Parkinson's disease

Physical Examination

Introduction:

• Introduce yourself to the patient.

• Confirm the patient's identity.

• Explain the purpose of the examination.

• Obtain consent.

• Ensure the patient is comfortable.

General Inspection:

• Note the patient's posture: Many patients with Parkinson's adopt a stooped posture.

• Observe for any tremor: A resting tremor is common in Parkinson's.

• Look for reduced arm swing when walking.

• Check for facial expression: Patients may have reduced blinking and a mask-like face.

• Inspect the hands for pill-rolling tremor.

Specific Examination:

• Resting tremor:

  • Observe the hands and other parts for a resting tremor.

  • Ask the patient to count backwards from 100, which may exacerbate the tremor.

• Rigidity:

  • Test for "lead-pipe" rigidity by flexing and extending the patient's relaxed elbow.

  • Feel for "cogwheel" rigidity (a ratchety resistance to movement) due to the superimposition of tremor on rigidity.

• Bradykinesia:

  • Ask the patient to perform rapid alternating movements such as tapping thumb and index finger or pronating and supinating the hands. Look for slowness or decrement in amplitude.

  • Ask the patient to tap their foot on the floor.

• Postural Reflexes:

  • With the patient standing, perform the pull test. Stand behind the patient and tell them you are going to pull them backwards. Ensure safety precautions are in place to catch the patient if they lose balance. In Parkinson's, patients may take several steps backward or even fall without any compensatory steps.

• Gait:

  • Observe the patient's gait. Look for a shuffling gait with reduced arm swing.

  • Look for festination, where the patient's steps may involuntarily become faster and smaller.

  • Observe the ability to turn. Parkinson's patients often have difficulty with turning and may take several small steps to turn around.

• Speech:

  • Ask the patient a few questions. In Parkinson's, speech can be quiet and monotonous.

• Facial Expression:

  • As mentioned, the facial expression can be reduced ("mask-like").

• Handwriting:

  • Ask the patient to write a sentence. Micrographia (small, cramped handwriting) is a feature of Parkinson's.

Other Relevant Examinations:

• Examine the cranial nerves, especially CN III (oculomotor nerve) for any abnormalities, as Parkinson's can sometimes affect eye movements.

• Check for any postural hypotension.

• Examine the upper limbs for any dystonia or other movement disorders.

• Vascular Parkinsonism: Assess pronator drift, EPR, BP and carotid bruit

• Cognitive function by Mini Mental Test Score

• Drug history for drug induced Parkinsonism

• Assess Kayser Fleischer ring and chronic liver insufficiency signs in young Parkinsonism to exclude Wilson’s disease.

Conclusion:

• Thank the patient.

• Help the patient to re-dress if necessary.

• Summarise your findings.

• Suggest further assessments or tests if needed.

Causes of Parkinsonism

• Idiopathic Parkinson's Disease:

  • The most common cause of parkinsonism.

  • A neurodegenerative disorder with unknown specific cause.

• Secondary Parkinsonism:

  • Caused by identifiable external factors or other medical conditions.

  • Includes:

    • Drug-Induced Parkinsonism: Due to medications like antipsychotics (e.g., haloperidol), antiemetics (e.g., metoclopramide).

    • Vascular Parkinsonism: Caused by multiple small strokes.

    • Toxin-Induced: Exposure to toxins like MPTP, carbon monoxide, or manganese.

    • Infectious Causes: Post-encephalitic, as seen in encephalitis lethargica.

    • Traumatic: Following head trauma, known as post-traumatic parkinsonism.

• Parkinson - Plus Syndrome

  • Multiple System Atrophy (MSA): With autonomic dysfunction and cerebellar signs.

  • Progressive Supranuclear Palsy (PSP): Characterised by vertical gaze palsy and early falls.

  • Corticobasal Degeneration (CBD): Notable for apraxia and cortical sensory loss.

  • Dementia with Lewy Bodies (DLB): Parkinsonism with early dementia and visual hallucinations.

• Hereditary Parkinsonism:

  • Caused by specific genetic mutations.

  • Examples include mutations in the LRRK2, PARK7, PINK1, or PRKN genes.

• Other Rare Causes:

  • Wilson’s Disease: A disorder of copper metabolism.

  • Normal Pressure Hydrocephalus: Characterized by the triad of gait disturbance, dementia, and urinary incontinence.

  • Brain Tumors or lesions affecting the basal ganglia.

Investigations

Parkinson's disease is primarily a clinical diagnosis, based on the presence of its cardinal symptoms: tremor, rigidity and bradykinesia. However, investigations, particularly imaging like DaTSCAN, can be used to support the diagnosis.

Management

• General Management:

  • Patient Education: Informing about the disease, progression, treatment options.

  • Lifestyle Modifications: Regular exercise, balanced diet, and maintaining social interactions.

  • Physiotherapy: To improve mobility, balance, and reduce fall risk.

  • Occupational Therapy: For adapting daily activities and maintaining independence.

  • Speech and Language Therapy: To manage speech and swallowing difficulties.

  • Psychological Support: Counseling for patient and family to cope with the diagnosis.

• Medical Management:

  • Levodopa/Carbidopa: Mainstay of treatment, helps replenish dopamine.

  • Dopamine Agonists (e.g., pramipexole, ropinirole): Mimic dopamine effects in the brain.

  • MAO-B Inhibitors (e.g., selegiline, rasagiline): Slow the breakdown of brain dopamine.

  • COMT Inhibitors (e.g., entacapone): Extend the effect of levodopa.

  • Anticholinergics (e.g., trihexyphenidyl): For tremor control, used cautiously.

  • Amantadine: For dyskinesia and mild symptom relief.

  • Adjusting Medications: Based on symptom control and side effects.

• Surgical Management:

  • Deep Brain Stimulation (DBS): For patients with advanced disease not responding to medications.

  • Other surgeries (less common): Pallidotomy, thalamotomy.

• Other Therapies:

  • Alternative Therapies: Yoga, Tai Chi, acupuncture (supportive, not primary treatment).

  • Nutritional Support: To manage weight and ensure adequate nutrition.

  • Support Groups: For emotional and social support.