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Science Selection Nov-Dec 2013 | Volume 121 | Issue 11-12

Environ Health Perspect; DOI:10.1289/ehp.121-A342

Before the Tremor: Premotor Symptoms of Parkinson’s Disease

Lindsey Konkel is a Worcester, MA–based journalist who reports on science, health, and the environment. She writes frequently for Environmental Health News and The Daily Climate.

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Citation: Konkel L. 2013. Before the tremor: premotor symptoms of Parkinson’s disease. Environ Health Perspect 121:A342;

News Topics: Sensory Health, Gastrointestinal Health, Neurologic Health, Surveillance and Monitoring, Aging

Published: 1 December 2013

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Related EHP Article

Research on the Premotor Symptoms of Parkinson’s Disease: Clinical and Etiological Implications

Honglei Chen, Edward A. Burton, G. Webster Ross, Xuemei Huang, Rodolfo Savica, Robert D. Abbott, Alberto Ascherio, John N. Caviness, Xiang Gao, Kimberly A. Gray, Jau-Shyong Hong, Freya Kamel, Danna Jennings, Annette Kirshner, Cindy Lawler, Rui Liu, Gary W. Miller, Robert Nussbaum, Shyamal D. Peddada, Amy Comstock Rick, Beate Ritz, Andrew D. Siderowf, Caroline M. Tanner, Alexander I. Tröster and Jing Zhang

Clinicians currently diagnose Parkinson’s disease (PD) by the presence of tremor and impaired movement. However, PD patients also suffer from a wide range of nonmotor symptoms, some of which may appear years before the motor signs. In this issue of EHP, a national group of experts reviews the current body of research on these premotor symptoms, which may offer clues to better understanding the development of PD and identifying at-risk populations.1

“A growing body of evidence suggests that Parkinson’s disease is more than a brain disorder. Premotor symptoms offer a unique opportunity to understand the early development of the disease,” says lead author Honglei Chen, head of the Aging and Neuroepidemiology Group at the National Institute of Environmental Health Sciences.

Although there is currently no cure for PD, which affects an estimated 1–2% of people over 60,2 figuring out how to spot this disease earlier in its development may give researchers an opportunity to identify more effective treatments, Chen says.

Epidemiological studies suggest that nonmotor symptoms such as hyposmia (poor sense of smell), chronic constipation, rapid eye movement sleep behavior disorder (in which sufferers appear to act out dreams in their sleep), daytime sleepiness, anxiety, and depression may occur before the appearance of motor dysfunction in PD patients. Motor symptoms typically become apparent when the substantia nigra—a portion of the brain important for movement—has lost 50% or more of its dopaminergic neurons.1

“The clinical signs of the disease are just the tip of the iceberg. There’s a lot going on under the surface that we don’t yet recognize,” says Andrew Feigin, a PD researcher at the Feinstein Institute for Medical Research in Manhasset, New York. Feigin was not involved in the current review.

The average age at PD diagnosis is 60, according to the National Institute of Neurological Disorders and Stroke.3 It’s unclear how far in advance of clinical symptoms early premotor symptoms may be recognized. Clinical studies have documented the onset of rapid eye movement sleep behavior disorder or constipation 10–20 years before PD diagnosis. Data are inconsistent for the timing of other premotor symptoms.1

Man sniffing food as it cooksHyposmia, or poor sense of smell, can signal Parkinson’s disease years before diagnosis.

© Getty Images

Questions also remain about the usefulness of premotor symptoms in understanding the early stages of disease and identifying at-risk people. Preliminary studies suggest that a single premotor symptom itself is inadequate for predicting disease.4,5

Few studies have explored combinations of premotor symptoms for early disease detection, although preliminary evidence indicates that multiple symptoms may occur in people at higher risk for PD. One study found that 2 of 24 people (8.3%) with more than three premotor symptoms developed PD within 5 years of follow-up compared with just 8 of 852 people (0.9%) with one symptom.1

“Research on premotor symptoms is really in its infancy,” says Chen, who along with his colleagues suggests that large prospective cohort studies with lengthy follow-ups are needed to evaluate the role of premotor symptoms in PD development.

According to some experts, premotor symptoms may suggest an origin of PD that lies outside the brain.6,7 One hypothesis posits that abnormal protein aggregates characteristic of PD appear first in the olfactory structures and enteric nerve, then spread by a prion-like cell-to-cell transfer to the substantia nigra.8 Some studies suggest that PD may originate in the cells of the nasal cavity or intestines and spread to the central nervous system and the brain.9,10,11,12

“The idea that GI and olfactory symptoms may precede the disease by years raises the level of interest in environmental toxicants, which primarily enter the body through inhalation and ingestion,” says Jeff Bronstein, a neurologist and molecular toxicologist at the University of California, Los Angeles. Bronstein was not involved in the review.

Previous studies have reported associations between PD and certain types of pesticides13 or lifetime exposure to metals such as lead.14 Exposures to other neurotoxic chemicals, such as polychlorinated biphenyls and methylmercury, have been implicated as potential risk factors for PD, although the current body of data for these exposures remains too weak to assess.15


1. Chen H, et al. Research on the premotor symptoms of Parkinson’s disease: clinical and etiological implications. Environ Health Perspect 121(11–12):1245–1252 (2013);

2. NHGRI. Learning about Parkinson’s Disease: What Do We Know about Heredity and Parkinson’s Disease? [website]. Bethesda, MD:National Human Genome Research Institute (updated 27 June 2011). Available: [accessed 28 October 2013].

3. NINDS. Parkinson’s Disease Backgrounder [website]. Bethesda, MD:National Institute of Neurological Disorders and Stroke (updated 18 October 2004). Available: [accessed 28 October 2013].

4. Berg D, et al. The PRIPS study: screening battery for subjects at risk for Parkinson’s disease. Eur J Neurol 20(1):102–108 (2013);

5. Siderowf A, et al. Impaired olfaction and other prodromal features in the Parkinson At-Risk Syndrome Study. Mov Disord 27(3):406–412 (2012);

6. Tomé CML, et al. Inflammation and α-synuclein’s prion-like behavior in Parkinson’s disease—is there a link? Mol Neurobiol 47(2):561–574 (2013);

7. Frost B, Diamond MI. Prion-like mechanisms in neurodegenerative diseases. Nature Rev Neurosci 11(3):155–159 (2010);

8. Dunning CJ, et al. Can Parkinson’s disease pathology be propagated from one neuron to another? Prog Neurobiol 97(2):205–219 (2012);

9. RL Doty. The olfactory vector hypothesis of neurodegenerative disease: is it viable? Ann Neurol 63(1):7–15 (2008);

10. Hawkes CH, et al. Parkinson’s disease: a dual-hit hypothesis. Neuropathol Appl Neurobiol 33(6):599–614. (2007);

11. Hawkes CH, et al. Parkinson’s disease: the dual hit theory revisited. Ann NY Acad Sci 1170:615–622 (2009);

12. Reichmann H. View point: etiology in Parkinson’s disease. Dual hit or spreading intoxication. J Neurol Sci 210(1–2):9–11 (2011);

13. Tanner CM, et al. Rotenone, paraquat, and Parkinson’s disease. Environ Health Perspect 119(6):866–872 (2011);

14. Weisskopf MG, et al. Association of cumulative lead exposure with Parkinson’s disease. Environ Health Perspect 118(11):1609–1613 (2010);

15. Caudle WM, et al. Industrial toxicants and Parkinson’s disease. NeuroToxicol 33(2):178–188 (2012);

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