How Does A Doctor Diagnose Parkinson’s

Diagnosing Parkinsons Disease At Dignity Health Southern California

As with many other brain and nervous system disorders, doctors do not have a specific test to diagnose Parkinsons disease. This means that before your doctor will determine a Parkinsons diagnosis, they will rule out other potential causes of your symptoms. Diagnosing Parkinsons disease can be challenging, because many other disorders have similar signs and symptoms.

Diagnosing Parkinsons may include:

• Medication history to rule out drug side effects as the cause of your symptoms
• Medical history evaluation, including any family history of Parkinsons disease or other movement disorders
• Imaging studies, including a cutting-edge diagnostic scan called DaTscan, which can differentiate Parkinsons disease from a more common movement problem called essential tremor
• Medication trial to determine if your symptoms improve with established therapy
• Physical examination to assess balance, gait, and muscle tone

This exclusionary approach to diagnosing Parkinsons disease will help your doctor give you an accurate diagnosis and an appropriate treatment plan. You can trust your complete neurological care and testing to the experienced team at Dignity Health Southern California.

How Can I Try To Get An Early Diagnosis

Theres still debate among medical professionals on how long non-motor symptoms may appear before an individual has noticeable changes in their movement. Its thought that they could appear years to decades beforehand.

But a formal Parkinsons diagnosis requires the symptom slowness of movement. In the time before this symptom appears, your doctor cant make a Parkinsons diagnosis, but they may alert you that youre at a high risk of developing Parkinsons in the future if these or other symptoms appear at any point.

How Do Doctors Diagnose Parkinsonism

No single test exists for doctors to diagnose Parkinsonism.

A doctor will start by taking a persons health history and review their current symptoms. They will ask for a medication list to determine if any medicines could be causing the symptoms.

A doctor will likely also order blood testing to check for underlying potential causes, such as thyroid or liver problems. A doctor will also order imaging scans to examine the brain and body for other causes, such as a brain .

Doctors can perform a test that tracks the movement of dopamine in the brain. This is known as the DaT-SPECT test.

The test uses radioactive markers designed to track dopamine in the brain. This allows a doctor to watch the release of dopamine in a persons brain and identify the areas of the brain that do or do not receive it.

Because Parkinsonism does not respond to typical treatments and can have a variety of symptoms, doctors can have difficulty coming to a quick diagnosis. It may take time for doctors to rule out other conditions and begin to make treatment recommendations.

Methodological Limitations Of The Diagnostic Studies

When interpreting the literature about diagnosis, the following methodological issues should be considered:

• lack of long-term prospective clinical and pathological as a reference standard
• lack of operational definitions such as defining specialists or clinical diagnostic criteria
• unclear whether investigators were blinded to initial diagnosis
• sample sizes necessarily limited by the number of cases available with neuropathological outcomes
• trial age groups are often young as studies were performed by neurologists who see a younger population of people with PD
• most studies included people with established disease lasting some years
• varying geographical locations
• some studies are in specialised units and may not reflect the diagnostic accuracy of other units in the UK
• exclusion of some studies using magnetic resonance volumetry and magnetic resonance spectroscopy as they lacked appropriate population, intervention and outcome criteria
• lack of statistical details of diagnostic accuracy such as sensitivity, specificity and positive predictive values
• lack of economic evaluations of SPECT.

Where Can I Find A Movement Disorder Specialist

People with Parkinsons disease often benefit from many different specialties on their care team. One specialist that can help you manage your condition is a movement disorder specialist. Movement disorder specialists help treat tics, , and other involuntary muscle movements that can interfere with your daily life. People with PD can benefit from movement disorder specialists at any stage of treatment.

How Is Parkinson’s Disease Managed

Your doctors will tailor your treatment based on your individual circumstances. You will manage your condition best if you have the support of a team, which may include a general practitioner, neurologist, physiotherapist, occupational therapist, psychologist, specialist nurse and dietitian.

While there is no cure for Parkinson’s disease, symptoms can be treated with a combination of the following.

