Parkinsonisms: What Parkinson’s Is… and What It Isn’t
Written by: Dr. Katie Wadland, PT, DPT, Board-Certified Geriatric Clinical Specialist, Owner of Healthy Aging PT
When most people hear “Parkinson’s disease,” they picture a very specific condition—and for many, that’s accurate. But in our work at Healthy Aging Physical Therapy, we often meet patients whose symptoms look like Parkinson’s… but don’t quite follow the same rules.
These are called Atypical Parkinsonism syndromes, or simply Parkinsonisms.
As a Parkinson’s specialty practice, we’ve had the unique opportunity to work closely with individuals living with conditions like Lewy Body Dementia (LBD), Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA) and Corticobasilar Degernation (CBD). These diagnoses are less common - but incredibly important to recognize, as while there is overlap with Parkinson’s disease, the rehabilitation approach must be thoughtfully adapted for each condition.
Let’s break it down.
What Are “Parkinsonisms”?
“Parkinsonism” is a term used to describe a group of neurological conditions that share key movement features seen in Parkinson’s disease, such as:
Slowness of movement (bradykinesia)
Stiffness (rigidity)
Balance and gait difficulties
However, these conditions have different underlying causes, faster progression, and often respond differently (or poorly) to typical Parkinson’s medications like levodopa.
How Are Parkinsonisms Diagnosed?
Diagnosis can be challenging and often evolves over time. Often, someone is initially diagnosed with Parkinson’s Disease, but when symptom progression is different than expected, or the individual does not respond to medications as expected, an atypical form may be suspected. Other signs might include:
Early balance impairment or falls
Cognitive or autonomic changes early in the disease course
Eye movement abnormalities (especially in PSP)
Imaging and neurological exam findings
In many cases, diagnosis is clinical and may take time, as symptoms unfold and patterns become clearer. Fortunately, we now have more concrete ways to differentiate between the different syndromes including DAT Scans and Skin Biopsies:
DAT Scans: A DaTscan is a specialized imaging test that looks at dopamine activity in the brain. By looking at the patterns, doctors can now better identify if symptoms are coming from a neurodegenerative cause, like Parkinson’s Disease or an Atypical Parkinson’s Syndrome, or from something else, like Essential Tremor or drug-induced symptoms. It is important to be aware a DAT Scan can NOT differentiate between idiopathic Parkinson’s and Atypical Parkinson’s Disease.
Skin Biopsies: A skin biopsy can be taken and analyzed for abnormal alpha-synuculein deposits. When these are identified in the sample, it can help differentiate between the idiopathic form of Parkinson’s and some of the atypical forms of the disease. It is important to note that while it can differentiate the two from one another, it can NOT identify which Atypical Parkinson’s disease a person may have.
As you can see, while we have many more tools at our disposal for proper diagnosis of Parkinson’s Disease and Atypical Parkinsonisms, it still remains a largely clinical diagnosis based on symptoms, progression of disease and response to medication treatment.
What are the Different Atypical Parkinson’s Diseases?
Lewy body Dementia (LBD)
Lewy Body Dementia is a neurodegenerative condition characterized by a combination of:
Cognitive impairment
Parkinsonian motor symptoms
Fluctuations in alertness
Visual hallucinations
What Makes It Different Than Parkinson’s?
Cognition is affected early, often before or alongside movement symptoms
Fluctuating attention and alertness (good days and bad days are common - and presentation may even within throughout the day)
Visual hallucinations are common
Patients may be sensitive to certain medications
How Is Rehab Different?
Rehabilitation for LBD requires a flexible, patient-centered approach:
Session-to-session variability is expected. Therapists must be prepared to adjust treatments, as needed, in real time.
Patients do best when care is focused on routine, familiarity, and caregiver involvement.
Due to the cognitive challenges, communication should be clear, calm and simple.
Balance and mobility training are still essential, but, patients may may need shorter sessions or breaks and should focus should focus more on compensatory strategies as it will be harder for patients to carryover instructions from session to session.
Progressive Supranuclear Palsy (PSP)
PSP is a neurodegenerative condition that affects:
Balance and walking
Eye movements (especially looking down)
Postural control (and most notably, results in retropulsion, or the sensation of falling backwards)
Spinal mobility (rigidity is a marked feature in people with PSP)
What Makes It Different Than Parkinson’s?
Early and frequent falls, often backward
Difficulty with vertical eye movements, especially downward gaze
Speech and swallowing issues tend to appear earlier
Minimal response to Parkinson’s medications
Axial rigidity (stiffness in the trunk more than limbs)
How Is Rehab Different?
Rehabilitation for PSP is very focused on safety and proactive management of symptoms:
Fall prevention is a #1 priority. This often involves prescribing an appropriate assistive device (we love the USTEP for our patients with PSP!), making changes to the home to make it safer and making recommendations for adequate supervision and teaching caregivers the skills they need to help their loved one move safely.
