Synopsis
Differentiate PSP's early axial, gaze and fall syndrome from CBS's asymmetric cortical-motor disorder, understand diagnostic uncertainty and prioritise swallowing, communication, mobility and anticipatory support.
- Progressive supranuclear palsy is suggested by early unexplained backward falls, axial rigidity, slowing of vertical saccades and later supranuclear vertical gaze palsy, especially downgaze impairment.
- The vestibulo-ocular reflex can initially overcome a supranuclear gaze limitation with a doll's-head manoeuvre, distinguishing it from ocular motor-nerve or muscle restriction when safely examined.
- PSP commonly adds frontal executive change, apathy or impulsivity, dysarthria, dysphagia, photophobia, blepharospasm and a surprised facial appearance.
Key red flags
Abrupt asymmetry, sudden language loss, fever, acute confusion or a step-change in swallowing suggests stroke, infection, seizure or medication harm rather than expected neurodegenerative progression.
Investigation priorities
Identify saccadic slowing, supranuclear gaze limitation, axial postural instability or the asymmetric cortical-motor combination.
Management branches
Axial parkinsonism is accompanied by early backward falls, visual scanning difficulty or frontal change.
- Map the date of first fall, freezing, speech, swallowing and cognitive change and directly examine vertical saccade velocity, gaze range, vestibulo-ocular response, axial tone and pull response.
- Arrange specialist MRI and movement-disorder assessment, screen injury and bone health and trial levodopa adequately when potential symptomatic benefit justifies it.
Key medicines
Levodopa combination therapyUse an adequate specialist-supervised trial titrated to gait, rigidity and meaningful daily activities.
Botulinum toxin type AAn expert injector selects muscles and dose at intervals usually around twelve weeks by product.