What Are The Stages Of Parkinson’s Disease

Doctors typically define 5 stages of Parkinsons disease:

• Stage 1. The earliest stage of Parkinsons. There may be some symptoms, but they are mild and do not interfere with daily tasks. Usually, tremors or motor symptoms are relegated to only one side of the body. Medications are often effective at controlling symptoms.
• Stage 2. Parkinsons is considered moderate. Symptoms like stiffness and tremors are more noticeable than in stage 1. Takes may take longer to complete, and both sides of the body may be affected. However, the Parkinsons patient can still live alone, and balance remains unaffected.
• Stage 3. This stage involves more pronounced symptoms that significantly impact daily life. Balance problems become more predominant, and basic reflexes decrease. Falls are more common in Stage 3 than other stages. However, between medication and therapy, Stage 3 patients can often retain their autonomy.
• Stage 4. Symptoms are even more advanced than in stage 3. At this stage, living alone is exceedingly challenging and potentially dangerous. Around a third of patients at this stage have hallucinations or delusions.
• Stage 5. Also known as end stage Parkinsons disease, stage 5 is the most advanced stage of Parkinsons. Muscle stiffness and tremors are severe and can make it impossible to move around. People usually require a wheelchair, and constant surveillance is necessary to prevent falls. Dementia, hallucinations, and delusions are common.

Deep Brain Stimulation Surgery

As Parkinsons disease progresses, deep brain stimulation surgery may become an option. Our team is one of the most experienced in the United States. Under the direction of Dr. Delaram Safarpour, Dr. Kim Burchiel, an OHSU neurosurgeon, pioneered asleep DBS so you dont have to be awake during surgery.

For this procedure, our team places tiny electrodes in your brain. The electrodes are connected to a small pacemaker-like device placed under the skin of your chest. The device sends mild electrical pulses to regulate movement and control Parkinsons symptoms such as:

• Tremors
• Slowness
• Imbalance

In some parts of the state, you can have follow-up care at a doctors office in your community.

Colin Halstead had deep brain stimulation surgery at OHSU to treat his Parkinsons. It gave me my life back, he says.

How Is Parkinsons Disease Tested And Diagnosed

At Banner Health, our neurologists have years of experience in testing and diagnosing Parkinson’s disease. Our team of compassionate experts knows that each patient is different, so we work with you to quickly find the right diagnosis to begin building your treatment plan.

Parkinsons is not simple to diagnose. No test exists to diagnose Parkinsons disease. Doctors test and diagnose Parkinsons based on your medical history, symptoms and neurological and physical exams. 

Many times a primary care provider is the first to suspect a Parkinsons diagnosis. If youre experiencing symptoms such as tremors, shaking, slow movement, stiffness and/or trouble with balance, talk to your doctor or seek the opinion of a neurologist. Banner Health neurologists are movement disorder specialists, who have experience and specific training to assess and treat Parkinsons.

The Diagnostic Criteria Used Today

In 2015, a Movement Disorder Society task force proposed a set of criteria that became known as the Movement Disorder Society United Parkinsons Disease Rating Scale , which includes non-motor symptoms in its criteria.9

The new criteria requires you to have slowness of movement, plus either a rest tremor or rigidity. It also requires that you do not meet any criteria in a list called absolute exclusion criteria. This list of symptoms indicates you most likely do not have PD or that you may have an atypical parkinsonism disorders that resemble Parkinsons disease but are ultimately different. If you meet any of those requirements, PD is ruled out. For example, one absolute exclusion criteria is if you are taking a drug that is known to cause Parkinsons-like side effects.

Next, you must meet at least two of the following four criteria:

• Dramatic improvement of motor symptoms when you take the gold-standard Parkinsons medication called levodopa
• The presence of dyskinesia as a result of taking levodopa dyskinesia is a possible side effect of levodopa among people with PD
• Rest tremor, meaning your tremor occurs when the body part is at rest
• Loss of smell, or if you have a test called MIBG scintigraphy and it indicates that you have autonomic dysfunction, which is when your autonomic nervous system doesnt work correctly, leading to issues with things like heart rate and blood pressure.

Brain Imaging And Other Tools To Aid Diagnosis Of Parkinsons

In addition to taking a history and performing a detailed neurologic examination, physicians sometimes use brain imaging to help support a particular diagnosis. However, these studies have their limitations in the diagnosis of Parkinsons disease and are typically used only in select patients. Brain imaging is not routinely performed by neurologists or movement disorder specialists when they are considering a diagnosis, especially if the persons symptoms strongly suggest to the physician that idiopathic Parkinsons disease is the correct diagnosis.

