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Review

Parkinson’s disease: clinical features and diagnosis

should be striatum of patients with addition, flexed posture
distinguishe PD paved the way for the and freezing (motor
d from first trials of levodopa in blocks) have been
weakness or PD patients the following included among classic
‘‘lessened year5 and subsequent features of parkinsonism,
muscular award of the Nobel Prize with PD as the most
Correspondence to: Professor J Jankovic, Department of Neurology,
power’’, a in Medicine to Carlsson in common form. Because
term 2000. The ability of
Parkinson’s Disease Center and Movement Disorders Clinic, Baylor College of Medicine, 6550 of the diverse profiles and
Fannin, Suite 1801, Houston, Texas 77030-3498, USA; josephj@bcm.tmc.edu originally injected levodopa to
lifestyles of those
used by improve akinesia in
Parkinson.2 patients with PD was first affected by PD, motor
Received 26 July 2007 and non-motor
More than demon-strated in 1961 and
100 years was followed by the impairments should be
Revised 3 September 2007 passed develop-ment of oral evaluated in the context
(1919) after levodopa later in the of each patient’s needs
Accepted 4 September 2007 the original decade.6 7 More recently, and goals.12
description genetic mutations,
by abnormal handling of A number of rating scales
J Jankovic Parkinson misfolded proteins by the
are used for the
before it ubiquitin–proteasome and
evaluation of motor
was the autophagy–lysosomal
ABSTRACT impairment and disability
recognised systems, increased
that patients oxidative stress, in patients with PD, but
Objective: Parkinson’s disease (PD) is a progressive with PD mitochondrial most of these scales have
neurological disorder characterised by a large number of motor lose cells in dysfunction, inflammation not been fully evaluated
and non-motor features that can impact on function to a variable the and other pathogenic for validity and
degree. This review describes the clinical characteristics of PD substantia mechanisms have been reliability.13 14 The Hoehn
with emphasis on those features that differentiate the disease nigra, and identified as contributing and Yahr scale is
from other parkinsonian disorders. 140 years factors in the death of commonly used to compare
passed dopaminergic and non- groups of patients and to
provide gross assessment
Methods: A MedLine search was performed to identify studies that (1957) dopaminergic cells in the
assess the clinical characteristics of PD. Search terms included before brains of patients with of disease progression,
‘‘Parkinson’s disease’’, ‘‘diagnosis’’ and ‘‘signs and symptoms’’. dopa-mine PD.8 9 It is beyond the ranging from stage 0 (no
was scope of this review to signs of disease) to stage 5
discovered discuss the various (wheelchair bound or
Results: Because there is no definitive test for the diagnosis of PD, the bedridden unless assisted).
disease must be diagnosed based on clinical criteria. Rest tremor,
as a pathogenic mechanisms,
bradykinesia, rigidity and loss of postural reflexes are generally putative management or treat-ment The Unified Parkinson’s
considered the cardinal signs of PD. The presence and specific neurotrans related complications that Disease Rating scale
presentation of these features are used to differentiate PD from related mit-ter by have been the subjects of (UPDRS) is the most well
parkinsonian disorders. Other clinical features include secondary motor Carlsson recent reviews and established scale for
symptoms (eg, hypomimia, dysarthria, dysphagia, sialorrhoea, and volumes.10 11 This article assessing disability and
micrographia, shuffling gait, festination, freezing, dystonia, glabellar colleagues focuses on the clinical impairment.13 15 Studies
reflexes), non-motor symptoms (eg, autonomic dysfunction, cognitive/ in Lund, features of PD and the making use of UPDRS to
neurobehavioral abnormalities, sleep disorders and sen-sory track the progression of PD
abnormalities such as anosmia, paresthesias and pain). Absence of rest
Sweden.3 differentiation of the
tremor, early occurrence of gait difficulty, postural instability, dementia, The disease from other suggest that the course of
hallucinations, and the presence of dysautonomia, ophthalmoparesis, discovery parkinso-nian disorders. PD is not linear and that
ataxia and other atypical features, coupled with poor or no response to by Ehringer the rate of deterioration is
levodopa, suggest diagnoses other than PD. Conclusions: A thorough and variable and more rapid in
understanding of the broad spectrum of clinical manifestations of PD is Hornykiewi the early phase of the
essential to the proper diagnosis of the disease. Genetic mutations or cz in disease and in patients with
variants, neuroimaging abnormalities and other tests are potential the postural instability gait
biomarkers that may improve diagnosis and allow the identification of difficulty (PIGD) of PD.16–
persons at risk. CLINICAL 18
We prospectively
FEATURES followed-up 297 patients
(181 men, 116 women)
In his 1817 ‘‘An essay on the shaking palsy’’, James Parkinson with clinically diagnosed
19603 4 that There are four cardinal
first described the clinical syndrome that was later to bear his PD for at least 3 years and,
dopamine features of PD that can
based on data from 1731
name.1 He identified six cases, three of whom he personally examined; concentrati be grouped under the visits during an average of
three he observed on the streets of London. Previously referred to as ons are acronym TRAP: Tremor 6.36 years (range 3–17),
‘‘paralysis agitans’’, Charcot later in the 19th century gave credit to markedly at rest, Rigidity, Akinesia we concluded that the
Parkinson by referring to the disease as ‘‘maladie de Parkinson’’ or decreased (or bradykinesia) and annual rate of decline in
Parkinson’s disease (PD). Charcot also recog-nised non-tremulous in the Postural instability. In the
forms of PD and correctly pointed out that slowness of movement
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of the patient. For example, deficit appears to be localised
