Freezing of Gait (FoG) Detection for Parkinson Disease

A Tay1 , SC Yen, PY Lee, CY Wang, A Neo, SW Phan, K Yogaprakash, S Liew, and WL Au

Abstract Freezing of Gait (FOG) is a symptom in Parkinsons Disease (PD) patients that negatively impacts their productivity and quality of life. There is a need for external cues
to aid PD patients to overcome this freezing phenomenon. Integrating biofeedback with monitoring devices will improve their
self-efcacy in going about their daily activities. This paper
presents a real-time PD monitoring and biofeedback system
using low-cost wearable sensors (e.g. accelerometers, gyroscope
and magnetic compass). The gait monitoring system that is able
to process real-time captured sensory data and detect FOG,
then triggering audio and vibration biofeedback to prevent or
reduce freezing. The systems FOG detection algorithm uses
time frequency analysis and kinematic parameters from gait
signals. The system is easy to use, low cost and maximises
battery life. Experimental trial runs on PD patients demonstrate
the feasibility of the proposed system.

I. I NTRODUCTION
A Singapore local population-based epidemiological study
showed that in every 1000 individuals aged 50 years and
above, 3 would be suffering from Parkinsons Disease (PD)
[1] with signicant impact on the quality of life for patients
and their families [2]. PD exerts a considerable economic
burden with a total societal cost of approximately SGD 2646 million per annum in Singapore [3]. Majority of the
annual total cost is due to productivity loss as a result of sick
leave, early retirement, and reduced salary. There is thus an
urgent need to develop effective treatment strategies to help
patients return to higher productivity level and to lead a better
quality of life. PD patients are referred to physiotherapists
early in the course of their disease to encourage regular
exercises to maintain joint mobility and exibility. Therefore,
it is important and urgent to develop effective treatment
strategies to help patients return to higher productivity levels,
and to lead a better quality of life. Fortunately, with early
intervention strategies and a good rehabilitation programme,
many PD patients in the early and moderate stages can often
remain economically productive. The challenge, however, is
the ability to deliver the appropriate care early to PD patients
in the community, and to encourage compliance to treatment
and rehabilitation strategies.
Freezing of gait (FOG) is a paroxysmal locomotive gait
disturbance observed in PD. FOG has three types of manifestations that can be distinguished by festination; small
SC Yen, A Tay, SW Phan, and K Yogaprakash are with the Department
of Electrical and Computer Engineering, National University of Singapore
(NUS).
PY Lee and CY Wang were with the Department of Electrical and
Computer Engineering, NUS.
WL Au is with the Department of Neurology, National Neuroscience
Institute
S Liew is with the Department of Physiotherapy, Tan Tock Seng Hospital
1 Email: eletaya at nus.edu.sg

978-1-4799-7862-5/15/$31.00 2015 IEEE

shufing steps with minimal forward movement, some leg

trembling but no forward movement and complete akinesia
which has no observable movement of legs [4]. FOG can
occur anytime, at the beginning or in the middle of motion,
before, during and after turns and in narrow spaces. Some
studies use dual tasking like additional verbal cognitive tasks
as distraction to bring out FOG. Patients in advanced stages
of PD have a greater risk of having freezing episodes [5].
FOG can be one of the factors that may even force PD
patients to choose to use a wheel-chair or limit daily activities
and stay at home. Caregivers are often the ones who shoulder
the responsibility of taking care of PD patients, which can
be strenuous and limit productivity. Hence, it is imperative
to leverage on the ability of smart technology to benet PD
patients, their caregivers and therapists.
Currently, there is signicant research interest in the use
of objective and quantitative measures to document the
various forms of abnormal movements, so that assessment
and evaluation may be performed using a common metric
[6]. Researchers have explored the use of gyroscopes and
accelerometers to quantify tremor and bradykinesia [7],
[8], and surface electromyography (sEMG) to objectively
quantify rigidity [9]. Adoption of these technologies to
quantify abnormal movements has been slow, partly due to
the use of bulky, expensive, and wired equipment that is
highly uncomfortable and not suitable for home use. The
wired equipment may obstruct and hinder normal movement,
and affect the analysis of gait and balance. The weight
of the bulky sensing devices may also interfere with limb
movements and control. Recent technological development
has made it possible to purchase commercial wireless sensing
devices, such as Kinesia (Cleveland Medical Devices, Inc,
OH, USA) for the measurement of tremor and bradykinesia
in the upper limbs, and GAITRite (CIR Systems Inc, PA,
USA) to measure gait. However, these systems are expensive
and not easy to integrate together, and denitely not suitable
for home use. To date, there is no single device that allows
clinicians to monitor all the different movement parameters
at the same time. There is also a lack of a portable monitoring
cum feedback device to aid PD patients in their motor
control and balance. It is thus clear that the ability to
incorporate biofeedback cues to wearable monitoring devices
will denitely aid PD patients to a greater extent, since
PD patients learn better through external cues [10], [11].
Although wearable technology has advanced signicantly
over the past couple of years, a recent review showed that
most of these systems still have bulky sensors and on-board
hardware [12].
In this work, our objective is to develop a wearable

Fig. 1.

