CLINICALEXAMINATIONOFPARKINSON’SDISEASE

PATIENTSAmaalAlDakheel,MDConsultant,MovementDisordersDirector,MovementDisordersProgramKingFaisalSpecialistHospital&ResearchCentreRiyadh,SaudiArabiaAldakheelAmaal@gmail.com

Disclosures

§  None

LearningObjectives

§  Identifythephenotypicspectrumofparkinsonism

§  IllustratetheclinicalphenotypeofParkinson'sdisease

§  Demonstrateclinicaltechniquesforexaminingpatients

withParkinson’sdisease

§  DescribetheclinicalcluesusefulinthediagnosisofAtypicalParkinsonism

TheEtiologyofParkinsonism

Parkinsonism

Degenerative Symptomatic

Parkinson'sDisease AtypicalParkinsonism

Alpha-synucleinopathy Tauopathy

MultipleSystemAtrophy(MSA)DementiaofLewy-bodies(DLB)

ProgressivesupranuclearPalsy(PSP)CorticobasalDegeneration(CBD)

Secondary

Parkinsonism

§  Parkinsonismremainsdefinedasbradykinesiaplusrigidityandresttremorsorboth

§  Bradykinesia-decrementinspeedoramplitudeisrequired

Parkinsonismisaclinicaldiagnosis

Bradykinesia

LookforaDecrementof(speedandamplitude)

RestTremor

Tremor

ActionTremor

ParkinsonianTremor

RestmeansREST!1-Nomuscularactivity2-NoGravity

Re-Emerging-Phenomenon

Video

PosturalTremor

KineticTremor

IntentionTremor

Maintainingapositionagainstgravity

Duringvoluntaryactions

Increasedamplitudewhenapproachinggoal

Essential/DystonicTremor Cerebellar

Tremor

Rigidity

§  Velocity-independenthypertoniaoftenwithcogwheelphenomenon•  Involving2joints

§  Differentialdiagnosis:•  Spasticity:velocity-dependent,flexorsmoreinvolvedthanextensors

•  Paratonia:inconsistent,distractible‘’Gegenhalten”

ClinicalPresentationofParkinsonism

Video

Video Video

Bradykinesia

RestingTremor Rigidity

and/or

GeneralExaminationThefacecangiveyoua

clue

“Procerussign”AstonishedlookofthePSPpatients

InPD-Facelacksexpressivemobility(hypomimia)Reducedblinking,2-10perminHypophoniaandmonotonousspeech

Video

GaitExamination

Video Video Video

Inclinicalexamination,trytoavoidcueing

Festinationofgait FreezingofgaitReducedArmswing

AxialSymptoms-AxialDystonia

Retrocollis Anterocollis Camptocormia Pisa-Syndrome

PSP MSA MSAPD

AxialSymptoms-Posturalinstability

Video Video Video Video

PosturalstabilityinPull-test PosturalinstabilityinPull-test

SpontaneousPosturalinstabilityinPull-test

ToCompleteyourexamination

§  Don’tforgettolookfor:

•  CerebellarSigns

•  PosturalbloodPressure

•  Cognitiveexamination(MoCA)

KeyMessage

§  Bradykinesia,restingtremor,rigidityandpostural

instabilitydetectionarethemainclinicalsignsof

Parkinson’sDisease

§  Clinicalsignscanvaryduringtheclinicalexamination

§  RecognizingtheredflagsforatypicalParkinsonismis

crucial

§  References:1.  Papapetropoulosetal,Anterocollis:clinicalfeaturesandtreatment

options,MedSciMonit.2008

2.  Dohertyetal,PosturaldeformitiesinParkinson’sdisease,Thelancet2011

3.  PrinciplesandPracticeofMovementDisorders,StanleyFahn,2007

4.  CaseStudiesinMovementDisorders:CommonandUncommon

PresentationsRobertoErro,KailashBhatia,MariaStamelou,2017

5.  MovementDisorders,RayL.Watts,DavidG.Standaert,2011