immobile patients who in the putamen and globus
total UPDRS scores was 1.34 points when
become excited may be able pallidus,28 resulting in a
assessed during ON and 1.58 points when
reduction in the muscle force
assessed during OFF. Patients who were older to make quick movements produced at the initiation of
and had the PIGD form of PD at onset such as catching a ball (or
movement. Analysis of
experienced more rapid disease progression than may be able to suddenly run electro-myographic
did those who were younger at onset and had the if someone screams ‘‘fire’’). recordings showed that
tremor dominant form of PD. Furthermore, the This phenomenon (kinesia patients with bradykinesia are
older group experienced significantly more paradoxica) suggests that unable to energise the
progression in mentation, freezing and parts I patients with PD have intact appropriate muscles to
and II UPDRS subscores. Handwriting was the provide enough force to
only component of the UPDRS that did not motor programmes but have initiate and maintain large fast
significantly deteriorate during the observation difficulties accessing them movements.31 Because
period. On the other hand, many studies have without an external trigger, patients with PD have
shown that younger patients are at a higher risk such as a loud noise, decreased electromyographic
for levodopa induced dyskinesias than older marching music or a visual activity,22 they need a series of
patients.19 In a prospective study of 145 clinic cue requiring them to step multiple agonist bursts to
accomplish larger movements.
based patients followed-up for 1 year and of 124 over an obstacle.
community based patients followed-up for 4 years,
the annual mean rate of deterioration in motor and
Although the
disability scores ranged from 2.4% to 7.4%. 20 The
pathophysiology of
current UPDRS is undergoing revisions so that the
revised scale will be more sensitive to detect small bradykinesia has not been Tremor
changes and it will integrate non-motor elements of well delineated, it is the
PD.15 Other types of rating scales include those that cardinal PD feature that
appears to correlate best Rest tremor is the most
assess psychiatric manifestations (eg, depression)21 common and easily
and quality of life.14 21 The most frequent clinical with degree of dopamine
deficiency.26 This is recognised symptom of PD.
features associated with PD are listed in table 1 and
are discussed in the following sections. supported by the observation Tremors are unilateral, occur
of decreased neuronal density at a frequency between 4
in the substantia nigra in and 6 Hz, and almost always
elderly patients with are prominent in the distal
parkinsonism regardless of part of an extremity. Hand
PD diagnosis.27 In addition, tremors are described as
Bradykinesia
positron emission tomography supination–pronation (‘‘pill-
in patients with PD has rolling’’) tremors that spread
Bradykinesia refers to slowness of movement demonstrated that the from one hand to the other.
and is the most characteristic clinical feature of decreased 18F-fluorodopa Rest tremor in patients with
PD, although it may also be seen in other uptake in the striatum and PD can also involve the lips,
disorders, including depression. Bradykinesia is accum-bens–caudate complex chin, jaw and legs but,
a hallmark of basal ganglia disorders, and it is proportional to the degree unlike essential tremor,
28
encompasses difficulties with planning, initiating of bradykinesia. rarely involves the
and executing movement and with performing neck/head or voice. Thus a
sequential and simultaneous tasks.22 The initial It is hypothesised that patient who presents with
manifestation is often slowness in performing bradykinesia is the result of head tremor most likely has
activities of daily living and slow movement and a disruption in normal motor essential tremor, cervical
23 24
reaction times. This may include difficulties cortex activity mediated by dystonia, or both, rather than
with tasks requiring fine motor control (eg, reduced dopaminergic PD. Characteristically, rest
buttoning, using utensils). Other manifestations of function. In a study
tremor disappears with
bradykinesia include loss of spontaneous
assessing recordings from action and during sleep.
movements and gesturing, drooling because of
single cortical neurons in Some patients also report an
impaired swallowing,25 mono-tonic and hypophonic
dysarthria, loss of facial expression (hypomimia) rats with haloperidol ‘‘internal’’ shaking that is
and decreased blinking, and reduced arm swing induced bradykinesia, a not associated with a visible
while walking. Given that bradykinesia is one of the decrease in firing rates tremor.32 The tremor of PD is
most easily recognisable symptoms of PD, it may correlated with brady- differentiated from that of
29
become apparent before any formal neurological kinesia. Functional essential tremor by a number
examination. Assessment of brady-kinesia usually neuroimaging studies also of features (table 2).
includes having patients perform rapid, repeti-tive, suggest impair-ment in the
alternating movements of the hand (finger taps, recruitment of cortical and
Some patients with PD have
hand grips, hand pronation–supination) and heel subcortical systems that
regulate kinematic parameters a history of postural tremor,
taps and observing not only slowness but also
of movement (eg, velocity).30 phenomenologically
decrementing amplitude.
Conversely, recruitment of identical to essential tremor,
various premotor areas, such for many years or decades
as those responsible for before the onset of
In common with other parkinsonian symptoms, visuomotor control, is parkinsonian tremor or
bradykinesia is dependent on the emotional state increased.30 Anatomically, the
Non-motor instability Hypomimia, dysarthria, dysphagia,
symptoms Cognitive impairment, sialorrhoea
Table 1 Parkinson’s disease bradyphrenia, tip-of-the- Depression, apathy, anhedonia,
symptoms tongue (word finding) fatigue, other behavioural and

