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• Response to Torres et al
  Bastiaan R Bloem, Rui Araújo, Bart P van de Warrenburg, Anthony E Lang and Andrew J Lees
  Published on: 11 July 2019
• Outside The Waiting Room
  Sergio A Castillo-Torres, Fernanda Flores-Alfaro and Ingrid Estrada-Bellmann
  Published on: 11 July 2019

• Published on: 11 July 2019

  Response to Torres et al

  • Bastiaan R Bloem, MD, PhD Radboud university medical centre
  • Other Contributors:
    • Rui Araújo, MD
    • Bart P van de Warrenburg, MD, PhD
    • Anthony E Lang, MD, FRCPC.
    • Andrew J Lees, MD, FRCP, FMedSci.

  We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available v...

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  We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available video materials of these individuals. An exception could be made for patients who are already part of one’s own clinic, and where a fortunate observation of e.g. this person’s gait outside the hospital may offer additional value to what can be noted within the hospital itself. For example, cobbled stones on the street can elicit occasional stumbles that might be missed on the perfectly even hospital floors. We also find it illustrative to see how difficult it can be for patients to step outside of their car (seats are usually very low, causing great problems for patients with Parkinson’s disease or proximal leg weakness). Finally, we have seen patients manifesting freezing of gait only when they approached the revolving doors of the hospital – these can be a great challenge for people with Parkinson's.

  Bastiaan R. Bloem, MD, PhD. (corresponding author)
  Radboud university medical centre
  Donders Institute for Brain, Cognition and Behaviour
  Department of Neurology
  Nijmegen, the Netherlands
  bas.bloem@radboudumc.nl
  
  Rui Araújo, MD.
  Neurology Department, Centro Hospitalar e Universitário de Coimbra
  Coimbra, Portugal
  rmma22@gmail.com
  
  Bart P. van de Warrenburg, MD, PhD.
  Radboud university medical centre
  Donders Institute for Brain, Cognition and Behaviour
  Department of Neurology;
  Nijmegen, the Netherlands
  bart.vandewarrenburg@radboudumc.nl
  
  Anthony E. Lang, MD, FRCPC.
  Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J Safra Program in Parkinson’s Disease, Toronto Western Hospital
  399 Bathurst Street, Toronto, Ontario
  lang@uhnresearch.ca
  
  Andrew J. Lees, MD, FRCP, FMedSci.
  National Hospital, Queen Square
  Reta Lila Weston Institute, University College London
   

  Reference

  1. Araujo R, Ferreira JJ, Antonini A, Bloem BR. "Gunslinger's gait": a new cause of unilaterally reduced arm swing. BMJ 2015;351:h6141.

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  Conflict of Interest:
  None declared.

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• Published on: 11 July 2019

  Outside The Waiting Room

  • Sergio A Castillo-Torres, MD Hospital Universitario "Dr. José Eleuterio González”
  • Other Contributors:
    • Fernanda Flores-Alfaro, MD
    • Ingrid Estrada-Bellmann, MD

  As I make my way to the outpatient clinic, late as usual after the morning rounds to start another busy day, an unusual walk in front of me seizes my attention: an elderly lady, with a narrow-based and short-stepped gait, decreased left-arm swing and stooped posture; unable to see her face, I assume she’s heading for the neurology outpatient clinic. Yet she passes by and I lose sight of her on the ophthalmology service. Not a patient of ours, I think to myself. That same night, while having supper at a restaurant with my soon-to-be-wife, I notice a few tables away a man on his seventies celebrating his birthday, surrounded by family. In front of the candle-sparkling birthday cake, I get a glimpse of an unusual face: elevated eyebrows, like on a permanent surprise, unable to direct his gaze to the cake—Procerus sign and vertical gaze paresis—I think to myself, while I notice the stooped posture and global slowness of movements while everyone on the table compliments him—parkinsonism also, definitely progressive supranucl…—“You’re doing that again, leave the man alone.” My train of thought gets wrecked by my fiancee, not being the first time, she knows I tend to distinguish and observe people with abnormal movements. I leave the man alone and finish my supper. -SACT.

  It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurolo...

