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11/13/24, 7\:08 PM Guide | Parkinson's disease examination

Parkinson's disease examination

Table of contents

Background

In OSCE scenarios, you may be asked to perform a focused examination to determine the presence (or absence) of a certain
condition. It is important to be able to con
to be comfortable with the relevant basic system examination (i.e. for a Parkinson’s disease examination you need to be
comfortable with performing a full neurological examination).
Parkinsonism is a clinical syndrome characterised by bradykinesia, rigidity, tremor and postural instability.
Idiopathic Parkinson’s disease (PD) is the most common cause of parkinsonism.
Other primary (atypical) Parkinsonian disorders can closely mimic PD, which makes a correct clinical diagnosis challenging.
These include progressive supranuclear palsy (PSP), multiple system atrophy (MSA), dementia with Lewy bodies (DLB) and
corticobasal syndrome (CBS).

Clinical features of Parkinson's disease

Typical features of Parkinson's disease\:
Bradykinesia
Rigidity
Tremor
Postural instability
Other features of Parkinson's disease\:
Depression
REM-sleep behavioural disorder
Autonomic dysfunction (e.g. constipation, urinary frequency)
Anosmia
Dementia (late feature, typically a

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Ask the patient to expose their hands, wrists and elbows (e.g. by rolling up their sleeves or removing a jacket). Observe the
patient as they perform these actions as they may provide useful information about the patient's dexterity and functional
independence.
Ask the patient to take a seat.
Ask if the patient if they have any pain before proceeding with clinical examination.
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General inspection

Parkinson’s disease can be a spot diagnosis– a lot of information can be gained from watching the patient walk into the room
and sit down in the chair (we will explore these signs in more detail in the formal assessment of gait).
Perform a brief general inspection of the patient, looking for clinical signs suggestive of Parkinson's disease\:
Reduced spontaneous movements and hand gestures
Less frequent blinking
Hypomimia\: a lack of facial expression.
Tremor\: typically asymmetrical and present at rest, often described as 'pill-rolling' in character.
Hypophonia\: soft, indistinct speech.
Abnormal posture\: typically stooped in appearance.
General inspection

Tremor

Resting tremor

A key and easily observable sign in Parkinson's disease is a resting tremor. Resting tremors occur when a body part is at
complete rest against gravity and cease during active movement.
Typical features of the resting tremor associated with Parkinson's disease include\:
A
Asymmetrical (i.e. one limb has more signi
4-6 Hz frequency
The tremor of Parkinson's disease can also involve the lips, chin and legs.
If there is no obvious tremor on inspection, ask the patient to close their eyes and count back from 20 which should
exacerbate a subtle tremor if present.

Action tremor

Although resting tremor is the typical form of tremor associated with PD, patients can also exhibit di
tremors. Action tremor can be either kinetic or postural in nature.
Postural tremor
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Postural tremor occurs during the maintenance of a position against gravity and worsens during active movement.
Assess for a postural tremor by asking the patient to raise their arms in front of their body and spread their
tremor may emerge after a latency of a few seconds (this is known as a re-emergent tremor).
Kinetic tremor
Kinetic tremor occurs during hand movement (e.g. when writing or during a
sometimes subdivided into 'simple kinetic tremor' in which the tremor remains constant throughout the movement vs 'intention
tremor' where the kinetic tremor gets worse as the patient approaches a target (e.g. in the
Assess for kinetic tremor by performing a
1. Position your
2. Ask the patient to touch their nose with the tip of their index
3. Ask the patient to continue to do this

Di

Essential tremor
Typical features\:
Frequency of 5-10 Hz
Kinetic tremor
Postural tremor (without latency, unlike PD)
Improves with rest and often involves the head and neck
Dystonic tremor
Typical features\:
Irregular
Asymmetrical
Kinetic tremor (common)
Postural tremor (position-dependent)
Variable frequency depending on the position of the a
Worsened by speci
Thumb extension is frequently involved
Inspect for evidence of postural tremor
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Bradykinesia

Bradykinesia is characterised by slowness in the initiation of voluntary movement with a progressive reduction in speed
during repetitive actions, such as voluntary

Assessment

Bradykinesia can be assessed by asking the patient to perform rapid alternating movements (as big and fast as possible). A
patient should be asked to perform 10-20 repetitions for each movement being assessed and the assessment should be
performed on one limb at a time. You should demonstrate the movement you want to assess to the patient (you don't need to
assess all of the movements below, just choose one or two).
Finger tapping
Ask the patient to oppose their thumb and fore
Hand grip
Ask the patient to make a
Pronation/supination
Ask the patient to pronate and supinate their hand repeatedly, as fast as they can.
Toe tap
Ask the patient to keep their heel on the ground and tap their toes against the

Interpretation

Whilst observing the patient perform one or several of the above movements observe for the following\:
Progressive reduction in speed
Progressive reduction in amplitude
Asymmetry (i.e. struggles to perform rapid movements with left
Slowness in the initiation of movement
Assess for bradykinesia

Tone

Parkinson's patients typically exhibit increased muscle tone on assessment.
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Increased muscle tone can be further subcategorised into spasticity and rigidity. Spasticity is associated with pyramidal tract
lesions (e.g. stroke) and rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson's disease).
Spasticity is “velocity-dependent”
, meaning the faster you move the limb, the worse it is. There is typically increased tone in the
initial part of the movement which then suddenly reduces past a certain point (known as "clasp knife spasticity
"). Spasticity is
also typically accompanied by weakness.
Rigidity is “velocity independent” meaning it feels the same if you move the limb rapidly or slowly. There are two main sub-
types of rigidity\:
Cogwheel rigidity involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during
movement of the limb. This subtype of rigidity is associated with Parkinson's disease.
Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is
typically associated with neuroleptic malignant syndrome.

