A multimodal rehabilitation strategy that combines physical, cognitive, and sensory training may help reduce freezing of gait (FOG) in patients with Parkinson’s disease (PD), according to experts who presented during a session at the 2026 French-Language Neurology Days (JNLF).

“To restore automatic walking patterns and postural stability, patients need complex exercises that incorporate dual-task training by combining cognitive, motor, and sensory stimulation,” said Anne Blanchard-Dauphin, MD, Department of Physical Medicine and Rehabilitation, Lille University Hospital, Lille, France. “Exercise intensity and consistency are also essential.”

Updated Definition

According to a new international definition, FOG in PD is characterized by sudden episodes during which patients are unable to walk effectively despite attempting to do so. During these episodes, the steps are often much shorter than the individual’s usual stride length.

Freezing is no longer characterized solely by a halt in walking. It also includes episodes of gait deterioration, characterized by much shorter steps and often difficulty initiating movement. These episodes may present as progressively worsening gait without a complete stop or as intermittent brief pauses before normal walking resumes.

FOG is one of the most disabling symptoms of PD and related disorders and often leads to falls and loss of independence. Because episodes vary considerably, assessment typically relies on a patient-reported FOG questionnaire and, ideally, video recordings obtained during clinical evaluation to better characterize FOG.

During a separate presentation, Marie-Laure Welter, MD, PhD, from the Neurophysiology Department, Rouen University Hospital, CHU Rouen, Rouen, France, reviewed the neurophysiologic mechanisms underlying FOG.

“A dopamine deficiency disrupts activity within the basal ganglia,” she said. “This creates an imbalance between the direct and indirect motor pathways, favoring the inhibitory pathway.”

Deep Brain Stimulation

In the early stages of PD, compensatory neural mechanisms can prevent freezing despite dopamine deficiency. However, as the disease progresses, additional brain regions, including the premotor cortex and mesencephalic locomotor region, become involved, reducing these compensatory mechanisms and increasing the likelihood of freezing episodes.

FOG remains one of the most difficult motor symptoms to treat in patients with PD. In selected patients, deep brain stimulation of the subthalamic nucleus may improve symptoms, although its benefits are often limited once freezing becomes resistant to dopaminergic therapy.

Trials are being conducted to evaluate the stimulation of additional targets downstream of the subthalamic nucleus, particularly within the midbrain. “The pedunculopontine nucleus has recently emerged as a potential target because it is the site of substantial cholinergic neuron loss,” Welter said.

At present, aside from optimizing dopaminergic therapy to alleviate symptoms, only specialized rehabilitation has demonstrated consistent benefits in the management of FOG. Several approaches have been proven to be effective, depending on the predominant underlying mechanism.

Cueing Strategies

Auditory and visual cueing can be particularly effective for patients with impaired internal walking rhythm. These structured exercises use external cues, such as music or a metronome, to help patients synchronize their gait.

“Cueing helps restore walking rhythm,” Blanchard-Dauphin said. Although these strategies are commonly used during rehabilitation sessions, they can be incorporated into daily life. Mobile applications and wearable technologies, including connected insoles, are becoming increasingly available to provide rhythmic cues during walking.

Walking on a treadmill can improve FOG, with additional benefits when combined with cueing strategies. Adhesive strips placed on a treadmill provide visual cues that help patients maintain a steady pace. Virtual reality can further enhance training by adding visual targets for patients to work toward. “Patients are generally receptive to this type of approach.”

Walking while counting backward is another exercise that may help improve gait.

Several studies have also shown that dancing can improve balance and reduce disruptions in walking rhythm, particularly ballroom dances such as tango and foxtrot, which involve long, fluid, and continuous movements.

LSVT BIG Therapy

LSVT BIG is a standardized, high-effort physical and occupational therapy program targeting restricted movement (hypokinesia) and range of motion, primarily in PD.

For impaired automaticity of walking, dual-task training is recommended to stimulate both cognitive and motor functions. “Patients should be encouraged to adopt techniques that help them become aware of their movements.” Walking while counting backward is an example of such an exercise.

Other rehabilitation exercises include complex walking activities, such as navigating obstacles, making U-turns, shifting weight, and taking wider turns. “The more complex the activities are and the more they stimulate motor function, attention, and proprioception, the more effective the rehabilitation,” she said.

In patients with bradykinesia (progressive slowing of voluntary movement), akinesia (difficulty initiating movement), and rigidity, LSVT BIG physical therapy has been shown to improve step length and movement amplitude. The program focused on increasing the amplitude of movement to improve mobility and movement precision.

The LSVT BIG consists of intensive, repetitive exercises that gradually increase in complexity and include large steps and broad arm and chest movements. The standard program includes four 1-hour sessions per week for 4 weeks, followed by home exercises performed for 15 minutes twice daily.

“This technique works well for motivated patients who enjoy exercise and do not have significant cognitive impairment or balance problems,” she said. Nordic walking has also been shown to improve stride length in less motivated patients.

Balance Training

Intensive strength training is recommended for patients with hypoexcitability, particularly for the triceps and gluteal muscles. High-intensity aerobic and resistance training using a stationary bicycle and treadmill is also recommended. “In the absence of contraindications, the goal is to reach 80%-85% of the maximum heart rate.”

If patients have postural instability, conventional rehabilitation focuses on exercises that improve anterior-posterior balance. Patients are encouraged to explore their limits of stability, for example, by reaching for objects placed in front of or behind them.

In addition to physical therapy, several studies have shown that Tai Chi can improve balance and walking speed in patients with PD. In France, the France Parkinson Association organizes group Tai Chi classes through its regional chapters.

“No matter what type of exercise they do, patients need to understand the importance of consistency,” Blanchard-Dauphin said. “Like everyone else, they should engage in physical activity at least 5 days a week for a minimum of 30 minutes a day. It is also important to maintain sufficient intensity, for example, by walking briskly during outings.”

This story was translated from Medscape’s French edition.