Approach to the Exam for Parkinson's Disease

To test for the presence of bradykinesia we will have the patient perform rapid alternating movements. It is important to remember that these movements must be performed as fast as possible and as big as possible, meaning with the amplest range possible. All these tests are positive for bradykinesia if the range of motion and/or the speed reduce over time. For this reason, it is crucial to ask the patient to do at least ten repetitions for each movement.

Also, in both the upper and lower extremities, the movements more affected by bradykinesia are the finest ones, such as the movements of the toes and fingers.

Finger tapping

In finger tapping the patient is instructed to tap the index finger on the thumb as fast possible and as big as possible. This means that the patient should try to separate the two fingers as much as possible before tapping them. Make sure to test both the right and the left side.

Click this link to watch an example for the “finger tapping test ” on the video.

Fist Open Close

If the patient has arthritis of the hand joints, the finger tapping is not a very sensitive test. In this case, we can use other tests such as the fist open close. To perform this test, instruct the patient to open and close the fist as fast as possible and by spreading the fingers as much as possible.

Click this link to watch an example for the “fist open close test” on the video.

Pronation/Supination of the Hand

This represents another alternative to the finger tapping test. The patient is instructed to flex the shoulder forward at 90° and fully extend the forearm. From this position, ask the patient to rapidly alternate pronation and supination of the hand. Again, look for a reduction in the speed and amplitude of movement, no matter how slight this is.

Click this link to watch an example for the “pronation/supination test” on the video.

Toe Tapping

It is possible to test for bradykinesia in the lower extremities too, where the most sensitive test is toe tapping. In this test the patient sits on a chair with both feet on the ground. The patient is instructed to rapidly tap the floor with the toes while the heel is kept in touch with the ground. The test is positive if the speed and/or amplitude of movement reduce over time.

Click this link to watch an example of the “toe tapping test” on the video.

Heel Tapping

To carry on the test, first the patient has to sit on a chair with the feet on the ground. Then, instruct the patient to repetitively and rapidly tap the whole foot on the ground. This maneuver tends to be less sensitive than toe tapping. Again, the test is positive if the speed or amplitude of movement reduces over time.

Click this link to watch an example for the “heel tapping test” on the video.

To test for the presence of rigidity, we need to passively manipulate the limbs of the patient. However, If the disease is in its early stage or the symptoms are well controlled with medications, we may not be able to see rigidity. We will need to use some activation maneuvers, that basically consist in performing repetitive movements with the limb contralateral to the one that is being tested.

Also, there are two types of rigidity:

-       Lead-pipe rigidity: where the tone is uniformly and smoothly increased throughout the entire range of movement

-       Cogwheel rigidity: where a tremor is superimposed on the hypertonia, making the movement irregular due to intermittent increase and reduction of tone

In Parkinson’s disease resting tremor most commonly manifests in the hands as a rotatory movement of the fingers, especially the thumb and index (pill-rolling). Even though we could observe a resting tremor while the patients are giving the history, sometimes they may assume a position that suppresses the tremor. For example, they could sit on their hands or hold them in their lap. The best position to uncover a resting tremor is with the patient sitting on the chair with both hands lying relaxed on the thighs.

Click this link to see an example of resting tremor on the video.

Postural tremor is a type of tremor that emerges when the patient maintains a position against gravity. To test for postural tremor, first have the patient fully extend the elbow and flex the arm forward at 90°. Then, ask the patient to spread the fingers out as much as possible and hold this position for a few minutes. This is necessary since a postural tremor in PD is often evidenced only a few seconds or minutes after the position in assumed.

Click this link to see an example of postural tremor on the video.

Action or kinetic tremor is a type of tremor that is uncovered only when the patient is carrying out a movement. To test for kinetic tremor we can use the finger to nose test. In performing this test, the patients are instructed to alternatively touch their nose and our finger. In doing so, the patients should stretch their arm completely and should not move too fast. In this way we have more chances of triggering the tremor.

There is a different variant of the finger to nose test, in which the finger of the examiner changes position every time that the patient tries to reach it. This variant of the test is used to test for ataxia, rather than for tremor.

Click here to jump to the section of the video showing how to perform the finger to nose test.

In this test we want to see if the patient is able to stand up from the sitting position without using the hands. To perform the test, first ask the patient to cross the arms on the chest and then to stand up. Make sure to keep one of your hands behind the patient’s back throughout the test, in order to prevent the patient to fall backwards and hit the head against the wall. In normal conditions the patients will be able to stand up without any difficulties.

This part of the exam consists in observing the patient’s gait. To increase the chances of picking up any abnormalities that may be present, the patient should walk back and forth several times, ideally, in a hallway at least 10 feet long.

While the patient is walking, we need to look for:

-       Loss of balance on the turns

-       Reduced step length

-       Loss of heel strike

-       Loss of arm swings

These are typical abnormalities of gait in Parkinson’s disease. Also, in the initial stages of the disease, these anomalies tend to be unilateral, making them easier to recognize.

Click here to jump to the section on the video showing an example of asymmetric heel strike and arm swing loss.

A gait with short steps and absent heel strike bilaterally is called “festinating” or “shuffling” gait and is typical of Parkinson’s disease.

Click here to see an example of festinating gait in the video.

In this test the examiner stands behind the patients and by pulling on their shoulder tries to make them fall backwards. If the patients are able to correct their center of gravity in just one or two steps, the test is negative for a balance abnormalities. The test is instead considered positive if the patients catch their balance in more than two steps or if they do not stabilize at all and tend to fall to the ground.

Click here to see an example of how the “Pull Test” should be performed.

To make sure the test is performed in a safe way, there are some precautions that should be taken:

-       First, there should be a wall behind the examiner, so that if the patients do not manage to correct their balance and fall backwards, the examiner can grab them and together they can fall on the wall;

-       Second, the examiner must teach the patients how to perform the test and must explain what is going to happen if they are going to lose balance and fall.

Click here to see an example of an abnormal result on the “Pull Test”.

Clinical Pearl

"When during a follow up visit we notice new worsening bradykinesia, tremor or rigidity, this does not necessary imply that a change in the medication regimen is needed, unless it is significantly impacting the quality of life of the patient. On the other hand, even the slightest impairment of gait and balance control necessitates an intervention, that may be as simple as physical therapy."