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Levine CB, Fahrbach KR, Siderowf AD, et al. Diagnosis and Treatment of Parkinson's Disease: A Systematic Review of the Literature. Rockville (MD): Agency for Healthcare Research and Quality (US); 2003 Jun. (Evidence Reports/Technology Assessments, No. 57.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Diagnosis and Treatment of Parkinson's Disease

Diagnosis and Treatment of Parkinson's Disease: A Systematic Review of the Literature.

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Appendix A. Major Parkinson's Disease Rating Scales

Numerous rating scales and diagnostic criteria are used to evaluate the severity of PD. While the most common scale in current use is the UPDRS, many of the studies in the database reported other scales. This section provides a brief description of the major scales and diagnostic criteria that are used to evaluate clinical severity of PD.

List of Scales Used

  1. Unified Parkinson Disease Rating Scale (UPDRS)
  2. Abnormal Involuntary Movements Scale (AIMS Score)
  3. Activities of Daily Living (ADL)
  4. Barthel Index
  5. Beck Depression Inventory
  6. Brief Psychiatric Rating Scale (BPRS)
  7. Columbia University Rating Scale (CURS)
  8. Dyskinesia rating scale
  9. Hamilton Depression Scale (HAM-D)
  10. Hoehn and Yahr Clinical Staging Scale
  11. Levodopa Equivalent Units (LEU)
  12. Mini-Mental Status Exam (MMSE)
  13. Northwestern University Disability Scale (NUDS or NWUDS)
  14. Phenyl Ethyl Alcohol or Detection Threshold (PEA)
  15. Parkinson Psychosis Rating Scale (PPRS)
  16. Proposed Diagnostic Criteria for Parkinson Disease
  17. Schwab & England Activities of Daily Living Scale (S&E) and (SEADL)
  18. Sickness Impact Profile (SIP)
  19. UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria
  20. University of Pennsylvania Smell Identification Test (UPSIT)
  21. Webster's Parkinson's Disease Rating Scale (WPDRS)

Unified Parkinson Disease Rating Scale (UPDRS)1

The UPDRS is a rating tool to follow the longitudinal course of Parkinson's Disease. A total of 199 points are possible. 199 represents the worst (total) disability, 0 indicates no disability.

UPDRS is made up of three distinct subscales:

  1. Mentation, behavior, and mood
  2. Activities of daily living (ADL) during “off” and “on” periods
  3. Motor function during “on” periods

A fourth subscale is also sometimes used:

  1. IV. Complications of therapy (In the past week)

Sections composing each subscale are usually 0–4 points.

These scores are calculated by interviewing the patient. Some sections require multiple grades assigned to each extremity.

I. MENTATION, BEHAVIOR, AND MOOD

  • 1. Intellectual Impairment
    • 0 = None.
    • 1 = Mild. Consistent forgetfulness with partial recollection of events and no other difficulties.
    • 2 = Moderate memory loss, with disorientation and moderate difficulty handling complex problems. Mild but definite impairment of function at home with need of occasional prompting.
    • 3 = Severe memory loss with disorientation for time and often to place. Severe impairment in handling problems.
    • 4 = Severe memory loss with orientation preserved to person only. Unable to make judgements or solve problems. Requires much help with personal care. Cannot be left alone at all.
  • 2. Thought Disorder (Due to dementia or drug intoxication)
    • 0 = None.
    • 1 = Vivid dreaming.
    • 2 = “Benign” hallucinations with insight retained.
    • 3 = Occasional to frequent hallucinations or delusions; without insight; could interfere with daily activities.
    • 4 = Persistent hallucinations, delusions, or florid psychosis. Not able to care for self.
  • 3. Depression
    • 0 = None
    • 1 = Periods of sadness or guilt greater than normal, never sustained for days or weeks.
    • 2 = Sustained depression (1 week or more).
    • 3 = Sustained depression with vegetative symptoms (insomnia, anorexia, weight loss, loss of interest).
    • 4 = Sustained depression with vegetative symptoms and suicidal thoughts or intent.
  • 4. Motivation/Initiative
    • 0 = Normal.
    • 1 = Less assertive than usual; more passive.
    • 2 = Loss of initiative or disinterest in elective (nonroutine) activities.
    • 3 = Loss of initiative or disinterest in day to day (routine) activities.
    • 4 = Withdrawn, complete loss of motivation.

II. ACTIVITIES OF DAILY LIVING (ADL) for both “off” and “on”

  • 5. Speech
    • 0 = Normal.
    • 1 = Mildly affected. No difficulty being understood.
    • 2 = Moderately affected. Sometimes asked to repeat statements.
    • 3 = Severely affected. Frequently asked to repeat statements.
    • 4 = Unintelligible most of the time.
  • 6. Salivation
    • 0 = Normal.
    • 1 = Slight but definite excess of saliva in mouth; may have nighttime drooling.
    • 2 = Moderately excessive saliva; may have minimal drooling.
    • 3 = Marked excess of saliva with some drooling.
    • 4 = Marked drooling, requires constant tissue or handkerchief.
  • 7. Swallowing
    • 0 = Normal.
    • 1 = Rare choking.
    • 2 = Occasional choking.
    • 3 = Requires soft food.
    • 4 = Requires NG tube or gastrotomy feeding.
  • 8. Handwriting
    • 0 = Normal.
    • 1 = Slightly slow or small.
    • 2 = Moderately slow or small; all words are legible.
    • 3 = Severely affected; not all words are legible.
    • 4 = The majority of words are not legible.
  • 9. Cutting food and handling utensils
    • 0 = Normal.
    • 1 = Somewhat slow and clumsy, but no help needed.
    • 2 = Can cut most foods, although clumsy and slow; some help needed.
    • 3 = Food must be cut by someone, but can still feed slowly.
    • 4 = Needs to be fed.
  • 10. Dressing
    • 0 = Normal.
    • 1 = Somewhat slow, but no help needed.
    • 2 = Occasional assistance with buttoning, getting arms in sleeves.
    • 3 = Considerable help required, but can do some things alone.
    • 4 = Helpless.
  • 11. Hygiene
    • 0 = Normal.
    • 1 = Somewhat slow, but no help needed.
    • 2 = Needs help to shower or bathe; or very slow in hygienic care.
    • 3 = Requires assistance for washing, brushing teeth, combing hair, going to bathroom.
    • 4 = Foley catheter or other mechanical aids.
  • 12. Turning in bed and adjusting bed clothes
    • 0 = Normal.
    • 1 = Somewhat slow and clumsy, but no help needed.
    • 2 = Can turn alone or adjust sheets, but with great difficulty.
    • 3 = Can initiate, but not turn or adjust sheets alone.
    • 4 = Helpless.
  • 13. Falling (unrelated to freezing)
    • 0 = None.
    • 1 = Rare falling.
    • 2 = Occasionally falls, less than once per day.
    • 3 = Falls an average of once daily.
    • 4 = Falls more than once daily.
  • 14. Freezing when walking
    • 0 = None.
    • 1 = Rare freezing when walking; may have start hesitation.
    • 2 = Occasional freezing when walking.
    • 3 = Frequent freezing. Occasionally falls from freezing.
    • 4 = Frequent falls from freezing.
  • 15. Walking
    • 0 = Normal.
    • 1 = Mild difficulty. May not swing arms or may tend to drag leg.
    • 2 = Moderate difficulty, but requires little or no assistance.
    • 3 = Severe disturbance of walking, requiring assistance.
    • 4 = Cannot walk at all, even with assistance.
  • 16. Tremor (Symptomatic complaint of tremor in any part of body.)
    • 0 = Absent.
    • 1 = Slight and infrequently present.
    • 2 = Moderate; bothersome to patient.
    • 3 = Severe; interferes with many activities.
    • 4 = Marked; interferes with most activities.
  • 17. Sensory complaints related to parkinsonism
    • 0 = None.
    • 1 = Occasionally has numbness, tingling, or mild aching.
    • 2 = Frequently has numbness, tingling, or aching; not distressing.
    • 3 = Frequent painful sensations.
    • 4 = Excruciating pain.

