EP 35 - “What to do, if even David Marsden would not have a clue”

🎙️ We’re back with Episode 35 of Parkinson Weekly, hosted by Prof. Bas Bloem.

Recorded live at the European Academy of Neurology (EAN) Congress in Geneva, this special episode sees Prof. Bas Bloem reflect on his C. David Marsden Award Lecture, entitled “What to do, if even David Marsden would not have a clue”.

Prof. Bloem explores how clinicians can approach particularly challenging movement disorder presentations when the diagnosis is far from straightforward. Drawing on the themes of his lecture, he outlines the value of a structured, multistep approach to reaching a clinically based diagnosis, even in the most complex cases.

The episode also highlights the importance of developing an eclectic approach to clinical practice. Prof. Bloem discusses the value of identifying your own clinical heroes, learning from the skills and qualities that make them exceptional, and incorporating the best of these into your own clinical repertoire — while combining them with your individual strengths, preferences and abilities.

Recorded from EAN 2026 in Geneva, this episode offers a fascinating insight into clinical reasoning, lifelong learning and the art of becoming a better clinician.

Tune in now to hear Prof. Bas Bloem share the key lessons from his C. David Marsden Award Lecture.

Have a question you’d like Bas to answer in a future episode? Email us at parkinsonweekly@gmail.com – we’d love to hear from you.

