Understanding Parkinson’s Disease Symptoms

Parkinson's disease, a neurological disorder that progresses over time, is estimated to affect nearly 2% of those over age 65, with nearly 90,000 people in the United States diagnosed each year. The Parkinson's Foundation estimates 1.2 million Americans will live with Parkinson's disease by 2030.

Scientists believe that a lack of the brain chemical dopamine is the underlying cause of Parkinson's disease. "Dopamine is produced in a region of the upper brainstem called the substantia nigra and is essential for smooth, controlled movement," says Adam Mednick, M.D., Ph.D., a board-certified neurologist in North Haven, CT. In the very early stages of Parkinson's disease, this dopamine shortage may manifest as a barely noticeable hand tremor, but over time result in issues with balance, movement, and muscle control throughout the whole body.

Parkinson's disease is best known for affecting movement, but can also impact cognition, digestion, mood, and sleep. By understanding the different Parkinson's symptoms that may present challenges at different stages of the disease, you'll be better equipped to manage changes that occur.

What Are Early Signs of Parkinson's Disease?

Although movement symptoms like tremor and stiffness are most commonly associated with Parkinson's disease, early non-motor changes may occur years prior to diagnosis, such as a loss of smell, sleep disruptions like thrashing, shouting, or acting out dreams, constipation, and unexplained mood changes.

"Symptoms can vary widely, but the most typical early symptoms might be a change in handwriting, some mild tremor, muscle stiffness, decreased arm swing, and masked face," says Melissa Werz, OTD, OTR/L, an occupational therapy doctorate program instructor at Duke University School of Medicine in Durham, NC.

Other possible early signs of Parkinson's disease include a soft or low voice and dizziness or fainting, per the Parkinson's Foundation.

Main Symptoms of Parkinson's Disease

The two major categories of Parkinson's disease symptoms are motor symptoms and non-motor symptoms.

"Motor symptoms are those that directly affect movement," says Daniel Truong, M.D., a neurologist and medical director of the Truong Neuroscience Institute at MemorialCare Orange Coast Medical Center in Fountain Valley, CA and editor in chief of the Journal of Clinical Parkinsonism and Related Disorders. These include:

• Balance problems
• Changes in walking
• Freezing
• Slowness of movement (known as bradykinesia)
• Stiffness or rigidity
• Tremor

Non-motor symptoms affect other bodily functions and can include:

• Changes in thinking or memory
• Constipation
• Depression or anxiety
• Fatigue
• Loss of smell
• Low blood pressure
• Pain
• Sleep problems
• Urinary problems

Common Parkinson's Movement Symptoms

Parkinson's disease affects people in different ways, and there's no guarantee that everyone will experience the same symptoms or follow a set timeline. However, these are common movement symptoms of Parkinson's disease.

Tremor or Shaking at Rest

Per the National Institute of Neurological Disorders and Stroke (NINDS), tremor is often first noticeable in a person's hand, although sometimes it's the foot or jaw that's affected first. A Parkinson's disease hand tremor typically involves the thumb and forefinger rubbing together in a back-and-forth motion, which NINDS says may look like "pill rolling." It is most apparent when the hand is at rest or when the person is under stress and tends to stop during sleep. However, Dr. Truong points out that not everyone with Parkinson's disease develops tremor.

Slowed Movement or Bradykinesia

Another key symptom of Parkinson's disease, bradykinesia can make everyday activities that once happened automatically more difficult, such as getting dressed, getting out of a chair, or walking, says Dr. Truong. Early signs of bradykinesia include subtle changes in fine motor control and a reduction in automatic facial or body movements, says the Parkinson's Foundation.

Muscle Stiffness and Rigidity

In someone with Parkinson's disease, rigidity feels like stiffness or increased resistance in the muscles, says Dr. Truong. According to NINDS, this symptom affects most people with the disease and can manifest as two different types: "lead pipe" rigidity, which feels like smooth, uniform resistance when someone else tries to move the relaxed joint; and "cogwheel" rigidity, which feels like short, jerky movements when someone else tries to move the relaxed joint. When rigidity affects the facial muscles, this causes a reduction in spontaneous facial expression, often referred to as facial masking or hypomimia.

