Parkinson's Examination Flashcards
Intro:
What should you ask the patient to do?
Expose hands, wrists and elbow
1) General inspection:
What 5 signs may you see when they are sitting up on the bed or chair?
What you notice when they are stood up?
What may you notice about their speech?
Remember, general inspection for neurological exams, you use the SWIFT mnemonic. What is it?
Reduced spontaneous movements and hand gestures
Reduced blinking
Hypomimia - lack of facial expression
Tremor - asset, present at rest, pill-rolling
Abnormal posture - stooped
Hypophonia - soft, indistinct speech
Swift Wasting Involuntary movements Fasciculations Tremor
3) Resting Tremor:
Describe the tremor that you would see?
What can you get them to do if the tremor is subtle?
4) Action tremor:
There are 2 types of action tremors - kinetic and postural.
Postural Tremor:
- Define?
- When is it worse?
- How do you assess this?
- What does a re-emergent tremor mean?
Kinetic tremor:
- Define?
- There are 2 types of kinetic tremor - simple kinetic tremor and intention tremor - define both?
- How is this tested for?
Close eyes and count back from 20
Pill-rolling appearance
Asymmetrical
4-6 Hz in amplitude
Postural tremor occurs during the maintenance of a position against gravity and WORSENS during active movement.
Ask patient to raise their hands in front of their body and spread fingers. - JUST put them in different positions in front of the body
Postural tremor may emerge after a latency of a few seconds (this is known as a re-emergent tremor). - https://tremorjournal.org/articles/10.5334/tohm.520/print/
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Kinetic tremor occurs during hand movement
Simple kinetic tremor in which the tremor remains constant throughout the movement vs ‘intention tremor’ where the kinetic tremor gets worse as the patient approaches a target (e.g. in the finger-to-nose test)
Writing or during a finger-to-nose movement
You could also see cerebellar signs which could suggest multiple system atrophy.
Tremors:
Essential tremors - how do they differentiate from the tremors we have in PD?
Dystonic tremor - it looks quite similar to PD. What may you notice about the postural tremor?
Is is better at rest
It is position dependent - in PD, it happens in all positions
5) Bradykinesia:
You ask them to perform rapidly alternating movements.
Should it be done on both limbs or one limb at a time?
You only need 2 movements - think of 2?
What may you notice when you watch them?
What other movement used to look for cerebellar lesions can be done here?
One limb at a time.
Finger tapping
Hand gripping - make fist then open and repeat
Progressive reduction in speed
Progressive reduction in amplitude
Asymmetry (i.e. struggles to perform rapid movements with left fingers)
Slowness in the initiation of movement
The movement that can show Dysdiadochokinesia
6) Tone:
Spasticity vs rigidity:
- What tends to cause S?
- What tends to cause R?
What is the main difference between S and R?
Rigidity is present in PD:
What is the difference between cogwheel rigidity and lead pipe rigidity?
Rigidity is “velocity independent” meaning it feels the same if you move the limb rapidly or slowly.
Pyramidal lesions (stroke)
Extrapyramidal lesions (PD)
The pyramidal tracts (corticospinal tract and corticobulbar tracts) may directly innervate motor neurons of the spinal cord or brainstem (anterior (ventral) horn cells or certain cranial nerve nuclei), whereas the extrapyramidal system centers on the modulation and regulation (indirect control) of anterior (ventral) horn cells.
Spasticity is “velocity-dependent”, meaning the faster you move the limb, the worse it is.
Cogwheel rigidity = tremor + hypertonia resulting in intermittent increases in tone during movement of the limb. This subtype of rigidity is associated with PD.
Lead pipe rigidity = hypertonia ONLY
This subtype of rigidity is typically associated with neuroleptic malignant syndrome.
NMS: life-threatening neurological disorder usually associated with antipsychotics that is characterized by a tetrad of features (fever, muscle rigidity, autonomic instability, and mental status changes) as well as rhabdomyolysis and elevated creatine kinase
6) Tone:
Assessment:
What can you do to distract them?
Get them to tap out rhythm on their other knee or paint something the wall
7) Gait:
What do you observe for when they stand up?
Observe gait:
- What 6 things do you look for?
- What does a festinant gait mean?
What test is used to observe postural instability?
Postural instability
Initiation - slow Step length - reduced stride (shuffling gait) Reduced arm swing Stooped posture Resting tremor Slow turning - postural instability
Each step may get progressively smaller as the patient attempts to retain balance (known as festinant gait).
Pull test
7) Gait:
Pull test:
Clearly explain the test: “I’m going to give you a quick tug on your shoulders and I’d like you to take two steps backwards to catch your balance. I will be behind you at all times and won’t let you fall.”
Perform a test run by tugging gently to see if they are able to maintain their balance (if not, end the assessment here).
Tug their shoulders backwards once more, this time with more force: healthy individuals will be able to correct their balance using one or two quick steps.
7) Gait:
Pull test:
Clearly explain the test: “I’m going to give you a quick tug on your shoulders and I’d like you to take two steps backwards to catch your balance. I will be behind you at all times and won’t let you fall.”
Perform a test run by tugging gently to see if they are able to maintain their balance (if not, end the assessment here).
Tug their shoulders backwards once more, this time with more force: healthy individuals will be able to correct their balance using one or two quick steps.
8) Further tests:
Not necessary!!!
What can you do to assess micrographia?
What other examinations would you want to do PSP?
What exam and what measurement would you do for MSA?
What about autonomic dysfunction in PD?
What about DLB?
Get them to write a sentence or draw a spiral - usually assymetrical
Eye exam for PSP
Cerebellar examination AND BP for MSA
Lying and standing BP
MMSE