Motor symptoms Tremor, bradykinesia, phenomenon psychiatric problems

rigidity, postural
 feeding, dystonia, symptoms: anosmia, seborrhoea vivid dreams,
), weight daytime
hygiene, slow striatal ageusia, pain (shoulder,
Decreased arm swing, loss drowsiness,
activities of deformity, back), paresthesias sleep
shuffling gait, festination daily living scoliosis, fragmentation,
difficulty arising from chair, camptocormia Sleep restless legs
turning in bed Dysautonomia (orthostatic disorders syndrome)
Glabellar reflex, hypotension, constipation, (REM
urinary and sexual dysfunction, behaviour
blepharospasm, Sensory
Micrographia, cutting food, abnormal sweating, disorder,
J Neurol Psychiatry 68–376. 007.13 369
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Table 2 Features differentiating Parkinson’s disease from essential tremor

Feature
Parkinson’s disease
Essential tremor

Age at onset (y)

55–75
10–80
Family history
+/–
++
Tremor frequency (Hz)
4–6
5–10
Tremor characteristics
Supination–pronation
Flexion–extension
Influencing factors

Rest
Increases
Decreases
Action
Decreases
Increases
Mental concentration
Decreases
Increases
Writing
Decreases (micrographia)
Increases (tremulous)
Walking
Increases
Decreases
Alcohol
—
Decreases
Postural tremor
Re-emergent
Without latency
Kinetic tremor
+/–
Yes
Limb tremor
Asymmetric
Symmetric
Distribution other than limbs
Face, jaw, lips, chin
Head, voice
Neuroimaging—dopaminergic system
Marked dopaminergic deficit
Mild dopaminergic deficit
Mid-brain sonography
Marked hyper-echogenicity
Mild hyper-echogenicity
Neuropathology
Nigrostriatal degeneration, Lewy bodies
Mild cerebellar degeneration, Lewy bodies