III. MOTOR EXAMINATION

  • 18. Speech
    • 0 = Normal.
    • 1 = Slight loss of expression, diction and/or volume.
    • 2 = Monotone, slurred but understandable; moderately impaired.
    • 3 = Marked impairment, difficult to understand.
    • 4 = Unintelligible.
  • 19. Facial Expression
    • 0 = Normal.
    • 1 = Minimal hypomimia, could be normal “Poker Face”.
    • 2 = Slight but definitely abnormal diminution of facial expression
    • 3 = Moderate hypomimia; lips parted some of the time.
    • 4 = Masked or fixed facies with severe or complete loss of facial expression; lips parted 1/4 inch or more.
  • 20. Tremor at rest (head, upper and lower extremities)
    • 0 = Absent.
    • 1 = Slight and infrequently present.
    • 2 = Mild in amplitude and persistent. Or moderate in amplitude, but only intermittently present.
    • 3 = Moderate in amplitude and present most of the time.
    • 4 = Marked in amplitude and present most of the time.
  • 21. Action or Postural Tremor of hands
    • 0 = Absent.
    • 1 = Slight; present with action.
    • 2 = Moderate in amplitude, present with action.
    • 3 = Moderate in amplitude with posture holding as well as action.
    • 4 = Marked in amplitude; interferes with feeding.
  • 22. Rigidity (Judged on passive movement of major joints with patient relaxed in sitting position. Cogwheeling to be ignored.)
    • 0 = Absent.
    • 1 = Slight or detectable only when activated by mirror or other movements.
    • 2 = Mild to moderate.
    • 3 = Marked, but full range of motion easily achieved.
    • 4 = Severe, range of motion achieved with difficulty.
  • 23. Finger Taps (Patient taps thumb with index finger in rapid succession.)
    • 0 = Normal.
    • 1 = Mild slowing and/or reduction in amplitude.
    • 2 = Moderately impaired. Definite and early fatiguing. May have occasional arrests in movement.
    • 3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
    • 4 = Can barely perform the task.
  • 24. Hand Movements (Patient opens and closes hands in rapid succesion.)
    • 0 = Normal.
    • 1 = Mild slowing and/or reduction in amplitude.
    • 2 = Moderately impaired. Definite and early fatiguing. May have occasional arrests in movement.
    • 3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
    • 4 = Can barely perform the task.
  • 25. Rapid Alternating Movements of Hands (Pronation-supination movements of hands, vertically and horizontally, with as large an amplitude as possible, both hands simultaneously.)
    • 0 = Normal.
    • 1 = Mild slowing and/or reduction in amplitude.
    • 2 = Moderately impaired. Definite and early fatiguing. May have occasional arrests in movement.
    • 3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
    • 4 = Can barely perform the task.
  • 26. Leg Agility (Patient taps heel on the ground in rapid succession picking up entire leg. Amplitude should be at least 3 inches.)
    • 0 = Normal.
    • 1 = Mild slowing and/or reduction in amplitude.
    • 2 = Moderately impaired. Definite and early fatiguing. May have occasional arrests in movement.
    • 3 = Severely impaired. Frequent hesitation in initiating movements or arrests in ongoing movement.
    • 4 = Can barely perform the task.
  • 27. Arising from Chair (Patient attempts to rise from a straightbacked chair, with arms folded across chest.)
    • 0 = Normal.
    • 1 = Slow; or may need more than one attempt.
    • 2 = Pushes self up from arms of seat.
    • 3 = Tends to fall back and may have to try more than one time, but can get up without help.
    • 4 = Unable to arise without help.
  • 28. Posture
    • 0 = Normal erect.
    • 1 = Not quite erect, slightly stooped posture; could be normal for older person.
    • 2 = Moderately stooped posture, definitely abnormal; can be slightly leaning to one side.
    • 3 = Severely stooped posture with kyphosis; can be moderately leaning to one side.
    • 4 = Marked flexion with extreme abnormality of posture.
  • 29. Gait
    • 0 = Normal.
    • 1 = Walks slowly, may shuffle with short steps, but no festination (hastening steps) or propulsion.
    • 2 = Walks with difficulty, but requires little or no assistance; may have some festination, short steps, or propulsion.
    • 3 = Severe disturbance of gait, requiring assistance.
    • 4 = Cannot walk at all, even with assistance.
  • 30. Postural Stability (Response to sudden, strong posterior displacement produced by pull on shoulders while patient erect with eyes open and feet slightly apart. Patient is prepared.)
    • 0 = Normal.
    • 1 = Retropulsion, but recovers unaided.
    • 2 = Absence of postural response; would fall if not caught by examiner.
    • 3 = Very unstable, tends to lose balance spontaneously.
    • 4 = Unable to stand without assistance.
  • 31. Body Bradykinesia and Hypokinesia (Combining slowness, hesitancy, decreased armswing, small amplitude, and poverty of movement in general.)
    • 0 = None.
    • 1 = Minimal slowness, giving movement a deliberate character; could be normal for some persons. Possibly reduced amplitude.
    • 2 = Mild degree of slowness and poverty of movement which is definitely abnormal. Alternatively, some reduced amplitude.
    • 3 = Moderate slowness, poverty or small amplitude of movement.
    • 4 = Marked slowness, poverty or small amplitude of movement.

