Physical Examination

Key Facts

  • Conduct a full neurological examination.
  • Rule out other conditions before diagnosing PD.
  • Sensory examination is usually unremarkable in PD.
  • Confirmatory diagnosis by a neurologist or movement disorders specialist is recommended.
  • Examine skin, given increased risk of melanoma.

Clinical Best Practices

  • Perform a full medical evaluation with a thorough neurological examination.
  • Confirmatory diagnosis by a neurologist or movement disorder specialist is recommended.

Many of the signs of PD are readily visible to the examiner in the majority of patients. The 4 cardinal symptoms including tremor, rigidity, akinesia/bradykinesia and postural instability should be evaluated. However, it is important to ask for and evaluate non-motor symptoms which are harder to identify and may not be specific.

 

 

Examination Component

Findings and what they may mean

Mental status

  • Cognitive impairment on the MMSE or MoCA may indicate cognitive impairment and/or dementia
  • If visual hallucinations and dementia are present before or within a year on parkinsonism onset, then consider the diagnosis of dementia with Lewy Bodies (DLB)
  • Depression, apathy and anxiety are common but not exclusive of PD

Cranial nerves

  • Impaired vertical eye movements would make one suspicious of progressive supranuclear palsy (PSP)
  • Check for hyposmia-it is usually an early marker of PD. You can use the UPSITi test
  • Masked face is typical in PD
  • PD patients may have a soft voice and /or mumbled or fast speech

Motor Examination

  • Asymmetric resting tremor with bradykinesia on one side is very typical of PD
  • PD tremors may occur in the tongue, jaw, lower lip, hand, or in the leg/foot
  • PD tremor worsens with distracting the patient with mental tasks, etc
  • Cogwheel rigidity is typical of PD
  • Many patients have drooling due to reduced spontaneous swallowing of saliva
  • Diminished gesturing is common in PD
  • Micrographia is typical of PD

Sensory examination

  • Impaired position sense in the toes may indicate that the patient has a sensory ataxia on top of PD gait problems
  • Sensory examination is usually unremarkable

Coordination examination

  • Conduct a dexterity test. Ask patient to finger tap. Finger taps should have not only a maintained speed over 10-15 seconds but a maintained amplitude as well; slowing of speed, decrement of amplitude, and pauses/arrests in finger and foot taps are consistent with bradykinesia
  • Ataxia would make one concerned about the possibility of multiple system atrophy (MSA)

Deep tendon reflexes

  • Asymmetry of reflexes and up going plantar responses (Babinski sign) may indicate prior strokes/brain infarcts and vascular parkinsonism; or an up going toe would be suggestive of MSA

Gait and balance

  • Gait dysfunction is frequently multifactorial, and not just related to parkinsonism
  • Freezing of gait is related to PD
  • A PD patient may have difficulties in rising from the chair
  • A PD patient may have difficulties in taking the first step
  • A PD patient may have limitations in turning
  • Reduced arm swing is common in PD
  • Postural instability is common. It can be measured with the Pull Testi. PD patients may have problems maintaining their balance
  • Timed Up and Go (TUG) test can be helpful for evaluation

Other