- Inspection: spontaneous movements, facial expression, resting tremor, posture
- Tremor: resting (accentuate by distraction), postural (extend arms fully), kinetic (past-pointing)
- Parkinsonian tremor: 4-6 Hz, asymmetric, at rest, in hands/chin/arms/legs
- Bradykinesia: paucity of facial expression, ↓ spontaneous blinking, lack of arm swing
- Test for bradykinesia using rapid alternating movements e.g. finger tapping (↓ amplitude = fatiguability)
- Tone: similar to upper limb exam (lead-pipe rigidity, cogwheel rigidity – accentuate with co-activation)
- rigidity vs spasticity: spasticity affects ‘anti-gravity’ muscles; Parkinsonian rigidity affects entire range of movement
- Gait: looking for step initiation, step length, heel strike, arm swing, posture, tremor, turning (festination, stoop, +ve pull test)
- Non-motor features: dementia, REM sleep behaviour disorders/excess daytime sleepiness; autonomic dysfunction e.g. incontinence, constipation, postural hypotension
- To complete the examination, offer:
- cerebellar examination, eye movements
- lying and standing BP; medication review
- MMSE/cognitive assessment