IV. COMPLICATIONS OF THERAPY (In the past week)

A. DYSKINESIAS

  • 32. Duration: What proportion of the waking day are dyskinesias present? (Historical information.)
    • 0 = None
    • 1 = 1–25% of day.
    • 2 = 26–50% of day.
    • 3 = 51–75% of day.
    • 4 = 76–100% of day.
  • 33. Disability: How disabling are the dyskinesias? (Historical information; may be modified by office examination.)
    • 0 = Not disabling.
    • 1 = Mildly disabling.
    • 2 = Moderately disabling.
    • 3 = Severely disabling.
    • 4 = Completely disabling.
  • 34. Painful Dyskinesias: How painful are the dyskinesias?
    • 0 = No painful dyskinesias.
    • 1 = Slight.
    • 2 = Moderate.
    • 3 = Severe.
    • 4 = Marked.
  • 35. Presence of Early Morning Dystonia (Historical information.)
    • 0 = No
    • 1 = Yes

B. CLINICAL FLUCTUATIONS

  • 36. Are “off” periods predictable?
    • 0 = No
    • 1 = Yes
  • 37. Are “off” periods unpredictable?
    • 0 = No
    • 1 = Yes
  • 38. Do “off” periods come on suddenly, within a few seconds?
    • 0 = No
    • 1 = Yes
  • 39. What proportion of the waking day is the patient “off” on average?
    • 0 = None
    • 1 = 1–25% of day.
    • 2 = 26–50% of day.
    • 3 = 51–75% of day.
    • 4 = 76–100% of day.

C. OTHER COMPLICATIONS

  • 40. Does the patient have anorexia, nausea, or vomiting?
    • 0 = No
    • 1 = Yes
  • 41. Any sleep disturbances, such as insomnia or hypersomnolence?
    • 0 = No
    • 1 = Yes
  • 42. Does the patient have symptomatic orthostasis?
    (Record the patient's blood pressure, height and weight on the scoring form)
    • 0 = No
    • 1 = Yes

AIMS Score (Abnormal Involuntary Movements Scale)2

This scale requires the examiner to observe the patient sitting quietly at rest and again while the patient carries out selected motor tasks (mouth opening, tongue protrusion, finger taps, and walking, among others). Seven body areas are rated: muscles of facial expression, lips and perioral area, jaw, tongue, upper and lower extremities, and trunk. A five-point scheme ranging from 0 (normal) to 4 (severe) is used to assess each body part. The worst dyskinesias seen in each body part are rated for the intensity of the movement and the chosen rating score is reduced by one point if that body region has dyskinesias during the quiet rest phase of the observation. There are also three global rating scales to complete: overall severity, incapacitation for the patient, and the patient's awareness of the dyskinesias. Finally, two interview questions for the patient concentrate on dental hygiene and the wearing of dentures.

Activities of Daily Living (ADL)3

The ADL scale measures the impact of PD on 14 categories, including:

  • Speech
  • Salivation
  • Swallowing
  • Handwriting
  • Cutting food and handling utensils
  • Dressing
  • Hygiene
  • Turning in bed and adjusting bedclothes
  • Falling
  • Freezing when walking
  • Walking
  • Left-sided tremor
  • Right-sided tremor
  • Sensory complaints.

Each category is scored on a 0–4 scale, with 0 indicating normal or unaffected functioning, and 4 signifying a patient who is helpless or non-ambulatory. For example, the response scale for cutting food and handling utensils is as follows:

  • 0 = Normal
  • 1 = Somewhat slow and clumsy, but no help needed
  • 2 = Can cut most foods, although clumsy and slow; some help needed
  • 3 = Food must be cut by someone, but can still feed slowly
  • 4 = Needs to be fed

The scores for the 14 categories are summed to give an overall ADL score. The overall score ranges from 0 to 56, with higher scores reflecting greater disability and the need for assistance.

Barthel Index4

Full credit is not given for an activity if the patient needs even minimal help/supervision. A score of 0 is given when patient cannot meet criteria as defined.

  1. Feeding
    1. (10 pts). Independent; feeds self from tray or table; can put on assistive device if needed; accomplishes feeding in reasonable time.
    2. (5 pts). Assistance necessary with cutting food, etc.
    3. (0 pts). Cannot meet criteria
  2. Moving (from wheelchair to bed and return)
    1. (15 pts). Independent in all phases of this activity.
    2. (10 pts). Minimal help needed or patient needs to be reminded or supervised for safety of 1 or more parts of this activity.
    3. (5 pts). Patient can come to sitting position without help of second person but needs to be lifted out of bed and assisted with transfers.
    4. (0 pts). Cannot meet criteria
  3. Personal Toilet
    1. (5pts). Can wash hands, face; combs hair, cleans teeth. Can shave (males) or apply makeup (females) without assistance; females need not brain or style hair.
    2. (0 pts). Cannot meet criteria
  4. Getting On and Off Toilet
    1. (10 pts). Able to get on and off toilet, fastens/unfastens clothes, can use toilet paper without assistance. May use wall bar or other support if needed; if bedpan necessary patient can place it on chair, empty, and clean it.
    2. (5 pts). Needs help because of imbalance or other problems with clothes or toilet paper.
    3. (0 pts). Cannot meet criteria
  5. Bathing Self
    1. (5 pts). May use bath tub, shower or sponge bath. Patient must be able to perform all functions without another person being present.
    2. (0 pts). Cannot meet criteria
  6. Walking on Level Surface
    1. (15 pts). Patient can walk at least 50 yards without assistance or supervision; may use braces, prostheses, crutches, canes, or walkerette but not a rolling walker. Must be able to lock/unlock braces, assume standing or seated position, get mechanical aids into position for use and dispose of them when seated (putting on and off braces should be scored under dressing). 15
    2. (10pts). Assistance needed to perform above activities, but can walk 50 yards with little help.
    3. (0 pts). Cannot meet criteria
  7. Propelling a Wheelchair
    Do not score this item if patient gets score for walking.
    1. (5 pts). Patient cannot ambulate but can propel wheelchair independently; can go around corners, turn around maneuver chair to table, bed toilet, etc. Must be able to push chair 50 yards.
    2. (0 pts). Cannot meet criteria
  8. Ascending and Descending Stairs
    1. (10 pts). Able to go up and down flight of stairs safely without supervision using canes, handrails, or crutches when needed and can carry these items as ascending/descending.
    2. (5 pts). Needs help with or supervision of any of the above items.
    3. (0 pts). Cannot meet criteria
  9. Dressing/Undressing
    1. (10 pts). Able to put on, fasten and remove all clothing; ties shoelaces unless necessary adaptions used. Activity includes fastening braces and corsets when prescribed; suspenders, loafer shoes and dresses opening in the front may be used when necessary.
    2. (5 pts). Needs help putting on, fastening, or removing clothing; must accomplish at least half of task alone within reasonable time; women need not be scored on use of brassiere or girdle unless prescribed.
    3. (0 pts). Cannot meet criteria
  10. Continence of Bowels
    1. (10 pts). Able to control bowels and have no accidents. Can use a suppository or take an enema when necessary (as for spinal cord injury patients who have had bowel training)
    2. (5 pts). Needs help in using a suppository or taking an enema or has occasional accidents.
    3. (0 pts). Cannot meet criteria
  11. Controlling Bladder
    1. (10 pts). Able to control bladder day and night. Spinal injury patients must be able to put on external devices and leg bags independently, clean and empty bag, and must stay dry day and night.
    2. (5 pts). Occasional accidents occur, cannot wait for bed pan, does not get to toilet in time or needs help with external device.
    3. C(0 pts). Cannot meet criteria.