Changes in Posture and Balance

Postural instability tends to become more prominent as Parkinson's disease progresses. "Impaired balance and a reduced ability to make the automatic corrections that normally help prevent a fall increases the risk of injury," says Dr. Truong.

How Parkinson's Disease Affects Walking

Changes in balance, taking smaller steps, and not clearing your foot when walking are Parkinson's disease symptoms that can make walking slower and less automatic, says Werz. Some people may stoop forward in what's known as a "Parkinsonian gait."

Perhaps the most dangerous walking symptom of Parkinson's disease is freezing, when the leg muscles refuse to respond to brain signals to move. Any of the walking-related symptoms associated with Parkinson's can increase a person's risk of falls, which is one reason physical therapy is important and mobility aids may be useful.

Short, Shuffling Steps

Small, shuffling steps are often characteristic of Parkinson's walking. "It can feel like the feet are dragging," says Dr. Truong. However, he adds that other people with Parkinson's disease may develop festination, in which each step becomes progressively faster, and the person has a hard time stopping or slowing down.

Trouble Starting, Stopping, or Turning

People with Parkinson's disease may hesitate before taking a first step ("start hesitation") and have difficulty stopping, turning, or changing direction, says Dr. Truong.

Freezing of Gait

Many people with Parkinson's disease describe feeling as if their feet are suddenly glued to the floor. "This can happen when starting to walk, turning, passing through a doorway, navigating a crowded area, or feeling rushed," Dr. Truong says.

Reduced Arm Swing and Coordination

Part of the Parkinsonian gait is less natural swinging in one or both arms, which can affect coordination. "Balance reflexes can also become less effective, increasing the risk of falls," notes Dr. Truong.

Other Physical Symptoms of Parkinson's Disease

Beyond tremor, stiffness, slowness, and walking difficulties, Parkinson's disease can cause a wide range of other physical symptoms. "These can include stooped posture, reduced facial expression, softer speech, smaller handwriting, difficulty swallowing, drooling, muscle cramps or dystonia, and pain," says Dr. Truong. "Fine motor tasks such as buttoning clothing or using utensils may also become more difficult."

Watch for these symptoms, not immediately associated with Parkinson's disease, but indications that you or a loved one may be experiencing the condition:

• Constipation
• Difficulty chewing or swallowing
• Dizziness or lightheadedness when standing
• Fatigue
• Loss of sense of smell
• Pain or muscle cramping
• Small or cramped handwriting
• Soft, low or monotone speech
• Urinary urgency or nighttime urination

Non-Movement Symptoms of Parkinson's Disease

Parkinson's disease can also affect automatic body functions, meaning processes the body engages in without conscious input from you. Non-movement Parkinson's symptoms include constipation, urinary urgency, sexual dysfunction, excessive sweating, and orthostatic hypotension (a drop in blood pressure when standing that can cause dizziness or fainting). Sleep disturbances and fatigue are also very common.

Let's take a closer look at each:

• Changes in blood pressure. According to research, up to 50% of people with Parkinson's disease experience orthostatic hypotension, which happens when your blood pressure drops very quickly when standing up after sitting or lying down. This can cause someone to become lightheaded and dizzy, and in extreme cases, cause the person to lose balance or faint.
• Cognitive challenges. People with Parkinson's disease may experience a range of cognitive symptoms, from mild thinking changes to severe memory loss, which can affect concentration, attention, and language, says the Parkinson's Foundation.
• Depression, anxiety, or apathy. According to NINDS, these mental health issues may happen during the early stages of Parkinson's disease, even before the start of movement problems.
• Sexual dysfunction. Parkinson's disease can affect sexual function in many ways, says NINDS. Movement symptoms like rigidity, bradykinesia, and issues with fine motor control can make sexual activities difficult. Additionally, mood changes and certain medications may lower sex drive.
• Sleep problems. Common sleep problems in Parkinson's disease include difficulty staying asleep, tossing and turning, and nightmares, very emotional dreams, or acting out dreams, per NINDS. People may also experience excessive daytime drowsiness or suddenly fall asleep during the day.

Do Parkinson's Symptoms Get Worse?

