How do patients with parkinsonism present? A clinicopathological study

Abstract

Background: The early clinical features of neurodegenerative parkinsonism can be subtle and often coexist with autonomic, sensory and psychic symptoms, making accurate early diagnosis challenging.

Methods: We retrospectively assessed the initial, clinical presentation and referral patterns of 494 patients with a pathological diagnosis of parkinsonism (344 with Parkinson's disease (PD), 89 with progressive supranuclear palsy (PSP) and 61 with multiple system atrophy (MSA)) archived at the Queen Square Brain Bank, London.

Results: Forty-four per cent of all patients were initially referred to a neurologist. Of those with PD, 28% were referred to a general physician, and approximately 5% each to orthopaedic surgeons, urologists, psychiatrists and rheumatologists. Pain was common in those not initially referred to neurologists and most lacked early tremor, rigidity and bradykinesia. More PSP patients were initially referred to ophthalmologists than in PD (9 vs 1%, chi(2)P < 0.001) and more MSA patients were referred to a urologist or gynaecologist than in PD (21 vs 5%, chi(2)P < 0.001). In PD a frozen shoulder, degenerative spine disease and benign prostatic hypertrophy were the most common early diagnoses. In PSP, the most common misdiagnosis was PD, followed by vascular parkinsonism and degenerative spinal disease. This was similar in MSA, but bladder outlet obstruction and idiopathic vocal cord palsy were other initial diagnoses.

Conclusion: The early clinical manifestations of PD, PSP and MSA are protean and often non-specific, leading to diverse specialist referrals. When diagnoses, such as frozen shoulder and cervical spondylosis, benign prostatic hypertrophy or unstable bladder and depression are made, specialists should consider the possibility of early parkinsonism and look carefully for additional subtle motor abnormalities.