Beck Depression Inventory5

This is a twenty question survey to be completed by the patient. Answers are scored on 0 to 3 scale, 0 = minimal, and 3 = severe.

  1. Sadness
  2. Hopelessness
  3. Past failure
  4. Anhedonia
  5. Guilt
  6. Punishment
  7. Self-dislike
  8. Self-blame
  9. Suicidal thoughts
  10. Crying
  11. Agitation
  12. Loss of interest in activities
  13. Indecisiveness
  14. Worthlessness
  15. Loss of energy
  16. Insomnia
  17. Irritability
  18. Decreased appetite
  19. Diminished concentration
  20. Fatigue
  21. Lack of interest in sex

<15 = Mild Depression

15–30 = Moderate Depression

>30 = Severe Depression

Brief Psychiatric Rating Scale (BPRS)6

This scale consists of 24 symptom constructs, each to be rated in a 7-point scale of severity ranging from 1 (not present) to 7 (extremely severe). Total score ranges from 24–168, with higher scores indicating more severe psychosis.

  1. Somatic concern
  2. Anxiety
  3. Depression
  4. Suicidality
  5. Guilt
  6. Elated
  7. Grandiosity
  8. Suspiciousness
  9. Hallucinations
  10. Unusual thought content
  11. Bizarre behavior
  12. Self-neglect
  13. Disorientation
  14. Conceptual disorganization
  15. Blunted affect
  16. Emotional withdrawal
  17. Motor retardation
  18. Tension
  19. Uncooperativeness
  20. Excitement
  21. Distractibility
  22. Motor hyperactivity
  23. Mannerisms and posturing

Columbia University Rating Scale (CURS)7

This scale was presented in 1970 by researchers from Columbia University who used it in their initial L-dopa trials. Total scores range from 0–65, 0 is normal and 65 is maximum disability. This scale was a modification of the Webster scale (see page C22), which was published in 1968. In addition to the activities measured in the Webster scale, this scale also measures salivation, arising from a chair, postural stability and rapid movements of fingers, hands and feet. Subsequent modifications of this scale include NYU Scale and Kings College Hospital Scale.

  1. Facial Expression
    • 0 = Normal
    • 1 = Minimal hypomimia, could be normal ‘poker face’
    • 2 = Slight but definitely abnormal dimunition of facial expression
    • 3 = Moderate hypomimia
    • 4 = Masked or fixed facies with severe or complete loss of facial expression
  2. Seborrhea
    • 0 = Normal
    • 1 = Greasy forehead, no dermatitis
    • 2 = Mild dermatitis, erythema, and scaling
    • 3 = Moderate dermatitis
    • 4 = Severe dermatitis
  3. Sialorrhea
    • 0 = None
    • 1 = Slight but definite excess of saliva in pharynx (patients may be unaware of it); no drooling
    • 2 = Moderately excessive saliva with minimal drooling, if any
    • 3 = Marked excess of saliva with some drooling
    • 4 = Marked drooling, requiring special measures
  4. Speech Disorder
    • 0 = Normal
    • 1 = Slight loss of expression, diction, and/or volume
    • 2 = Monotone, slurred but understandable
    • 3 = Marked impairment, difficult to understand
    • 4 = Unintelligible
  5. Arising from chair (with straight back)
    • 0 = Normal
    • 1 = Slow
    • 2 = Pushes self up from arms or seat
    • 3 = Tends to fall back and may have to try several times but can get up without help
    • 4 = Unable to arise without help
  6. Posture
    • 0 = Normal erect
    • 1 = Not quiet erect, slightly stooped, could be normal for older people
    • 2 = Moderate simian posture, definitely abnormal
    • 3 = Marked simian posture with kyphosis
    • 4 = Severe flexion with extreme abnormality of posture
  7. Postural Stability (If Romberg is normal, judge response to sudden posterior displacement produced by push of sternum)
    • 0 = Normal
    • 1 = Retropulsion, but recovers unaided
    • 2 = Absence of postural response; would fall if not caught
    • 3 = Very unstable, tends to fall
    • 4 = Unable to stand without assistance
  8. Gait Disturbance
    • 0 = Freely ambulatory, good stepping, turns readily
    • 1 = Walks slowly, may shuffle with short steps; no festination or propulsion
    • 2 = Walks with great difficulty, with festination, short steps; shows freezing and pulsing but requires little or no assistance
    • 3 = Severe disturbance, requires frequent assistance
    • 4 = Cannot walk, even with help
  9. Tremor (Head and four limbs are scored separately; maximum score = 20.)
    • 0 = Absent
    • 1 = Slight and infrequently present
    • 2 = Moderate in amplitude but only intermittently present
    • 3 = Moderate and present most of the time
    • 4 = Marked in amplitude and present most of the time
  10. Finger Dexterity (Tested in both hands; maximum score = 8; patients taps thumb with forefinger, then with each finger in rapid succession.)
    • 0 = No dysfunction
    • 1 = Slightly slow, may be normal
    • 2 = Definite dysfunction
    • 3 = Very slow with frequent errors
    • 4 = Unable to perform test
  11. Succession Movements (Tested in both hands; maximum score = 8; patient taps knees alternatively with palm and dorsum of hands.)
    • 0 = No dysfunction
    • 1 = Slightly slow; may be normal
    • 2 = Definite dysfunction
    • 3 = Very slow with frequent errors
    • 4 = Unable to perform test
  12. Foot Tapping (Tested in both feet; maximum sore = 8; using heel as fulcrum, patients taps floor with ball of foot.)
    • 0 = Normal
    • 1 = Slightly slow
    • 2 = Slow
    • 3 = Markedly slow
    • 4 = Unable to perform test
  13. Bradykinesia (Combining both slowness and poverty of movement in general.)
    • 0 = None
    • 1 = Minimal slowness giving movement a deliberate character
    • 2 = Mild degree of slowness and poverty of movements; definitely abnormal
    • 3 = Moderate slowness; occasional hesitation on initiating movements and arrests of ongoing movements
    • 4 = Marked slowness and poverty of movement; frequent freezing and long delays in initiating movements

Dyskinesia Rating Scale8

Several variations of the rating scale for dyskinesia are used. This Dyskinesia Scale Score is the arithmetic mean of the intensity and duration scores, and is only assessed in the “on” state.

