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As Parkinson's disease progresses beyond the early stage described above, many of the difficulties experienced by patients are related to the four basic categories of symptoms (TRAP), including:

• Difficulty Walking - Problems with walking can occur early or late in Parkinson's disease and include:

  • festination - an involuntary tendency to take small shuffling steps or "running steps" resulting in the patient walking with increasing speed to prevent falling. It is related to the abnormal center of gravity experienced by the patient and is sometimes called a "catch-up" gait. Festination consists of a combination of shortening of the stride while quickening the gait. It is often difficult for the patient who is "running" to stop when they reach their destination.
  • lack of arm swinging of one or both arms - this contributes to difficulty walking since the brain associates walking and arm swinging together so that when one is impaired, the other may be impaired as well.
  • stooped posture - this may result from a greater contraction of chest muscles than back muscles. Exercise is very important to counteract tightening and stiffness of the muscles in Parkinson's disease since stooped posture affects balance and can significantly interfere with walking.
  • "freezing" is a sudden, temporary inability to move one's legs or feet. Freezing may present as a sudden inability to either start or continue walking. Freezing during walking often occurs when the Parkinson's disease patient approaches a doorway, turns, or is in an area with many people. It appears without warning, lasts a few seconds, and usually increases in frequency. Over time, the duration of "freezing" episodes may increase. "Freezing" is one of the major causes of falling in patients with Parkinson's disease and occurs in approximately 30% of cases. Anxiety can also contribute to freezing, either initiating it or preventing its resolution.

• Problems with chewing and swallowing - chewing and swallowing relate to the overall symptoms of muscle rigidity and involve three areas:

  • tongue - the tongue does not depress sufficiently to allow food to proceed to the throat
  • throat - bits of food that are not completely swallowed collect in the throat and may fall into the airway causing coughing or choking
  • esophagus - muscles in the gastrointestinal track including the muscles involved with moving food down into the stomach from the esophagus can be affected by Parkinson's disease resulting in food chunks feeling like they are "stuck" or going down slowly. This can lead to heartburn or gastroesophageal reflux.

• Drooling - Excessive drooling occurs when saliva accumulates at the back of the mouth and because of impaired musculature, is not swallowed. In addition to the humiliation experienced by the patient, drooling can also be dangerous since it can lead to aspiration of saliva into the lungs and cause choking or pneumonia.

• Loss of automatic movement (e.g., blinking, smiling) resulting in a "mask-like" appearance to the face.

• Speech impairment - speech problems include: soft voice, slurring words, speaking too quickly, or hesitating before speaking. Speech impairment may be one of the first presenting symptoms of Parkinson's disease.