in the substantia nigra, brainstem and

cerebellum some cases

Treatment
Anticholinergics, amantadine,
Alcohol, beta-blockers, primidone,

dopaminergic drugs, deep brain

topiramate, gabapentin, botulinum toxin,
stimulation
deep brain stimulation

usually accompanied by the

other PD related features. We and others have provided ‘‘cogwheel’’ phenomenon, In addition, rigidity of the
a growing body of evidence that indicates that essential particularly when associated neck and trunk (axial rigidity)
tremor is a risk factor for PD.33 with an underlying tremor, may occur, resulting in
present throughout abnormal axial postures (eg,
In addition to rest tremor, many patients with PD also anterocollis, scoliosis).
have postural tremor that is more prominent and the range of passive Postural deformities resulting
disabling than rest tremor and may be the first movement of a limb (flexion, in flexed neck and trunk
manifestation of the disease.34 35 Parkinson’s related extension or rotation about a posture and flexed elbows and
postural tremor (‘‘re-emergent tremor’’) is differentiated joint). It may occur knees are often associated
from essential tremor in that the appearance of tremor is proximally (eg, neck, with rigidity. However, flexed
often delayed after the patient assumes an out-stretched shoulders, hips) and distally posture generally occurs late
horizontal position.34 Because re-emergent tremor occurs at (eg, wrists, ankles). in the disease. Striatal limb
the same frequency as classical rest tremor and is Reinforcing manoeuvres (eg, deformities (eg, striatal hand,
responsive to dopaminergic therapy, it is likely that it voluntary movements of the striatal toe) may also develop
represents a variant of the more typical rest tremor. There contralateral limb), known as in some patients. Striatal hand
are several clues to the diagnosis of existent essential the Froment’s manoeuvre,39 is characterised by ulnar
tremor when it coexists with PD, including longstanding usually increase rigidity and are deviation of the hands,
history of action tremor, family history of tremor, head and particularly useful in detecting flexion of the
voice tremor, and no latency when arms are outstretched in mild cases of rigidity. metacarpophalangeal joints
a horizontal position in front of the body, although some and extension of the proximal
patients may also have a re-emergent tremor related to their and flexion of the distal
PD, tremulous handwriting and spiral, and improvement of Rigidity may be associated
with pain, and painful interphalangeal joints (fig
the tremor with alcohol and beta-blockers.
shoulder is one of the most 1A); striatal foot is
frequent initial manifestations characterised by extension or
The occurrence of rest tremor is variable among of PD although it is flexion (fig 1B) of the toes.43
patients and during the course of the disease. In one commonly misdiagnosed as
44
In one study, striatal toe
36
study, Hughes and colleagues reported that 69% of arthritis, bursitis or rotator (extension of the big toe) was
patients with PD had rest tremor at disease onset and that reported in 21% of patients
cuff injury.40 41 A prospective
75% had tremor during the course of their disease. Tremor with clinically diagnosed PD.45
study of 6038 persons (mean
was lost in 9% of patients late in the disease. Others have Patients with striatal
age 68.5 years) with no
reported that a small proportion of patients (11%) never deformities tend to be younger
evidence of dementia or
have tremor,37 although a prospective study in patients with and to experience earlier onset
parkinsonism at baseline found
autopsy proven disease found that 100% of patients had of initial parkinsonian
38 that the presence of stiffness,
tremor at some point. Clinical–pathological studies have symptoms.44
tremor and imbalance were
demonstrated that patients with PD and promi-nent tremor
each associated with increased
have degeneration of a subgroup of midbrain (A8) neurons,
whereas this area is spared in PD patients without tremor.
risk for PD (hazard ratios 2.11, Other skeletal abnormalities
2.09 and 3.47, respectively).42 include extreme neck flexion
Among this cohort, 56 new (‘‘dropped head’’ or ‘‘bent
cases of PD were identified spine’’), truncal flexion
over a mean follow-up of 5.8 (camptocor-mia) and
years. scoliosis.44 46–48 Camptocormia
Rigidity
is characterised by extreme
flexion of the thoracolumbar
Rigidity is characterised by increased resistance, spine. The condition is
Postural deformities
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further impair balance control German Parkinson
in patients with PD.56 In one Association, 47% of patients
exacerbated by walking and is relieved by
study, 38% of those evaluated reported freezing; it occurs
sitting, lying in the supine position or by
experienced falls, and 13% more frequently in men than
volitionally extending the trunk when the patient fell more than once a week.57 in women and less frequently
leans against a wall or a high walker or a table As expected, the frequency of in patients whose main
