Parkinsons / extrapyramidal exam

Question 1

What exposure is necessary?

Answer 1

Ask the patient to expose their hands, wrists and elbows (e.g. by rolling up their sleeves or removing a jacket). Observe the patient as they perform these actions as they may provide useful information about the patient’s dexterity and functional independence.

Question 2

What is general inspection?

Answer 2

Reduced spontaneous movements and hand gestures

Less frequent blinking

Hypomimia: a lack of facial expression.

Tremor: typically asymmetrical and present at rest, often described as ‘pill-rolling’ in character.

Hypophonia: soft, indistinct speech.

Abnormal posture: typically stooped in appearance.

Question 3

What are the main dimensions of the parkinsons exam?

Answer 3

Tremor

Tone

Bradykinesia

Gait

Question 4

What are the different dimensions of tremor?

Answer 4

Resting

Action (including postural and kinetic)

Question 5

What do you look for in the resting tremor?

Answer 5

Affects the hands: a small tremor in the index finger and thumb is common, causing the typical ‘pill-rolling’ appearance.

Asymmetrical (i.e. one limb has more significant symptoms).

4-6 Hz in amplitude

The tremor of Parkinson’s disease can also involve the lips, chin and legs.

If there is no obvious tremor on inspection, ask the patient to close their eyes and count back from 20 which should exacerbate a subtle tremor if present.

Question 6

What is a postural tremor?

Answer 6

Postural tremor occurs during the maintenance of a position against gravity and worsens during active movement.

Question 7

How do you assess for a postural tremor?

Answer 7

Assess for a postural tremor by asking the patient to raise their arms in front of their body and spread their fingers. Postural tremor may emerge after a latency of a few seconds (this is known as a re-emergent tremor).

Question 8

How do you assess for a kinetic tremor?

Answer 8

Assess for kinetic tremor by performing a finger-nose test:

1. Position your finger so that the patient has to fully outstretch their arm to reach it.
2. Ask the patient to touch their nose with the tip of their index finger and then touch your fingertip.
3. Ask the patient to continue to do this finger to nose motion as fast as they are able to.

Question 9

Why do we test for postural and kinetic tremor?

Answer 9

PD patients may have these tremors

Question 10

What is a kinetic tremor?

Answer 10

A tremor that occurs during hand movement

Question 11

How do you interpret the results of a finger nose test?

Answer 11

Kinetic tremor is also sometimes subdivided into ‘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).

Question 12

What is the features of an essential tremor?

Answer 12

Frequency of 5-10 Hz

Kinetic tremor

Postural tremor (without latency, unlike PD)

Improves with rest and often involves the head and neck

Question 13

What is another type of tremor?

Answer 13

Dystonic

Question 14

How do you assess bradykinesia?

Answer 14

Finger tapping (pincer grip)

Hand grip (fist)

Pronation/suppination

Toe tap (heel is kept on ground)

Question 15

What are you looking for during the bradykinesia exercises?

Answer 15

• 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

Question 16

What is the difference between rigidity and spasticity?

Answer 16

Increased muscle tone can be further subcategorised into spasticity and rigidity. Spasticity is associated with pyramidal tract lesions (e.g. stroke) and rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s disease).

Spasticity is “velocity-dependent”, meaning the faster you move the limb, the worse it is. There is typically increased tone in the initial part of the movement which then suddenly reduces past a certain point (known as “clasp knife spasticity”). Spasticity is also typically accompanied by weakness.

Question 17

How do you assess tone?

Answer 17

Test shoulder, elbow and wrist in hand shake position

Note if cogwheeling or leadpipe rigidity

An activation manoeuvre can accentuate subtle rigidity associated with early Parkinson’s – ask the patient to actively tap their thigh with their contralateral arm whilst you perform the movement.

Question 18

How do you assess gait/postural instabiltiy?

Answer 18

Sitting to standing (arms crossed across chest - make sure you are standing close). This screens for postural instability.

Gait

Pull test

Question 19

What do you look for in parkinsons gait?

Answer 19

Initiation: typically slow to start walking due to failure of gait ignition and hesitancy.

Step length: reduced stride length with short steps is common (shuffling gait). Each step may get progressively smaller as the patient attempts to retain balance (known as festinant gait).

Arm swing: reduced arm swing on or both sides (often an early feature of PD).

Posture: flexed trunk and neck causing a stooped appearance.

Tremor: resting tremor can be observed when the patient is distracted by walking.

Turning: impaired balance on turning or hesitancy is common due to postural instability.

Question 20

What are some other potential assessments?

Answer 20

• Ask the patient to write a sentence and draw a spiral to assess for asymmetric progressive micrographia (a typical feature of PD).
• Ask the patient to undo and do up their top shirt button (if present) to assess dexterity and speed of movement.
• Perform a cerebellar examination: if concerned about cerebellar pathology.
• Measure lying and standing blood pressure: autonomic abnormalities (e.g. postural hypotension) are a feature of Parkinson’s disease and multiple system atrophy.
• Assess eye movements: vertical gaze palsy and slow saccadic eye movements are associated with progressive supranuclear palsy (PSP).
• Perform a cognitive assessment (e.g. MMSE)
• Analyze the drug chart: medications such as neuroleptics, dopamine blocking antiemetics and sodium valproate can induce secondary parkinsonism.

Question 21

Summary:

Answer 21

Inspection

Tremor (resting, postural and kinetic)

Bradykinesia (Pincer, fist, pronation, toe tap)

Tone (including activation manouvre)

Gait (standing to sitting, gait and pull test)

Other tests (Writing, button of shirt)