The intensity score is given as score and definition:

  • 0 = absent
  • 1 = minimal severity: patient is not aware of dyskinesias
  • 2 = patient is conscious of the presence of dyskinesias but there is no interference with voluntary motor acts
  • 3 = dyskinesias may impair voluntary movements but patient is normally capable of undertaking most motor tasks
  • 4 = intense interference with movement control, and daily life activities are greatly limited
  • 5 = violent dyskinesias, incompatible with any normal motor task
    The duration score is given as score and definition:
  • 0 = absent
  • 1 = only present when carrying out motor tasks
  • 2 = present between 25–50% of waking hours
  • 3 = present between 51–75% of waking hours
  • 4 = present between 76–99% of waking hours
  • 5 = continuous throughout the day, 100%

Hamilton Depression Scale (HAM-D)9

This is a twenty one question survey to be completed by a physician. The range is 0–64 points, higher score = more severe depression.

  • 1. Depressed mood (0 to 4)
  • 2. Feelings of guilt (0 to 4)
  • 3. Suicide (0 to 4)
  • 4. Insomnia
    • 5. Early (0 to 2)
    • 6. Middle (0 to 2)
    • 7. Late (0 to 2)
  • 8. Work activities (0 to 4)
  • 9. Retardation to stupor (0 to 4)
  • 10. Agitation (0 to 2)
  • 11. Fear (0 to 4)
  • 12. Anxiety (0 to 4)
  • 13. Gastrointestinal symptoms (0 to 2)
  • 14. Systemic somatic symptoms (0 to 2)
  • 15. Decreased libido or menstrual disturbance (0 to 2)
  • 16. Hypochondiasis (0 to 4)
  • 17. Weight loss (0 to 2)
  • 18. Diminished insight (0 to 2)
  • 19. Symptom diurnal variation (1 to 2)
  • 20. Feelings of unreality (0 to 4)
  • 21. Paranoid symptoms (0 to 3)
  • 22. Obsessive Compulsive Symptoms (0 to 2)

10–13: Mild depression

14–17: Moderate depression

>17: Severe depression

Hoehn and Yahr Clinical Staging Scale10

Stages I–V, lower stage indicates better function.

Stage I.

Unilateral involvement only, usually with minimal or no functional impairment.

Stage II.

Bilateral or midline involvement, without impairment of balance.

Stage III.

First sign of impaired righting reflexes. This is evident by unsteadiness as the patient turns or is demonstrated when he is pushed from standing equilibrium with the feet together and eyed closed. Functionally the patient is somewhat restricted in his activities but may have some work potential depending upon the type of employment. Patients are physically capable of leading independent lives, and their disability is mild to moderate.

Stage IV.

Fully developed, severely disabling disease; the patient is still able to walk and stand unassisted but is markedly incapacitated.

Stage V.

Confinement to bed or wheelchair unless aided.

Modified Hoehn and Yahr Staging

Stage 0 = No signs of disease.

Stage 1 = Unilateral disease.

Stage 1.5 = Unilateral plus axial involvement.

Stage 2 = Bilateral disease, without impairment of balance.

Stage 2.5 = Mild bilateral disease, with recovery on pull test.

Stage 3 = Mild to moderate bilateral disease; some postural instability; physically independent.

Stage 4 = Severe disability; still able to walk or stand unassisted.

Stage 5 = Wheelchair bound or bedridden unless aided.

This rating system has been largely replaced by the Unified Parkinson's Disease Rating Scale (UPDRS).

Levodopa Equivalent Units (LEU)11

Conversion formula:

100 LEU = 100 mg regular L-dopa, given with a peripheral decarboxylase inhibitor = 133 mg L-dopa plus DCI in controlled-release tablets = 10 mg bromocriptine = 1 mg pergolide mesylate.

Mini-Mental Status Exam (MMSE)12

Range 0–30, lower scores indicate more severe impairment.

This scale is widely used for assessing cognitive mental status. As a clinical instrument, the MMSE has been used to detect impairment, follow the course of an illness, and monitor response to treatment. While the MMSE has limited specificity with respect to individual clinical syndromes, it represents a brief, standardized method by which to grade cognitive mental status. It assesses orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal and written commands. Furthermore, it provides a total score that places the individual on a scale of cognitive function.

Northwestern University Disability Scale (NUDS or NWUDS)13

Clinical experience suggested that the symptoms of Parkinson's Disease make themselves felt most frequently in the areas of walking, personal hygiene, dressing, eating and feeding, and speaking. These five areas constitute the range of this scale. It was decided to assign a maximum of 20 points to each of the five sub-scales, in this way a total of 100 points is possible, so that the degree of disability may be expressed as a percentage. Lower score represents greater disability.

Scale A: Walking

Never Walks Alone

  • 0 Cannot walk at all, even with maximum assistance.
  • 1 Needs considerable help even for short distances; cannot walk outdoors with help.
  • 2 Requires moderate help indoors; walks outdoors with considerable help.
  • 3 Requires potential help indoors and active help outdoors.

Sometimes Walks Alone

  • 4 Walks from room to room without assistance, but moves slowly and uses external support; never walks alone outdoors.
  • 5 Walks from room to room with only moderate difficulty; may occasionally walk outdoors without assistance.
  • 6 Walks short distances with ease; walking outdoors is difficult but often accomplished without help; rarely walks longer distances alone.

Always Walks Alone

  • 7 Gait is extremely abnormal; very slow and shuffling; posture grossly affected; there may be propulsion.
  • 8 Quality of gait is poor and rate is slow; posture moderately affected; there may be a tendency toward mild propulsion; turning is difficult.
  • 9 Gait only slightly deviant from normal in quality and speed; turning is the most difficult task; posture essentially normal.
  • 10 Normal.

Scale B: Dressing

Requires Complete Assistance

  • 0 Patient is a hindrance rather than a help to assistant.
  • 1 Movements of patient neither help nor hinder assistant.
  • 2 Can give some help through bodily movements.
  • 3 Gives considerable help through bodily movements.

