Clinimetrics of freezing of gait

The clinical assessment of freezing of gait (FOG) provides great challenges. Patients often do not realize what FOG really is. Assessing FOG is further complicated by the episodic, unpredictable, and variable presentation, as well as the complex relationship with medication. Here, we provide some practical recommendations for a standardized clinical approach. During history taking, presence of FOG is best ascertained by asking about the characteristic feeling of "being glued to the floor." Detection of FOG is greatly facilitated by demonstrating what FOG actually looks like, not only to the patient but also to the spouse or other carer. History taking further focuses on the specific circumstances that provoke FOG and on its severity, preferably using standardized questionnaires. Physical examination should be done both during the ON and OFF state, to judge the influence of treatment. Evaluation includes a dedicated "gait trajectory" that features specific triggers to elicit FOG (gait initiation; a narrow passage; dual tasking; and rapid 360 degrees axial turns in both directions). Evaluating the response to external cues has diagnostic importance, and helps to determine possible therapeutic interventions. Because of the tight interplay between FOG and mental functions, the evaluation must include cognitive testing (mainly frontal executive functions) and judgment of mood. Neuroimaging is required for most patients in order to detect underlying pathology, in particular lesions of the frontal lobe or their connections to the basal ganglia. Various quantitative gait assessments have been proposed, but these methods have not proven value for clinical practice.