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, Russia, 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 Slovakia Summit 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 https://mc.manuscriptcentral.com/bmj Page 1 of 12 BMJ 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 https://mc.manuscriptcentral.com/bmj Page 3 of 12 BMJ 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 Vladimir Putin, Prime Minister 12 13 Dmitry Medvedev 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 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 12 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.