Improvement of Freezing of Gait in Patients with Parkinson's Disease by Imagining Bicycling
A 70-year-old woman noticed short shuffling steps and difficulty in turning her body while walking at the age of 67. She gradually developed difficulty walking, mainly due to FOG. Neurological findings at the age of 67 revealed a depressive state, masked face, resting tremor, cogwheel type rigidity, bradykinesia, severe FOG, postural instability, and autonomic dysfunction, such as pollakisuria, constipation, and orthostatic hypotension. After gradual increases of L-dopa/decarboxylase inhibitor (DCI; 200–900 mg/day) and L-threo-3,4-dihydroxyphenylserine (100–600 mg/day), these parkinsonian symptoms improved, except for the severe FOG and postural instability (fig. ; see online suppl. video segment ; for all online suppl. material, see ). Visual and auditory cues also did not improve severe FOG and, therefore, her quality of life was limited. When she was instructed to imagine that she was pedaling a bicycle prior to trying to initiate gait, she was able to begin walking smoothly without FOG (fig. ; online suppl. video segment ). Imagining taking a large step, climbing stairs, or stepping over regular horizontal lines did not improve severe FOG. When the patient was additionally instructed to imagine and mimic bicycling after having initiated walking, her gait was more rhythmical and without interruption (online suppl. video segment ). There was little time between the first and second video segments. After several visits, severe FOG in its normal condition without imagining bicycling and the improvement of FOG after imagining bicycling were similar to the results shown in online supplementary video segments and . Routine blood examinations were normal. The coefficient of variation of the R-R interval was reduced to 1.68%. A brain MRI showed mild chronic ischemic changes in the deep white matter. 99mTc-ECD SPECT showed mild hypoperfusion in the anterosuperior frontal and posterolateral parietal lobes. The heart-to-mediastinum (H/M) ratio in 123I-metaiodobenzylguanidine myocardial scintigraphy decreased (early H/M: 1.89, delayed H/M: 1.68).