The case of the freezing man

CASE PRESENTATION A 78-year-old man was referred for ‘trouble walking’ and difficulty ‘getting started’. On the background of excellent health, his gait disorder had begun insidiously 5 years before presentation. The first neurologist suspected Parkinson’s disease, but there was no improvement with antiparkinsonian medications. A second neurologist considered normal pressure hydrocephalus. The first of several spinal taps offered slight improvement, but not subsequent lumbar punctures. There was never an abrupt change to suggest a stroke. The patient had noticed that it was easier to get started with a visual cue such as stepping over a special bar added to the bottom of his cane, or holding the cane upside down and stepping over the handle. He occasionally used a motorized cart. He reported slight loss of dexterity in the upper limbs. There was no cognitive impairment. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed mild age-appropriate atrophy without hydrocephalus or significant signal changes in the white matter. Cervical MRI showed degenerative changes without canal stenosis.