(fig 2A– C).48 In addition to PD, other causes of falls correlated with the symptom is tremor.63 Freezing
camptocormia include dystonia and extensor severity of disease.57 most commonly affects the
truncal myopathy.49 50 Another truncal deformity is Treatment (dopami-nergic legs during walking, but the
the Pisa syndrome, which is characterised by a therapy, pallidotomy, deep arms and eyelids can also be
tilting of the trunk, particularly when sitting or brain stimulation) can involved.64 It typically
51
standing. improve some axial signs58 manifests as a sudden and
but usually does not robustly transient (usually ,10 s)
Postural instability improve postural instability, inability to move. This may
measured by platform tilt and include hesitation when
visual tilt.59 Targeting other beginning to walk (start
Postural instability due to loss of postural nuclei for deep brain hesitation) or a sudden
reflexes is generally a manifestation of the late stimulation in addition to the inability to move the feet
stages of PD and usually occurs after the onset of subthalamic nucleus and during specific situations (eg,
other clinical features. The pull test, in which the globus pallidus, such as the turning or walking through a
patient is quickly pulled backward or forward by zona incerta and narrow passage, crossing busy
the shoulders, is used to assess the degree of pedunculopontine nucleus, is streets, approaching a destina-
retropulsion or propulsion, respectively. Taking being tion). Freezing is associated
more than two steps backwards or the absence of with substantial social and
any postural response indicates an abnormal clinical consequences for
postural response. Postural instability (along patients. In particular, it is a
explored as a potential common cause of falls.62
with freezing of gait) is the most common cause
surgical treatment of gait
of falls and contributes significantly to the risk
difficulties and postural
of hip fractures.52 The long latency to the onset of
stability.60
falls differentiates PD from other neurodegenerative
disorders, such as progressive supranuclear palsy
(PSP) and multiple systems atrophy (MSA).53 In Freezing Five subtypes of freezing
one study, the average time from onset of symptoms have been described: start
to the first fall was 108 months in patients with PD hesita-tion, turn hesitation,
Freezing, also referred to as hesitation in tight quarters,
compared with 16.8 and 42 months, respectively, in
52 motor blocks, is a form of destination hesitation and
patients with PSP and MSA.
akinesia (loss of movement) open space hesitation.65
and is one of the most Episodes are more severe in
Several other factors also influence the disabling symptoms of PD.61
occurrence of postural instability in patients with Although freezing is a the OFF state and are
mitigated by levodopa
PD. These include other parkinso-nian characteristic feature of PD, it therapy. In addition, patients
symptoms, orthostatic hypotension, age related does not occur universally.62 often develop tricks to
sensory changes and the ability to integrate Based on responses by 6620 overcome freezing attacks.
visual, vestibular and proprioceptive sensory patients to a questionnaire This includes marching to
input (kinesthesia).54 55 The fear of falling can sent to 12 000 members of the command, stepping over
typical Figure 2
Parkinson’s Camptocormia in a
patient with
disease. Parkinson’s
Patient consent disease
has been manifested by
received to flexion of the trunk
publish this (A) which the
patient can correct
figure. by pushing himself
into extension
posture (B) or by
lying in a supine
position
(C). Patient
consent has
Figure 1 Striatal been received
hand (A) and to publish this
foot (B) figure.
deformity in a
patient with
J Neurol Psychiatry 8–376. jnnp.2007.1 371
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Dysphagia is usually caused appreciated feature of PD.92
objects (eg, a walking stick, cracks in the floor), by an inability to initiate the These include autonomic
swallowing reflex or by a dysfunction, cogni-
walking to music or a beat, and shifting body
66–68 prolongation of laryngeal or tive/neurobehavioral
weight. oesophageal movement. disorders, and sensory and
Dysphagia is often sleep abnorm-alities.
Risk factors for the development of freezing subclinical, particu-larly in
include the presence of rigidity, bradykinesia, the early course of the
81
postural instability and longer disease duration.61 disease. PD related drooling
In contrast, tremor at disease onset is associated may result from a decrease in Autonomic dysfunction
25
with a decreased risk of freezing. As freezing swallowing.
typically occurs later in the course of the disease or Autonomic failure may be
is not the predominant symptom, alternative the presenting feature of PD,
diagnoses should be con-sidered when these although it is more typically
presentations occur. Freezing, particularly when it A number of neuro- associated with MSA.
occurs during the ON period, does not usually ophthalmological
abnormalities may be seen Features include orthostatic
