The parkinsonian signs form one of the most cohesive constellations in neurology. Each is a small piece of the broader basal ganglia syndrome — reduced amplitude of movement, altered tone, characteristic posture, abnormal automatic accompaniments of action. Together they produce the parkinsonian patient that any neurologist learns to recognize across the waiting room. Individually, each sign is a useful bedside test that detects early disease, refines the diagnosis when parkinsonian features are present, and helps distinguish idiopathic Parkinson disease from its mimics.

This page is a catalog of the specific parkinsonian signs, organized by what each tests and what each reveals. Cardinal features (bradykinesia, rigidity, tremor, postural instability) are covered in the Pyramidal vs Extrapyramidal page; this page focuses on the named bedside tests and the supplementary findings.

Tests of Bradykinesia

Finger Tap Test

The patient taps the thumb and index finger together as rapidly and as widely as possible for 10-15 seconds. Observe both the speed and amplitude. The parkinsonian patient shows:

  • Reduced speed: fewer taps per second than normal.
  • Reduced amplitude: the fingers cannot be separated widely.
  • Progressive decrement: the amplitude decreases with continued tapping (the “sequence effect”). The first few taps may be reasonably good; the later taps become smaller and slower.
  • Asymmetry: one hand is typically worse than the other in early disease.

The finger tap test is one of the most sensitive and informative bedside tests for parkinsonism. The combination of reduced speed, reduced amplitude, and progressive decrement is essentially diagnostic.

Hand Grip Test

The patient repeatedly opens and closes the hand as rapidly as possible. Similar features apply: reduced speed, reduced amplitude, progressive decrement, asymmetry.

Foot Tap Test

The patient taps the foot on the floor (heel anchored, toes up and down) rapidly. Similar features and similar diagnostic value to the hand tests.

Pronation-Supination

The patient rotates the hand back and forth on the thigh. Reduced amplitude and progressive decrement are characteristic of parkinsonism.

Tests of Rigidity

Wrist and Elbow Tone Examination

Detailed in the Pyramidal vs Extrapyramidal page. Move the patient’s wrist or elbow passively through a full range of motion, slowly and then more quickly. Parkinsonian rigidity is velocity-independent — the resistance is constant whether the limb is moved slowly or quickly. Two subtypes:

  • Lead-pipe rigidity: smooth, sustained resistance.
  • Cogwheel rigidity: smooth resistance interrupted by regular catching, as if rolling over the teeth of a cog. Reflects superimposed tremor on background rigidity.

Froment Maneuver (Activated Rigidity)

Mild rigidity that is not evident on routine examination can be brought out by activation. Ask the patient to perform a voluntary movement with the contralateral limb (open and close the opposite hand, tap the opposite foot) while you assess the tone of the tested limb. Activation of the contralateral limb increases tone on the tested side, revealing rigidity that is otherwise subtle.

Axial Rigidity

Some parkinsonian patients (especially those with PSP) have prominent axial rigidity that may be missed on routine limb testing. Ask the patient to relax while you assess neck tone: passively flex and extend the neck, and rotate the head. Resistance to passive movement of the neck — particularly to forward neck flexion — is axial rigidity. In PSP, the neck is often held in extension, with marked resistance to forward flexion.

Tests of Tremor

Rest tremor is the classical tremor of Parkinson disease. Discussed in detail on the Abnormal Movements page. The classic features:

  • 4-6 Hz “pill-rolling” tremor of the thumb and fingers, often unilateral or asymmetric at onset.
  • Present at rest, reduced or absent during voluntary movement.
  • Reemerges in the new position: when the patient holds the arms outstretched, the tremor may briefly disappear, then return as a “reemergent” tremor after a few seconds.
  • Variable activation: distracting the patient (asking them to count backward, perform mental tasks) may bring out the tremor that was suppressed.

