Early signs of  Parkinson’s  disease: making the diagnosis

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

Well it is the start of a new year and a new decade. Welcome twenty ten. I wish all the readers of my blog a very happy new year. Recently I saw a patient in my office and he shall be the subject of my post. He came to see because of his tremor. Actually I should not say he came to see me, the patient infact felt there was nothing wrong with him.

“Dr. Sethi, I have noticed a tremor in my right hand for the past 3 months. It does not bother me. I feel fine. It is my wife who wants me to come and get this checked out” he said.

As I examined him I realised his ” hand shakes” problem was something more sinister as I found tell tale signs suggestive of Parkinson’s disease. That is what I shall discuss here, how does one go about making the diagnosis of Parkinson’s disease ? What are the points in the history and examination that make me as a doctor consider this diagnosis?

Parkinson’s disease may start off very innocuously. All my patient had noticed was that for the past3 months he had a tremor in his right hand. The tremor did not bother him and did not interfere with any activity of daily living such as writing, getting dressed, eating and so forth.  He in fact would not have sought a neurological consultation if his wife had not insisted.  That said and done, there are certain characteristics of the tremor which can aid in the diagnosis. The classical tremor described with Parkinson’s disease is what is called a resting tremor. Now pray what does that mean? Simple the tremor is most prominent when the hands are rest. Let me explain with the aid of an example. While I was talking to my patient and eliciting his medical history, my visual attention was focussed at his hands which were at rest on his lap. I noticed his right hand to have a tremor, the tremor became more prominent when he was distracted. If I asked him to look at his right hand, he could stop the tremor for a few seconds but then the tremor came back. He did not have  a tremor in his left hand or in his legs. When the arms were extended (held up in front of him), the tremor  abated.

So point number 1:  Sporadic Parkinson’s disease usually starts of in the sixth to seventh decade of life. The initial presentation may be quite subtle with only a mild tremor. The tremor initially is asymmetrical (that is it may only be in one hand) and classically it is a resting tremor (most prominent when the hands are completely at rest). The tremor becomes less prominent when the hands are doing something (in motion) and completely abates when the patient falls asleep. Remember the tremor at least initially during the disease course may not be bothersome for the patient and may not impair his quality of life. Hence the patient may not seek attention and the diagnosis may be delayed.

There are some other early signs of Parkinson’s disease. On close inspection I was able to document them in my patient too. When he spoke to me, his face lacked the usual emotions. What do I mean by that. Well when we speak our face show a variety of emotions, we frown, we roll our eyes, sometimes our eyes smile and so forth. A Parkinson’s disease patient has what is called a “mask-like” face-there is a paucity of normal facial expressions.

So point number 2.  Mask like face

Parkinson’s disease patients have a characteristic gait. For want of better words, they walk stiffly. The classical gait is described as bent forward, walking with short quick steps (as if they are going to topple over) and the arms are held by the side (they do not have the usual arm swing).

So point number 3. Gait (They walk funny!!!)

So if you or any of your loved ones show these signs, make sure you get a neurological opinion. Your doctor shall be able to elicit further points in the history and examination which shall help secure the diagnosis of sporadic Parkinson’s disease. Remember the diagnosis of Parkinson’s disease remains a clinical diagnosis (one made by a doctor after history and examination). There are no confirmatory tests (at least none that are used in the office setting).