Parkinson’s Disease is one of the most commonly diagnosed motor disorders. It is important to be familiar with the physical exam so that you can confirm the diagnosis and monitor how the treatment is benefiting the patient over time.
Parkinson’s Disease Exam
The physical exam in Parkinson’s disease (PD) is essential both for making a diagnosis and following the patient over time. It consists of a series of tests and maneuvers that help us identify and evaluate the four main characteristics of the disease:
- Gait & Balance abnormalities
In order to make a diagnosis, we must observe bradykinesia plus either one of the other motor abnormalities. Once a diagnosis is made and the patient is started on treatment, it is important to check these four features at every follow up visit, so that we can gauge the treatment based on how the exam has changed over time.
Some of the clinical features of PD. Image credit
Parkinson’s Disease Exam
Before beginning the interactive part of the physical exam, it is very important to focus on observing the patients while they are giving the history, to notice any motor disturbances present at rest.
In particular we should focus on:
- Spontaneous movements, generally reduced in PD
- Hands gestures while talking, usually reduced or absent
- Eyeblink, whose spontaneous rate is reduced
- Resting tremor, usually affecting one hand only
- Fidgeting and crossing/uncrossing of the legs, that may indicate dyskinesia, a complication of chronic Levodopa therapy
It is important to remember that the inspection starts as soon as the patient walks in to the room.
Parkinson’s Disease Exam
Bradykinesia is defined as a generalized slowness of movement, with patients struggling in particular with starting a movement. It is seen in almost every patient with Parkinson’s disease, making its presence essential for diagnosis. It is also one of the most debilitating symptoms of PD.
To test for the presence of bradykinesia we will have the patient perform rapid alternating movements. It is important to remember that these movements must be performed as fast as possible and as big as possible, meaning with the amplest range possible. All these tests are positive for bradykinesia if the range of motion and/or the speed reduce over time. For this reason, it is crucial to ask the patient to do at least ten repetitions for each movement.
Also, in both the upper and lower extremities, the movements more affected by bradykinesia are the finest ones, such as the movements of the toes and fingers.
Finger tapping
In finger tapping the patient is instructed to tap the index finger on the thumb as fast possible and as big as possible. This means that the patient should try to separate the two fingers as much as possible before tapping them. Make sure to test both the right and the left side.