respond to dopaminergic therapy, but patients
in patients with PD. These hypotension, sweating
treated with selegiline have been found to be at
lower risk.69 Botulinum toxin injections, although include decreased blink rate, dysfunction,93
effective for a variety of parkinsonian symptoms ocular surface irritation,
such as tremors, dystonia and sialorrhoea, have not altered tear film, visual A commu-
been found consistently effective in the treatment ofhallucinations,
freezing.70 blepharospasm and nity based study found that
decreased convergence.82 47% (42/89) of PD patients
The degree of abnormality in met the diagnostic criteria
ocular pursuit and saccades as
Other motor abnormalities for orthostatic
well as antisaccades83 is
hypotension.96
related to the degree of
Patients with PD may exhibit a number of disease progression.84
secondary motor symptoms that may impact on Dopaminergic therapy Cognitive and
their functioning at home, at work and while generally improves these neurobehavioural
driving.71 Because of a breakdown of the frontal changes, but one study found abnormalities
lobe inhibitory mechanisms, some patients display no difference in smooth
a re-emergence of primitive reflexes. 72 73 One study ocular pursuit between ON
and OFF periods in patients Neuropsychiatric
that included 41 patients with PD found that the
with PD.85 Other neuro- disturbances can be as
primitive glabellar reflex was present in 80.5% of
ophthalmological disabling as motor
patients.74 This symptom was a moderately
sensitive (83.3%) indicator of a parkinsonian abnormalities associated with symptoms. The Sydney
disorder but was not specific (47.5%) for PD. PD Multicenter Study of PD
Patients with PD in this study also experienced an found that 84% of patients
increased frequency (34.1%) of the palmomental include apraxia of eyelid evaluated showed cognitive
reflex. This symptom was not sensitive (33.3%) but opening, limitation of decline and that 48% met
was more specific (90%) than the glabellar reflex. upward gaze and oculogyric the diagnostic criteria for
In addition, these primitive reflexes cannot crises.86 87 dementia after 15 years of
differentiate among the three most common follow-up.97 Another
parkinsonian disorders (PD, PSP, MSA).74 community based prospective
Similarly, the ‘‘applause sign’’, initially thought to Respiratory disturbances in study found that patients with
be specific for PSP, is frequently present in other patients with PD can be PD are at almost sixfold
parkinsonian disorders, particularly corticobasal restrictive or obstructive.88 increased risk for dementia.98
75
degeneration. In some cases, unintended These complications are PD related dementia is also
movements accompany voluntary activity in associated with substantial associated with a number of
homologous muscles on the opposite side of the morbidity and mortality; other neuropsychiatric
body. These so-called mirror movements may be pneumonia is an independent comorbidities. Among 537
observed in early asym-metric PD.76 predictor of mortality in such patients, depression
nursing home patients with (58%), apathy (54%), anxiety
PD.89 The obstructive pattern (49%) and hallucinations
may be related to rigidity, (44%) were frequently
cervical arthrosis or restricted reported.99 In a study of 114
Bulbar dysfunction manifested by dysarthria, range of motion in the neck, patients with PD, 27.6%
hypophonia, dysphagia and sialorrhoea, and the restrictive pattern may screened positive for
frequently observed in patients with PD, can be be related to chest wall depression during the average
rigidity.90 Respiration may 14.6 months of follow-up;
equally or even more disabling than the cardinal
also be compromised by 40% were neither treated with
features. These symptoms are thought to be levodopa related respiratory antidepressants nor referred
related to orofacial–laryngeal bradykinesia and dyskinesia in patients with
77 for further psychiatric
rigidity. Speech disorders in patients with PD are PD.91 evaluation.100 In addition to
characterised by monotonous, soft and breathy cognitive and affective
speech with variable rate and frequent word finding disorders, many patients with
difficulties, referred to as ‘‘tip-of-the-tongue PD exhibit features of
phenomenon.’’78 79 Speech therapy, such as the Lee Non-motor features obsessive–compulsive and
Silverman Voice Treatment,80 that emphasises impulsive behaviour, such as
efforts to improve the volume and quality of the craving (especially for
speech, may ameliorate the symptoms of dysarthria. Non-motor symptoms are a sweets),101 binge eating,
common and under
compulsive foraging, hypersexuality, pathological of this article; the reader is largely attributed to the
gambling, compulsive shopping and punding, referred to some recent pharmacological therapy for
characterised by intense fascination with repetitive reviews of this topic.104 PD,105 some clinicians now
handling, examining, sorting and arranging of believe that these features are
objects.102 These beha-vioural symptoms, an integral part of the
