Parkinson Disease Clinical Presentation   -- Updated: Jun 04, 2020 

From:  Medscape  --  https://emedicine.medscape.com/article/1831191-clinical  

Author: Robert A Hauser, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...

Onset of motor signs in Parkinson disease is typically asymmetric, with the most common initial finding being an asymmetric resting tremor in an upper extremity. Over time, patients notice symptoms related to progressive bradykinesia, rigidity, and gait difficulty. The first affected arm may not swing fully when walking, and the foot on the same side may scrape the floor. Over time, axial posture becomes progressively flexed and strides become shorter.

 Common early motor signs of Parkinson disease include tremor, bradykinesia, rigidity, and dystonia.

Tremor  --  Although tremor is the most common initial symptom in Parkinson disease, occurring in approximately 70% of patients, it does not have to be present to make the diagnosis. Tremor is most often described by patients as shakiness or nervousness and usually begins in one upper extremity and initially may be intermittent. Upper extremity tremor generally begins in the fingers or thumb, but it can also start in the forearm or wrist. After several months or years, the tremor may spread to the ipsilateral lower extremity or the contralateral upper extremity before becoming more generalized; however, asymmetry is usually maintained.

Tremor can vary considerably, emerging only with stress, anxiety, or fatigue. Classically, the tremor of Parkinson disease is a resting tremor (occurring with the limb in a resting position) and disappears with action or use of the limb, but this is not seen in all patients. Initially, the tremor may be noticed during activities such as eating or reading a newspaper. Although Parkinson disease is a rare cause of tremor affecting the head or neck, tremors of the chin, lip, or tongue are not uncommon. As with other tremors, the amplitude increases with stress and resolves during sleep.

Bradykinesia  --  Bradykinesia refers to slowness of movement. Symptoms of bradykinesia are varied and can be described by patients in different ways. These may include a subjective sense of weakness, without true weakness on physical examination; loss of dexterity, sometimes described by patients as the "message not getting to the limb"; fatigability; or achiness when performing repeated actions.

Facial bradykinesia is characterized by decreased blink rate and facial expression. Speech may become softer, less distinct, or more monotonal. In more advanced cases, speech is slurred, poorly articulated, and difficult to understand. Drooling is an uncommon initial symptom in isolation but is reported commonly (especially nighttime drooling) later in the disease course.

 Truncal bradykinesia results in slowness or difficulty in rising from a chair, turning in bed, or walking. If walking is affected, patients may take smaller steps and gait cadence is reduced. Some patients experience a transient inability to walk, as though their feet are frozen to the floor. This "freezing" is seen commonly in patients with more advanced disease; it is more prominent as patients attempt to navigate doorways or narrow areas and can result in patients getting trapped behind furniture or being unable to cross a door threshold easily.

 In the upper extremities, bradykinesia can cause small, effortful handwriting (ie, micrographia) and difficulty using the hand for fine dexterous activities such as using a key or kitchen utensils. In the lower extremities, unilateral bradykinesia commonly causes scuffing of that foot on the ground, as it is not picked up during leg swing. This may also be described as dragging of one leg.

Rigidity  --  Some patients may describe stiffness in the limbs, but this may reflect bradykinesia more than rigidity. Occasionally, individuals may describe a feeling of ratchety stiffness when moving a limb, which may be a manifestation of cogwheel rigidity.

Dystonia  --  Dystonia is a common initial symptom in young-onset Parkinson disease, which is defined as symptom onset before age 40 years. Dystonia in Parkinson disease commonly consists of a foot involuntary turning in (inversion) or down (plantar flexion), often associated with cramping or aching in the leg. Dorsiflexion of the big toe may also occur. Another common dystonia in Parkinson disease is adduction of the arm and elbow, causing the hand to rest in front of the abdomen or chest. Dystonic postures can wax and wane, occurring with fatigue or exertion.

Whether stooped posture is due to truncal dystonia is a matter of debate. One study suggests that the stooped posture may be due to vertebral fractures resulting from vitamin D deficiency with compensatory hyperparathyroidism. [27] Vitamin D supplementation may reduce the risk for stooped posture.