Parkinson's Stages: How Difficulty Walking Could be a Clue

It all started when you were signing the checks. The quivering in your hand. The doctor just confirmed your suspicions - Parkinson’s disease. As a successful business owner in your late fifties, you wonder what to expect. Will you be forced into early retirement? Doc said that you’re only in the first stage, but your internet search on Parkinson’s symptoms stages doesn’t help you to grasp what that means. This article will help you understand what’s going on with your body and what to expect during each stage of Parkinson’s disease.

What is Parkinson's Disease?

Parkinson’s Disease is a disorder of the deep part of the brain. It is well-associated with symptoms that affect muscle movement, or motor symptoms. Parkinson’s currently affects about 1 million Americans. The majority of cases are diagnosed after age 60, and men are twice as likely to be develop the condition as women. Only about 10% of Parkinson’s cases seem to have a genetic link. Experts suspect that there may be environmental causes as well. Parkinson’s disease is a chronic progressive disease; this means that there is no cure, and that symptoms gradually intensify over time.

What Causes Parkinson's Symptoms?

The area of the brain affected by Parkinson’s is called the basal ganglia. More specifically, the area of concern within the basal ganglia is called the substantia nigra. As part of it’s normal function, the substantia nigra releases dopamine. Dopamine is a neurotransmitter, which means that it is a chemical produced by the brain whose function is to communicate messages between nerve cells. The messages that are initiated within the substantia nigra are primarily associated with controlling our intentional muscle movements and posture. 

Parkinson’s disease occurs when the cells located within the basal ganglia begin to degenerate. As these cells become dysfunctional and die, they release less dopamine. This decreased dopamine release leads to a reduced ability to control muscle movements, both intended and unintended. 

An additional factor that may contribute to Parkinson’s symptoms is alpha-synuclein. This is a protein that is found in clumps in the brain called Lewy bodies. It is also found in other areas of the body, which may contribute to some of the nonmotor symptoms seen in Parkinson’s disease. 

Symptoms and Stages

In 1967, Neurology journal published a paper that was written by Margaret Hoehn and Melvin Yahr. These doctors completed a study in Parkinson’s patients that investigated the course of the disease. In order to measure disease progression, the doctors created a staging scale that is still used today to describe the progression of Parkinson’s Disease. 

There are 5 classic motor, or movement-related symptoms that are commonly found in Parkinson’s disease. These symptoms are typically used to diagnose patients and include:

•         tremor

•         bradykinesia, or slowness of movement

•         rigidity, or muscle stiffness

•         postural instability, or problems with balance

•         difficulty walking

While Parkinson’s is primarily known for it’s ability to affect the motor system, patients may experience nonmotor symptoms as well. Nonmotor symptoms affect other systems of the body including the mood, the gastrointestinal system, and the senses.

Parkinson’s is a variable disease. Not all patients will develop all symptoms, and each patient will experience their symptoms to different degrees than others. Some patients will have more severe impairment in earlier stages, while other patients who may be in more progressive stages experience milder forms of disease. For example, a patient may have a severe tremor that only affects one side of their body, and thus can be categorized as stage 1. Another patient may have a milder tremor that affects both sides of the body, and thus be categorized as stage 2. It is important to note that with the exception of balance in Stage 3, Parkinson’s disease stages are not dependent on a particular symptom or set of symptoms being present.

Stage 1 - Mild Disease

Stage 1 Parkinson’s disease has 2 distinct characteristics: unilateral (affecting only one side of the body) motor symptoms that only mildly affect your ability to perform daily activities, such as eating and getting dressed. Sometimes patients in this stage may even go undiagnosed because the symptoms are so mild and begin gradually. Some symptoms that may show up during this stage include:

Motor Symptoms

•         Tremor2 out of 3 Parkinson’s patients will exhibit a tremor as their first symptom. Eventually, up to 80% of patients will develop one. The tremor associated with Parkinson’s is characteristic because it is a resting tremor. This means that when you hold your hand, leg, foot, or jaw still, visible shaking is present. However, when you move that body part on purpose, the tremor disappears. The shaking also stops when you sleep. 

•         Rigidity- Rigidity, or muscle stiffness is also an early sign of Parkinson’s. Specifically, you may hear the term cogwheel rigidity. During a motion that should be smooth, such as straightening the elbow, some patients will demonstrate start-and-stop movement, or ratchet-like movement. 

•         Trouble Walking- Due to their muscle rigidity and later balance problems, Parkinson’s patients often have trouble walking and develop a distinctive gait. These walking difficulties worsen as their disease progresses. Specific features include:

•         less swinging of the arms

•         shuffled walk, where the patient takes small steps and drags their feet

•         festination, where patients take quick, almost running steps due to a lack of balance

•         freezing, where patients cannot move their feet, as if they are stuck to the ground

•         Micrographia- As you noticed when you were signing your employees paychecks, changes in handwriting can occur due to muscle stiffness and shaking. Typically the handwriting becomes smaller and shows evidence of a tremor. 

