Variability in pull test (PT) performance can lead to inadequate evaluation of postural instability in patients with Parkinson's disease (PD). Assessing 66 PTs by 25 examiners, at least two of four raters agreed that specific items were performed incorrectly for stance in 27.3%, for strength and briskness of the pull in 84.9%, for examiner's response in 36.4%, and for technique issues in 9.1%. Examiners were consistent in their errors, and only 9% of examinations were error-free.

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Parkinsonism is a rare neurological complication of cancer treatment. Although individual case reports of this syndrome have been reported, the clinical features and prevalence of this syndrome are unknown. We present 3 patients, encountered over 6 months at one institution, who developed parkinsonism after treatment with various chemotherapeutic agents. Parkinsonism was severe in 2 patients, affecting postural reflexes, speech, and swallowing. All 3 patients responded dramatically to treatment with levodopa, and parkinsonism spontaneously improved or remitted over months. This unusual complication of cancer therapy is treatable and may be underappreciated.

Sirs: While the precise localization of the primary pathology in essential tremor (ET) is unknown, the inferior olive and cerebellar-thalamic-cortical loops have been implicated in the pathogenesis of this disorder [1][2][3][4]. Confirmation of the involvement of several of these structures comes from the stroke literature, where acute lesions in the cerebellum [5] and thalamus [6][7][8][9] have been reported to result in the unilateral resolution of tremor in ET cases. In addition, surgical lesions such as ventrolateral thalamotomy have proven to be effective in alleviating contralateral tremor in patients with ET [10]. Although the terminal portion of the abnormal cerebellar-thalamic-cortical loops in ET are thought to be in the sensorimotor cortex, and more specifically, the frontal lobes, we know of no published case reports that demonstrate the cessation of ET after a hemispheric stroke. We present a patient with a large area of damage in the right hemisphere that resulted from two infarcts. His tremor unilaterally disappeared in the contralateral arm after the second infarct.The patient is a 75 year old right-handed retired dentist with an action tremor. His mother had had hand tremors. He first noticed a mild bilateral action tremor at age 45 years while performing dental work. By age 50, the tremor had become more apparent while writing, eating and drinking; however, he continued to work as a dentist. He did not take medications to control the tremor.At age 61, he acutely developed mild left hemiparesis, involving the arm more than leg. He was hospitalized and placed on intravenous heparin and received in-patient physical therapy. At the time of hospital discharge two weeks later, he had regained almost complete strength in his left arm and leg (Medical Research Council, MRC score = 5 -out of 5), but had mild functional compromise in the left arm. As a result, he ceased his activities as a dentist. Computed tomography (CT) from this hospitalization is not available for review, but a note in the hospital chart reported a "right frontal cerebral infarct". The severity of his tremor did not change after this stroke. Over the ensuing two years, the hand tremor worsened. At age 63, he developed acute mild weakness in the left leg with weakness and a cessation of action tremor in the left arm. The tremor in the right hand remained unchanged. The CT report from the day of the event revealed a large area of decreased attenuation in the right frontal cortex that extended into the adjacent parietal and temporal cortices. The films are currently unavailable for review. With intensive in-patient physical therapy over the ensuing month, he regained his ability to walk and only partially recovered strength and function in his left arm and hand. Over the ensuing two years, his left arm tremor did not re-appear, but his right arm action tremor continued to worsen.At age 65, he was examined by us at the Center for Parkinson's Disease and Other Movement Disorders at Columbia Presbyterian Medical Center. He was alert and ...