Motor Symptoms

The onset of PD is insidious. A thorough patient history including past and present medications, family history, environmental exposure, and a detailed description of symptom onset is essential in making an accurate diagnosis. Patients feel slowed down or trapped in their body unable to move. The tremor of PD occurs during rest and disappears with purposeful movement. Tremor usually affects the hands or feet, but may occur in other body parts such as in the lip and chin. The hand tremor can appear as if the patient is rolling a pill between their fingers. Patients describe rigidity as stiffness. Upon physical exam, it feels like uniform resistance as the muscles seem to be in a constant state of increased tone. It is defined as cogwheel rigidity when the examiner extends or flexes the patient's extremities and feels as if they are rhythmically hitting a series of teeth on the rim of a wheel, or a gear that is meshing with another gear with teeth. Bradykinesia is noted when there is hesitancy in movement initiation, slowness in movement performance, or rapid fatiguing during movement. Patients may have a decrease in automatic movements, such as blinking, a decrease in facial expressions (often termed masked facies), or a decrease in arm swing while walking. Postural instability is a result of the loss of reflexes necessary to maintain balance when standing or ambulating. Patients may report a feeling of unsteadiness. Gait abnormalities may be evidenced by shuffling, leg dragging, festination, propulsion, retropulsion, or freezing. Rigidity and bradykinesia may make handwriting difficult as evidenced by micrographia.2, ,8

Because of a high diagnostic error rate, patients who are thought to have PD should be referred to a movement disorder specialist before starting medication. The diagnosis can often be made by history and physical. However, special imaging tests such as a MRI or single photon emissions computed tomography (SPECT) may be warranted to rule out stroke, intoxications, or other degenerative disorders.4,

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