What are the essential components of history taking and physical examination for diagnosing and managing Parkinson's disease?

Essential Components of History Taking and Physical Examination for Parkinson's Disease

The diagnosis of Parkinson's disease (PD) requires a comprehensive clinical assessment focusing on cardinal motor features including bradykinesia, rest tremor, rigidity, and postural instability, along with systematic evaluation of non-motor symptoms which often precede motor manifestations. 1, 2

History Taking Components

Demographic and Risk Factors

• Age of onset (typically 40-70 years) with documentation of timeline showing insidious onset and progressive course 3
• Family history of PD or other movement disorders 3
• Environmental exposures (pesticides, toxins) 1
• Medication history that could cause parkinsonism 3

Cardinal Motor Symptoms

• Tremor: Assess for rest tremor (4-6 Hz), its location (typically asymmetric starting in one hand), and whether it diminishes with action 1, 2
• Bradykinesia: Document slowness in initiating movements, reduced amplitude of movements, and progressive reduction in speed/amplitude with repetitive movements 2, 4
• Rigidity: Ask about stiffness in limbs, neck, or trunk 2
• Postural instability: History of falls or near-falls 2

Secondary Motor Symptoms

• Hypomimia (masked facies) 2
• Micrographia (small handwriting) 2
• Shuffling gait or freezing episodes 2
• Speech changes (hypophonia, dysarthria) 2
• Dysphagia or sialorrhea (drooling) 2

Prodromal and Non-Motor Symptoms

• Sleep disturbances: REM sleep behavior disorder (acting out dreams), insomnia, excessive daytime sleepiness 1, 5
• Autonomic dysfunction: constipation, urinary urgency, orthostatic hypotension, sexual dysfunction 5, 2
• Sensory symptoms: hyposmia/anosmia (reduced/absent sense of smell), pain, paresthesias 1, 5
• Neuropsychiatric symptoms: depression, anxiety, apathy 1, 5
• Cognitive changes: executive dysfunction, attention deficits, visuospatial difficulties 1, 2

Response to Medications

• Previous trials of dopaminergic medications (especially levodopa) and response 1, 4
• Presence of motor fluctuations or dyskinesias if on treatment 1

Physical Examination Components

General Observation

• Facial expression (hypomimia) 2
• Spontaneous movement (reduced) 2
• Posture (stooped) 2
• Speech (soft, monotonous) 2

Motor Examination

• Bradykinesia assessment: 1, 2

  • Finger tapping (index to thumb)
  • Hand opening/closing
  • Pronation-supination movements
  • Foot tapping
  • Evaluate for progressive reduction in speed and amplitude

• Tremor assessment: 2

  • Observe at rest
  • During postural maintenance (arms outstretched)
  • During action/goal-directed movements
  • Note frequency, amplitude, and asymmetry

• Rigidity assessment: 2, 4

  • Passive movement of limbs, neck, and trunk
  • Test with and without activation maneuvers (e.g., contralateral limb movement)
  • Note "cogwheel" quality

• Postural stability: 2

  • Pull test (retropulsion test)
  • Observe recovery from perturbation

Gait Assessment

• Stride length and arm swing 2
• Turning (en bloc turning) 2
• Festination (acceleration of steps) 2
• Freezing (especially at doorways or when turning) 2

Other Neurological Assessments

• Cranial nerve examination (including extraocular movements) 2
• Sensory examination 2
• Deep tendon reflexes 2
• Coordination testing 2
• Primitive reflexes (glabellar tap, palmomental reflex) 2

Red Flags Suggesting Alternative Diagnoses

• Early falls or postural instability (suggests atypical parkinsonism) 2
• Symmetric onset of symptoms 2
• Absence of rest tremor 2
• Early severe autonomic dysfunction 2
• Early hallucinations or dementia (not related to medications) 2
• Poor or no response to adequate doses of levodopa 1, 2
• Presence of ataxia, ophthalmoparesis, or other atypical features 2

Common Pitfalls to Avoid

• Failing to obtain collateral history from caregivers (patients often have impaired insight) 3, 6
• Overlooking non-motor symptoms which may precede motor symptoms by years 1, 5
• Not performing a complete medication review to rule out drug-induced parkinsonism 3
• Inadequate assessment of response to levodopa (which can be diagnostic) 1, 4
• Relying solely on tremor for diagnosis (up to 30% of PD patients may not present with tremor) 2

By systematically evaluating these components, clinicians can improve diagnostic accuracy and identify PD earlier, potentially allowing for earlier intervention and better outcomes for patients.