The loss of dopamine-producing nerve cells progresses for many years before clear movement problems appear. As a result, the first signs of the disease are often attributed to ageing, fatigue or low mood, which delays a neurological consultation.
What you’ll learn from this article
- Which symptoms may precede movement problems
- How parkinsonian tremor differs from essential tremor
- How the disease affects walking, speech, handwriting and facial expression
- Which non-motor symptoms are easiest to overlook
- When to see a neurologist
Parkinson’s disease manifests mainly as slowness of movement, resting tremor and muscle stiffness, which usually begin on one side of the body. These motor symptoms are accompanied by non-motor symptoms such as a reduced sense of smell, constipation, sleep disturbances and low mood. Some of them appear several years before movement problems.
Early signs that may precede motor symptoms
Changes in the brain begin long before the disease is diagnosed. During this period, symptoms not directly related to movement may occur, and on their own they are not specific. A reduced or lost sense of smell is among the earliest of these. According to NHS information on Parkinson’s disease symptoms, it can precede other symptoms by several years.
REM sleep behaviour disorder is also significant. The sleeping person moves violently, talks or shouts because they are acting out their dreams. Chronic constipation, low mood and anxiety are also counted among the early signs.
The next changes are already motor in nature, although they are very subtle. One arm stops swinging freely when walking, and handwriting gets smaller as the person writes. Some people experience pain or stiffness in the shoulder on one side of the body. None of these symptoms alone confirms the disease. However, when several occur together, they warrant a medical consultation. A fuller list of early symptoms is available on the page of our rehabilitation program for Parkinson’s disease.
Resting tremor and how to tell it apart from other types of tremor
Tremor is the most recognisable symptom of Parkinson’s disease, although not every patient has it. It most often affects the fingers and hand while the arm rests loosely on the lap or the armrest of a chair. The thumb rubbing against the index finger then resembles “pill-rolling”. The tremor disappears during sleep but becomes stronger with stress, fatigue or concentration on another task.
Over time it spreads to the leg on the same side, and later to the other side of the body. It may also affect the jaw, lips and chin. A head tremor points rather to a different diagnosis, most often essential tremor.
| Feature | Tremor in Parkinson’s disease | Essential tremor |
|---|---|---|
| When it appears | At rest, decreases with movement | During movement and when holding a position, e.g. drinking from a cup |
| Onset | Usually one side of the body | Usually both hands at once |
| Body areas | Hand, fingers, leg, jaw | Hands, head, voice |
| Accompanying symptoms | Slowness of movement, stiffness, gait changes | Usually no other neurological symptoms |
| Handwriting | Letters get smaller as writing continues | Letters shaky and irregular, normal size |
Telling the two conditions apart is ultimately the neurologist’s task, because it requires assessing the whole clinical picture.
Slowness of movement, muscle stiffness and changes in walking
The diagnosis of parkinsonism rests on slowness of movement, known as bradykinesia. Movements become slower, and when an action is repeated, its range gradually shrinks. Buttoning a shirt, cutting food or getting up from a chair take more and more time. Facial expression also becomes reduced, so the face appears indifferent even though emotions remain intact. Blinking becomes less frequent, and speech becomes quieter and more monotonous.
The doctor detects muscle stiffness by passively bending and straightening the patient’s limb. The resistance persists throughout the full range of motion and is sometimes jerky, which is called cogwheel rigidity. Patients feel it as tension, pain or heaviness in the neck, shoulders and back.
Walking shows the effects of both these mechanisms. Steps become short and shuffling, the posture bends forward, and the arm on the affected side does not swing. Turning on the spot takes several small steps. As the disease progresses, freezing of gait may occur. This is a sudden inability to lift the feet off the floor, especially in doorways or narrow passages. We describe this mechanism in more detail in our article on how Parkinson’s disease progresses and what on and off phases are.
Non-motor symptoms that often go unnoticed
Parkinson’s disease also disrupts the autonomic nervous system, which regulates blood pressure as well as bowel and bladder function. This shows up as constipation, urinary urgency, excessive sweating and a drop in blood pressure on standing up. The last of these causes dizziness when getting up and makes falls more likely.
Sleep and mood are affected too. Patients often wake up during the night and feel sleepy and chronically tired during the day. Depression, anxiety and apathy can appear at any stage, even before diagnosis. Slowed thinking and difficulty concentrating and planning are more common later in the disease. In some people, dementia develops in the advanced stage, sometimes accompanied by visual hallucinations.
Swallowing difficulties (dysphagia) and drooling form a separate group. They result from slower work of the throat and mouth muscles, and consequently increase the risk of choking. A speech and language therapist should therefore assess them, even if they seem minor.
How symptoms change as the disease progresses
Parkinson’s disease develops slowly, and the pace of change differs from person to person. In the early period, symptoms usually affect one side of the body and do not limit independence. At this stage, medicines that make up for the dopamine deficiency relieve them well.
Later, symptoms affect both sides of the body, and everyday tasks take longer. Next, problems with balance and postural reflexes appear, which increase the risk of falls. During this period, the effect of medication may be uneven throughout the day. Periods of good mobility alternate with returning stiffness and slowness, and some patients develop involuntary movements called dyskinesias.
In the advanced stage, the patient needs help with walking, dressing and personal hygiene. Speech and swallowing problems and non-motor symptoms then come to the fore. We explain the causes of the disease and its mechanism in our article on what Parkinson’s disease is.
When to see a neurologist and how rehabilitation helps
A visit to a neurologist is advisable when one-sided resting tremor, slowness of movement or a change in walking persists. A combination of several early signs also justifies it, for example a reduced sense of smell, restless sleep and shrinking handwriting. Diagnosis is based mainly on the medical history and a neurological examination. Imaging tests are used mostly to rule out other causes of the symptoms.
Rehabilitation responds directly to the difficulties described above. Physiotherapy includes gait, balance and range-of-motion training, which limits the effects of stiffness and reduces the risk of falls. A speech and language therapist works on voice volume and safe swallowing, while a neuropsychologist assesses cognitive function and supports the patient with emotional difficulties. At Origin centres, we combine these therapies in a program tailored to the stage of the disease and the dominant symptoms. People who want to assess their potential for improving mobility can book a rehabilitation potential consultation.
Frequently asked questions
Can Parkinson’s disease occur without hand tremor?
Yes. In some patients, tremor never appears or only develops after several years. Slowness of movement, muscle stiffness and gait changes then dominate, which can delay the diagnosis.
What symptoms can indicate Parkinson’s disease in an elderly person?
The most noticeable signs are a slower, shuffling gait, a stooped posture and reduced facial expression. These are accompanied by quieter speech, small handwriting and difficulty getting up from a chair. Similar symptoms can have other causes, so a neurologist should assess them.
Can Parkinson’s disease start with shoulder pain?
One-sided shoulder pain and stiffness can be among the early symptoms of the disease. They result from increased muscle tension and reduced movement of the limb. If orthopaedic treatment does not help and other motor symptoms appear, a neurological consultation is advisable.
How can I tell parkinsonian tremor from tremor caused by stress or coffee?
Tremor caused by stress, caffeine or certain medicines gets worse during movement and usually affects both hands. In Parkinson’s disease, the tremor occurs at rest and decreases during purposeful activity. It most often starts on one side of the body and is accompanied by slowness of movement.
Do Parkinson’s symptoms change during the day?
Later in the disease, mobility often depends on how well the medication is working at a given moment. When the medicines work well, the patient moves more freely, and as a dose wears off, stiffness and slowness return. Fatigue, stress and lack of sleep also make symptoms worse.
