A 69-year-old man was referred for assessment of abnormal gait and posture. For 1 year, he had experienced progressive gait difficulty, characterized by festination and falling to either side. He also described feeling "glued to the ground" on occasion. He complained of tremor with action (particularly writing), hypophonia, and slight slurring of speech. He admitted to frequent inappropriate crying and laughter, urinary frequency and urgency, and severe constipation. He denied postural lightheadedness. His wife described slowness in responding to questions and mild memory difficulty. Six months prior to his initial assessment, he described an episode of sudden deterioration in his ambulation with incomplete recovery; other than this his symptoms had been slowly progressive. At the time of assessment he was unable to walk without assistance, and used a walker.Past medical history included "borderline" hypertension which was untreated, Type II diabetes mellitus diagnosed five years previously, hypothyroidism, and benign prostatic hypertrophy. He had smoked a pack of cigarettes daily for the previous 15 years. Current medications were glyburide, thyroxine, and vitamin B12 supplementation.On examination, his blood pressure was 170/100 lying and 155/100 standing. His general examination was otherwise unremarkable. On mental status testing, he was unable to give the date, nor name the clinic which he was visiting. He gave his date of birth as October 28, 1922 rather than October 31. He recalled one of three words at 5 minutes. He demonstrated normal limb praxis, but could not demonstrate how to suck through a straw or blow a kiss.His voice was hypophonic and speech slightly dysarthric. His face was expressionless, without eyelid retraction (see videotape). Jaw jerk was increased, and glabellar tap was positive. Horizontal eye movements were normal aside from saccadic smooth pursuit. Volitional vertical saccades were generated with some difficulty. Up-gaze was moderately diminished in range. Upward fast phases of optokinetic nystagmus (OKN) were absent and downward OKN fast phases were diminished. Cranial nerve examination was otherwise unremarkable.On motor examination, there was axial and bilateral limb rigidity. Bulk and power were normal. Rapid alternating movements were slow, irregular, and of low amplitude bilaterally, but without progressive decomposition. A mild tremor was present, greater with action than posture and absent at rest. Reflexes were pathologically brisk throughout, Hoffman's sign was present bilaterally and plantar responses were upgoing bilaterally. Sensory examination showed only mildly diminished vibration sensation in the distal lower extremities. His posture was markedly flexed, and gait was shuffling, but narrowbased. There was severe postural instability and he was unable to walk without assistance due to falling to either side. Writing was micrographic.A trial of Sinemet, up to 1,000 mg of levodopa daily, provided no benefit. A gradual progression of all symptoms ensued.