Clinical Presentation

The clinical diagnosis of PD is based on the presence of one or more of four hallmark neurologic signs, including resting tremor, cogwheel rigidity, bradykinesia or akinesia, and impairment in posture and equilibrium. Besides these signs, identified in the mnemonic TRAP, there also may be other signs, including facial and postural changes, voice and speech abnormalities, depression, and muscle fatigue. Prior to the diagnosis of PD, most patients will have symptoms for months to years, including a general feeling of slowness or stiffness and/or difficulties with handwriting and other skills that require manual dexterity.

Most often patients will complain initially of a unilateral arm resting tremor. The tremor is a repetitive movement of low amplitude that occurs five or more times per minute. This alternating movement is described as "pill rolling" because it involves repetitive movements of the fingers and thumb. These tremors also can be seen in the legs or face and most often dissipate when intentional movement is performed. The resting tremor of PD can be differentiated from the kinetic tremor of other neurologic disorders by asking the patient to perform the finger-to-nose maneuver. The resting tremor of PD will become less prominent with the performance of this test and resume once the purposeful movement is ended and the limb is supported and at rest.

Cogwheel rigidity is elicited by causing passive movement of the limb through a full range of motion. As the limb is moved, the muscles will develop an increased tone, and a ratchet-like movement is noted. Bradykinesia, the general sense of slowness of voluntary movement, is often felt to be the most debilitating symptom of PD. In its most extreme form, PD causes akinesia, the inability to perform the movements necessary for daily living, such as turning over in bed, rising from a seated position, or walking. When PD impairs postural reflexes, patients may have an impaired ability to turn or change direction while walking or may lose their balance and fall.

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