BMJ

Confidential: For Review Only

“Gunslin ger’s gait”: a new cause of unilaterally reduced arm swing

Journal: BMJ

Manuscript ID BMJ.2015.029709

Article Type: Christmas

BMJ Journal: BMJ

Date Submitted by the Author: 03-Oct-2015

Complete List of Authors: Araújo, Rui; Centro Hospitalar e Universitário de Coimbra, Neurology Ferreira, Joaquim; Instituto de Medicina Molecular,, Laboratório de Farmacologia Clínica e Terapêutica Antonini, Angelo; Department for Parkinson's disease, IRCCS San Camillo, Via Alberoni 70, Neurology Bloem, Bastiaan; Radboud University Nijmegen Medical Center, The Netherlands, Neurology

Clinical Neurology, Movement Disorders, Gait, Reduced arm-swing, , Keywords: Gunslinger

Note: The following files were submitted by the author for peer review, but cannot be converted to PDF. You must view these files (e.g. movies) online.

Video 1_segment 1_Putin presidential inauguration 2012.3gp Video 1_segment 2_Putin 2005.mov Video 1_segment 3_Putin judo skills.mp4 Video 1_Segment 4_Putin_normal handwriting.mp4 Video 1_segment 5_Putin_fast right hand.mp4 Video 1_segment 6_Putin_weight lifting.mp4 Video 2_segment 1_Medvedev presidential inauguration 2008.3gp Video 2_segment 2_Medvedev_reduced arm swing.mp4 Video 2_segment 3_Medvedev proposing Putin 2011.wmv Video 2_Segment 4_Medvedev_handedness.mp4 Video 3_segment 1_Serdyukov victory day parade 2012.3gp Video 3_segment 2_Serdyukov_reduced arm swing nr 2.mp4

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1 2 3 “Gunslinger’s gait”: a new cause of unilaterally reduced arm swing 4 5

6 Rui Araújo, MD; Joaquim J. Ferreira, MD; Angelo Antonini, MD; Bastiaan R. Bloem, MD, PhD 7 8 Confidential:Rui Araújo, Centro Hospitalar e Universitário For de Co imbra;Review Department of Neurology, Only 9 Coimbra, Portugal 10 11 Joaquim J. Ferreira, Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of 12 Medicine, University of Lisbon, Portugal 13 Angelo Antonini, Department for Parkinson's disease, IRCCS San Camillo, Via Alberoni 70, 14 Venice, Italy 15 Bastiaan R. Bloem, Radboud university medical centre; Donders Institute for Brain, Cognition 16 17 and Behaviour; department of neurology; Nijmegen, the Netherlands 18 19 Title character count: 66 20 Number of references: 29 21 Number of tables: 0 22 Word count abstract: 185 23 24 Word count paper: 3291 25 26 Full names and emails of the authors 27 Rui Araújo, [email protected] 28 Joaquim J. Ferreira, [email protected] 29 Angelo Antonini, [email protected] 30 31 Bastiaan R. Bloem, [email protected] 32 33 Corresponding author: 34 Prof. Bastiaan R. Bloem 35 Department of Neurology (935) 36 37 Radboud university medical centre 38 PO Box 9101, 6500 HB Nijmegen 39 The Netherlands 40 Tel. +31 24 3615 202 41 e-mail: [email protected] 42 43 44 45 Search terms: Clinical Neurology; Gait; Movement Disorders; Arm-swing, Russia 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 12

2 1 Araújo 2 3 Author contribution: 4 Dr Rui Araújo is a resident in neurology. He identified most of the videos and drafted the first version 5 of the manuscript. Joaquim Ferreira is professor of neurology and commented on earlier versions of 6 the manuscript. Angelo Antonini is professor of neurology; he discussed Cases 1-5 with neurologists 7 in Russia, and commented on later versions of the manuscript. Bastiaan R. Bloem is a professor of 8 Confidential:movement disorder neurology. He took the For initiative for Reviewthis manuscript, offered substantialOnly input to 9 early versions of the manuscript, and is the guarantor of the article. Prof. Bloem affirms that the 10 manuscript is an honest, accurate, and transparent account; and that no important aspects have 11 been omitted. 12 13 14 Acknowledgments 15 Prof. Bastiaan R. Bloem was supported by a research grant of the National Parkinson Foundation. Prof.

