Axial motor clues to identify atypical parkinsonism: A multicentre European cohort study

Carlijn D.J.M. Borm, Florian Krismer, Gregor K. Wenning, Klaus Seppi, Werner Poewe, Maria Teresa Pellecchia, Paolo Barone, Erik L. Johnsen, Karen Østergaard, Tanya Gurevich, Ruth Djaldetti, Luisa Sambati, Pietro Cortelli, Igor Petrović, Vladimir S. Kostić, Hana Brožová, Evžen Růžička, Maria Jose Marti, Eduardo Tolosa, Margherita Canesi, Bart Post, Jorik Nonnekes, Bastiaan R. Bloem, Maria Stamelou, Vladimir S. Kostic, Thomas Klockgether, Richard Dodel, Michael Abele, Wassilios Meissner, Heinz Reichmann, Tim Lynch, Jaroslaw Slawek, Mag Klaus Seppi, Daniela Berg, Joaquim Ferreira, Henry Houlden, Niall P. Quinn, Håkan Widner, Alexander Gerhard, Karla Maria Eggert, Alberto Albanese, Francesca del Sorbo, Maria T. Pellecchia, Bas Bloem, Carlijn Borm, Alfredo Berardelli, Carlo Colosimo, Jose Berciano, Latchezar Traykov, Nir Giladi, Olivier Rascol, Monique Galitzky, Thomas Gasser
Parkinsonism & Related Disorders. 2018-11-01; 56: 33-40
DOI: 10.1016/j.parkreldis.2018.06.015

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Borm CDJM(1), Krismer F(2), Wenning GK(2), Seppi K(2), Poewe W(2), Pellecchia MT(3), Barone P(3), Johnsen EL(4), Østergaard K(4), Gurevich T(5), Djaldetti
R(6), Sambati L(7), Cortelli P(7), Petrović I(8), Kostić VS(9), Brožová H(10), Růžička E(10), Marti MJ(11), Tolosa E(12), Canesi M(12), Post B(1), Nonnekes J(13), Bloem BR(14); European MSA Study Group (EMSA-SG).

Collaborators: Østergaard K(15), Stamelou M(16), Tolosa E(17), Kostic VS(18), Cortelli P(19), Klockgether T(20), Dodel R(20), Abele M(20), Meissner W(21), Reichmann H(22), Lynch T(23), Slawek J(24), Poewe W(25), Wenning GK(25), Klaus Seppi M(25), Krismer F(25), Berg D(26), Ferreira J(27), Houlden H(28), Quinn NP(28), Widner H(29), Gerhard A(30), Eggert KM(31), Albanese A(32), Sorbo FD(32), Barone P(33), Pellecchia MT(33), Bloem B(34), Borm C(34), Djaldetti R(35), Berardelli A(36), Colosimo C(37), Berciano J(38), Traykov L(39), Giladi N(40), Gurevich T(40), Rascol O(40), Galitzky M(41), Gasser T(42).

Author information:
(1)Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Parkinson Centre Nijmegen (ParC) Nijmegen, The Netherlands.
(2)Department of Neurology, Medical University Innsbruck, Austria.
(3)Centre for Neurodegenerative Diseases, Department of Medicine and Surgery, University of Salerno, Italy.
(4)Department of Neurology, University Hospital, Aarhus, Denmark.
(5)Neurological Institute, Tel-Aviv Sourasky Medical Centre, Tel Aviv, Israel.
(6)Department of Neurology, Rabin Medical Centre, Petach-Tiqva, Israel.
(7)IRCCS Institute of Neurological Sciences of Bologna and Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
(8)Institute of Neurology, Clinical Centre of Serbia, Belgrade, Serbia.
(9)Institute of Neurology, Clinical Centre of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
(10)Department of Neurology and Centre of Clinical Neuroscience Charles
University in Prague, Czech Republic.
(11)Neurology Service, Hospital Clínic Universitari, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain.
(12)Department of Neurology, Parkinson Centre Milano, Italy.
(13)Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, The Netherlands.
(14)Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Parkinson Centre Nijmegen (ParC) Nijmegen, The Netherlands. Electronic address: .
(15)Aarhus, Denmark.
(16)Athens, Greece.
(17)Barcelona, Spain.
(18)Belgrade, Serbia.
(19)Bologna, Italy.
(20)Bonn, Germany.
(21)Bordeaux, France.
(22)Dresden, Germany.
(23)Dublin, Ireland.
(24)Gdansk, Poland.
(25)Innsbruck, Austria.
(26)Kiel, Germany.
(27)Lisbon, Portugal.
(28)London, United Kingdom.
(29)Lund, Sweden.
(30)Manchester, United Kingdom.
(31)Marburg, Germany.
(32)Milan, Italy.
(33)Naples, Italy.
(34)Nijmegen, The Netherlands.
(35)Petach- Tiqva, Israel.
(36)IRCCS Neuromed, Pozzilli, IS, Italy; IRCCS Neuromed, Pozzilli, IS, Italy.
(37)Rome, Italy.
(38)Santander, Spain.
(39)Sofia, Bulgaria.
(40)Tel-Aviv, Israel.
(41)Toulouse, France.
(42)Tübingen, Germany.


Differentiating Parkinson’s disease (PD) from atypical parkinsonian disorders (APD) such as Multiple System Atrophy, parkinsonian type (MSA-p) or Progressive Supranuclear Palsy (PSP-RS) can be challenging. Early signs of postural Instability and gait disability (PIGD) are considered clues that may signal presence of APD. However, it remains unknown which PIGD test – or combination of tests – can best distinguish PD from APD. We evaluated the discriminative value of several widely-used PIGD tests, and aimed to develop a short PIGD evaluation that can discriminate parkinsonian disorders.


In this multicentre cohort study patients were recruited by 11 European MSA Study sites. Patients were diagnosed using standardized criteria. Postural instability and gait disability was evaluated using interviews and several clinical tests.


Nineteen PD, 21 MSA-p and 25 PSP-RS patients were recruited. PIGD was more common in APD compared to PD. There was no significant difference in axial symptoms between PSP-RS and MSA-p, except for self-reported falls (more frequent in PSP-RS patients). The test with the greatest discriminative power to distinguish APD from PD was the ability to perform tandem gait (AUC 0.83; 95% CI 71-94; p < 0.001), followed by the retropulsion test (AUC 0.8; 95% CI 0.69-0.91; p < 0.001) and timed-up-and-go test (TUG) (AUC 0.77; 95% CI 0.64-0.9; p = 0.001). The combination of these three tests yielded highest diagnostic accuracy (AUC 0.96; 95% CI 0.92-1.0; p < 0.001).


Our study suggests that simple “bedside” PIGD tests – particularly the combination of tandem gait performance, TUG and retropulsion test – can discriminate APD from PD.

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