Requires Partial Assistance

  • 4 Performs only gross dressing activities alone (hat, coat).
  • 5 Performs about half of dressing activities independently.
  • 6 Performs more than half of dressing activities alone, with considerable effort and slowness.
  • 7 Handles all dressing alone with the exception of fine activities (tie, buttons).

Complete Self-Help

  • 8 Dresses self completely with slowness and great effort
  • 9 Dresses self completely with only slightly more time and effort than normal
  • 10 Normal

Scale C: Hygiene

Requires Complete Assistance

  • 0 Unable to maintain proper hygiene even with maximum help.
  • 1 Reasonably good hygiene with assistance, but does not provide assistant with significant help.
  • 2 Hygiene maintained well; gives aid to assistant

Requires Partial Assistance

  • 3 Performs a few tasks alone with assistant nearby.
  • 4 Requires assistance for half of toilet needs.
  • 5 Requires assistance for some tasks not difficult in terms of co-ordination.
  • 6 Manages most of personal needs alone; has substituted methods for accomplishing difficult tasks (electric razor).

Complete Self-Help

  • 7 Hygiene maintained independently, but with effort and slowness; accidents are not infrequent; may employ substitute methods.
  • 8 Hygiene activities are moderately time-consuming; no substitute methods; few accidents.
  • 9 Hygiene maintained normally, with exception of slight slowness.
  • 10 Normal.

Scale D: Eating and Feeding

Eating

  • 0 Eating is so impaired that a hospital setting is required to get adequate nutrition.
  • 1 Eats only liquids and soft food; these are consumed very slowly.
  • 2 Liquids and soft food handled with ease; hard foods occasionally eaten, but require great effort and much time.
  • 3 Eats some hard food routinely, but these require time and effort.
  • 4 Follows a normal diet, but chewing and swallowing are labored.
  • 5 Normal

Feeding

  • 0 Requires complete assistance.
  • 1 Performs only a few feeding tasks independently.
  • 2 Performs most feeding activities alone, slowly and with effort; requires help with specific tasks (cutting meat, filling cup).
  • 3 Handles all feeding alone with moderate slowness; still may get assistance in specific situations (cutting meat in restaurant); accidents not infrequent.
  • 4 Fully feeds self with rare accidents; slower than normal.
  • 5 Normal

Scale E: Speech

  • 0 Does not vocalize at all.
  • 1 Vocalizes but rarely for communicative purposes.
  • 2 Vocalizes to call attention to self.
  • 3 Attempts to use speech for communication, but has difficulty in initiating vocalization; may stop speaking in middle of phrase and be unable to continue.
  • 4 Uses speech for most of communication, but articulation is highly unintelligible; may have occasional difficulty in initiating speech; usually speaks in single words or short phrases.
  • 5 Speech always employed for communication, but articulation is still very poor; usually uses complete sentences.
  • 6 Speech can always be understood if listener pays close attention; both articulation and voice may be defective.
  • 7 Communication accomplished with ease, although speech impairment detracts from content.
  • 8 Speech easily understood, but voice or speech rhythm may be disturbed.
  • 9 Speech entirely adequate; minor voice disturbances present.
  • 10 Normal.

Phenyl Ethyl Alcohol or Detection Threshold (PEA)14

Detection threshold is a measure of the lowest concentration of a particular olfactory stimulus required to activate peripheral receptors and trigger the perception of the stimulus. To assess olfactory threshold, ascending (10-7 -1 mol) dilutions of phenyl-ethyl-alcohol are administered; the threshold value is defined as the lowest concentration that is perceived.

Parkinson Psychosis Rating Scale (PPRS)15

This scale was designed to assess the severity of specific symptoms of levodopa-induced psychosis in patients with Parkinson's disease.

Visual Hallucinations

  1. Absent
  2. Mild: Occasional; complete or partial insight; nonthreatening
  3. Moderate: Frequent; absence of full insight; can be convinced; may be threatening
  4. Severe: Persisitent hallucinations; no insight; associated with heightened emotional tone, agitation, agression

Illusions and Misidentification of Persons

  1. Absent
  2. Mild: Occurring infrequently
  3. Moderate: Occurring very often
  4. Severe: Occurring persistently

Paranoid Ideation (persecutory and/or jealous type)

  1. Absent
  2. Mild: Associated with suspiciousness
  3. Moderate: Associated with tension and excitement
  4. Severe: Accusations of family members, aggression and/or lack of cooperation (i.e., refusal to eat and/or take medication)

Sleep Disturbances

  1. Absent
  2. Mild: Associated with anxiety
  3. Moderate: Night terrors with recurrent awakening and feeling of danger
  4. Severe: Nightmares with recurrent awakenings, associated with agitation and confusion

Confusion

  1. Absent
  2. Mild: Disorientation in time/place/person
  3. Moderate: Confusion combined with impaired attention/concentration/ registration/recall/interruption of goal-directed actions
  4. Severe: Very confused with or without delirium

Sexual Preoccupation

  1. Absent
  2. Mild: Thoughts, dreams, worry about sexual competence
  3. Moderate: Increased demand for sexual activity
  4. Severe: Violent sexual impulsiveness

8–12: Mild disease

13–18: Moderate disease

19–24: Severe disease

Proposed Diagnostic Criteria for Parkinson's Disease16

Criteria for POSSIBLE diagnosis of Parkinson disease:

At least 2 of the 4 features in Group A* are present; at least 1 of these is tremor or bradykinesia
AND
EITHERNone of the features in Group B** is present
ORSymptoms have been present for less than 3 years, and none of the features in Group B is present to date
AND
EITHERSubstantial and sustained response to levodopa or a dopamine agonist has been documented
ORPatient has not had an adequate trial of levodopa or dopamine agonist

Criteria for PROBABLE diagnosis of Parkinson disease:

At least 3 of the 4 features in Group A are present

AND

None of the features in Group B is present (note: symptom duration of at least 3 years is necessary to meet this requirement)

AND

Substantial and sustained response to levodopa or a dopamine agonist has been documented

Criteria for DEFINITE diagnosis of Parkinson disease:

All criteria for POSSIBLE Parkinson disease are met

AND

Histopathologic confirmation of the diagnosis is obtained at autopsy***

*Group A features: Characteristic of Parkinson disease

  1. Resting tremor
  2. Bradykinesia
  3. Rigidity
  4. Asymmetric onset

**Group B features: Suggestive of alternative diagnoses

  1. Prominent postural instability in the first 3 years after symptom onset
  2. Freezing phenomena in the first 3 years
  3. Hallucinations unrelated to medications in the first 3 years
  4. Dementia preceding motor symptoms or in the first year
  5. Supranuclear gaze palsy (other than restriction of upward gaze) or slowing of vertical saccades
  6. Severe, symptomatic dysautonomia unrelated to medications
  7. Documentation of a condition known to produce parkinsonism and plausibly connected to the patient's symptoms (such as suitably located focal brain lesions or neuroleptic use within the past 6 months)

***Proposed criteria for histopathologic confirmation of Parkinson disease:

  1. Substantial nerve cell depletion with accompanying gliosis in the substantia nigra
  2. At least 1 Lewy body in the substantia nigra or in the locus ceruleus (note: it may be necessary to examine up to 4 nonoverlapping sections in each of these areas before concluding that Lewy bodies are absent)
  3. No pathologic evidence for other diseases that produce parkinsonism (eg, progressive supranuclear palsy, multiple system atrophy, cortical-basal ganglionic degenration)

Schwab & England Activities of Daily Living Scale (S&E) or (SEADL)17

Range 0–100%, with higher % meaning less severe disease

The rating can be assigned by the rater or by the patient.

  • 100%-Completely independent. Able to do all chores without slowness, difficulty, or impairment.
  • 90%-Completely independent. Able to do all chores with some slowness, difficulty, or impairment. May take twice as long.
  • 80%-Independent in most chores. Takes twice as long. Conscious of difficulty and slowing.
  • 70%-Not completely independent. More difficulty with chores. 3 to 4X along on chores for some. May take large part of day for chores.
  • 60%-Some dependency. Can do most chores, but very slowly and with much effort. Errors, some impossible.
  • 50%-More dependant. Help with 1/2 of chores. Difficulty with everything.
  • 40%-Very dependant. Can assist with all chores but few alone.
  • 30%-With effort, now and then does a few chores alone of begins alone. Much help needed.
  • 20%-Nothing alone. Can do some slight help with some chores. Severe invalid.
  • 10%-Totally dependant, helpless.
  • 0%-Vegetative functions such as swallowing, bladder and bowel function are not functioning. Bedridden.

Sickness Impact Profile (SIP)18

The Sickness Impact Profile (SIP) is a general quality of life scale. It consists of 136 items (statements) which measure 12 distinct domains of quality of life:

  • Ambulation
  • Movement and mobility
  • Body care
  • Social interaction
  • Communication
  • Alertness
  • Emotional behavior
  • Sleep
  • Eating
  • Work
  • Household management
  • Recreation

The SIP can be administered by an interviewer or by the patients themselves. Although it is easy to administer and score, it is relatively time-consuming, taking approximately 30 minutes to complete.

Patients identify those statements which describe their experience. Each item is weighted depending on the severity of dysfunction. For each category, the scores are summed and expressed as a percentage of the maximum score possible. Higher scores represent greater dysfunction. Although scores can be calculated for each of the 12 individual domains, three summary scores are typically calculated and reported: total score (includes all domains), a physical score (ambulation, body care, and movement and mobility), and a psychosocial score (emotional behavior, social interaction, alertness, and communication).

UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria19

  1. Diagnosis of PARKINSONIAN SYMPTOMS:
    BRADYKINESIA (slowness of initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions).
    And at least one of the following:
    1. a. muscular rigidity
    2. b. 4–6 Hz rest tremor
    3. c. postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction.
  2. Exclusion criteria for Parkinson's disease:
    1. history of repeated strokes with stepwise progression of Parkinsonian features
    2. history of repeated head injury
    3. history of definite encephalitis
    4. oculogyric crises
    5. neuroleptic treatment at onset of symptoms
    6. more than one affected relative
    7. sustained remission
    8. strictly unilateral features after three years
    9. supranuclear gaze palsy
    10. cerebellar signs
    11. early severe autonomic involvement
    12. early severe dementia with disturbances of memory, language and praxis
    13. Babinski sign
    14. presence of a cerebral tumor or communicating hydrocephalus on CT scan
    15. negative response to large doses of levodopa (if malabsorption excluded)
    16. MPTP exposure
  3. Supportive prospective criteria for PARKINSON'S DISEASE. Three or more required for diagnosis of definite Parkinson's Disease.
    1. unilateral onset
    2. rest tremor present
    3. progressive disorder
    4. persistent asymmetry affecting the site of onset most
    5. excellent response (70–100%) to levodopa
    6. severe levodopa-induced chorea
    7. levodopa response for 5 years or more
    8. clinical course of 10 years or more

University of Pennsylvania Smell Identification Test (UPSIT)14

This is a standardized tool that has been widely used in the evaluation of patients affected by neurodegenerative disorders. This “scratch and sniff” test consists of 40 multiple-choice items. The range of scores is 0–40, 40 being the best score. The patient is required to mark one of the four alternatives even if no smell is perceived. To establish the meaning of a given individual's test score, it is compared to scores from normal persons of equivalent age and gender using tables providing an easy-to-interpret measure of an individual's performance. In this classification scheme, anosmia is defined as total inability to perceive qualitative odor sensations, whereas microsmia is defined operationally as decreased ability to smell. Microsmia can be further subdivided into “severe,” “moderate,” and “mild” classes. The 40-item UPSIT can be used in both clinical and experimental settings to test patients affected by PD and related disorders.

Webster's Parkinson's Disease Rating Scale (WPDRS)20

This scale was developed as a simple rating scale that can be used to evaluate the degree of total parkinsonian disabilities. It applies a gross clinical rating to each of the 10 listed items, assigning value rating of 0–3 for each item, where 0 = no involvement and 1, 2, and 3 are equated to early, moderate, and severe disease, respectively. Scores range from 0 to 30, and decline represents decrease in severity of PD signs. Values of 1 to 10 indicate early illness; 11 to 20, moderate disability; and 21 to 30, severe or advanced disease.

Bradykinesia of Hands - Including Handwriting

  • 0 = No involvement.
  • 1 = Detectable slowing of the supination-pronation rate, evidenced by beginning difficulty in handling tools, buttoning clothes, and with handwriting.
  • 2 = Moderate slowing of supination-pronation rate, one or both sides, evidenced by moderate impairment of hand function. Handwriting is greatly impaired, micrographia present.
  • 3 = Severe slowing of supination-pronation rate. Unable to write or button clothes. Marked difficulty in handling utensils.

Rigidity

  • 0 = Non-detectable.
  • 1 = Detectable rigidity in neck and shoulders. Activation phenomenon is present. One or both arms show mild, negative, resting rigidity.
  • 2 = Moderate rigidity in neck and shoulders. Resting rigidity is positive when patient not on medication.
  • 3 = Severe rigidity in neck and shoulders. Resting rigidity cannot be reversed by medication.