sometimes referred to as ‘‘hedonistic homeostatic disease.106 This is supported
dysregulation’’, have been attributed to dopamine by the observation that rapid
dysregulation syndrome associated with the use of Sleep disorders eye movement sleep
dopaminer-gic drugs, particularly dopamine behaviour disorder, which
agonists, but the mechanism of these aberrant occurs in approximately one-
behaviours is not well understood.103 Cognitive and Although sleep disturbances third of patients
behavioural dysfunction in PD is not well (eg, excessive sleepiness,
understood, and its discussion is beyond the scope sleep attacks) were once
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frequent but are often not
with PD, is a substantial risk recognised as parkinsonian
symptoms.41 116–121 One study
Box 1 UK Parkinson’s Disease Society factor for the development
found that olfactory
of PD.107–110 Rapid eye
Brain Bank’s clinical criteria for the movement sleep behaviour dysfunction (hyposmia) may
diagnosis of probable Parkinson’s be an early marker of PD; it
disorder, now considered a
disease correlated with a 10%
pre-parkinsonian state, is
increased risk for the disease
characterised by an increase
2 years later compared with
Step 1 Bradykinesia in violent dream content110
other asymptomatic
At least one of the following criteria: accompanied by talking,
relatives.122 A study involving
Rigidity 62 pairs of twins discordant
yelling, swearing, grabbing, for PD found that smell
punching, kicking, jumping identification was reduced in
4–6 Hz rest tremor
and other dramatic, violent twins affected with PD than in
and potentially injurious those who were
Postural instability not caused by primary motor activity which may asymptomatic.123 It has been
visual, vestibular, cerebellar or also involve the bed partner. postulated that olfactory
proprioceptive dysfunction Insomnia, particularly sleep dysfunction is related to either
fragmentation, is also neuronal loss in the
corticomedial amygdala124 or
Step 2 frequent (.50% prevalence),
to decreased dopaminergic
but the occurrence is highly
neurons in the olfactory bulb.
variable among patients.111
Exclude other causes of parkinsonism 112
The sleep abnormalities
observed in patients with PD
Step 3 may possibly be related to a ASSESSMENT OF
50% loss of hypocretin PATIENTS WITH PD
(orexin) neurons.113 114
At least three of the following supportive Although excessive daytime
Diagnostic criteria
(prospective) criteria: Unilateral onset sleepiness may contribute to
fatigue, this common PD is diagnosed on clinical
Rest tremor Progressive disorder symptom is also seen criteria; there is no
independently of sleepiness.115 definitive test for diagnosis.
Persistent asymmetry primarily affecting Historically, pathological
side of onset Excellent response (70–100%) Sensory abnormalities confirmation of the hall-
to levodopa mark Lewy body on autopsy
has been considered the
Sensory symptoms such as criterion
Severe levodopa induced chorea (dyskinesia) olfactory dysfunction, pain,
Levodopa response for 5 years or more par-esthesia, akathisia, oral
Clinical course of 10 years or more pain and genital pain are standard for diagnosis.125
Hallucinations the patient’s features in group A are present
unrelated to symptoms and
Box 2 National Institute of medications in
Neurological Disorders and the first 3 years (such as
Stroke (NINDS) diagnostic Dementia suitably None of the features in group B is
criteria for Parkinson’s preceding motor located focal present (note: symptom duration >3
disease (PD) 128 symptoms or in brain lesions years is necessary to meet this
the first year or neuroleptic requirement) and Substantial and
Supranuclear use within the sustained response to levodopa or
Group A features gaze palsy past 6 months) a dopamine agonist has been
(characteristic of PD) (other than documented
restriction of
Criteria for
Resting tremor upward gaze) Criteria for possible PD
definite PD
Bradykinesia or slowing of
All criteria for
Rigidity vertical
probable At least two of the four features in
saccades
Parkinson’s group A are present; at least one
Asymmetric onset Severe,
are met and of these is tremor or bradykinesia
symptomatic
Histopathologi and
dysautonomia
Group B features (suggestive of cal
alternative diagnoses) Features unrelated to confirmation of
unusual early in the clinical medications Either none of the features in
the diagnosis
course group B is present or symptoms
is obtained at
Documentatio have been present (3 years and
autopsy
Prominent postural n of condition none of the features in group B is
instability in the first 3 known to present and
Criteria for
years after symptom onset produce
probable PD
Freezing phenomenon in parkinsonism Either substantial and sustained
the first 3 years and plausibly response to levodopa or a
connected to At least three dopamine agonist has been
of the four
documented or the patient trial of dopamine
has not had an adequate levodopa or a agonist
J Neurol Psychiatry –376. 5 373
Neurosurg 2008;79:368doi:10.1136/jnnp.2007.13104
ders.137