Therapists should assess and treat ocular coordination impairments. When patients can’t look down well, this impacts depth perception and fields of vision, making things like using stairs, curbs and navigating uneven terrain more difficult. People with PSP benefit from working on compensatory skills like visual scanning, and also on using visual exercises to maintain the ocular control they have.
Because of the areas impacted by PSP, people with PSP will have a more difficult time improving balance reactions and walking. They frequently do better with use of external cuing, like using targets on the floor or a laser, or by putting signs up throughout the home to remind them to use safe strategies like pushing off the chair to stand up, or holding on to a surface for support before reaching for something.
It is critical for someone with PSP to get therapy early! Progression of PSP is faster than in typical Parkinson’s Disease and the earlier we can address emerging changes and new symptoms, the more impact we can have on safety and quality of life.
Multiple Systems Atrophy (MSA)
MSA is a progressive neurological condition that affects:
Movement (Parkinsonian features)
Posture (more rounded, head-down positions)
Autonomic Nervous System (causing changes in blood pressure, bladder control and breathing)
What Makes It Different Than Parkinson’s?
Significant autonomic dysfunction causing frequent low blood pressure and syncope (passing out)
Bowel and bladder dysfunction is more common
Progression is faster than in typical Parkinson’s Disease
Minimal response to Parkinson’s medications
May also include cerebellar features like coordination issues
How Is Rehab Different?
Rehabilitation for MSA is requires careful monitoring and management of blood pressure in particular:
Vital sign monitoring should be completed before and during sessions and sessions may need to be modified to keep blood pressure in safe ranges.
Education should focus on strategies to maintain blood pressure in safe ranges throughout the day. This often requires a combination of medication management and coordination with doctors, and education for the patient and caregivers for using things like compression stockings or abdominal binders to help keep blood pressure high enough when they stand up.
Because orthostatic hypotension is common in MSA (drops in blood pressure with standing), it is important to include a seated warm up and slow progression to standing and walking activities during sessions.
Hydration is critical for patients with MSA. Being dehydrated will make the autonomic dysregulation worse and is a frequent cause of falls and hospitalizations for these patients.
Corticobasilar Degeneration (CBD)
CBD Corticobasal Degeneration (CBD) is a rare neurodegenerative condition that affects both the cortex (brain) and the basal ganglia, leading to a combination of movement and higher-level motor planning difficulties. It often presents asymmetrically, meaning one side of the body is significantly more affected than the other.
What Makes It Different Than Parkinson’s?
CBD has several unique features that sets it apart:
Marked asymmetry with one side affected more than the other
Apraxia is a key feature, which is difficulty performing purposeful or functional movements with a limb despite having the strength and motor control to do so
‘Alien Limb’ phenomenon is common - an arm or leg may seem to move involuntarily or feel disconnected from the body
Cortical sensory deficits make it difficult to interpret sensory information
Myoclonus is often present which looks like jerky or uncontrolled movements
Minimal to no response to Parkinson’s medications
Unlike Parkinson’s disease, where movement is primarily limited by slowness and rigidity, CBD involves a breakdown in motor planning and control at a higher neurological level.
How Is Rehab Different?
Rehabilitation for CBD Rehabilitation for CBD requires a shift in approach from “strength and movement” to motor planning, task breakdown, and functional adaptation:
Therapy should focus on task-specific training, and patients do best when breaking down movements into smaller, step-by-step components
Cuing should incorporate external cues, hand-over-hand support and modeling or demonstration as interpretation of body-based or sensory-cues will be very hard to understand
Compensation with the less affected side is critical to maintaining independence as long as possible
Consider use of adaptive strategies and equipment early on so training can be incorporated while motor control and cognition is at it’s best.
The Big Picture: Similar…But Not the Same
While all Parkinsonisms share common movement challenges, the differences between them matter—a lot. In Parkinson’s disease, we typically see a slower progression, a good response to medication (especially early on), and a rehabilitation approach that emphasizes amplitude, intensity, and long-term maintenance. In contrast, atypical Parkinsonisms often present with a faster or more complex progression and a more limited response to medication. Because of this, rehabilitation must shift—becoming more adaptive, more preventative, more caregiver-inclusive, and more medically integrated to address the broader range of symptoms these conditions can bring.
Hopefully this information has helped you better understand some of the key differences between typical, or idiopathic, Parkinson’s disease and the atypical forms of Parkinsonism. Whether you are a patient, caregiver, or therapist reading this, it is critical to recognize these differences—not only to advocate for an accurate diagnosis if things “just don’t feel right,” but also to find providers who understand these conditions and can truly individualize care.
