What components should be included in a thorough physical exam for Parkinson's disease?

Components of a Thorough Physical Examination for Parkinson's Disease

A comprehensive physical examination for Parkinson's disease should focus on motor symptoms (bradykinesia, rigidity, tremor, and postural instability) along with careful assessment of non-motor manifestations that significantly impact morbidity, mortality, and quality of life.

Motor Examination Components

1. Assessment for Bradykinesia/Akinesia

• Observe spontaneous movements and facial expressions
• Test finger tapping (speed, amplitude, rhythm, and fatigue)
• Test hand opening/closing movements
• Assess foot tapping
• Evaluate rapid alternating movements
• Observe gait for reduced arm swing and step length

2. Rigidity Assessment

• Test passive movement of limbs while patient is relaxed
• Check for "cogwheel" rigidity (ratchet-like resistance)
• Assess for lead-pipe rigidity (continuous resistance)
• Test neck, arms, and legs
• Use activation maneuvers (have patient move contralateral limb) to enhance subtle rigidity

3. Tremor Evaluation

• Observe for rest tremor (4-6 Hz) with hands at rest
• Check for postural tremor with arms outstretched
• Assess for action/kinetic tremor during finger-to-nose testing
• Note tremor distribution (asymmetry is typical in PD)

4. Postural Stability Testing

• Perform pull test (stand behind patient and pull backward at shoulders)
• Assess ability to maintain balance when pushed
• Observe for retropulsion (tendency to fall backward)
• Test ability to rise from chair without using arms

5. Gait Assessment

• Observe for shuffling, festinating gait
• Check turning (en bloc turning)
• Test ability to initiate walking
• Assess stride length and speed
• Look for freezing of gait (especially at doorways or when turning)

Non-Motor Examination Components

1. Cognitive Assessment

• Screen for executive dysfunction, attention deficits, and visuospatial impairment
• Use Montreal Cognitive Assessment (MoCA) as preferred screening tool 1
• Test for bradyphrenia (slowed thinking)

2. Autonomic Function

• Check blood pressure lying and standing (for orthostatic hypotension)
• Assess for excessive sweating
• Look for seborrheic dermatitis
• Inquire about bowel/bladder dysfunction

3. Cranial Nerve Examination

• Test olfaction (hyposmia is common)
• Assess for hypophonia (soft voice)
• Check for hypomimia (reduced facial expression)
• Evaluate eye movements for slowed saccades
• Test for glabellar tap reflex (Myerson's sign)

4. Sensory Examination

• Test for pain sensitivity
• Assess proprioception
• Check for paresthesias

5. Psychiatric Assessment

• Screen for depression, anxiety, and apathy
• Assess for hallucinations or psychosis
• Look for impulse control disorders

Special Examination Techniques

1. Parkinsonian Signs

• Test for micrographia (have patient write a sentence)
• Assess speech for hypophonia, monotony, and festination
• Look for camptocormia (forward flexion of trunk) and Pisa syndrome (lateral flexion)

2. Differential Diagnostic Features

• Check for vertical gaze palsy (suggests Progressive Supranuclear Palsy) 1
• Test for cerebellar signs (ataxia, dysmetria)
• Look for alien limb phenomenon and cortical sensory deficits (suggests Corticobasal Syndrome) 1
• Assess for autonomic failure and REM sleep behavior disorder (suggests Multiple System Atrophy)

Documentation Approach

Document findings systematically using standardized rating scales when possible:

• Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS)
• Hoehn and Yahr staging
• Schwab and England Activities of Daily Living Scale

Common Pitfalls to Avoid

1. Failing to test for bradykinesia, which is essential for diagnosis
2. Not accounting for medication state during examination (on vs. off)
3. Missing subtle asymmetry in early disease
4. Overlooking non-motor manifestations that significantly impact quality of life
5. Confusing essential tremor (primarily postural/action) with parkinsonian tremor (primarily rest)

A thorough physical examination is crucial for accurate diagnosis, appropriate treatment planning, and monitoring disease progression in Parkinson's disease. The examination should be performed both in medicated and unmedicated states when possible to fully assess treatment response.