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For Doug McCorkle's Mother You wrote the following; Question from Mom: Mom's main problem is "freezing" during her off times. During these times, she finds that she can sometimes accomplish small tasks (walking across the room, for example) with a great expenditure of time and effort OR she can sit back and wait until her medicine kicks in and get a lot more done with less effort. The question is: Is it better to rest up and wait for the medicine (it's certainly more comfortable) or is there some benefit in fighting the brady- and akinesias ? ANSWER: I honestly believe that OFF time is harmful to the human system. We would always like to be ON since that is as close to normal as we can be. When we are normal, all systems are operating in an acceptable range. When we are OFF, one or more system is operating outside of an acceptable range. This puts stress on one or more systems. I feel it as bradykinesia, rigidity, dyskinesia, dystonia and many other symptoms. Operating in this unacceptable range must cause harm. If one considers that those with PD prior to today's medications had a shortened life span, need I say more. Today, the expected life span of those of us with PD is about normal. I can only attribute that to medication that keeps us out of the OFF and ON with dyskinesia states as much as possible. Vision can play a major role is helping one out of OFF states. Freezing is the inability to initiate movement. Often movement can be made backwards. Or often movement can be made up or down a stairway. Yet, when confronted with walking forward, the feet seem to be glued to the floor. This freezing seems to happen most often when passing through a door way, walking down a narrow hallway, attempting to turn around in a confined area, and other similar situations that pose a change of "environment" on us. A relatively simple model might be proposed that goes like this: We are walking in a normal way when our eyes detect a environmental requirement to change this normal walk. The signal sent by the eyes to the brain is really two signals (1) tells the feet to stop in their current place until they are told otherwise and (2) tells the brain to come up with an alternate walk pattern due to a perceived environmental requirement. In the normal brain system, these two signals are acted on instantaneously. The signal to stop to the feet arrives just before a new signal is received altering the walk pattern. The corrections come fast enough that no noticeable stop ever happens. The case for PD is slightly different. The signal to stop is received and acted on. The signal for modification is either delayed or never is given. The net of a perceived change requirement is freezing. In the worst case, the feet freeze and the body continues causing one to fall. Now that is serious. Somewhat similar to freezing is akinesia. In akinesia, one is unable to initiate movement. This is the second half of freezing. Once one has stopped (freezing) the next thing is to initiate movement. If this is impossible, it is called akinesia. As stated earlier, often the patient can walk backwards, up and down stairways, but not forwards. Looking a little closer at balance, when walking backwards, the center of balance or equilibrium does not change. In other words, walking backwards is similar to just standing. The same thing is also true when going up and down stairways. Our center of balance stays almost at the same place as when standing. Now consider walking forward. The first thing one notes is the body must lean forward followed by a foot to catch the forward fall. In a way what is happening is the body is thrust forward and the center of equilibrium gets pushed forward. If nothing else happens we will fall on our face. Thus a foot follows the lean and if we hold the lean, another foot must follow, and "like magic" the human is moving on two feet. Note what had to happen. (1) The body had to be put at risk and (2) a foot had to be set forward to prevent the fall. A simple definition of akinesia might be a time when the brain considers the risk of body harm too high. The problems of akinesia and freezing are most profound when in an OFF state. One possible way around some of the OFF time problems is to create a "visual" pathway in areas prone to freezing. By this I mean, put marks on the floor and step over them when walking. For many, this reduces the severity of the visual signal to stop. In some people, the need to stop is gone and it seems like "old times" again. If you saw the movie, "Awakenings," Lucy needed the floor patterned else she stopped at the edge of the pattern. Now a little on the mechanics of this procedure. Testing the patient response. Using an ordinary deck of playing cards, place a card at about 18" intervals down a hallway, through a door way or where ever this problem of freezing happens. You might find that 18" is too big for very small people, and too small for large people. The intent is to have the patient step over the marks, thus the cards should be placed at normal walking stride. Now it may be necessary to place more than one card to form a mark. What ever works is the answer. Be sure the marks are placed at normal stride and not at slow or reduced stride. Now that the marks on down, the only thing left is to have the patient try walking over the marks. This is a new perceived visual pattern requiring a little learned effort. Generally walking over the marks only takes a few tries before the patient automatically starts to use the marks as visual cues. What is expected? (1) You may have difficulty getting the patient to stop walking over the marks. The reason is the patient is feeling more than just the ability to walk in areas that used to cause problems. The walking loosens the muscles and you should observe arm swing, knee bending, foot lifting, facial expression etc. All of these may become normal without medicine. Surprised? (2) It does not work for everyone with freezing and akinesia. But remember, it may take some getting use to. The cues are new and this may require learning a new skill. It may be better to leave the patient alone to explore at their pace what is happening. Often the patient will say, "I don't feel anything new, it must not be working!" You, however, can see the difference. (3) It the marks are making a difference, the use of masking tape (the kind that is colored and is of the long staying without permanent damage used be used. This may be purchased at most hardware stores for about $5:00 a roll or less. Now that the house has all these marks, how is the patient doing? I hope much better. I know for one lady who would fall about 2 or 3 times a day, she hasn't fallen in her home since the marks were put down. For another, the marks are so enabling that and they wondered why it hadn't been stated before. What do you have to lose? A half hour to try something maybe. That is cheap compared to a fall. Let me know what happens. Regards, Alan Bonander, age 56, PD 12 years, infusion, pallidotomy. PS: Much of the material above is from Tom Riess in conversations, demonstrations and reading papers.