16 Niall Quinn first identified the absent arm swing in Case 1 and helped revise earlier versions of the 17 manuscript. 18 19 Disclosures 20 BRB has received honoraria from serving on the scientific advisory board for Zambon and Danone, 21 and received research support and grants from The National Parkinson Foundation, the Netherlands 22 Organisation for Scientific Research (NWO), the Michael J Fox Foundation, Prinses Beatrix Spierfonds, 23 Stichting Parkinson Fonds, and Alkemade-Keuls Fonds. AA has received compensation for 24 consultancy and speaker related activities from UCB, Boston Scientific, Boheringer Ingelheim, 25 26 AbbVie, Zambon. AA received research support from Mundipharma, Neureca foundation, the Italian 27 Ministry Research Grant N RF-2009-1530177 and RF-2010-2319551, and Horizon 2020 Program Grant 28 N: 643706. He serves as consultant for Boehringer-Ingelheim for legal cases on pathological 29 gambling. RA and JJF have no conflicts of interest. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 2

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3 1 Araújo 2 3 “Gunslinger’s gait”: a new cause of unilaterally reduced arm swing 4 5 ABSTRACT 6 Objective: A reduced arm swing can be present in a range of medical conditions, such as shoulder 7 pathology, Erb’s palsy or stroke. Reduced arm swing is also a cardinal feature of early Parkinson’s 8 Confidential:disease, and can even be a first presenting signFor of parkinsonism. Review We review video footageOnly on 9 YouTube to introduce a new possible cause of a unilaterally reduced arm swing. 10 Methods: Analysis of YouTube videos depicting the gait of highly ranked Russian officials. 11 Results: We found a comparable walking pattern in Russian President , Prime Minister 12 13 and three other highly ranked Russian officials, all presenting with a consistently 14 reduced right-sided arm swing, in the absence of other overt neurological abnormalities. 15 Conclusions: We propose that this new gait pattern, which we term “gunslinger’s gait”, may result 16 from a behavioural adaptation, possibly triggered by KGB or other forms of weaponry training where 17 trainees are taught to keep their right hand close to the chest while walking, allowing them to quickly 18 draw a gun when faced with a foe. This should be included in the differential diagnosis of a 19 unilaterally reduced arm swing. 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3