Helping diagnose Parkinsons with DaTscan and other tests

Rather, use of imaging is most helpful when the diagnosis is uncertain, or when physicians are looking for changes in the brain that are more typical of one of several Parkinsonian syndromes and other conditions that can mimic Parkinsons. Imaging studies to evaluate Parkinsons disease and Parkinsonian syndromes include magnetic resonance imaging , which examines the structure of the brain, and DaTscan, an imaging test approved by the Food and Drug Administration to detect the dopamine function in the brain. A DaTscan may help differentiate idiopathic Parkinsons disease from certain other neurologic disorders. Most physicians offices will have access to MRI; however, DaTscan imaging may only be available at larger hospitals or medical centers.

What Is Parkinsons Disease

Parkinsons disease is a kind of movement disorder. It affects the nervous system and causes problems with muscle movement. It is a chronic and progressive disease. This means that it doesnt go away, and the symptoms get worse over time.

Some nerve cells in the brain make a chemical called dopamine. Dopamine sends signals to help coordinate movement and coordination. In people who have Parkinsons disease, these cells die or do not work properly. The level of dopamine produced decreases. This affects the persons ability to control their movement normally.

There is no cure for Parkinsons disease, but treatment can help relieve the symptoms.

How Parkinsons Disease Is Diagnosed

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• How It All Fits Together

Diagnosing Parkinsons disease can be complicated because there isnt a specific blood test or screening test that can determine whether or not you have it.

Instead, Parkinsons is diagnosed clinically, which means a doctor will examine you, review your symptoms and medical history, and diagnose accordingly. 

Parkinsons disease is a neurological condition that can make movement difficult. If your general practitioner thinks you might have Parkinsons, they may refer you to a neurologist who specializes in movement disorders for a diagnosis. 

It can be challenging to catch Parkinsons in the early stages because the symptoms may be too mild to notice or meet the diagnostic criteria. Also, early Parkinsons symptoms are often mistaken for typical signs of .

The symptoms of Parkinsons disease are also similar to those of other health conditions, which may be misdiagnosed as Parkinsons at first. Your doctor may suggest specific tests and scans to help eliminate other conditions that can mimic the symptoms of Parkinsons disease.

What Parkinsons Diagnosis Criteria Do Doctors Use

Until the 1980s, there was no formal diagnostic criteria for Parkinsons disease. Beginning with James Parkinsons 1817 article, An Essay on the Shaking Palsy, and Margaret Hoehn and Melvin Yahrs description of the five stages of motor progression in 1967, scientists focused on the unique ways Parkinsons disease affects movement. A few scientists also noted non-motor symptoms like issues with automatic body functions, such as heart rate and blood pressure.

With the discovery in the 1950s of levodopa, a drug that gets turned into dopamine in your brain and thus replaces some of the dopamine that is lost due to PD, and the discovery of how dramatically levodopa improves motor symptoms, the medical community continued to focus more of their efforts on defining and treating Parkinsons as a motor condition.7

Symptoms Of Parkinson’s Disease

The symptoms and rate of progression of Parkinsons are different among individuals. Effects of normal are sometimes confused for Parkinsons. It is difficult to accurately diagnose this disease because there is not a test that can accurately do it.

There are physical and non-physical symptoms that could indicate someone has Parkinsons disease:

Physical symptoms

• Weight loss

Early stage symptoms

disease occurs gradually. At first, the symptoms might not even be noticeable. Early symptoms can include feeling mild or having difficulty getting out of bed or a chair. The person might start to notice that they are speaking softer than usual, or that their handwriting looks different.

Usually, it is friends or family members who are the first to notice changes in someone with early Parkinson’s. For example, they may notice that the person’s face lacks expression and animation, or that the person does not move an arm or leg normally.

Passive Manipulation Of Limbs

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

Upper Extremity Testing

For the upper extremity the most sensitive joint where to check for rigidity is the wrist. To uncover rigidity, passively rotate the wrist and feel for a resistance to the movement. It is very important that the arm of the patient is fully relaxed when rotating the wrist. To do this, place your proximal hand under the patients forearm, while your distal hand grabs and rotates the wrist of the patient. When rigidity is present, the range of motion will be preserved but you will feel a resistance in performing the movement.

Wrist rotation with activation maneuver.

It is also possible to test for rigidity in the elbow by passively flexing and extending the forearm.

Elbow flexion-extension with activation maneuver.

Lower Extremity Testing

Testing For Parkinsons Disease

There is no lab or imaging test that is recommended or definitive for Parkinsons disease. However, in 2011, the U.S. Food and Drug Administration approved an imaging scan called the DaTscan. This technique allows doctors to see detailed pictures of the brains dopamine system.

