How to perform a physical examination on a patient suspected of having extrapyramidal symptoms?

Physical Examination for Extrapyramidal Symptoms

The physical examination for extrapyramidal symptoms should systematically assess for hypomimia, muscular rigidity, bradykinesia, hypokinesia, parkinsonian-like tremor, dyskinesia, and asterixis, as these are the most common manifestations of extrapyramidal dysfunction. 1

Key Components of the Examination

1. Facial Assessment

• Evaluate for hypomimia (reduced facial expression)
• Check for reduced blink rate
• Observe for mask-like facies 2

2. Motor Function Assessment

• Rigidity Testing:

  • Assess for muscular rigidity by passive movement of limbs
  • Check for cogwheel rigidity (ratchet-like resistance to passive movement) 2
  • Test tone in neck, arms, and legs

• Movement Assessment:

  • Evaluate for bradykinesia (slowness of movement)
  • Assess hypokinesia (reduced amplitude of movement)
  • Observe gait for shuffling, reduced arm swing
  • Test speech for monotony and slowness 1

3. Tremor Evaluation

• Observe for parkinsonian-like tremor (typically resting tremor)
• Check for tremor in hands, feet, lips, and tongue 1

4. Asterixis Testing

• Test for "flapping tremor" by:
  • Having patient hyperextend wrists with separated fingers
  • Asking patient to rhythmically squeeze examiner's fingers
  • Also check for asterixis in feet, legs, arms, tongue, and eyelids 1

5. Involuntary Movement Assessment

• Look for dyskinesia (abnormal involuntary movements)
• Check for tics or chorea-like movements (though these are rare) 1
• Observe for acute dystonic reactions (abnormal posturing)

6. Reflexes and Pyramidal Signs

• Test deep tendon reflexes (may be hyper-reflexic in non-comatose patients)
• Check for Babinski sign (may be positive)
• Note that reflexes may diminish in more severe cases 1

Special Considerations

High-Risk Populations

• Elderly patients, very young patients, males, and patients with previous history of tremors are at higher risk for developing extrapyramidal symptoms when on antipsychotics 3

Medication History

• Always review medication history, as extrapyramidal symptoms can be caused by:
  • Antipsychotics (most common)
  • Some antidepressants
  • Antiemetics
  • Lithium
  • Anticonvulsants
  • Rarely, oral contraceptives 4

Standardized Assessment

• Consider using standardized rating scales such as the Extrapyramidal Symptom Rating Scale (ESRS) or the Abnormal Involuntary Movement Scale (AIMS) for objective documentation 5, 3
• Regular assessment every 3-6 months is recommended for patients on medications that can cause extrapyramidal symptoms 3

Differential Considerations

• Rule out other causes of similar symptoms:
  • Idiopathic Parkinson's disease
  • Vitamin B12 deficiency (can present with reversible extrapyramidal symptoms) 2
  • Hepatic encephalopathy (can present with extrapyramidal dysfunction) 1

Impact on Cognitive Function

• Note that extrapyramidal symptoms may be associated with impaired cognitive performance, particularly in tasks requiring speed of processing 6
• Document any cognitive deficits as they may be related to the extrapyramidal symptoms

Common Pitfalls to Avoid

• Don't confuse drug-induced parkinsonism with idiopathic Parkinson's disease
• Remember that asterixis is not pathognomonic of extrapyramidal symptoms and can be seen in other conditions like uremia 1
• Be aware that mental and motor signs may not progress in parallel, making severity assessment challenging 1
• Don't overlook mild extrapyramidal symptoms, as even these may represent markers of long-term neurocognitive impairment 6