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4 1 Araújo 2 3 INTRODUCTION 4 If you ever find yourself in a neurology meeting and notice a group of individuals scrutinizing the way 5 people walk, they are most likely to be movement disorders enthusiasts. Their passion to screen for 6 abnormal walking patterns may even extend to examining YouTube footage, where sometimes 7 remarkable discoveries can be made. 1 We were struck to find several consecutive YouTube 8 Confidential:recordings of Russia’s President Vladimir Putin,For manifesting Review a clearly reduced right sidedOnly arm swing 9 (Video 1, Segment 1 and 2). Putin’s distinct walk has been debated previously, and different theories 10 emerged, ranging from Erb’s palsy to intrauterine stroke. 4 Both can be discarded in light of Putin’s 11 excellent physical skills – he is a judo black belt and well-trained in martial arts ( Video 1, Segment 3 ). 5 12 13 For movement disorders experts like us, the first – and admittedly biased – diagnosis that comes to 14 mind is that of Parkinson’s disease (PD), where an asymmetrically reduced arm swing is a distinct 2 15 feature. In fact, it can be the earliest presenting sign of PD, as was demonstrated by video reviews of 16 football games played by the legendary English midfielder Ray Kennedy; original footage showed an 17 asymmetrically reduced arm swing, even at the time when Kennedy played elite football; only later 18 this turned out to be the presenting sign of his PD. 3 The topic of early “preclinical” PD is now a 19 subject of a lively debate in the literature. 4-6 It is becoming clear that many symptoms and signs (e.g. 20 constipation, or a reduced smell) can precede overt PD, and this includes a reduced arm swing on 21 one side. Indeed, an asymmetrically reduced arm swing can be an early sign in otherwise clinically 22 intact subjects with a predisposition to later develop PD. 7 Such observations raised a debate among 23 us whether President Putin might possibly also be in a very early stage of PD, even in the absence of 24 other obviously suggestive features. However, further review of additional YouTube footage revealed 25 26 an alternative and more likely explanation, which we present here as a new cause of a reduced arm 27 swing during walking. 28 29 METHODS 30 In our search for possible explanations, we encountered a training manual of the former Russian 31 KGB. 8 According to this manual, KGB operatives were instructed to keep their weapon in their right 32 hand close to their chest, and to move forward with one side, usually the left, presumably allowing 33 subjects to draw the gun as quickly as possible when confronted with a foe. Indeed, under “Chapter 2 34 – Movement”, the manual literally gives the following instruction on how operatives should move in 35 the field: “When moving, it is absolutely necessary to keep your weapon against the chest or in the 36 right hand. Moving forward should be done with one side, usually the left, turned somewhat in the 37 direction of movement.” We wondered whether this could explain President Putin’s gait, since he 38 9 39 had received KGB training earlier in his life. If this were true, then it would be reasonable to expect a 40 similar gait “abnormality” in other Russian officials who might have received similar instructions 41 during weaponry training by the KGB or by other military or intelligence agencies. We therefore 42 performed a YouTube search for videos of other Russian officials, with surprising results. 43 44 RESULTS 45 An asymmetrically reduced arm swing was identified in several highly ranked Russian officials, 46 including current Prime Minister Dmitry Medvedev, two former Ministers of Defence (Anatoly 47 Serdyukov, and ) and Anatoly Sidorov, a highly ranked military commander. 48 49 Legends to the videos 50

51 Case 1, Vladimir Putin () 52 53 The first segment shows footage taken during the Presidential Inauguration of Vladimir Putin in 54 (Video 1, Segment 1 – May 7, 2012) . The video clearly shows his virtually absent right arm 55 swing as he walks along the red carpet in the Kremlin. The second segment confirms the consistency 56 of the arm swing reduction, several years earlier during a meeting between Putin and George W. 57 Bush in (February 23-25, 2005) (Video 1, Segment 2 – Slovakia Summit ). This makes it 58 unlikely that an intermittent problem (like a painful shoulder) explained the arm swing reduction. 59 60 4

