Understanding Parkinson’s symptoms: A clear guide to movement and non-movement signs

Welcome to Parkinson Pharos! This guide helps patients and families understand Parkinson’s disease. One of the most common questions we receive is about the different symptoms that patients may experience. It is important to remember that Parkinson's affects everyone differently, and not all symptoms will be experienced by every person. But knowing what to look for can help you and your loved ones continue with confidence.

Parkinson's disease is a progressive neurological condition, meaning it causes problems in the brain that get worse over many years. Therefore, symptoms may change in the course of the disease. Here is an easy-to-understand look at the symptoms often related to Parkinson's, organized into clear categories for better understanding.

The 4 main (core) movement-related symptoms

Doctors diagnose Parkinson's disease through the presence of specific movement, or "motor," symptoms:

1. Tremor (shaking): This often begins in one hand, foot, or jaw and is most noticeable when at rest, rather than during movement. Approximately, 7 out of 10 (70%) of people with Parkinson's experience tremors. Tremors often disappear during sleep and can improve with movement.

2. Bradykinesia (slow movement): This symptom is required for a Parkinson's diagnosis. It means that movements become much slower, making everyday activities such as dressing, bathing, or standing from a chair more difficult and taking more time.

3. Rigidity (stiffness): Muscles may become stiff and tense in any part of the body, causing aches, pain, or a feeling of inflexibility. When an examiner moves the arm of a Parkinson’s patient, it might feel jerky, like the second hand on a mechanical clock; this is called "cogwheel rigidity".

4. Postural instability (balance problems): As Parkinson's progresses, one might find it harder to balance, leading to a tendency to lean forward or a higher risk of falls. This typically occurs in later stages of the disease.

   
   

Other movement-related symptoms

In addition to the core 4 movement-related symptoms, Parkinson's can also affect: 

1. Gait (walking) changes: A shuffling walk with smaller, quicker steps, sometimes called "festination". There may be difficulty in starting movement ("start hesitation") or sudden episodes of "freezing", where feet feel stuck to the floor while walking.

2. Speech changes: The voice often becomes softer (hypophonia) and more monotone; some people develop fast, blurred ‘festination of speech.’

3. Swallowing difficulties (dysphagia): Throat muscles can weaken, making swallowing challenging, increasing the risk of choking or drooling. Dysphagia is more common in later disease stages, but can appear earlier. 

4. Handwriting changes (micrographia): Handwriting may become noticeably smaller and more cramped.

5. Loss of automatic movements: This includes blinking less often, smiling less spontaneously, or not swinging arms naturally when walking.

6. Masked face (hypomimia): The facial expressions may become reduced.

   
   

Involuntary (not made by choice) movements

1. Dyskinesia: These are uncontrolled, dance-like movements caused as a side effect of Parkinson's medications. Levodopa can cause dyskinesia in about 4 out 10 (40%) patients after 4-6 years of use. Other dopaminergic medicines (such as dopamine agonists and COMT inhibitors) can contribute to dyskinesia, especially when used with levodopa. It is more common in young onset Parkinson's disease patients.

2. Dystonia: This involves sustained muscle contractions that cause repetitive, twisting movements or abnormal, often painful, postures. It is also more common in young onset Parkinson' disease patients.

   
   

The "invisible" non-motor symptoms

Many people experience non-motor symptoms, which are not directly related to movement, long before any changes in movement become obvious. These can significantly affect quality of life.

Mental and emotional health changes

1. Depression and anxiety are very common and may appear before movement symptoms. Depression is a state of ongoing sadness or hopelessness. Anxiety is excessive worry, feeling of unease, or fear.

2. Apathy: Lack of interest even for activities once enjoyed. 

3. Hallucinations: Seeing or listening to things that are not real. This can happen at later disease stages.

4. Delusions: These are false beliefs that a person may have although there is strong evidence that this is not true. This can also happen at later disease stages.

5. Compulsive or impulsive behaviors: These may include hypersexuality (uncontrollable sexual thoughts), pathological gambling, binge eating, or compulsive buying/shopping. These can occur in 15 to 20 out 100 (15%-20%) patients taking dopamine agonists.

6. Cognitive (thinking and memory) changes: Slowed thinking or memory problems. In later stages, some people develop Parkinson's dementia, affecting memory, attention, and language. [Understanding cognitive changes].

   
   

Sleep Problems

1. Insomnia: Many people experience difficulty staying asleep at night.

2. Restless sleep or feeling very sleepy during the day.

3. Vivid dreams or nightmares.

4. Physically acting out dreams: This is known as rapid eye movement (REM) sleep behavior disorder (RBD). RBD can be a strong early indicator of Parkinson's, sometimes appearing years before other symptoms.

   
   

Sensory changes

1. Loss of sense of smell (anosmia/hyposmia): This can happen years before other symptoms become noticeable.

2. Nerve pain: Unpleasant sensations like burning, coldness, or numbness. This type of pain often affects the side of the body where movement-related symptoms first appeared. For example, if Parkinson’s started with a tremor in the right hand, a person is more likely to develop pain in the right shoulder, wrist, or fingers.

3. Vision changes: Issues with vision can also occur.

   
   

Skin-related symptoms

1. Seborrheic dermatitis: This is a condition where oily, red patches on scalp, face, or other areas appear.

2. Very dry skin.

3. Mottled skin (livedo reticularis): This is a condition where patchy, web-like discoloration might appear. This can be a side effect of amantadine, a drug used in Parkinson’s disease treatment.

   
   

Autonomic (automatic body function) issues

1. Constipation and gastrointestinal problems: These are common and can also be early signs.

2. Urinary problems: This can include needing to urinate frequently at night (nocturia) or unintentionally passing urine (urinary incontinence).

3. Orthostatic hypotension: A sudden drop in blood pressure when standing up, causing dizziness or lightheadedness, and sometimes even fainting.

4. Excessive sweating (hyperhidrosis): Some people experience this.

5. Sexual dysfunction: This can affect both men and women due to changes in nerve signals.

6. Excessive saliva production (drooling): Also known as sialorrhea.

   
   

Other symptoms

1. Fatigue: Many people with Parkinson's experience a strong sense of tiredness, especially later in the day, which is not always improved by rest.

   
   

Remember, the above symptoms can be effectively managed with available treatments and therapies. If you are concerned about any symptoms, the best first step is always to talk to your neurologist to help get an accurate diagnosis and guide you toward the best care options.

Early diagnosis allows for timely support and helps you maintain your independence.