3.4.144

raclopride imaging of dopamine D2 receptors140

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Review
plus syndromes). Several
typically based on the presence of a combination features, such as tremor, and single
of cardinal motor features, associated and early gait abnormality (eg,
exclusionary symptoms, and response to freezing), postural
instability, pyramidal tract photon emission computed
levodopa.126 Although the diagnosis of PD is tomography of striatal
straightforward when patients have a classical findings and response to
dopamine reuptake sites.141
presentation, differentiating PD from other forms of levodopa, can be used to One study suggested that
parkinsonism can be challenging early in the course differentiate PD from other
brain parenchyma sonography
of the disease, when signs and symptoms overlap parkinso-nian disorders.
may be highly specific for
with other syndromes.127 Although differences in the
differentiating between PD
density of post-synaptic
and atypical parkinsonism142;
Diagnostic criteria have been developed by the dopamine receptors in however, it also showed
UK Parkinson’s Disease Society Brain Bank patients with PD or other abnormal hyperechogenicity
(box 1) and the National Institute of atypical parkinsonian not only in PD but in essential
Neurological Disorders and Stroke (NINDS) disorders have been used to tremor.143 Although these
(box 2). 128 explain the poor response to neuroimaging techniques are
levodopa therapy in the promis-ing, further refinement
latter group, this may not be in resolution and
However, the reliability and validity of these the only explanation. Recent improvement in sensitivity are
129
criteria have not been clearly established. A positron emission needed before their diagnostic
study that included 100 patients who underwent tomography imaging studies potential is fully realised.
biopsy after clinical diagnosis using the UK have shown relative
Parkinson’s Disease Society Brain Bank criteria preservation of dopamine
found that 76% of patients met the pathological
receptors in PSP,136
criteria; when the diagnostic criteria were
suggesting downstream
CONCLUSIONS
retrospectively applied, accuracy improved to
changes as a possible
82%.130 In a later study of the brains of patients
examined by neurologists, diagnostic accuracy was
mechanism for the lack of PD is a progressive
response. Furthermore, neurodegenerative disorder
considerably higher (91– 92%).131
patients with MSA often have manifested by a broad
excellent initial responses but spectrum of motor and non-
A study evaluating 800 patients from the frequently develop levodopa motor features. The natural
DATATOP trial suggested that movement related orofacial dyskinesias progression of PD is
disorder specialists are skilful at diagnosing and lose antiparkinsonian variable but is usually more
PD.132 In this study, patients were followed-up from efficacy. Although rapid in patients with late
early pretreatment stages for a mean of 7.6 years. improvement with levodopa is onset and with the PIGD
Based on autopsy data, imaging studies, response to suggestive of PD, it does not
form of PD. In a
levodopa and atypical clinical features, only 8.1% definitively differentiate PD
comprehensive review of
of patients did not meet the diagnostic criteria at the from other parkinsonian
final diagnosis. Although this represents an disor- the literature, the
improvement in diagnostic accuracy over earlier standardised mortality ratio
studies, it must be noted that not all diagnoses were One study found that only has been reported to range
confirmed on pathological examination. between 1 and
77% of patients with

Misdiagnosis of PD can arise for a number of Because there are no

pathologically proven PD definitive diagnostic tests
reasons. In a community based study of patients had a ‘‘good’’ or ‘‘excellent’’
taking antiparkinsonian medication (n = 402), for it,
initial
the most common causes of misdiagnoses were
essential tremor, Alzheimer’s disease and clinicians require thorough
vascular parkin-sonism.127 133 More than 25% of response to levodopa.36 knowledge of the clinical
patients in this study did not respond to Subcutaneous injection of
manifesta-tions of PD to aid
antiparkinsonian medication. In addition, many of apomorphine has been used to
them in differentiating it
the prominent features of PD (eg, rigidity, gait differentiate between PD and
from related disorders.
disturbance, bradykinesia) may also occur as a other parkinso-nian disorders;
however, this test is not Future research may
result of normal aging or from comorbid and uncover disease specific
multifactorial medical conditions (eg, diabetes, superior to levodopa therapy
and contributes little to biomar-kers allowing for its
cancer).134 135
diagnostic evaluation.138 differentiation from other
neurodegenera-tive
disorders. Not only will
Neuroimaging techniques
Differential diagnosis such testing be useful for
may also be useful for
differentiat-ing PD from other diagnosing the disease in
139 affected persons, it will be
Parkinsonian disorders can be classified as four parkinsonian disorders. useful for identifying family
types: primary (idiopathic) parkinsonism, Potential imaging studies
include high field strength (1.5 members or populations at
secondary (acquired, symptomatic) risk, thus providing an
parkinsonism, heredodegenerative parkinsonism T) heavily T2 weighted MRI,139
[ 18
F]-fluorodopa positron opportunity to initiate
and multiple system degeneration (parkinsonism 139 11 neuroprotective therapy at
emission tomography, [ C]-
an asymptomatic stage.
Acknowledgements: I would like to thank the
National Parkinson Foundation for its support of
our NPF Center of Excellence and Susan
Quin˜ones, PhD for editorial assistance.
Competing interests: None.
Patient consent: Patient consent has been
received to publish the figures in this paper.
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Parkinson's disease: clinical features and

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J Jankovic

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