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5 1 Araújo 2 3 The third fragment shows Putin while he displays his considerable judo skills, excluding marked 4 paresis or a chronic orthopedic problem as the cause of the asymmetrically reduced arm swing 5 (which is again clearly discernible in this video) (Video 1, Segment 3 ). A diagnosis of PD is very 6 unlikely, because other video material shows no evidence of tremor, his handwriting is fast – without 7 evidence of micrographia ( Video 1, Segment 4), he is capable of fast movements with his right hand 8 Confidential:(Video 1, Segment 5), he is an excellent swimmer For with symmetricalReview arm movements Only ( Figure 1 ) and he 9 has no difficulty lifting weights with both arms (Video 1, Segment 6 ). The handwriting segment 10 suggests that Putin is right-handed ( Video 1, Segment 4 ). Moreover, this movement pattern persisted 11 unchanged over several years, which is inconsistent with a neurodegenerative disorder like PD. 12 13 14 Case 2, Dmitry Medvedev (current Prime Minister) 15 This video shows footage taken during the Russian Presidential Inauguration in Moscow on May 7, 16 2008 (Video 2, Segment 1). According to his profile, Medvedev has not received formal military 17 training, 10 but while walking on the red carpet during his presidential inauguration, right arm swing is 18 markedly reduced. In the next segment, Medvedev and Putin are videotaped walking side by side on 19 the Red Square on the day of the Presidential election (May 7, 2008), both with a clearly reduced arm 20 swing ( Video 2, Segment 2 ). This moment had been captured by Angus Roxburgh, who noted that 21 Medvedev was “trying to ape Putin’s macho gait”. 11 Medvedev’s reduced arm swing is also clearly 22 visible in the next segment, where Medvedev is proposing Putin for President in September 2011 for 23 the upcoming elections in 2012 (Video 2, Segment 3 ). Note that Medvedev has no difficulty lifting 24 weights with both arms, excluding a structural right arm problem (Video 1, Segment 6 ). Like Putin, 25 26 Medvedev appears to be right-handed, unlike who is sitting next to him (Video 2, 27 Segment 4 ). 28 29 Case 3, (Minister of Defence, 2007-2012) 30 This video shows footage taken during the Victory Day parade of the Russian army in Moscow (May 31 9, 2012), to celebrate the surrender of Nazi Germany to the (Video 3, Segment 1). The 32 video shows Minister of Defence Anatoly Serdyukov stepping out of the car and walking toward 33 President Putin, with a reduced right arm swing. A second video unequivocally demonstrates 34 Serdyukov’s reduced right arm swing on a different occasion (the Russian-Indian Meeting in 2008, 35 New Delhi) (Video 3, Segment 2) . There is uncertainty whether Serdyukov received military training, 36 although one source claims he was in the Soviet Army for at least one year. 12 A signing ceremony 37 suggests that he too is right-handed ( Video 3, Segment 3 ). There is no other good evidence that he 38 39 received formal military training, but his position as Minister of Defense for five years does establish 40 a clear link to the military apparatus in Russia. 41 42 Case 4, Sergei Ivanov (Minister of Defence from 2001-2007, presently chief of the presidential 43 administration of Russia) 44 This video shows footage taken during the Victory Day parade of the Russian army in Moscow on 45 May 9, 2006 (Video 4, Segment 1). Sergei Ivanov, at the time Minister of Defence and also President 46 Putin’s friend and KGB colleague, 13 displays markedly reduced arm swing. Additionally, Ivanov can be 47 seen walking with a reduced arm swing when meeting in in 2001 (Video 4, 48 Segment 2) . Finally, in August 2015, during a visit to Sevastopol in the Crimea, Ivanov walks alongside 49 Putin and Medvedev with a visibly reduced arm swing on the right side (Video 4, Segment 3) . Once 50 again, a signing ceremony suggests that Ivanov is also right-handed ( Video 4, Segment 4 ). 51

52 53 Case 5, Anatoly Sidorov (current Commander of the Western Military District) 54 This video, taken during an exercise of Russian troops in Leningrad on February 26, 2014, shows 55 Anatoly Sidorov accompanying President Putin and Russian Defence Minister Sergei Shoigu (Video 5). 56 Sidorov (on the right) clearly shows a reduced right arm swing. Sergei Shoigu (on the left) shows a 57 normal and symmetrical arm swing, but President Putin again displays the reduced right arm swing. 18 58 59 60 5

