Case history
Case history #1
A 64-year-old man presents for evaluation of gait problems. He has experienced several unexpected falls over the past 2 years. He has trouble finding a cause for the falls and reports that he has not been tripping, feeling dizzy, or having vertigo symptoms. He feels stiffness in his neck, back, and shoulders. His partner explains that the patient also seems to have 'slowed down' in terms of his cognitive ability and movement speed. He does not seem interested in doing things he enjoyed. His partner has also noticed that the patient’s speech has changed, becoming distorted and quieter. During the neurological examination, you notice that the patient's vertical saccades are slower than his horizontal eye movements. He lacks optokinetic nystagmus. Prominent and symmetrical axial rigidity is noticed. The patient's gait is normal, but he promptly loses his balance when you perform the pull test. He appears to fall into the chair rather than sitting down in a deliberate and orderly manner. Speech is dysarthric. Brain MRI shows atrophy in the midbrain region.
Case history #2
A 55-year-old patient comes to follow up on his diagnosis of Parkinson's disease (PD). He has recently moved into the area after having to retire early from his job as a sales manager. His recent PD diagnosis was due to walking and movement problems over the past 3-4 years. He is taking the recommended dose of levodopa/carbidopa three times daily and reports that it only minimally improves his symptoms. About 4 years ago, he first noticed problems in finding words. His writing became sloppy, and he also had problems reading. His wife also noticed slowness in gait with mild shuffling. During the past 2 years, he has had increasing difficulties with walking and feels more fatigued and imbalanced. He fell once 2 months ago and hit his back when trying to carry a box. Cognitively, he reports difficulty doing mental calculations that used to be very easy for him and he has had to ask his wife to help him with planning his travels. More recently, his wife feels that his voice has become softer and slower, and tasks such as dressing and eating take longer for him. In the last few months, he has frequently been coughing on swallowing liquids. His wife is concerned that he might have developed depression because he seems less interested in his usual hobbies and prefers to spend time watching TV. On examination, masked facies is apparent and vertical eye movements are limited but improve with the doll’s head manoeuvre. The patient has non-fluent aphasia and executive dysfunction. There is moderate rigidity on the neck and mild rigidity on both hands. His gait is wide-based with small steps. He loses balance and falls back on the pull test. A recent brain MRI shows no abnormality.
Other presentations
The presentation of PSP can vary according to the phenotypic subtype of the condition, although most patients will develop the typical features of PSP-Richardson’s syndrome (PSP-RS) as the condition progresses. See Diagnosis approach.
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