The 4 Primary Symptoms of Parkinson’s Disease

This information is taken from Introduction to Parkinson’s Disease, a continuing education course authored by Dr. AQ Rana, leading PD researcher and founder of the World Parkinson’s Program.

The two primary categories of symptoms for Parkinson’s disease are the primary motor symptoms and the secondary non-motor symptoms. The primary motor symptoms of Parkinson’s disease usually start gradually on one side of the body. The usual age of onset is 55 to 60 years. Understanding the motor symptoms of Parkinson’s disease helps professionals understand physical behavior and limitations in PD clients. Understanding can help with choosing appropriate intervention, ensuring safety, and facilitating patience in client interactions and interventions.

The following motor symptoms are seen in Parkinson’s:

1. Bradykinesia
2. Rigidity or Stiffness
3. Resting Tremor
4. Postural Instability

Bradykinesia is described as slowness in the execution of movements while performing daily activities. Patients take longer time to complete daily tasks such as eating, dressing, or showering. This is viewed by some patients and physicians as the most disabling feature of Parkinson’s disease and may be tested by asking the patient to do rapid fist clenching, finger tapping, rapid turning of each arm and heel tapping on the ground. Patients might also describe difficulty fastening their buttons, cutting food, or tying shoelaces. The effects of bradykinesia progress over-time and can be seen in a variety of ways.

Different manifestations of bradykinesia include:

• Slow speed of voluntary movements
• Decreased amplitude of voluntary movements
• Early fatigue with repetitive movements
• Delayed initiation of movements
• Difficulty rising from a low chair
• Short stride of gait
• Reduced arm-swing

Rigidity or Stiffness is caused by an involuntary increase in tone of the limbs and axial musculature. The examiner feels increased resistance to passive movements especially around the wrist and elbows. The rigidity in limbs in Parkinson’s disease is much greater than the axial rigidity (tested by side to side neck movements).

Initially the rigidity can be very subtle and accompanied by “cog-wheeling” (a ratchety feeling). The amount of resistance remains the same throughout the range of motion. Rigidity of Parkinson’s disease is also asymmetrical at onset and worsens as the disease progresses. In the early stages of this disease, patients may not be aware of this symptom.

A Resting Tremor may be the first symptom noticed by Parkinson’s disease patients and is seen in approximately 70% of those suffering from this disease. It is an involuntary rhythmic movement that most commonly starts in the upper limbs. For example, initially the tremor may start in the thumb or index finger, referred to as pill-rolling tremor, later involving the whole hand, arm, leg, lips, or chin as the disease progresses.

Resting tremors usually start on one side of body and over time develop on the other side as well. Traditionally, the tremor is present when the limbs are at rest and diminishes when the individual attempts to perform an activity. In most cases, the presence of a resting tremor will support the diagnosis of Parkinson’s disease. The tremor is low in frequency, and the movement of hand or arm is a supination-pronation type movement (rotating or turning in and out movements of the hand or arm) in most patients. However, in some cases it can also be of a flexion extension type movement (up and down movement of hand or arm).

To see pill rolling tremor, view this video: https://www.youtube.com/watch?v=e532YW-Zwf0&feature=youtu.be

Resting tremors can be socially bothersome, but is less disabling since it often vanishes with the initiation of activity (especially in the early stages of Parkinson’s disease). Approximately 20% to 30% of patients with Parkinson’s disease may not have resting tremors, but those who have it tend to have a better prognosis than patients without resting tremors.

• When resting tremors involve the legs, it is seen only when the patient is lying down or sitting and disappears when the individual starts to walk.
• Conversely, resting tremors in the hands or arms may increase when the patient is walking.
• Lastly, resting tremors seen in Parkinson’s disease worsen with stress and disappear when one is asleep.

With Postural Instability, initially Parkinson’s patients experience:

• a slow speed of walking
• shortened stride length
• narrowing of their base
• leaning towards one side
• turning as a whole and slowly (turning enbloc)

These features contribute to balance problems and patients can become unsteady while walking and turning which may result in falls. A pull test is done to assess retropulsion; the patient’s ability to hold on to themselves when pulled backwards. The patient is told to stand as firmly as possible in one place with their feet apart and they are pulled backwards from their shoulders. Those with impaired postural reflexes will not be able to hold themselves and may fall backwards if not held. Moreover, Parkinson’s disease patients with postural instability often fall into their chairs when they try to sit in them. Postural instability might not be noticeable in the early stages of Parkinson’s disease.

View this resource video. https://www.youtube.com/watch?v=9J4LD9pQsoQ&feature=youtu.be

For more information about Parkinson’s disease see Introduction to Parkinson’s Disease, a continuing education course available at the FCEA Website.