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6 1 Araújo 2 3 We could not find additional videos demonstrating a reduced arm swing in Sidorov. A photograph of 4 him holding a pointer stick in the right hand might suggest that he is right-handed ( Figure 2 ). 5 6 DISCUSSION 7 This series of videos raises the interesting theory that weaponry training (including KGB or other 8 Confidential:forms of military or intelligence training) may For be a hitherto Review unrecognized cause of aOnly unilaterally 9 reduced arm swing during walking. Five highly ranked Russian officials presented with an 10 asymmetrical arm swing, which was always reduced on the right side, and which was consistently 11 observed during separate occasions in four cases. We considered several explanations. First, it is 12 13 unlikely that this can be attributed to a strong preference for the left arm. Cases 1-4 have videos 14 while readily signing documents with their right hand, and we found one photo where case 5 15 (Sidorov) uses the right hand for gesturing, so we presume them all to be dextral. Putin’s habit of 16 wearing his watch on the right wrist has led to some speculation regarding his hand dominance. 17 However, Putin does this on purpose, so the winding mechanism does not to stick to his hand – a 18 downside when wearing big chunky watches, which Putin admittedly prefers.14 19 20 Second, we do not think that the unilaterally reduced arm swing in these five Russian officials signals 21 the presence of an underlying PD. A diagnosis of PD requires, by definition, a presence of not only 22 bradykinesia (this could be the reduced arm swing), but also the presence of rest tremor, rigidity, or 23 both.15 However, none of the five Russian officials displayed any other evident motor signs 24 suggestive of early parkinsonism. For example, additional video material demonstrates that Putin has 25 26 otherwise excellent motor skills: his handwriting is fast, there is no evidence of micrographia or 27 tremor, he can perform fast movements with his right hand, he is a judo black belt without evidence 28 of hypokinesia or balance problems, he is an excellent swimmer (notably with symmetrical arm 29 movements) and has no difficulty lifting weights. This contrast markedly with, for example, Adolf 30 Hitler for whom examination of videos and photos established a much more convincing case of PD, 31 with not only a reduced use of one arm, but also a progressive course of hypomimia, rest tremor, 32 micrographia, stooped posture, hypokinesia and shuffling gait.16;17 33 34 We also consider it unlikely that the reduced arm swing represents a signal of an early “preclinical” 35 stage of parkinsonism, which does not require presence of other motor signs. This preclinical stage is 36 typically characterized by non-motor signs such as REM sleep behaviour disorder or constipation, 4-6 37 but these could understandably not be retrieved from the videos. One might argue that these five 38 39 men – who all appear to be right-handed – might have been more prone to develop early parkinsonian symptoms on the right side, because PD symptoms emerge more often on the 40 18;19 41 dominant hand side. However, the highly consistent presentation (right-sided features in all) 42 across Russian officials with a similar career profile would argue against the possibility of this being 43 an early sign of preclinical parkinsonism in all five persons. 3 Moreover, in all cases this movement 44 pattern was observed unchanged over several years, while in PD, a reduced arm swing would more 45 likely be associated with appearance of other motor features within the observed period. 46 47 More importantly, rather than interpreting this gait pattern as being pathological, we feel that there 48 is another – and perhaps more plausible – explanation, namely a behavioural adaptation resulting 49 from military or intelligence training. A supportive argument is the fact that trainees undergoing KGB 50 training are taught to keep their right hand close to the chest even while walking, allowing them to 51 quickly draw a gun when faced with a foe. It is conceivable that other forms of weaponry training are 52 53 associated with a similar behavioural gait adaptation. Indeed, we found other examples of a reduced 54 arm swing related to weaponry training: cowboys of the Wild West, as depicted in movies, frequently 55 have a reduced right arm swing. Examples include actor William Berger in “They call him cemetery” 56 (1971), actor Klaus Kinski in “Un genio, due compari, un pollo” (1975), actor Clint Eastwood in “Dirty 57 Harry” (1971), actors Javier Bardem and Woody Harrelson in the movie “No country for old men” 58 59 60 6