Prototype sensor module consisting of microprocessor, sensors, and local storage modules and corresponding strap.

wireless PD monitoring and biofeedback system to address

the above issues. Each of the wearable device consists of a
core set of different sensors (e.g. accelerometer, gyroscope,
compass, ex-sensors, etc) and accompanying electronic
components that utilize radio technology (e.g. Bluetooth,
Wi) to transmit data wirelessly to a computer. The separation allows for new sensors to be integrated into the network
easily. The proposed PD biofeedback system prototype, a
wearable gait monitoring system, is able to process realtime captured sensory data and capture FOG events, and then
trigger audio and vibration biofeedback to prevent or reduce
freezing when FOG has occurred. The systems adaptive
gyroscope-based FOG detection algorithm uses automated
temporal gait analysis using wearable wireless sensors. The
inclusion of local storage capability of critical data also
means that the PD patients can use the system on the go,
not limited to wireless communication distance. By using
this system, PD patients will be more aware of their risk of
falling and also benet from the periodic cueing to pace their
steps after an FOG occurrence, hence improve their quality
of life. The system is highly mobile and hands-free, which
allows the patient to walk freely for long periods of time and
distance.
This paper is organised as follows. In Section II, we
described in detailed the wearable wireless devices. Experimental trial runs and discussion are presented in Section III
followed by conclusion in Section IV.

the system also includes local storage which means that the
table or PC can be removed. The system runs on rechargeable
lithium-ion batteries that are completely embedded inside the
wearable package, each charge can last up to 8 hours with
continuous data transmission at a rate of 50Hz. Each sensor
node weighs 15 grams, which is much lighter than most
systems reported in the literature [8].

Fig. 2.

Locating where wearable sensors are mounted.

II. W EARABLE W IRELESS PD M ONITORING S YSTEM

The prototype of the PD monitoring device has been
developed as shown in Figure 1. The PD monitoring device
consists of multiple wireless wearable sensors that can be
attached to different parts of the body. Figure 2 shows
the location where the sensors are mounted. Each of these
wireless wearable sensors consists of a microcontroller, a
wireless module for data transmission to a data-logging
device, and various motion sensors. The motion sensors
used include a 3-axis accelerometer, a 3-axis gyroscope,
and a 3-axis digital compass. The separation of the sensor
and communication modules allows for new sensors to be
integrated into the network easily. The data from multiple
radio modules are then transmitted wirelessly to the tablet
or PC for further processing and analysis. This version of

A. Sensors
The Inertial Measurement Units (IMUs) are integrated
with a microcontroller in a Printed Circuit Board (PCB).
The main components of the PCB include: an BMA180
accelerometer, a ITG3200 gyroscope, and an ATMEGA328
microcontroller. The accelerometer used is BMA 180, which
is a digital ultra-high-performance, low-g acceleration sensor
with tri-axial readings. It has 7 programmable g-ranges from
1g to 16g and build-in internal lters. It is set to have
conguration of 1.5g range with 1200Hz low-pass lters
and 12 bits output for this work. The accelerometer is
mainly used to monitor the body posture of the patients
during a range of exercises, such as Time Up and Go
(TUG) and Sit-to-Stand (STS) exercises. The reliability of

the sensor readings has been validated previously in [13];

