Objective: To report improvement in freezing of gait following unilateral transcranial direct current stimulation in  a patient with with atypical parkinsonism and severe freezing of gait.

Background: Treatment of freezing of gait (FOG) in Parkinson’s disease (PD) and atypical parkinsonism remains a challenge.

Transcranial direct current stimulation (tDCS) has shown promise in treatment of FOG in PD. In this case report, we explore transcranial direct stimulation in patient with atypical parkinsonism who had severe FOG.

Method: A 66-year-old gentleman presented with painful spasms of upper limb followed by posturing of fingers, first symptomatic in 2020. Subsequently, he noted slowness in all activities of daily living, worsening gait imbalance, recurrent backward falls and difficulty in rising from sitting position. On examination, there was hypophonia, intermittent resting bilateral upper limb tremor, fixed contractures of bilateral upper limbs, mild lower limb rigidity and bradykinesia. A diagnosis of dystonia parkinsonism  secondary to corticobasal degeneration was considered. TRODAT 99- m technetium scan revealed asymmetrical severe decrease in tracer uptake in bilateral basal ganglia with preserved tracer uptake in right caudate nucleus.  On administration of levodopa- carbidopa 125 mg  twice daily, there was severe worsening of freezing of gait and start hesitation, that failed to improve despite immediate cessation of levodopa.  tDCS was administered based on the protocol suggested by Valentino et al(1). Anode stimulation was performed alternately to the left dorsolateral prefrontal region and primary motor cortex  for 20 minutes each. The  current stimulation was initiated at 0.5 mA and gradually incremented to 2 mA .  During the stimulation, patient underwent gait training  as well as dual task training with auditory cues . The stimulation was performed 3 times a week over the next 3 months.

Results: Following tDCS, patient’s gait gradually improved and now he is able to walk independently with no start hesitation of freezing of gait on most of the days .

Conclusion: tDCS targeting primary motor cortex and dorsolateral prefrontal cortex with concurrent gait training  may help in reduction in treatment resistant FOG in  atypical parkinsonism

References: Valentino F, Cosentino G, Brighina F, Pozzi NG, Sandrini G, Fierro B, Savettieri G, D’Amelio M, Pacchetti C. Transcranial direct current stimulation for treatment of freezing of gait: a cross‐over study. Movement Disorders. 2014 Jul;29(8):1064-9.

Dagan M, Herman T, Harrison R, Zhou J, Giladi N, Ruffini G, Manor B, Hausdorff JM. Multitarget transcranial direct current stimulation for freezing of gait in Parkinson’s disease. Movement Disorders. 2018 Apr;33(4):642-6.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/freezing-of-gait-in-atypical-parkinsonism-improves-with-transcranial-direct-current-stimulation/