The Glabellar Tap (Myerson Sign)

Repeatedly tap the patient’s glabella (the bony prominence between the eyebrows) from above so they cannot see your hand approaching. The normal response is brief reflex blinking that habituates within a few taps. The parkinsonian patient continues to blink throughout the tapping — the response fails to habituate.

The Myerson sign is reasonably sensitive for parkinsonism but is not specific. It is also seen in:

  • Frontal lobe disease.
  • Advanced Alzheimer disease.
  • Normal pressure hydrocephalus.
  • Some elderly patients without identifiable disease.

The positive sign supports parkinsonism in the presence of other features but does not establish the diagnosis alone.

The Pull Test (Postural Reflexes)

Detailed in the Postural & Righting Reflexes page. Stand behind the patient, warn them, and pull firmly backward at the shoulders. The normal patient takes one or two backward steps with rapid recovery; the parkinsonian patient takes multiple uncontrolled backward steps (retropulsion) or falls.

The pull test is the most important single test of fall risk in parkinsonism. Early failure (in the first one to two years of disease) suggests progressive supranuclear palsy or vascular parkinsonism; late failure (in stages 3-5) is typical of idiopathic Parkinson disease.

The Applause Sign

Ask the patient to clap three times after the examiner’s demonstration. The normal patient claps three times. The patient with progressive supranuclear palsy continues to clap many times (six, ten, fifteen) before stopping. The applause sign is highly characteristic of PSP and other tau-related frontal-subcortical disorders. It reflects the inability to stop a programmed motor sequence — a frontal-executive dysfunction that overlaps with the cardinal features of PSP.

Tests of Speech and Voice

Parkinsonian speech is hypokinetic: reduced loudness (hypophonia), reduced prosody (monotone), reduced articulation, sometimes with rapid blurred speech (festinating speech). Have the patient:

  • Count aloud from one to twenty.
  • Read a paragraph aloud.
  • Sustain the “ah” vowel as long as possible — parkinsonian patients often have reduced phonation time.

The findings can be subtle. Family members often notice that the patient “mumbles” or “talks softer” before any other motor symptoms.

Tests of Handwriting (Micrographia)

Ask the patient to write a sentence in their normal style. Parkinsonian micrographia shows:

  • Small letters from the start.
  • Progressive shrinking of the letters across the sentence (“decrementing micrographia”).
  • Spidery, irregular letter formation.
  • Sometimes tremor-related distortion.

Micrographia is a useful early sign and can be assessed by comparing the patient’s current writing with their past writing (signatures on old documents).

Tests of Spontaneous Movement

Arm Swing During Gait

Watch the patient walk across the room and observe the arm swing. Asymmetric reduction in arm swing is one of the earliest signs of parkinsonism, often present years before tremor or bradykinesia become evident on formal examination.

Facial Expression (Hypomimia)

Observe the patient’s face during the history and the exam. Reduced spontaneous facial movement, reduced blink rate (normal 15-20/min, parkinsonian 5-7/min), and reduced emotional reactivity of the face. The “masked facies” can give the false impression that the patient is depressed when in fact the affective experience may be normal.

Spontaneous Postural Adjustments

A healthy person makes constant small shifts of posture; the parkinsonian patient sits or stands with more fixity. Watch for the absence of these normal small movements.

Gestures During Conversation

Patients use fewer hand gestures than expected, particularly on the more affected side.

Tests for Atypical Features

Several findings on examination should raise concern for atypical parkinsonism rather than idiopathic Parkinson disease. The “red flags” for atypical parkinsonism:

  • Symmetric onset: idiopathic PD is asymmetric; symmetric onset suggests MSA, PSP, vascular parkinsonism, or drug-induced.
  • Early postural instability: falls in the first one to two years suggest PSP.
  • Vertical gaze palsy: especially downgaze; classical for PSP.
  • Severe early autonomic failure: orthostatic hypotension, urinary dysfunction, erectile dysfunction; suggests MSA.
  • Cerebellar features: ataxia accompanying parkinsonism suggests MSA-C.
  • Apraxia or alien limb: corticobasal syndrome.
  • Cognitive decline early: dementia with Lewy bodies (within first year), MSA, PSP.
  • Pyramidal signs: spasticity, Babinski; uncommon in idiopathic PD, more frequent in MSA.
  • Poor response to levodopa: PSP, vascular parkinsonism, MSA often poorly responsive; idiopathic PD typically dramatically responsive.
  • Rapid progression: idiopathic PD progresses over years; rapid decline suggests atypical syndromes.