the integrated sensor was compared and analyzed against a
commercial product, the Kinesia system. The Kinesia system
is developed by the Great Lake Neurotechnologies.
The PD biofeedback system has to continuously capture
the orientation and movement of the lower body limbs during
gait monitoring. The information captured would then have
to be interpreted to determine the gait phase each instant. It
would detect indicators of FOG and occurrences of FOG.
When this happens, a Bluetooth packet is sent to trigger
a buzzer. A log of the past 5 seconds of data leading up
to FOG is stored onto non-volatile local storage. A mute
button is available to toggle biofeedback manually. After
usage, an application is used to pull the information stored
sensor information from local storage and generate plots of
the angular velocity over time.
A basic three layer architecture is used. Application layer,
sensor layer and input layer. This ensures modularization of
the system, allowing each layer to concentrate on its own
responsibility. Modularization makes it possible for the same
sensor layer and input layer to be used another separate
application such as Home Rehabilitation.
Local Storage: The FRAM FM25H20 is a 2-megabit
nonvolatile memory. A ferroelectric random access memory
(FRAM) performs read and write operations like a RAM
at bus speed. FRAM exhibits lower power consumption than
Serial Flash. These capabilities make it ideal as it can handle
frequent or rapid writes with low power operation. FRAM
has 3,000 times less power consumption than a typical serial
EEPROM device such as the 25LC1024, as well as nearly
500 times the write speed at 25 megahertz (MHz). The
signicant power savings come from the fast write speeds.
Unlike other non-volatile storage options, there is no waiting
for writes to nish and hence no data polling. FRAM has
10,000 times greater endurance. Signal transmission between
the sensors and from the sensors to the tablet/PC is via
Bluetooth Low Energy (BLE).
The LocalStorage class provides both basic API for read
and write operations as well as high level methods to transfer
over data from one FRAM to another and to retrieve the latest
sensor data stored. The LocalStorage class is initialised by
the main class and is continuously called at the rate of 80Hz
to write each sample of sensor data into the buffer FRAM0.
Whenever a FOG event is detected, a method is called to
transfer over the past 5 seconds of data into a record.
When the sensor node is connected to a PC, the PC will
initiate a connection and the main class will read from the
FRAMs directly and send via Bluetooth Low Energy over to
the PC application.

Fig. 4.

Normal subject left leg gyroscope gait data plot

stumbles. Figure 3 illustrates the sequence of events in a

gait cycle.
The swing phase produces peaks in gyroscope z-axis as
the leg experiences the maximum angular velocity at that
instant. The peak detection algorithm lters out noise below
50 rad/s. Multiple peaks (jagged tooth) where there should
only be one peak will be ltered by comparing the time of
occurrence.
Both toe off and heel strike events produce troughs in gyroscope z-axis as the leg experiences the maximum negative
angular velocity at that instance of push off or touch down
to the ground. In Figure 4, there are two and a half normal
gait cycles. The absolute value of toe off and heel strike
are signicantly lower than the value of the swing angular
velocity. Toe off angular velocity is generally slightly lower
than the heel strike angular velocity, but it is not safe to
assume that it is always so.
By denition, a toe off event precedes the next swing
event. However, since this is a causal algorithm, the future
values cannot be known at current time. Waiting for the next
peak to occur will be too late to identify the trough as a
toe off. Therefore, to differentiate between toe off and heel
strike events in real time, the time difference between the
trough detected and the previous swing is used to determine
if it is a heel strike or toe off. Figure 4 marks out t1 , t2 and
t3 , which are the time differences between swing, heel strike
and toe off.
In Equations 1 and 2, x, y are constants in milliseconds to
determine the window of time to detect for a heel strike and
toe off respectively. It varies for each patient as each walks
at a different speed.

B. FOG Detection

t1 = theel-strike tswing ,

Within one gait cycle, each leg goes through a swing phase
and a stance phase. Heel strike is the instance from swing to
stance phase and toe off is the instance from stance to swing
phase.
Tracking each of these transitions on both legs helps
to quickly pinpoint the phase where the patient freezes or

t2 = ttoe-off tswing ,

t1 < x

(1)

t2 < x + y

(2)

The algorithm aims to detect two specic characteristics

of FOG. Firstly, complete freezing when a certain amount
of time has passed and no forward movement is detected.
Secondly, insufcient forward movement when the angular

Fig. 3.

Gait cycle[15]

velocity detected falls below the threshold. This is when the

patient appears to be stumbling or trembling while moving
forward.
The algorithm constantly updates the average stride time
and the threshold levels to adapt to the patients gait. The
average stride time helps to determine the acceptable range
of timing to wait for the next gait phase. Slower or faster
walkers will be accommodated dynamically.
1) Stride Time measurement: Stride time is the time taken
between the successive points of contact on the ground of the
same foot. Given the timestamp for each data, the stride time
can be calculated using the time difference between each
legs swing detected. The stride time is useful for setting the
pace of biofeedback signals. It is measured in milliseconds.
2) Thresholds: For swing, toe off and heel strike event
detection, a threshold value is maintained for each of them.
Using mean and standard deviation of the peak angular
velocities, the threshold can increase or decrease. Equations
3 to calculate the next threshold each time. Constant k is
used to adjust the sensitivity of threshold.
x
=

N
1 
xi
N i=0



N
1 
(xi x
)2
=
N i=0
T hreshold = x k

(3)

(4)
(5)

