Clinical features

The classical features of Parkinson’s disease are TRAP:

Tremor

Rigidity

Akinesia or bradykinesia (a- = lack of, brady- = slow, kinesia = movement)

Postural instability.

Early symptoms are often subtle. The patient may describe stiffness, difficulty in fine movements, especially writing, fatigue and a feeling of slowing down. Some patients will first notice a tremor. The onset is usually unilateral or may be limited to one limb.

The tremor, occurring in 70% of untreated patients, typically occurs at rest but may occur on sustained posture and mainly affects the hands. It is coarse and slow. The rigidity is usually best appreciated at the elbow and wrist. The increase in tone is not sustained and repeatedly gives, producing the characteristic cogwheeling.

The face is immobile and the skin may appear greasy. There may be a dysarthria, with a monotonous voice that tends to trail off. Fast repeated movements tend to slow up, so-called bradykinesia. This can be tested by asking the patient to drum their fingers on a table or repeatedly bringing index finger and thumb together (Fig. 1). Writing becomes small and spidery (Fig. 2). The posture tends to become stooped and the patient stands with slightly flexed elbows (Fig. 3). On walking there is a loss of arm swing, the steps become shorter and there may be difficulty starting or stopping. The patient may be unsteady or fall on turning. This reflects the loss of postural reflexes; these can be tested by standing behind the patient and gently pulling the patient backwards. This would normally lead to a minor adjustment in posture, but a patient with altered postural reflexes may take multiple steps backwards. In more severe disease, there may be freezing – where the patient cannot start to walk – a form of akinesia. The gait may be festinant, where the patient cannot stop once started.

Fig. 1 Tests for bradykinesia. (a) Ask the patient to tap their fingers together quickly. (b) Ask the patient to twist their hand as if polishing door knobs. With bradykinesia, the movements become smaller and slower – compare the two sides.

Fig. 2 Writing of a patient with Parkinson’s disease.

Related posts:

CNS neoplasia I: Intracranial tumours Parkinson’s disease and other akinetic rigid syndromes II Intracranial pressure Rehabilitation Giddiness Walking difficulties and clumsiness

Stay updated, free articles. Join our Telegram channel

Join