Nonmotor Symptoms

•         Constipation- Constipation occurs in the vast majority of Parkinson’s patients, and is sometimes one of the earliest symptoms to present itself. It is thought to occur because the GI tract moves much more slowly in Parkinson’s disease.

•         Hyposmia or Anosmia- A decreased sense of smell (hyposmia) or total loss of smell (anosmia) may seem completely unrelated to Parkinson’s, but they are sometimes the very first symptoms that patients notice. While the exact cause of this phenomenon is unknown, it may be due to the buildup of alpha-synuclein proteins in the parts of the brain that control this sense. 

•         Difficulty Sleeping- A variety of sleep-related issues may occur during the course of Parkinson’s disease. 

•         insomnia - often an early symptom, sometimes appearing even before diagnosis

•         frequent nighttime awakening

•         discomfort due to motor symptoms - patients may have difficulty getting comfortable as their muscle stiffness progresses 

•         REM sleep behavior disorder - causes patients to move their limbs in their sleep as they “act out” their dreams

•         restless legs syndrome

•         daytime drowsiness due to sleep disorders

•         Depression and Anxiety- Parkinson’s patients may develop depression and anxiety long before their official diagnosis. There is a close correlation between depression and Parkinson’s - as many as 40-50% of patients also experience depression. 

Stage 2 - Mild Disease

Stage 2 Parkinson’s disease is characterized by movement difficulties that affect the midline or both sides of the body. At this point, patients are still considered to have mild disease and are still able to care for themselves. Some symptoms that could be present at this stage include:

Motor Symptoms

•         Bradykinesia (Slow Movement)- Bradykinesia is a hallmark motor symptom of Parkinson’s disease. Slower movement is a gateway manifestation that can lead to other problems such as difficulty walking. 

•         Posture Changes- Patients with Parkinson’s may begin develop a stooped posture as a result of muscle stiffness.  

Slow and stiff muscles in the facial area lead to several other symptoms, which may include:

•         Facial Masking- Another easily recognizable mark of Parkinson’s Disease is a “masked face.” In this condition, the patient’s face droops into a blank stare with a lack of emotion. 

•         Difficulty Swallowing- Trouble with swallowing puts patients more at risk of choking, drooling, or aspiration, which can lead to pneumonia. 

•         Decreased Blinking- A slower blink rate leads to dry eyes and sometimes vision problems such as double vision and color vision disturbances. 

Nonmotor Symptoms

•         Changes in Voice and Speech 

•         speaking in a quieter voice

•         loss of tone or expression in the voice

•         words that trail off as the patient continues to speak

•         slurred speech

•         Pain- Patients often experience pain that can be attributed to a variety of sources, including muscle stiffness and posture.

Stage 3 - Moderate Disease

Stage 3 disease is characterized by postural instability, or a lack of balance. Once a patient develops postural instability, their risk of a fall greatly increases. While activities of daily living are certainly more challenging, at this point patients are still able to care for themselves. Other symptoms that could be present at this stage include:

Nonmotor Symptoms

•         Orthostatic Hypotension- Hypotension, or low blood pressure, may occur when you stand up from a sitting or lying position. This may be evident by dizziness or even fainting.

•         Urinary Problems

•         urgency - feeling as if you need to go immediately

•         frequency - needing to urinate often

•         nocturia - waking up at night with the need to urinate

•         hesitancy - having a hard time starting

•         incontinence - having a hard time holding in urine

•         Sweating- You may notice that you begin to sweat more, even when there seems to be no good reason for it. 

•         Weight Loss- As patients progress through the later stages, weight loss is common. One explanation, though certainly not the only contributing factor, could be the loss of smell. The loss of smell could affect the taste of food, and therefore lead to a decreased appetite. 

Stage 4 - Severe Disease

Patients in stage 4 disease have become severely physically disabled. They may be able to walk without the use of assistive devices, but they are no longer able to care for themselves alone. It is necessary to have a caregiver involved to help the patient with their activities of daily living. Other symptoms that may be experienced include:

Nonmotor Symptoms

•         Cognitive Problems- Cognitive, or thinking issues, often become prevalent as the disease progresses. This may range from trouble concentrating to full-blown dementia. 

Stage 5 - Severe Disease

Stage 5 is the most severe form of disease. At this stage, there is a considerable increase in physical impairment, and patients are often restricted to a wheelchair or bed.

Nonmotor Symptoms

•         Psychosis- As the mental condition of patients begins to decline, many begin to experience psychotic symptoms as well. They may have hallucinations, where they see or hear things that are not there. Patients also may hold false beliefs, or delusions, or become paranoid.

Research in Parkinson’s is ongoing. Therapies include medications, physical and occupational therapy, and a number of assistive devices. Initial research suggests that the use of textured consoles, such as these made by Naboso, helps to improve the gait of those with Parkinson’s disease. 

A new diagnosis can always be scary. But a step taken with fear is still a step in the right direction. Congratulations on taking charge of your health and putting yourself one step ahead by learning about what you face. There is no reason to be discouraged. Many years can pass before disease progression occurs. By learning what to expect, you have empowered yourself to take charge of your diagnosis.


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