Assessment

Assess tone in the muscle groups of the shoulder, elbow and wrist on each arm, comparing each side as you go\:
1. Support the patient's arm by holding their hand and elbow.
2. Ask the patient to relax and allow you to fully control the movement of their arm.
3. Move the muscle groups of the shoulder (circumduction), elbow (
full range of movements.
4. Feel for abnormalities of tone as you assess each joint (e.g. spasticity, rigidity, cogwheeling, hypotonia).
An activation manoeuvre can accentuate subtle rigidity associated with early Parkinson's – ask the patient to actively tap their
thigh with their contralateral arm whilst you perform the movement.
Assess tone

Gait

Sitting to standing

Ask the patient to stand from their seated position with their arms across their chest to screen for postural instability. Make
sure to stand close to the patient so that you are able to intervene if they lose their balance.
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Observe gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Initiation\: typically slow to start walking due to failure of gait ignition and hesitancy.
Step length\: reduced stride length with short steps is common (shu
the patient attempts to retain balance (known as festinant gait).
Arm swing\: reduced arm swing on or both sides (often an early feature of PD).
Posture\:
Tremor\: resting tremor can be observed when the patient is distracted by walking.
Turning\: impaired balance on turning or hesitancy is common due to postural instability.

Pull test

You can further assess for postural instability by performing the pull test. This test should only be performed by an
experienced clinician and ideally with another member of sta
Assessment
1. Position yourself behind the patient.
2. Clearly explain the test\:
c a t c h y o u r b a l a n c e . “ I’ m g o i n g t o g i v e y o u a q u i c k t u g o n y o u r s h o u l d e r s a n d I' d l i k e y o u t o t a k e t w o s t e p s b a c k w a r d s t o
I w i l l b e b e h i n d y o u a t a l l t i m e s a n d w o n’ t l e t y o u f a l l .
”
3. Perform a test run by tugging gently to see if they are able to maintain their balance (if not, end the assessment here).
4. Tug their shoulders backwards once more, this time with more force\: healthy individuals will be able to correct their balance
using one or two quick steps.
Observe gait

Other assessments

Ask the patient to write a sentence and draw a spiral to assess for asymmetric progressive micrographia (a typical feature of
PD).
Ask the patient to undo and do up their top shirt button (if present) to assess dexterity and speed of movement.
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To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
“ T o d a y I p e r f o r m e d a n e u r o l o g i c a l e x a m i n a t i o n o n a 7 5- y e a r-o l d g e n t l e m a n t o a s s e s s f o r c l i n i c a l f e a t u r e s o f P a r k i n s o n’ s
d i s e a s e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t d e m o n s t r a t e d h y p o m i m i a , r e d u c e d s p o n t a n e o u s m o v e m e n t s i n h i s a r m s
a n d a s o f t v o i c e. A n a s y m m e t r i c a l t r e m o r w a s n o t e d i n h i s l e f t h a n d a t r e s t , i n v o l v i n g h i s f o r e
e m e r g e n t p o s t u r a l t r e m o r i n h i s l e f t h a n d w a s e l i c i t e d u p o n e x t e n s i o n o f b o t h a r m s . A s y m m e t r i c b r a d y k i n e s i a w a s
d e t e c t e d o n t h e l e f t s i d e w i t h p r o g r e s s i v e s l o w n e s s a n d a m p l i t u d e o f a l t e r n a t i n g m o v e m e n t s . A s s e s s m e n t o f t o n e
r e v e a l e d r i g i d i t y i n t h e l e f t w r i s t , e l b o w a n d a n k l e . O b s e r v a t i o n o f t h e p a t i e n t’ s g a i t d e m o n s t r a t e d a s t o o p e d p o s t u r e w i t h
a r e d u c e d a r m s w i n g. H e h a d a s h o r t s t r i d e l e n g t h a n d w a s h e s i t a n t w h e n t u r n i n g. T h e s e
t h e c l i n i c a l f e a t u r e s o f p a r k i n s o n i s m.
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Perform a cerebellar examination\: if concerned about cerebellar pathology.
Measure lying and standing blood pressure\: autonomic abnormalities (e.g. postural hypotension) are a feature of Parkinson's
disease and multiple system atrophy.
Assess eye movements\: vertical gaze palsy and slow saccadic eye movements are associated with progressive
supranuclear palsy (PSP).
Perform a cognitive assessment (e.g. MMSE)
Analyze the drug chart\: medications such as neuroleptics, dopamine blocking antiemetics and sodium valproate can induce
secondary parkinsonism.

Reviewer

Professor Oliver Bandmann
Professor of Movement Disorders Neurology
Source\: geekymedics.com
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