III. C LINCIAL DATA AND D ISCUSSIONS

A. Participants
From end 2013 to March 2014, 8 PD patients (TRP004
- TRP011), under their signed consent, had their gait data
collected at NNI clinic using the PD logger system streamed
to an iPad. 2 PD patients did not freeze during the whole
session (TRP008, TRP009). Out of 8 patients, 5 showed
freezing during either TUG, 10 metre walk or free non-timed

walk (TRP004 - TRP007, TRP010). The types of FOG events

that occurred include: Turning, Dual tasking, Approaching
target, Gait starting, Walking straight and Obstacles.
B. Data Analysis
For advanced stage PD patients, most of the FOG events
occur close to each other, and do not fully recover speed
before the next FOG. The FOG events of interest are those
where normal gait at full speed precedes FOG. Figure 5 and
Figure III-B are two examples of the targeted type of FOG
events.
The data plots show a trend that within 1 or 2 steps
before the FOG episode, the value of angular velocity
decreases proportionally. In a threshold model of detection,
the algorithm would ideally detect the decrease in angular
velocity before the FOG occurs within 1 or 2 steps.
1) Time analysis of Gait phases: The time taken for each
gait phase transition is observed in Patient TRP004 and
TRP005. The objective is to determine if there is a time
characteristic of 2 gait cycles before leading up to a FOG
event. Table I lists out the different gait phase transitions and
the number assigned to each transition.
In Figure 7 and Figure 8, the normal gait transition times
are plotted against the average of the normal gait and the preFOG gait transition times. Patient TRP004 has a slower gait
than TRP005, and has a degree of asymmetry as well. This
is conrmed in the video recordings. In both cases, two gait
cycles at the onset of freezing either fell below the average
or slightly above.
The number of freezing events captured are not significant enough to make a correlation, however the results
are consistent with the ndings from Nieuwboer et al. [16]
who concluded that the stride characteristics of the onset
of freezing showed severe and cumulative loss of stride
length on top of greatly accelerated cadence consistent with
hastening.
2) Gait Phase Sequence: The normal gait phase sequence
is as follows: Left toe off, left swing, left heel strike, right

Fig. 5.

PD Patient TRP004 with FOG at 257s while approaching target

Fig. 6.

PD Patient TRP005 with FOG at 41s

TABLE I
N UMBERING OF G AIT P HASES
Phase Before
Left Toe Off
Left Swing
Left Heel Strike
Right Toe Off
Right Swing
Right Heel Strike

Phase After
Left Swing
Left Heel Strike
Right Toe Off
Right Swing
Right Heel Strike
Left Toe Off

Type
1
2
3
4
5
6

toe off, right swing, right heel strike. TRP005 gait phase
sequence detected from 38 seconds to 44 seconds are listed in
Table II. FOG occurs at 40 seconds. Between 38191 to 38447
milliseconds and 43833 to 44259 milliseconds onwards, the
gait sequence is in the right order. From 39100 to 43833
milliseconds, the gait phase detected are only toe off events.
The angular velocity of those toe off events range from -940
to -1495 rad/s, more than half compared to average toe off

Fig. 7. Box Plot: Time taken for each gait phase transition for patient
TRP004

R EFERENCES

Fig. 8. Box Plot: Time taken for each gait phase transition for patient
TRP005

angular velocity -3120 rad/s. In the video recorded, TRP005

at that moment experienced FOG and was unable to fully
lift his foot off from the ground, experiencing leg tremoring.
TABLE II
TRP005 G AIT PHASE SEQUENCE AT 38 S
Leg
Left
Left
Left
Right
Right
Right
Right
Left
Right
Right
Right

Time (ms)
38191
38361
38447
39100
39782
41744
42340
42455
43833
44046
44259

Gyro[2]
-1251
3110
-1722
-1495
-1188
-976
-1011
-940
-2145
3411
-1026

Phase
toe off
swing
heel strike
toe off
toe off*
toe off*
toe off*
toe off*
toe off
swing
heel strike

IV. C ONCLUSIONS
In this paper, we report preliminary work on the Parkinson
Disease Monitoring and Biofeedback system. Experimental
trial runs on PD patients demonstrate promising results. The
low cost wearable wireless sensor nodes incorporate triaxial accelerometer, gyroscope and magnetic compass. The
prototype system includes two integrated sensors located at
each ankle position to track gait movements. The system
includes local storage capability which is useful for FOG
detection when patients are outside the home and clinic
environment. Using this system, PD patients will be more
aware of their risk of falling and also benet from the
periodic cueing to pace their steps after an FOG occurrence,
hence improve their gait performance.
ACKNOWLEDGMENT
SC Yen and A Tay would like to thank all students
from the Department of Electrical and Computer Engineering
at NUS that have contributed to this project. The authors
acknowledge the funding support from NUS and NNI.

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