Drug-Induced Parkinsonism

Drug-induced parkinsonism is common and often missed. The classical offenders are dopamine receptor antagonists — first-generation antipsychotics (haloperidol, fluphenazine), risperidone, olanzapine (less commonly), and importantly the antiemetics metoclopramide and prochlorperazine. The clinical features:

  • Symmetric onset (typically), rather than asymmetric.
  • Often without rest tremor (postural or action tremor instead).
  • May respond partially to anticholinergics or amantadine.
  • Reversible on discontinuation, though sometimes slowly (months).

Always review the medication list in any patient presenting with parkinsonism. The list of culprits is long, and the patient often has been taking the medication for years without anyone connecting it to the new symptoms.

🔍 Did You Know?

The applause sign — the patient continues to clap many times after being asked to clap three times — is one of the most specific bedside findings for progressive supranuclear palsy. It reflects the inability to stop a programmed motor sequence and is sometimes called a “stickiness of thought” or “motor perseveration.” A positive applause sign in a patient with parkinsonism and early postural instability is essentially diagnostic of PSP. The sign is uncommon in idiopathic PD even in late stages.

Pitfalls and Pearls

  • Always test both sides. Asymmetric onset favors idiopathic PD; symmetric onset suggests an atypical syndrome.
  • The progressive decrement in finger tapping is highly characteristic of parkinsonism, distinguishing it from generalized slow speed (which can have many causes).
  • The pull test predicts falls. Early failure in parkinsonism is an important clinical finding.
  • Vertical gaze palsy, especially downgaze, points to PSP, not idiopathic PD.
  • Severe early autonomic failure points to MSA. A patient with mild parkinsonism and severe orthostatic hypotension is showing MSA until proven otherwise.
  • Drug-induced parkinsonism is reversible. Always review the medication list. Metoclopramide and the older antipsychotics are common culprits.
  • Asymmetric arm swing reduction is the earliest sign of parkinsonism in many patients. Watch every patient walk.
  • The applause sign is highly specific for PSP. A positive sign in a patient with parkinsonism and early falls is essentially diagnostic.
  • Levodopa response is the diagnostic test for idiopathic PD. A patient with parkinsonism who does not respond to adequate doses of levodopa probably does not have idiopathic PD.
  • Lower-half parkinsonism (gait abnormalities greater than arm involvement) points to vascular parkinsonism or normal pressure hydrocephalus.
  • The Myerson sign is sensitive but not specific. Useful in supporting parkinsonism in the context of other features.

References

  1. Campbell WW. DeJong’s The Neurologic Examination. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013. Chapter 30.
  2. Postuma RB, Berg D, Stern M, et al. MDS clinical diagnostic criteria for Parkinson’s disease. Mov Disord. 2015;30(12):1591-1601.
  3. Höglinger GU, Respondek G, Stamelou M, et al. Clinical diagnosis of progressive supranuclear palsy. Mov Disord. 2017;32(6):853-864.
  4. Wenning GK, Stankovic I, Vignatelli L, et al. The Movement Disorder Society criteria for the diagnosis of multiple system atrophy. Mov Disord. 2022;37(6):1131-1148.
  5. Dubois B, Slachevsky A, Pillon B, Beato R, Villalponda JM, Litvan I. “Applause sign” helps to discriminate PSP from FTD and PD. Neurology. 2005;64(12):2132-2133.
  6. Tolosa E, Wenning G, Poewe W. The diagnosis of Parkinson’s disease. Lancet Neurol. 2006;5(1):75-86.