Introduction

Parkinson's disease is signaled by the presentation of a core of symptoms.

The four cardinal features of Parkinson's disease, easily remembered by the acronym, 'TRAP,'
are:

 Tremor
 Rigidity
 Akinesia
 Postural changes.

This section will discuss the clinical symptoms of Parkinson's disease, some of which are
typically not seen until further along in the progression of the disease.

Glossary

Akinesia The absence of movement

Basal Ganglia A large group of nuclei deep within the brain that affects movement. The
basal ganglia include the caudate nucleus, putamen, globus pallidus,
subthalamic nucleus, and substantia nigra.
Blood Brain A protective barrier that allows only certain substances to enter the brain
Barrier from blood vessels
Bradykinesia Slowness in performing movements
Chorea Ongoing, rapid, and irregular flitting movements of the body that appear
willful, but are involuntary
Dopamine Agonist A drug that binds primarily with dopamine receptors and mimics the action
of dopamine
Dyskinesia Abnormal involuntary movements that typically are medication induced
Dystonia Involuntary twisting of the body due to abnormal muscle contractions
Enzyme Proteins that serve as catalysts for biochemical reactions within the brain
Essential Tremor The most common form of tremor, which typically begins in adolescence
and young adulthood and becomes more pronounced in middle to advanced
years, i.e., after age 50. It comprises a single symptom such as
uncontrollable shaking of the head, hands, arms, or other part of the body,
which stops when at rest. The condition is often hereditary.
Festinating Gait Involuntary acceleration of one's gait
Hypomimia A mask-like face with little expression
Levodopa (L- The chemical precursor to dopamine in the brain; also the most common and
Dopa) most effective agent for managing symptoms of Parkinson's disease.
Lewy Bodies Eosinophilic structures with a dense protein core found in the cytoplasm of
pigmented neurons; a pathological marker of Parkinson's disease when
found within the substantia nigra.
Micrographia Handwriting that decreases in size
Neurotransmitters Chemicals that transmit nerve impulses across a space (or synapse) from
one nerve to another
Receptor A structure on the surface of a cell that selectively binds with substances
such as neurotransmitters and hormones
Striatum A mass of grey matter that includes the putamen and caudate
Substantia Nigra Dopamine-producing nerve cells located in the brain stem that control
voluntary movement
Synapse The junction between two nerve cells, or neurons
   

Tremor
The classic type of tremor seen in Parkinson's disease is a rest tremor that occurs when the
individual is relaxed and at rest. The affected person may appear to be rolling a pill, due to the
movement of the index finger and thumb. The tremor in the limb usually, but not always,
subsides when the individually purposefully moves that limb. This sign is present in about 75%
of patients; its absence in the other 25% of patients make diagnosis slightly more difficult.

Rest tremor begins on one side of the body in the early stages of Parkinson's disease, and
subsequently involves the other side, often years later. Therefore, 'asymmetric rest tremor' is
considered a hallmark symptom of early Parkinson's disease. It can also affect the legs, chin, or
jaw (as in a chewing motion).

A voice or a head tremor may suggest conditions other than Parkinson's disease such as essential
tremor or a dystonic head tremor.

Rigidity
A second symptom that typifies Parkinson's disease is an increase in muscle tone that results in
resistance to movement, termed rigidity. This can take the form of lead pipe rigidity, which
appears as increased tone and resistance to movement that is consistent across the full range of
motion. Cog wheel rigidity implies the presence of tremor superimposed on lead pipe rigidity.
The location of rigid muscles in people with Parkinson's disease is typically more in the limbs
than in trunk muscles, with frozen or painful shoulders not an unusual presenting symptom.

Akinesia and Bradykinesia

An additional symptom leading to a diagnosis of Parkinson's disease is the absence of
movement, akinesia, or the slowness of movement, bradykinesia. This symptom manifests as a
slowness in initiating movement in a limb. Once begun, repetitive movement gradually slows
and becomes smaller. For example, handwriting progressively decreases in size, a condition
called micrographia.

Impaired movements result, for example, in difficulty turning in bed, standing up from sitting in
a chair, and getting out of a car. When patients walk, their arm swing may be reduced on one
side (unilateral) or on both sides (bilateral). Their gait may be shuffling or festinating, i.e.,
increasing in velocity. In some people suffering from Parkinson's disease, akinesia is seen in
facial characteristics: decreased blinking, a reptillian 'stare,' or an immobile or mask-like face
(hypomimia). In addition, there is a gradual softening of the voice (hypophonia).