How do paramedics assess for parkinsonism?

Paramedic Assessment of Parkinsonism

Paramedics should assess for parkinsonism using a focused motor examination that identifies the cardinal features: bradykinesia (slowness of movement) plus at least one of resting tremor, rigidity, or postural instability. 1, 2

Essential Clinical Assessment Components

Primary Motor Signs to Evaluate

Bradykinesia Assessment:

• Observe the patient's facial expressions for reduced animation or "masked facies" 1
• Watch for slowness in voluntary movements during routine activities like buttoning clothes or reaching for objects 1
• Note any difficulty with fine motor tasks or gross motor activities like walking 1
• Assess speech for reduced volume or monotone quality 1

Tremor Evaluation:

• Look for resting tremor that occurs when the limb is completely relaxed and supported 2, 3
• Note if tremor diminishes with purposeful movement 2
• Observe for asymmetric presentation, as parkinsonism often affects one side more than the other 1

Rigidity Testing:

• Instruct the patient to completely relax while you passively move their limbs through full range of motion 1, 4
• Test both upper and lower extremities, comparing sides for asymmetry 1, 4
• Feel for constant resistance throughout the movement (lead-pipe rigidity) 1
• Note any "cogwheel" phenomenon—a ratchet-like, jerky resistance that occurs when rigidity combines with tremor 1, 4
• Use activation maneuvers: have the patient open and close the opposite hand while testing for rigidity, as this enhances detection of subtle rigidity 1, 4

Critical Red Flags for Atypical Parkinsonism

Paramedics should recognize features suggesting diagnoses other than typical Parkinson's disease:

• Vertical gaze palsy (especially downward gaze limitation) suggests Progressive Supranuclear Palsy 1
• Asymmetric rigidity with alien hand phenomenon suggests Corticobasal Syndrome 1, 4
• Ataxia suggests alternative diagnoses 1
• Early postural instability or falls may indicate atypical parkinsonism 5

Practical Prehospital Approach

Step 1: Observe During Initial Contact

• Note the patient's facial expressions, spontaneous movements, and gait as you approach 1
• Watch for slowness in responding to questions or commands 1

Step 2: Focused Motor Examination

• Test for rigidity bilaterally using passive limb movement with activation maneuvers 1, 4
• Observe for resting tremor in hands, arms, or legs 2, 3
• Assess bradykinesia through observation of voluntary movements 1

Step 3: Document Key Findings

• Note which cardinal features are present (bradykinesia, tremor, rigidity) 2, 3
• Document asymmetry of symptoms 1
• Record any red flag features suggesting atypical parkinsonism 1, 6

Common Pitfalls to Avoid

• Failure to have the patient completely relax during rigidity testing leads to false positives from voluntary muscle contraction 1
• Not using activation maneuvers may cause you to miss subtle rigidity that would otherwise be detectable 1, 4
• Confusing spasticity with rigidity: Spasticity shows velocity-dependent resistance that increases with faster stretching, while rigidity shows constant resistance throughout movement 1
• Missing drug-induced parkinsonism: Always obtain medication history, particularly for antipsychotics and antiemetics that can cause parkinsonian symptoms 4

Clinical Context

While paramedics cannot definitively diagnose Parkinson's disease (which requires specialized evaluation and sometimes imaging like I-123 ioflupane SPECT/CT), 1, 7 recognizing parkinsonian features is valuable for appropriate triage and hospital notification. The presence of bradykinesia plus rigidity, tremor, or both constitutes the clinical syndrome of parkinsonism and warrants neurological evaluation. 2, 3

Postural instability typically appears later in disease progression and is not useful for early detection, 8 so paramedics should focus on the triad of bradykinesia, rigidity, and resting tremor for prehospital assessment. 1, 2