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7 1 Araújo 2 3 (2007) ( Video 6, various segments ). This similarity motivated us to introduce the term “gunslinger’s 4 gait” to label this new gait phenotype. 5 6 To “prove this case”, it is obviously essential to link the five Russian officials described here to KGB 7 membership, or at least to other forms of weaponry training ( it is reasonable to assume that military 8 Confidential:or intelligence training in Russia shares some For aspects with Review the “KGB training”, and thatOnly a reduced 9 arm swing is probably a reminiscence of that). Both Putin and Ivanov were KGB officials, but this is 10 not the case for Medvedev, Serdyukov and Sidorov. However, Sidorov is a current member of the 11 Russian military, so he has clear links to the military apparatus in Russia. Serdyukov’s Wikipedia 12 13 profile states that he has served in the Soviet Army for at least one year, but does not elaborate on 14 the subject. Other than that, there is no good evidence that he had additional military training. 15 Importantly, however, he was Minister of Defense for five years, so he too has clear links to the 16 military apparatus in Russia. 17 18 The case is weakest for Dmitry Medvedev, who does not have formal or unequivocal links to any 19 military or intelligence agency. However, there are several ways via which a top-end Russian 20 politician might display “Gunslinger’s gait”, even in the absence of any formal military or intelligence 21 training. The first is the Russian military tradition, which is still a significant part of the Russian 22 society, as is reflected by the annual Victory Day parade, and by the growing trend to reinstate a 23 basic military training program in schools, as was the case in the Soviet Union time.20 Moreover, 24 there is a growing number of “military camps” in Russia and neighboring countries, where children 25 21;22 26 and adolescents are also trained in blatantly military fashion . In this regard, it is conceivable that 27 a proportion of Russian individuals has been exposed to some form of “military training”, being no 28 strangers to the concept of walking with the right arm held close to the body. 29 30 A second, and more persuasive, explanation is the “imitate the boss” phenomenon. Putin’s 31 popularity ranks very high among the Russian electorate, which craves for “someone like 32 Putin”.{Gamburg, 2015 13263 /id} There is substantial evidence that Medvedev is being coached in 33 order to sound, look and – importantly – walk like the President. 24-26 The similarities between Putin 34 and Medvedev, particularly in terms of gait, have been acknowledged before. Specifically, one article 35 said: “You could only get amazed at how his (Medvedev’s) gait resembled that of Vladimir Putin: he 36 walked quickly, with his right hand close to the body, and waving his left one”. 27 Another article 11 37 also commented on Medvedev’s gait, describing the day of the Russian Presidential election in 2008 38 39 when Medvedev became President: “When the result was announced Putin and Medvedev walked 40 out together on to Red Square in leather jackets and jeans, Medvedev trying to ape Putin’s macho 41 gait” (Video 2, Segment 2). As such, it is conceivable that Medvedev’s reduced arm swing is also a 42 behavioral adaptation, resulting from the “imitating the boss” phenomenon. Similar mechanisms 43 may have been at play for the other officials presented here. Indeed, an article from the Moscow 44 Times quotes other politicians who caught up mannerisms from their superiors, concluding that “it is 45 nothing new in Russia to imitate the boss”. 26 This might be particularly the case if the boss is Vladimir 46 Putin – further evidence for his unparalleled magnetism comes from the fact that that many top-level 47 bureaucrats and members of the party have taken up the habit of wearing their watch 48 on the right side, like Putin does, in order to show their allegiance. 28 49 50 This imitation phenomenon has some parallels in the field of neurology, namely to cases of 51 hyperekplexia. Specifically, gene-negative relatives of affected individuals (i.e. subjects with the 52 53 minor form) can also display the exaggerated startle reflexes seen in the genetically affected 54 individuals with the major form. It is considered that this minor form of hyperekplexia could 55 represent a learned (behaviorally adapted) startle reflex in subjects who are subjected regularly to 56 family members with organic startle attacks. 29 Once adopted, such behavioural changes can persist 57 for long periods of time, and even become permanent. Indeed, long-term effects of repeated 58 physical training and acquisition of particular walking patterns, such as in ballet dancers or soldiers, 59 60 7

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8 1 Araújo 2 21;22 3 have been described. Additional evidence comes from patients with psychogenic movement 4 disorders; their movement abnormalities also represent a behavioural adaptation, and the longer 5 these persist, the more chronic and persistent they become. 23 Taken together, we consider it 6 possible that a form of imitation – leading to an overlearned behavioral adaptation – may account for 7 Medvedev’s (and possibly also Serdyukov’s) reduced arm swing. 8 Confidential: For Review Only 9 We were surprised to see no less than five very comparable gait presentations among high-end 10 Russian politicians. Identifying even more cases would of course further strengthen our case. 11 Unfortunately, YouTube video footage of KGB or other intelligence agents is understandably hard to 12 13 retrieve. We discovered this gait abnormality in individuals who are still politically active and, as 14 such, are more exposed to the public eye. Moreover, these public figures are, more often than 15 others, filmed while walking distances that allow for a valid neurological gait examination. Indeed, it 16 is perhaps no surprise that our discovery was based largely on video coverage of major events in 17 Russia, where Putin and other officials marched long distances along red carpets, creating perfect 18 conditions for gait examination. We always tell our neurology residents that one cannot adequately 19 assess gait (and especially arm swing) in the limited confines of the consulting room, urging them to 20 take their patients out into the corridor. The video clips presented here exemplify this well. We 21 extensively browsed YouTube and could not find any other good examples. It is fair to say that we did 22 identify a few examples of top-end Russian politicians with KGB or military background for whom 23 reasonably useful YouTube videos were available, and who did not consistently display a unilaterally 24 reduced arm swing. One example is , former prime minister and head of the Foreign 25 26 Intelligence Service, who is rumored to have served as a KGB official. His gait can be seen during two 27 occasions (Video 7), showing a somewhat diminished right arm swing in the first segment, but who 28 sways both arms fairly equally in the second segment. It thus appears that a reduced arm swing is 29 not an obligatory observation in high-end Russian officials. 30 31 We have no reason to believe that this phenomenon is exclusive to Russian politicians. We already 32 mentioned the example of Wild West cowboys, walking with a similarly reduced arm swing. We also 33 examined YouTube videos of American generals, but could not find a clearly reduced arm swing, for 34 example in General David Petraeus (Video 8). It is possible that Russia, in light of its military culture, 35 its strong “follow the leader” tradition, and its fascination with Vladimir Putin, is perhaps particularly 36 susceptible to develop this form of behavioral gait adaptation. 37

