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The Many Faces of Parkinsons Disease
The Many Faces Of Parkinsons Disease
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The Many Faces of Parkinsons Disease

April 8, 2011

Up to 30 per cent of patients with Parkinsons disease do not exhibit tremor at the time of diagnosis.

Dr Claire Reynolds, Patrick Browne and Prof Tim Counihan examine the challenges in determining a diagnosis of Parkinsons disease and the main treatment options available to doctors.
With a prevalence rate of around 2 per cent, most physicians in primary care can expect to encounter several patients with Parkinsonism in their practice. For the experienced clinician, recognising the symptoms and signs of Parkinsons disease (PD) is reasonably straightforward.
The typical patient shuffles into the doctor’s surgery, slightly stooped, looking older than their years. When seated, a coarse tremor affecting one or other hand will emerge, with the hands at rest on the lap. It is this ‘pill-rolling’ rest tremor that is usually the biggest tip-off to the diagnosis. The remaining typical (Table 1) clinical features can then be elicited with more detailed examination.

Table 1: Typical features in early Parkinsons disease

  • Asymmetric tremor at rest
  • Stooped posture
  • Expressionless face (hypomimia)
  • Low-volume monotonous voice (hypophonia)
  • Micrographia
  • Slowness of movements (bradykinesia)
  • Shuffling gait with fragmented turning
  • Cog-wheel rigidity of muscle tone

Life, however, is often not quite so simple. Up to 30 per cent of patients with PD do not exhibit tremor at the time of diagnosis. Moreover, other tremor disorders can often be confused with PD, although if the patient exhibits a clear tremor at rest, in the presence of slow movements, the diagnosis is rarely in doubt. In a recent community-based study of PD misdiagnosis in the west of Scotland, 36 of 610 patients (6 per cent) on treatment for Parkinsons disease had either essential tremor or vascular Parkinsonism (Newman EJ, Breen K, Patterson J et al, Mov Disord 2009;24:2379-85).

The diagnosis may be further complicated by the difficulty in recognising bradykinesia for both doctor and patient. Many patients attribute stiffness and slowness of movement to advancing age, or arthritis. Complaints of a persistent ‘frozen shoulder’ are a common early sign of emerging Parkinsonism. One of the most useful markers of bradykinesia is to examine the patient’s handwriting; ask them to write a sentence across the page. Writing that starts reasonably clearly but becomes smaller in amplitude across the page is a reflection of true bradykinesia, distinguishing it from other causes of poor script (such as due to arthritis or other musculoskeletal ailment).