#7542 - The Parkinsons Exam - Medical Finals & OSCEs Notes

The Parkinson’s Exam

General Inspection

The lack of facial expression leads to a mask-like facies, hypomimia. They may drool and the tremor may be very obvious. In true idiopathic Parkinson’s Disease the findings are almost always asymmetrical. Watch throughout for the restless movements of akithisia.

Are there any mobility aids?

Gait

The posture is characteristically flexed, fixed as a forwards stoop, and there are few spontaneous movements (hypokinesia). They may have difficulty initiating the standing up movement at the beginning of the exam and have an unstable posture. Watch for freezing and hesitation of initiating movements during the next stages.

Ask the patient to walk, turn quickly, stop and restart. They may turn ‘en bloc’.

Bradykinesia – it will take them a long, slow time for each movement, unless they are festinating.

Shuffling gait – small steps with feet hardly lifted from the ground. Often difficulty in initiating the movement.

Festination – once the movement is initiated the patient hurries and has difficulty stopping, looking like he might fall over at the end, trying to catch up with his centre of gravity

No normal arm swinging (akinesia)

Still standing – test propulsion and retropulsion if it is safe to do so. This is the same theory as the ‘pull test’: a gentle tug towards you demonstrating an inability to catch balance and the need for several steps forwards. Propulsion is pushing from behind, retropulsion from in front. They may fall over.

Kinesia paradoxica – the striking phenomenon of being able to initiate movement upon an external cue, of something that they could not previously do. These are often rapid movements and they cannot do slow ones. E.g. they may run down the stairs or start to ride a bike, even though they can only walk with difficulty. When they start to run down the stairs they may not be able to stop in time.

Back on the couch.

Face: titubation (nodding of the head) is a type of tremor. Mouth hypokinesia may be seen as drooling. There may be an absence of blinking or slow blinking. Hypomimia.

Test the glabellar tap. Tap over the middle of the forehead in a non-threatening way. The sign is positive if the patient continues to blink as long as there are taps. Normal people stop after a few taps.

Assess speech: monotonic and hypotonic speech = one tone, quiet, hoarse, and lacks intonation. Sometimes palilalia is present: repeating at the end of a word. Speech may also have a rapid festinating pattern. There may be dysarthria.

Ocular movements: Supranuclear gaze palsy is found in Progressive Supranuclear Palsy, one of the differential diagnoses. There may be decreased eye convergence leading to diplopia.

Feel/look for greasiness or sweatiness as these are signs of autonomic dysfunction.

Arms: look for a resting tremor. This is characteristically pill-rolling: movement of fingers at MCPs is combined with movements of the thumb. It is a coarse resting tremor. There is also a pronation-supination tremor at the wrist.

Tremor can be reinforced by asking the patient to distract themselves by counting serial 7s or moving the contralateral limb e.g. by rapidly opposing the finger and thumbs.

On finger-nose testing the tremor decreases as it is not an intention tremor, however there is sometimes a faster action tremor seen. There may be decreased coordination on these tests.

Test tone. Tone is increased in Parkinson’s disease. There is marked rigidity which is the same throughout movement and thus called lead-pipe rigidity. At the wrists there is cogwheeling. This is rigidity with an interrupted nature as the muscles give way with a series of jerks due to the underlying tremor. Reinforce the hypertonia by asking the patient to turn their head from side to side or wave the contralateral arm.

Writing: Micrographia is characteristic. Ask to write their name and address. They may also show signs of dementia here.

Legs

Again there will be bradykinesia and increased tone. There may be decreased proprioception sensation. There may be signs of restless leg syndrome. There may be coordination difficulties. Cogwheeling is possible to elicit at the ankle too.

Orthostatic Hypotension

This is a characteristic of the autonomic dysfunction and causes many to fall. Test using a lying-standing blood pressure measurement; watch for a fall of >20mmHg systolic and/or >10mmHg diastolic.

Higher centres

Test for dementia and depression using the GIDS, Beck Depression Inventory or PHQ-9. Dementia: GPCOG, MMSE.

They may be very somnolent, test using an Epsom Score.

Ask if they have vivid dreams; ask a partner if they act out their dreams in their sleep.

Ask about other symptoms: delusions, hallucinations of people or animals, cravings, gambling, hypersexuality, depression, insomnia, somnolence, fatigue, anxiety, constipation, anosmia, urinary...