38 39 We conclude that unawareness of weaponry training might lead a clinician to misdiagnose healthy 40 individuals as having a pathological gait, and perhaps even as being parkinsonian. We recommend 41 that neurologists – in particular those working in Russia – include “gunslinger’s gait” in their 42 differential diagnosis of an asymmetrically reduced arm swing, along with other known causes such 43 as PD and shoulder pathology. 44 45 REFERENCES 46 (1) Stamelou M, Edwards MJ, Espay AJ, Fung VS, Hallett M, Lang AE et al. Movement disorders 47 on YouTube--caveat spectator. N Engl J Med 2011; 365:1160-1161. 48 (2) Bloem BR, Bhatia KP. Gait and balance in basal ganglia disorders. In: Bronstein AM, Brandt T, 49 Nutt JG, Woollacott MH, editors. Clinical Disorders of Balance, Posture and Gait. 2 ed. Arnold: 50 London; 2004. 173-206. 51 (3) Lees AJ. When did Ray Kennedy's Parkinson's disease begin? Mov Disord 1992; 7:110-116. 52 53 (4) Berg D, Lang AE, Postuma RB, Maetzler W, Deuschl G, Gasser T et al. Changing the research 54 criteria for the diagnosis of Parkinson's disease: obstacles and opportunities. Lancet Neurol 55 2013; 12:514-524. 56 (5) Goldman JG, Postuma R. Premotor and nonmotor features of Parkinson's disease. Curr Opin 57 Neurol 2014; 27:434-441. 58 59 60 8