Transcript

SPEAKER_01 0:00

Hi, this is Paul Bloem, recording Parkinson Weekly live from the European Academy of Neurology. Today's episode is a quick summary of my C David Marsden lecture award that I gave about heroes, about a multi-step approach that will make you reach a diagnosis if even David Marsden himself would not have a clue. Wanna hear more? This is Parkinson Weekly. For those of you who don't know, David Marsden was the all-time hero in the field of movement disorders. Co-founder of the Movement Disorder Society published over a thousand papers and not just many papers, really, really good and influential papers. In my talk, which was entitled What to Do If Even Marsden Wouldn't Have a Clue, I discussed a multi-stepped approach to arrive at the diagnosis when you are uncertain. And even though David Marsden was an astute clinician, even he must have seen particular cases where the diagnosis was initially uncertain. And in my talk, I walked through a series of steps that can help you to arrive at the diagnosis. And I will give you the quick summary here. But step number one, that's the one you should really remember, particularly if you are a young neurologist, maybe a fellow, a resident in training, is to find your heroes. Be eclectic. Don't just take anybody. Find people that you appreciate, that you value for a certain reason. And then once you've identified your heroes, don't copy-paste all of them, but emulate certain elements that you like in their style. Add it all up and add your own unique sauce, your personal style, your allergies, your skills, and the sum of your heroes plus your own sauce is gonna be you as a clinician. And that's how I was built. And in my talk, I gave a few examples of Bill Langston, famous guy who discovered the MPTP patient, who's still one of my heroes. I discussed Professor Vince, who was my mentor in Leiden, where I was trained as a neurologist, who still follows me in my mind every day. And I just sketched a number of heroes in the field that influenced my thinking and that have become a part of me. And I hope that you will also continue your personal search for those heroes. Then the remainder of my multi-stepped approach. Of course, number one is careful history taking. I cited the opening page of Harrison's, the famous book of internal medicine, and it said, listen carefully to the patient. He or she is trying to tell you what disease they have. And we often skip a good history taking, but in my clinic, history taking is about 90%. The physical exam is maybe 10%. And just as an example, something that struck me in my clinical practice is that when people with Parkinson's will tell you that they have started to put on their pants sitting instead of standing upright, that proved to be a predictor of falls in people with Parkinson's disease. Simple question, beautiful example of a pearl that you can apply in your clinical practice. Of course, the physical exam is very, very important. And of course, you need to take your time. For example, for gate, always take people outside of your examination room and watch them in the corridor because you need ample space for that. Sometimes people will tell you, I've got these fluctuating problems, and just today I happened to have a good day. Ask for a home video, and home videos can be extremely informative. Plus, you can discuss the home videos with colleagues and friends so you can add extra value to that one particular video. And another lovely element that I introduced in my talk was listening to the signs of Parkinson's. Parkinsons can be seen with the naked eye, the tapping score, but you know, this is a normal score, this is a score of one, this is a score of two, this is a score of three, and you can already begin to imagine that's a very delicate, difficult scale. What I often do is listen to Parkinson's. I listen, for example, how they walk into my clinic. I listen to the bradykinesia here. And you can hear the rhythm better with your ears than your eyes will ever be able to pick this up. So that was part number two. Part number three, very important, is phone a friend in my university medical center. When we are in doubt, we film the patient and we then discuss it each Wednesday with our team of movement disorders experts. And if you don't have such a team, you can always send the video to a colleague elsewhere. And asking an experienced colleague for his or her opinion is in our experience way more valuable than just blindly calling for more tests. Another factor that we still underestimate is the factor time. Sometimes clinical pictures need to evolve, they need to ripen. And we know that, for example, in early stages of MSA or PSP, the picture can still be remarkably similar to Parkinson's disease. And sometimes time is needed to bring out the full picture. This is what general practitioners do all the time, but I think we as neurologists, as movement disorders experts, sometimes also need more time, but you need to carefully explain to the patient and the family why you need more time. Another element that is sometimes helpful is to do ancillary testing. And ancillary testing should be used judiciously. And by judiciously, I mean don't call for a test in the hope that it will give you a normal result. For example, you see a functional neurological disorder, you think I'll do an MRI and I'll hope it's normal, and lo and behold, you will find a kist in the arachnoid space near the cerebellum. It doesn't explain the functional neurological disorder, but now you've created a new problem. But I do sometimes call for tests because I use them as part of my therapy. So, for example, in a person with a functional neurological disorder, distractability that brings out the inconsistency of the movements is a useful diagnostic weapon. And sometimes, even though I am certain in my clinic, I do a polymyography, so now I can print out the results and show that the tremor frequency changes as I perform different tests with the patient to explain to them that this is not a clock, a pathological clock ticking in the brain, but it's something that I can influence from the outside. So sometimes ancillary testing can be used not just for diagnostic purposes, but it can also be used for therapeutic purposes. And that brings me to the pre-final element, which is the treatment response. Don't ever treat a patient just for diagnostic purposes, but if you give a treatment because you think the patient deserves an improvement of his or her symptoms, then the response to treatment will help you in deciding about the diagnosis. If you're in doubt about Parkinson's disease or atypical Parkinsonism, a trial of Levadopa, if that yields you a beneficial, gratifying response, increases the likelihood that this is Parkinson's disease. It will decrease the likelihood of atypical Parkinsonism. So there are a number of reasons why sometimes the response to treatment will not only give you help for the patient but also give you diagnostic information. And finally, and this is interesting because this has largely disappeared from our repertoire, is pathological examination. Can be done during life. Muscle biopsies is used all the time by muscle doctors, neuromuscular experts, but also post-mortem brain examination. And in my talk, I mentioned a beautiful paper by Stuart Factor, who followed people with primary progressive freezing of gait over time until they died, looked at the brain after death to find that primary progressive freezing of gait is usually a tauopathy, although, interestingly, sometimes it can be Lewy body pathology, including Parkinson's disease. So, a beautiful example of how pathology is telling you something about the diagnosis during life, and of course, that comes too late for the patient, but it may be helpful for the family, and it makes you a better doctor, so that the next time you see a similar problem, you will be able to diagnose better. So, that was the content of my C. David Marsden Award lecture. If there's one thing you should remember, find your heroes, emulate what you like about them, add your own source, and that'll be you as a unique clinician. Good luck with your career and see you soon on Parkinson Weekly.

SPEAKER_00 10:28

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