A DaTscan involves an injection of a small amount of a radioactive drug and a machine called a single-photon emission computed tomography scanner, similar to an MRI.

The drug binds to dopamine transmitters in the brain, showing where in the brain dopaminergic neurons are.

The results of a DaTscan cant show that you have Parkinsons, but they can help your doctor confirm a diagnosis or rule out a Parkinsons mimic.

What To Expect At The Appointment

To make a Parkinsons diagnosis, your doctor will look for the three main motor symptoms: bradykinesia , tremor and rigidity. Remember, not everyone with Parkinsons disease has a tremor. They will also ask questions and examine you to see if there are possible other explanations for your symptoms besides Parkinsons.

The doctor will ask you questions and look for Parkinsons signs like:

• If you have a resting tremor, meaning your tremor appears when your limb like an arm or leg is still 
• If your tremor and/or other movement issues occur on one side of your body only
• If your handwriting has become very small
• If you have issues with balance 
• If the way you walk has changed; for example, you are taking small steps or having trouble turning
• If you have stiffness, aka rigidity, in your arms or legs; for example, you dont swing your arm when you walk
• If you have difficulty with fine motor movements like combing your hair or brushing your teeth
• If your voice has become softer or more difficult for others to hear 

To assess your non-motor symptoms, your doctor may ask you questions about:

• If youve lost your sense of smell
• If you experience constipation
• If you talk or act out dreams while you sleep

Motor Symptoms Of Parkinsons

Common motor symptoms of Parkinsons disease include:

• Difficulty swallowing or chewing. These symptoms are more common in late stage Parkinsons disease. The muscles involved in swallowing and chewing may be affected, making it harder to eat. Saliva may accumulate in the mouth and lead to drooling.
• Loss of balance and poor posture. Parkinsons patients may become more hunched or have poorer posture. This in turn can affect your gait and balance, leading to falls.
• Rigid muscles. Stiffness when the arm, leg, or neck is moved back and forth.
• Slow movements . Like tremors, bradykinesia also tends to get worse with time. This can make every day tasks like dressing more time consuming and challenging.
• Soft or slurred speech. Parkinsons can slow down and slur your speech. You may speak with more hesitations, or your voice may be more monotone.
• Tremors. Tremors are involuntary movements that usually start in the limbs. For instance, your hands may shake while at rest, or you may rub your fingers together . Tremors often get worse as Parkinsons progresses.

Besides Medication How Else Can I Manage The Disease

There are multiple lifestyle choices and home remedies that you can incorporate to help improve your PD symptoms.4,5

• Exercise: can benefit people at every stage of PD to enhance or maintain balance, endurance, flexibility, and strength. Studies show exercise can improve your symptoms no matter what you exercise you do.
• Alternative medicine: Tai Chi, , , yoga, Alexander technique, and pet therapy can all help with balance, flexibility, and emotional stability that can sometimes be challenging for people with PD.
• Nutrition: Maintaining a healthy diet is important, and adding plenty of liquid, fiber, fresh fruits, and vegetables, and healthy fats to your diet can help constipation that can affect people with PD and improve your overall health.

What Treatments Are Available To Me

There is no cure for Parkinsons disease, but there are many treatments that can help improve your symptoms and delay the progress of the disease. The combination of medication and other treatments that work best for you depend on your specific symptoms as well as your total health history.

Available treatments include:

• Prescription medications: Prescription medications often include levodopa, MAO inhibitors, and/or anticholinergics. Levodopa is often the first-line treatment for people with PD. It increases the neurotransmitter dopamine in the brain. MAO inhibitors affect how fast dopamine is cleared from the brain. Anticholinergics affect a different neurotransmitter in the brain and can sometimes help reduce PD tremors.
• Surgical treatment, including deep brain stimulation: is generally reserved for people who are in the later stages of the disease or who dont improve with medication, therapy, and other lifestyle changes.
• Over-the-counter medications and supplements: There is a lot of ongoing research about how effective alternative medicines and can be in reducing PD symptoms. Some supplements might be able to help, but some can actually cause harm, including vitamin E supplements, although dietary vitamin E is good for your body. Be sure to inform your doctors about any supplements you are taking, since they can often interfere with prescription medications.