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9 1 Araújo 2 3 (6) Berg D, Postuma RB, Bloem BR, Chan P, Dubois B, Gasser T et al. Time to redefine PD? 4 Introductory statement of the MDS Task Force on the definition of Parkinson's disease. Mov 5 Disord 2014; 29:454-462. 6 (7) Nurnberger L, Klein C, Baudrexel S, Roggendorf J, Hildner M, Chen S et al. Ultrasound-based 7 motion analysis demonstrates bilateral arm hypokinesia during gait in heterozygous PINK1 8 Confidential:mutation carriers. Mov Disord 2015; For 30:386-392. Review Only 9 (8) Dolmatov AI. KGB Alpha Team Training Manual: How the soviets trained for personal 10 combat, assassination, and subversion. Colorado: Paladin Press; 1993. 11 (9) Gessen M. The man without a face; the unlikely rise of Vladimir Putin. New York: Blue River 12 13 Books; 2012. 14 (10) The Government of the Russian Federation, Biography of Dmitry Medvedev, Available at 15 http://government.ru/en/gov/persons/183/bio . 2014. 16 (11) Roxburgh A. The Strongman: Vladimir Putin and the struggle for Russia. IB Tauris & Co Ltd, 17 New York 2013. 18 (12) Anatoly Serdyukov (Wikipedia) (2014). Available at 19 http://en.wikipedia.org/wiki/Anatoliy_Serdyukov . 2014. 20 (13) Russia Profile (Ria Novosti) (2010), Sergei Borisovich Ivanov, Russian Profile (Internet). 21 Available at 22 http://www.russiaprofile.org/bg_people/resources_whoiswho_alphabet_i_Ivanovsb.html . 23 2014. 24 (14) http://www.homeenglish.ru/ArticlesPutin.htm . 2015. 25 26 (15) Berg D, Postuma RB, Adler CH, Bloem BR, Chan P, Dubois B et al. MDS Research Criteria for 27 Prodromal Parkinson's Disease. Mov Disord 2015;in press. 28 (16) Gerstenbrand F, Karamat E. Adolf Hitler's Parkinson's disease and an attempt to analyse his 29 personality structure. Eur J Neurol 1999; 6:121-127. 30 (17) Boettcher LB, Bonney PA, Smitherman AD, Sughrue ME. Hitler's parkinsonism. Neurosurg 31 Focus 2015; 39:E8. 32 (18) Uitti RJ, Baba Y, Whaley NR, Wszolek ZK, Putzke JD. Parkinson disease: handedness predicts 33 asymmetry. Neurology 2005; 64:1925-1930. 34 (19) van der Hoorn A, Burger H, Leenders KL, de Jong BM. Handedness correlates with the 35 dominant Parkinson side: a systematic review and meta-analysis. Mov Disord 2012; 27:206- 36 210. 37 (20) Anonymous. United Russia pushes for military training in schools. The Moscow Times 2012 38 39 Jun 5. 40 (21) Silchenko V. Putin's Teenage Army: Inside Donetsk's Youth Warrior Training Camps. VICE 41 News 2015 Jun 8. 42 (22) Luxmoore M. Putin's Boy Scout Army. Foreign Policy 2015 May 1. 43 (23) Gamburg V. A man like Putin. https://www.youtube.com/watch?v=zF-f6aAZ-XM , 2015. 44 (24) Blomfield A. Medvedev coached to be more like Putin. The Telegraph 2008 Feb 29. 45 (25) Parfitt T. Spin doctors reinvent the 'Nano-President'. The Observer 2008 Mar 2. 46 (26) Mereu F. Medvedev taking words from Putin's mouth. The Moscow Times 2008 Feb 27. 47 (27) Kolesnikov A. Vladimir Putin Toppled Himself. Kommersant 2008 Aug 5. 48 (28) Osborn A. Vladimir Putin hands over watch to cheeky metalworker. The Telegraph 2009 Sep 49 15. 50 (29) Bakker MJ, van Dijk JG, van den Maagdenberg AM, Tijssen MA. Startle syndromes. Lancet 51 Neurol 2006; 5:513-524. 52 53 54 55 56 57 58 59 60 9

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10 1 Araújo 2 3 Legends to the figures 4 5 Figure 1: Russian President Vladimir Putin perofrming the butterfly swim in a Siberian Lake, in 2009. 6 Arm movements appear to be symmetric. Source: 7 http://www.theguardian.com/world/2009/aug/06/vladimir-putin-butterfly-stroke 8 Confidential: For Review Only 9 Figure 2: Anatoly Sidorov talking to minister Shoigu, holding a pointer with his right hand. Source: 10 https://russiandefpolicy.files.wordpress.com/2014/06/shoygu-with-western-md-commander- 11 general-colonel-anatoliy-sidorov-photo-mil-ru.jpg 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 10

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1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Russian President Vladimir Putin performing the butterfly swim in a Siberian Lake, in 2009. Arm movements 28 appear to be symmetric. Source: http://www.theguardian.com/world/2009/aug/06/vladimir-putin-butterfly- 29 stroke 30 246x148mm (72 x 72 DPI) 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 12 of 12

1 2 3 4 5 6 7 8 Confidential: For Review Only 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Anatoly Sidorov talking to minister Shoigu, holding a pointer with his right hand. Source: 32 https://russiandefpolicy.files.wordpress.com/2014/06/shoygu-with-western-md-commander-general- 33 colonel-anatoliy-sidorov-photo-mil-ru.jpg 194x137mm (72 x 72 DPI) 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj