BACKGROUND: Freezing of gait (FOG) is a disabling feature of Parkinsons disease (PD). Although physical practice (PP) improves gait, maintaining gains remains challenging. Mental practice (MP), including Dynamic Neuro-Cognitive Imagery (DNI), may enhance gait control, but evidence on remote combined interventions is limited. PURPOSE: To investigate whether adding MP grounded in DNI principles to remote physical practice supports greater and more sustained improvements than remote physical practice alone in people with PD and FOG. METHODS: A prospective, single-blind, parallel-group randomized controlled trial was conducted. Forty-three participants with idiopathic PD and FOG were randomized to an experimental group (EG, n = 20) or control group (CG, n = 23), stratified by cognitive performance. Both groups received 10 remote sessions over 6 weeks. All performed structured physical practice targeting gait components; the EG additionally performed MP based on DNI, while the CG performed time-matched seated stretching. Assessments were conducted at baseline (BI), post-intervention (AI), and 30-day follow-up (FU). The primary outcome was Rapid Turns Test performance; secondary outcomes included FOG severity, motor aspects of daily living, mobility-related quality of life, and global cognition. RESULTS: All randomized participants were included in intention-to-treat analyses; 38 completed all assessments. Significant group and time interactions were found for Rapid Turns Test duration (p = 0.0019) and FOG time (p = 0.0108). Both groups improved short-term, but only the EG maintained gains at follow-up. Additional interactions favored the EG for mobility-related quality of life (p = 0.001) and global cognition (p = 0.0018). Self-reported FOG improved over time in both groups (p < 0.001) without between-group differences, while motor aspects of daily living showed a time effect only (p = 0.001). CONCLUSION: MP based on DNI principles may enhance retention of gains when combined with remote physical practice, supporting its use as an adjunct in FOG rehabilitation.

The authors have declared no competing interest.

NCT06957405

https://www.medrxiv.org/content/10.1101/2025.04.28.25326452v1.article-metrics

The study was supported by Sao Paulo Research Foundation (FAPESP) through the Research, Innovation and Dissemination Center for Neuromathematics (CEPID NeuroMat, grant number 2013/07699-0 and individual support by FAPESP for the author PRS by grant number 2025/14403-7.

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The study was approved by the Research Ethics Committee of the School of Medicine of the University of Sao Paulo under protocol number 7.253.458.

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