonic posture. Ranging from a simple touch in the face to a more complex movement, many tricks have been described including motor, forcible, imaginary, and reverse sensory tricks.
From our clinical perception, we have theorized that cueing works for freezing in a similar way as sensory tricks work on suppressing dystonia so that a dystonic component of lower-limb muscles could be involved in FOG.

Method: We conducted a review of the literature, identified by search in PubMed for the combined terms “freezing of gait” and “dystonia”. References were selected due to relevance to this work.

Results: We found several reports of FOG treated with botulinum toxin (BT), which also consider the existence of a dystonic component, either in distal or proximal lower-limb muscles, showing recent promising results with tensor fasciae latae injections. Other BT studies demonstrated an inconsistent benefit, but it is important to highlight the need for larger controlled studies.
Also, Shimo et. al reported a case of PD with FOG that raised suspicion to be caused by dystonia, with surface electromyography revealing a dystonic co-contraction in his legs only during forward walking.
Moreover, the literature has, for years, exposed that FOG has a favourable response to behavioural tricks, justifying cueing – either visual, auditory or tactile -, as a successful method for rehabilitation.
Overall, these findings support an overlap with task-specific dystonia.

Conclusion: The increasing perception of clinical response to behavioral tricks in FOG seems to point out a similarity between cueing of FOG and sensory tricks of dystonia. This potential relationship may open a new therapeutic window for FOG, like BT or benzodiazepines.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/lower-limb-dystonia-as-an-explanation-for-freezing-of-gait-responsive-to-cueing-in-parkinsons-disease/