Posture

  • 0 = Normal posture. Head flexed forward less than 4 inches.
  • 1 = Beginning poker spine. Head flexed forward up to 5 inches.
  • 2 = Beginning arm flexion. Head flexed forward up to 6 inches. One or both arms raised but still below waist.
  • 3 = Onset of simian posture. Head flexed forward more than 6 inches. One or both hands elevated above the waist. Sharp flexion of hand, beginning interphalangeal extension. Beginning flexion of knees.

Upper Extremity Swing

  • 0 = Swings both arms well.
  • 1 = One arm definitely decreased in amount of swing.
  • 2 = One arm fails to swing.
  • 3 = Both arms fail to swing.

Gait

  • 0 = Steps out well with 18–30 inch stride. Turns about effortlessly.
  • 1 = Gait shortened to 12–18 inch stride. Beginning to strike one heel. Turn around time slowing. Requires several steps.
  • 2 = Stride moderately shortened - now 6–12 inches. Both heels beginning to strike floor.
  • 3 = Onset of shuffling gait, steps less than 3 inches. Occasional stuttering-type or blocking gait. Walks on toes-turns around very slowly.

Tremor

  • 0 = No detectable tremor found.
  • 1 = Less than one inch of peak-to-peak tremor movement observed in limbs or head at rest or in either hand while walking or during finger to nose testing.
  • 2 = Maximum tremor envelope fails to exceed 4 inches. Tremor is severe but not constant and patient retains some control of hands.
  • 3 = Tremor envelope exceeds 4 inches. Tremor is constant and severe. Patient cannot get free of tremor while awake unless it is a pure cerebellar type. Writing and feeding himself is impossible.

Facies

  • 0 = Normal. Full animation. No stare
  • 1 = Detectable immobility. Mouth remains closed. Beginning features of anxiety or depression.
  • 2 = Moderate immobility. Emotion breaks through at markedly increased threshold. Lips parted some of the time. Moderate appearance of anxiety or depression. Drooling may be present.
  • 3 = Frozen facies. Mouth open ¼ inches or more. Drooling may be severe.

Seborrhea

  • 0 = None.
  • 1 = Increased perspiration, secretion remaining thin.
  • 2 = Obvious oiliness present. Secretion much thicker.
  • 3 = Marked seborrhea, entire face and head covered by thick secretion.

Speech

  • 0 = Clear, loud, resonant, easily understood.
  • 1 = Beginning of hoarseness with loss of inflection and resonance. Good volume and still easily understood.
  • 2 = Moderate hoarseness and weakness. Constant monotone, unvaried pitch. Beginning of dysarthria, hesitancy, stuttering, difficult to understand.
  • 3 = Marked harshness and weakness. Very difficult to hear and to understand.

Self-Care

  • 0 = No impairment.
  • 1 = Still provides full self-care but rate of dressing definitely impeded. Able to live alone and often still employable.
  • 2 = Requires help in certain critical areas, such as turning in bed, rising from chairs, etc. Very slow in performing most activities but manages by taking much time.
  • 3 = Continuously disabled. Unable to dress, feed himself, or walk alone.

Appendix A References

  • 1. Fahn S, Marsden CD, Calne DB, et al., eds. Recent Developments in Parkinson's Disease. vol 2. Florham Park, NJ: MacMillan Health Care Information, 1987.
    • 2.
    Goetz C G. Rating scales for dyskinesias in Parkinson's disease. Mov Disord. 1999;14(Suppl 1):48–53. [PubMed: 10493403]
    • 4.
    Mahoney F I, Barthel D. Functional evaluation: The Barthel Index. Maryland State Med J. 1965;;14:56–61. [PubMed: 14258950]
    5.
    Beck A T, Ward C H, Mendelson M. et al. An inventory for measuring depression. Arch Gen Psych. 1961;4:561–7. [PubMed: 13688369]
    6.
    Overall J E, Gorham D R. The Brief Psychiatric Rating Scale (BPRS): Recent developments in ascertaining and scaling. Psycholpharmacol Bull. 1988;24:101–4.
    7.
    Hely M A, Chey T, Wilson A. et al. Reliability of the Columbia scale for assessing signs of Parkinson's disease. Mov Disord. 1993;8:466–72. [PubMed: 8232356]
    8.
    Langston J W, Widner H, Goetz C G. et al. Core Assessment Program for Intercerebral Transplantation (CAPIT). Mov Disord. 1992;7:2–13. [PubMed: 1557062]
  • 9.http://www.fpnotebook.com/PSY72.htm.
    • 10.
    Hoehn M, Yahr M. Parkinsonism: Onset, progression and mortality. Neurology. 1967;17:427–42. [PubMed: 6067254]
    11.
    de Bie R M A, de Haan R J, Nijssen P C G. et al. Unilateral pallidotomy in Parkinson's Disease: A randomised, single-blind, multicentre trial. Lancet. 1999;354:1665–9. [PubMed: 10568567]
    12.
    Folstein M F, Folstein S E, McHugh P R. Mini-Mental State: A practical method for grading the state of patients for the clinician. J Psychiat Res. 1975;12:189–98. [PubMed: 1202204]
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    Canter G J, de La Torre R, Mier M. A method for evaluating disability in patients with Parkinson's disease. J Nerv Ment Dis. 1961;133:143–7. [PubMed: 13876261]
    14.
    Liberini P, Parola S, Spano P F. et al. Olfaction in Parkinson's disease: Methods of assessment and clinical relevance. J Neurol. 2000;247:88–96. [PubMed: 10751109]
    15.
    Friedberg G, Zoldan J, Weizman A. et al. Parkinson psychosis rating scale: A practical instrument for grading psychosis in Parkinson's disease. Clin Neuropharmacol. 1998;21:280–4. [PubMed: 9789707]
    16.
    Gelb D J, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease. Arch Neurol. 1999;56:33–9. [PubMed: 9923759]
  • 17. Gillingham FJ, Donaldson MC, eds., Third Symp. of Parkinson's Disease, Edinburgh, Scotland, E&S Livingstone, 1969, pp.152–7.
    • 19.
    Gibb W R G, Lees A J. The relevance of the Lewy body to the pathogenesis of idiopathic Parkinson's disease. J Neurol Neurosurg Psychiatry. 1988;51:745–52. [PMC free article: PMC1033142] [PubMed: 2841426]
    20.
    Webster D D. Critical analysis of the disability in Parkinson's Disease. Mod Treatment. 1968;5:257–82. [PubMed: 5655944]

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