Although your primary care doctor may have recognized the symptoms of PD, he or she is trained primarily in family medicine or internal medicine and may see few people with PD. Although primary care doc-tors recognize the symptoms of PD, they may not be up-to-date on all the latest developments and treatments, nor have they had the neurological training to deal effectively with it.
To confirm a diagnosis of PD it is best to see a neurologist—better yet, a neurologist who specializes in PD, called a movement disorder specialist. To find a neurologist nearby, contact the American Academy of Neurology (www.aan.com), which maintains a list of neurologists. Likewise, the Movement Disorder Society (www.movementdisorders.org) maintains a list of movement disorder specialists.
Because treating PD requires more than an occasional visit, it is important to find a neurologist with whom you can have a good working relationship. Like any chronic disease, it requires that you and your family work together with the neurologist to find the best treatment or treatments.
A knowledgeable neurologist can provide more than medicine to treat your symptoms: he or she can provide understanding, advice, and reassurance. At your first visit, the neurologist will want to know why you came, your medical history, your family his-tory (especially a history of PD or tremor), and what, if anything, in your history may have contributed to your symptoms.
Bring a summary of your medical his-tory, including serious and chronic illnesses, hospitalizations, surgeries, allergies, drugs taken, and lifestyle risks. If what you have to talk about feels difficult, or if you’re likely to forget what’s said, bring a trusted friend or family member with you.
The doctor or his assistant may ask about your activities of daily living (ADLs) (see Table 3), which will likely include questions about speech, salivation, swallowing, handwriting, cutting food and handling utensils, dressing, hygiene, turning in bed, falling, freezing, walking, tremor, and sensory symptoms.
Any and all of these areas may be affected by PD and the neurologist’s careful questioning may help determine how the disease is progressing. The neurological examination covers several areas. Rigidity is examined by testing muscle tone at your wrists, elbows, shoulders, and knees by holding the limb and moving it both slowly and rapidly. The testing of deep tendon reflexes, by tapping with a rubber reflex hammer on the tendons at your jaw, elbows, knees, and ankles, reveals much to an examiner.
The examiner will note if the reflexes are increased on one side of your body versus the other (as after a stroke), whether they are increased in your legs versus your arms (as in a myelopathy—see below), or if they are absent (as in damage to the nerves in your arms and legs). In PD the deep tendon reflexes are normal, but in some of the Parkinson-like disorders they may be increased. Testing of strength or power provides insight into how your nervous system works.
Rapid alternating movements of your hands and feet are tested by asking you to tap your fingers to your thumb, turn the palms of your hands up and down, turn your wrists from side to side as though you’re screwing in a light bulb, and move your feet up and down as though you’re walking. The examiner will observe the speed, amplitude and rhythm of your movements and compare your left with your right side. Rapid alternating movements are decreased in PD.
Tests of coordination are carried out by asking you to touch your finger to your nose and then to the tip of the neurologist’s finger. Another test involves running the heel of one foot down the shin of the opposite leg. This provides information on a region of your brain called the cerebellum. Coordination is normal in PD, but it may be impaired in some of the Parkinson-like disorders. Eye movements are also evaluated. They are normal in PD, but are impaired in a Parkinson-like disorder called progressive supranuclear palsy (PSP).
Speech (the mechanics) is also affected in PD. The neurologist may ask you to say specific words to determine which muscles are affected. For example, saying the words “mama” or “papa” uses the orbicularis oris muscle—your lips. Saying the word “lulu” uses your tongue muscle, while the vowels, “A”, “E”, “I”, “O”, “U”, are sounds you make with the muscles of your throat.
The sensory examination includes an evaluation of your ability to perceive a light touch, such as a pin prick, and your ability to tell (with your eyes closed) whether your thumb or great toe is being moved up or down. Not every neurologist does the same examination; some neurologists may emphasize one part of the examination over another.
At the Muhammad Ali Parkinson Center, as in most movement disorder centers, the neurologist will examine you using the motor portion of the Unified Parkinson’s Disease Rating Scale (UPDRS). This portion evaluates symptoms such as speech, facial expression, tremor, rigidity, bradykinesia, arising from a chair, posture, turning, walking, and postural stability using the following scale:
0 = normal
1 = minimally impaired
2 = moderately impaired
3 = markedly impaired
4 = unable to perform
An overall score of “0” means there is no disability and “108” indicates complete disability. As in golf, the lower the score, the better you are. As a rule, overall scores of 20 or below indicate relatively mild to moderate disability, while overall scores of 40 or more indicate marked disability.
Sometimes a neurologist will evaluate you in the morning after you have gone 12 to 24 hours without carbidopa/levodopa, then again one hour after a test dose of carbidopa/levodopa. This often provides you and the neurologist with insight into the state of the underlying disease and its responsiveness to anti-Parkinson drugs.