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  As I make my way to the outpatient clinic, late as usual after the morning rounds to start another busy day, an unusual walk in front of me seizes my attention: an elderly lady, with a narrow-based and short-stepped gait, decreased left-arm swing and stooped posture; unable to see her face, I assume she’s heading for the neurology outpatient clinic. Yet she passes by and I lose sight of her on the ophthalmology service. Not a patient of ours, I think to myself. That same night, while having supper at a restaurant with my soon-to-be-wife, I notice a few tables away a man on his seventies celebrating his birthday, surrounded by family. In front of the candle-sparkling birthday cake, I get a glimpse of an unusual face: elevated eyebrows, like on a permanent surprise, unable to direct his gaze to the cake—Procerus sign and vertical gaze paresis—I think to myself, while I notice the stooped posture and global slowness of movements while everyone on the table compliments him—parkinsonism also, definitely progressive supranucl…—“You’re doing that again, leave the man alone.” My train of thought gets wrecked by my fiancee, not being the first time, she knows I tend to distinguish and observe people with abnormal movements. I leave the man alone and finish my supper. -SACT.

  It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurology(1), where they elaborate on the importance of beginning the neurological examination before the patient enters the doctor's office. An excellent chronicle on many signs that we might have seen but not acknowledged, in a clear and concise manner. However, while reading the article some concerns (unrelated to the quality and value of the article) were brought to our attention. How about outside the clinic or the Hospital?

  Should we approach the gentleman or the lady portrayed in the first two paragraphs by author SACT? For neurologists, particularly for movement disorders specialists, patients can be found everywhere. Should neurologists be observant of the Goldwater rule (2), that prohibits psychiatrists to diagnose a subject they have not personally examined, and to communicate that diagnosis without the subjects consent? Are we then only to observe and describe just like James Parkinson did(3)? We observe as a clinical exercise, to describe phenomenology but we would never approach a person in public to invite them to our clinic, or to give an unsolicited diagnosis; that would be preposterous, we have no right to do so. In ‘Do no harm’, Henry Marsh states that neurologists are like kids looking for “strange and obscure diseases, sometimes untreatable, (...) deeply fascinating, and which they collect like rare butterflies and report in their journals(4)”. Yet we feel this description to be quite unfair because phenomenology might seize our attention, but we must strive to be like the great physician that Sir William Osler envisioned, the one who cares about “the patient who has the disease.”.

  As a general neurology resident, the movement disorders field seems more and more appealing. The fact that even outside the doctor’s office we can start the diagnostic process, prompted one of the authors (SACT) to write the opening paragraphs, based on real-life experiences, in order to ask for the author’s advice on how to approach this situation; and to encourage more residents into neurology and movement disorders, because of the growing pandemic of neurodegenerative disorders like Parkinson’s disease that is calling us into action(5).  

  Acknowledgments: SACT would like to thank Mariana Castillo-Torres (Bachelor in Languages for Interpreting and Translation), for her kind assistance on English-language, editing and style.

  Contributorship Statement: SACT contributed to the conceptual design of the article with the opening paragraphs and drafting of the manuscript. FFA contributed with the drafting of the manuscript, and a review of intellectually relevant content. IEB contributed to article conception and design, drawing from personal experiences, as well as a review for intellectually relevant content. All authors agreed on the final version of the manuscript.

  References

  1. Araujo R, van de Warrenburg B, Lang A, et al. The Waiting Room: neurological observations made outside the movement disorder specialist's consulting office. Pract Neurol 2019 doi: 10.1136/practneurol-2018-002110

  2. Lilienfeld SO, Miller JD, Lynam DR. The Goldwater Rule: Perspectives From, and Implications for, Psychological Science. Perspect Psychol Sci 2018;13(1):3-27. doi: 10.1177/1745691617727864

  3. Kempster PA, Hurwitz B, Lees AJ. A new look at James Parkinson's Essay on the Shaking Palsy. Neurology 2007;69(5):482-5. doi: 10.1212/01.wnl.0000266639.50620.d1

  4. Marsh H. Do no harm: stories of life, death and brain surgery: Hachette UK 2014.

  5. Dorsey ER, Bloem BR. The Parkinson Pandemic-A Call to Action. JAMA Neurol 2018;75(1):9-10. doi: 10.1001/jamaneurol.2017.3299

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  Conflict of Interest:
  None declared.

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