What Are The Symptoms Of Parkinson’s Disease

The main symptoms of Parkinson’s disease are:

• tremor or shaking, often when resting or tired. It usually begins in one arm or hand
• muscle rigidity or stiffness, which can limit movement and may be painful
• slowing of movement, which may lead to periods of freezing and small shuffling steps
• stooped posture and balance problems

The symptoms of Parkinson’s disease vary from person to person as well as over time. Some people also experience:

• loss of unconscious movements, such as blinking and smiling
• difficulties with handwriting
• drop in blood pressure leading to dizziness
• difficulty swallowing
• sweating

Many of the symptoms of Parkinson’s disease could be caused by other conditions. For example, stooped posture could be caused by . But if you are worried by your symptoms, it is a good idea to see your doctor.

The Mystery Of Parkinsons Disease

April 15, 2021

NCH Medical Group Neurologist Saju Abraham answers questions about Parkinsons disease.

Parkinsons disease is not uncommon in the United States about one million people have Parkinsons and more than 50,000 new cases are diagnosed each year. And yet the cause of Parkinsons remains unclear, and its debilitating impact on patients can vary widely. Many of us may know someone with Parkinsons and yet still feel it is a mystery. 

Parkinsons disease is treatable, NCH Medical Group Neurologist Saju Abraham, M.D. emphasizes, but it is a serious neurological disorder that affects the bodys movement and can include tremors and trouble walking. 

Dr. Abraham answers some basic questions about Parkinsons to try to help us unlock the mysteries behind this disease.  

Q: Do we know what causes Parkinsons disease?

Dr. Abraham: While we havent established a clear cause to Parkinsons, we do know that many things contribute to its onset, including genetics, environmental triggers and trauma. What usually happens is that dopamine producing cells breakdown causing abnormal brain activity leading to the disease.

Q: We hear a lot about screening and early intervention for other serious conditions, but are there screening options available for Parkinsons?

Q: Is there any way to prevent Parkinsons disease?

Q: What are some signs and symptoms of Parkinsons disease?

Q: Can you live a full life with Parkinsons disease?

Dr. Saju Abraham can be reached at .

What Are My Next Steps

If your doctor doesnt diagnose Parkinsons, they can help you find out what the best next step is depending on what condition they suspect. In some cases, treatment may be as simple as changing the dosage of a medication that may be leading to Parkinsons-like symptoms.

Receiving a Parkinsons diagnosis can be overwhelming. If your diagnosis is confirmed, contact a movement disorder specialist as soon as possible. A specialist can help you develop a strategy to delay the onset of more severe disease and manage symptoms youre already experiencing.

Physical And Neurological Examination

Your doctor will conduct a physical and neurological examination. This can involve observing your behavior, movements, and mental state and conducting tests or asking you to perform certain exercises. 

These are some of the symptoms of Parkinsons your doctor can determine visually:

• Fewer spontaneous movements or hand gestures
• Reduced frequency of blinking
• Tremors in your hands while they are at rest, often only in one hand
• Hunched posture or forward lean while walking
• Stiff movements

These are some of the exercises your doctor may ask you to do to evaluate your movements, balance, and coordination:

• Opening and closing your fist
• Tapping your fingers, toes, and heels
• Holding your arms out in front of you
• Moving your finger from one point to another
• Rotating your wrists or ankles
• Standing from a chair

Deep Brain Stimulation Benefits for Parkinson’s Can Last at Least 15 Years

Is Early Diagnosis Possible

Experts are becoming more aware of symptoms of Parkinsons that precede physical manifestations. Clues to the disease that sometimes show up before motor symptoms and before a formal diagnosis are called prodromal symptoms. These include the loss of sense of smell, a sleep disturbance called REM behavior disorder, ongoing constipation thats not otherwise explained and mood disorders, such as anxiety and depression.

Research into these and other early symptoms holds promise for even more sensitive testing and diagnosis.

For example, biomarker research is trying to answer the question of who gets Parkinsons disease. Researchers hope that once doctors can predict that a person with very early symptoms will eventually get Parkinsons disease, those patients can be appropriately treated. At the very least, these advances could greatly delay progression.

Parkinson’s Disease and Movement Disorders Center

Our center provides compassionate and timely treatment to patients with movement disorders, such as dystonia, ataxia, essential tremor and similar conditions. But our mission goes beyond patient care excellence. By offering educational events and support groups, we empower patients and caregivers to become better partners in their health.