Parkinson's disease is progressive, but there is no single timeline for when or how fast symptoms evolve. Over time, movement symptoms may affect walking and posture, and daily tasks may become more difficult, but everyone who lives with Parkinson's experiences their own range of symptoms and rate of progression, and new treatments are increasingly making it possible to live well with Parkinson's disease.

"Over time, movement may become slower, medications may not work as consistently between doses, and problems such as dyskinesia, freezing, and gait difficulties may emerge," says Dr. Truong. "Later, balance problems, falls, speech and swallowing difficulties, cognitive changes, and other non-motor symptoms may increase."

There is therefore no meaningful single "average" timeline for an individual patient. "Parkinson's disease generally evolves over many years and often decades, rather than changing dramatically over weeks or months," says Dr. Truong, adding that a person's age at disease onset, the pattern of symptoms, cognition, other health conditions, and individual biology can all influence the course.

About a third of people with Parkinson's disease will eventually develop dementia, a decline in thinking and reasoning skills, according to the Alzheimer's Society. Parkinson's disease dementia typically develops years after someone has experienced the early movement symptoms of the disease.

When Does Someone Need Mobility Support?

Mobility aids for Parkinson's are an invaluable tool for preserving activity and independence. "An increased number of falls or near misses, changes in confidence while ambulating or doing tasks, and feelings of unsteadiness, can be signs that it may be time to consider additional support," says Werz.

As an occupational therapist who works with people with Parkinson's disease, Werz always asks clients how their change in mobility is impacting daily activities to determine any adjustments that can be made and what type of mobility support might make things easier. "For instance, if they have decreased balance while dressing, we may discuss sitting down to dress (especially for lower body dressing)," she says. "If they are at an increased risk for falls my first questions are asking if they have had falls, what the circumstances of those falls were, and what activity were they doing. Then we would assess ways they could modify the task or use adaptive equipment/strategies to reduce their risk of falls during the task."

Other signs that it may be time for mobility support include:

• Avoiding activities because of fear of falling
• Difficulty carrying items while walking
• Difficulty walking from room to room
• Freezing that makes it difficult to move safely
• Holding onto furniture or walls when moving around the house
• Increasing fatigue during routine outings
• Trouble standing up or transferring safely

Mobility Support for Parkinson's Symptoms

If a client is having falls while moving around, Werz refers them to physical therapy for further assessment for a mobility aid such as a walker, rollator, or trekking poles (or a wheelchair if it's determined that it's not safe for them to move around independently).

But Dr. Truong notes that mobility aids are not simply about preventing falls. "Their larger purpose is to help people continue doing the things that matter to them safely and independently," he says. A walker or rollator can provide stability, improve confidence, and allow someone to walk farther without being as concerned about falling. (Rollators are often preferred over walkers with Parkinson's since they provide balance support while allowing for a smoother walking motion.) Some specialized devices also provide visual or auditory cues that may help with freezing.

A wheelchair or power chair can be useful for longer distances or situations in which walking has become unsafe or exhausting, while a person may still be able to walk with assistance at other times.

Just because you use a mobility aid does not mean you are giving up walking or becoming dependent. Rather, when used appropriately, mobility support can enable greater participation in exercise, family activities, travel, shopping, and social life while conserving energy and reducing fall risk.

Staying Ahead of Parkinson's

As heroes like Michael J. Fox have proven, with the right tools, support, and determination, it's possible to delay or slow the progression of Parkinson's disease symptoms for many years.

The right treatment plan is central to living well with Parkinson's disease. Medication is crucial to replace deficient dopamine and has a direct impact on symptoms, particularly slowness, stiffness, and tremor, says Dr. Mednick. However, he adds that medical treatment alone isn't enough to address the many ways Parkinson's disease affects a person's mobility, independence, and safety.

Alongside medication, regular exercise, physical/occupational therapy, good sleep, nutrition, social connection, and attention to mood and cognitive health all help keep you engaged physically, mentally, and socially, says Dr. Truong. Problems such as freezing, falls, and swallowing difficulties should be addressed early in treatment rather than simply accepted as inevitable. Moreover, treatment should evolve as the disease evolves, he adds.

Work with your doctor to come up with a plan that's right for you. Remember, the goal is not simply to treat symptoms—it is to help you remain as active, independent, and engaged in life.