Unified Parkinson's Disease Rating Scale (UPDRS)

Assesses signs and symptoms of Parkinson’s disease as part of diagnosis and progression monitoring.

Refer to the text below the calculator for more information about the UPDRS and its scoring.

The Unified Parkinson's Disease Rating Scale (UPDRS) is a rating tool that includes series of ratings for typical Parkinson’s symptoms which result in the movement hindrances of this disease.

The UPDRS consist of four sections:

Mentation, Behavior And Mood
Activities Of Daily Living (for both “on” and “off”)
Motor Examination
Complications Of Therapy (In the past week)

The Hoehn and Yahr Staging and Schwab and England Activities of Daily Living Scale are also included.

The UPDRS scoring consists of 4 subscores of its sections, an overall score and 2 results of the scales:

UPDRS score – points scored out of 199 possible, which are grouped in four sections:

I. Mentation, Behavior And Mood;

II. Activities Of Daily Living (for both “on” and “off”);

III. Motor Examination;

IV. Complications Of Therapy (In the past week).

The Hoehn and Yahr Staging – stage 0 to stage 5;
Schwab and England Activities of Daily Living Scale – 0 to 100%.

Mentation, Behavior And Mood

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.

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 florrid psychosis. Not able to care for self.

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.

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.

Activities Of Daily Living (for both “on” and “off”)

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.

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.

Swallowing

(0) Normal.

(1) Rare choking.

(2) Occasional choking.

(3) Requires soft food.

(4) Requires NG tube or gastrotomy feeding.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

20a

Tremor at rest (Head: face, lips, chin)

(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.

20b

Tremor at rest (Right hand)

(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.

20c

Tremor at rest (Left hand)

(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.

20d

Tremor at rest (Right leg)

(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.

20e

Tremor at rest (Left leg)

(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.

21a

Action or Postural Tremor (Right hand)

(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.

21b

Action or Postural Tremor (Left hand)

(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.

22a

Rigidity (Neck)

(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.

22b

Rigidity (Right hand)

(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.

22c

Rigidity (Left hand)

(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.

22d

Rigidity (Right leg)

(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.

22e

Rigidity (Left leg)

(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.

23a

Finger Taps (Right hand)

(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.

23b

Finger Taps (Left hand)

(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.

24a

Hand Movements (Right hand)

(Patient opens and closes hands 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.

24b

Hand Movements (Left hand)

(Patient opens and closes hands 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.

25a

Rapid Alternating Movements of Hands (Right hand)

(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.

25b

Rapid Alternating Movements of Hands (Left hand)

(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.

26a

Leg Agility (Right leg)

(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.

26b

Leg Agility (Left leg)

(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.

Arising from Chair

(Patient attempts to rise from a straight-backed 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.

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.

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.

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.

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.

Complications Of Therapy (In the past week)

A. Dyskinesias

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.

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 disabled.

Painful Dyskinesias: How painful are the dyskinesias?

(0) No painful dyskinesias.

(1) Slight.

(2) Moderate.

(3) Severe.

(4) Marked.

Presence of Early Morning Dystonia

(Historical information.)

(0) No

(1) Yes

B. Clinical Fluctuations

Are “off” periods predictable?

(0) No

(1) Yes

Are “off” periods unpredictable?

(0) No

(1) Yes

Do “off” periods come on suddenly, within a few seconds?

(0) No

(1) Yes

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

Does the patient have anorexia, nausea, or vomiting?

(0) No

(1) Yes

Any sleep disturbances, such as insomnia or hypersomnolence?

(0) No

(1) Yes

Does the patient have symptomatic orthostasis?

(Record the patient’s blood pressure, height and weight on the scoring form)

(0) No

(1) Yes

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.

Schwab And England Activities Of Daily Living Scale

100% = Completely independent. Able to do all chores without slowness, difficulty or impairment. Essentially normal. Unaware of any difficulty.

90% = Completely independent. Able to do all chores with some degree of slowness, difficulty and impairment. Might take twice as long. Beginning to be aware of difficulty.

80% = Completely independent in most chores. Takes twice as long. Conscious of difficulty and slowness.

70% = Not completely independent. More difficulty with some chores. Three to four times as long in some. Must spend a large part of the day with chores.

60% = Some dependency. Can do most chores, but exceedingly slowly and with much effort. Errors; some impossible.

50% = More dependent. Help with half, slower, etc. Difficulty with everything.

40% = Very dependent. Can assist with all chores, but few alone.

30% = With effort, now and then does a few chores alone or begins alone. Much help needed.

20% = Nothing alone. Can be a slight help with some chores. Severe invalid.

10% = Totally dependent, helpless. Complete invalid.

0% = Vegetative functions such as swallowing, bladder and bowel functions are not functioning. Bedridden.

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Unified Parkinson's Disease Rating Scale Explained

The Unified Parkinson's Disease Rating Scale (UPDRS) is a rating tool that includes series of ratings for typical Parkinson’s symptoms which result in the movement hindrances of this disease.

The UPDRS consist of four sections:

I. Mentation, Behavior And Mood
II. Activities Of Daily Living (for both “on” and “off”)
III. Motor Examination
IV. Complications Of Therapy (In the past week)

The Hoehn and Yahr Staging and Schwab and England Activities of Daily Living Scale are also included.

The UPDRS is administered by interview and clinical observation, with some items requiring multiple grades for each extremity.

The UPDRS was originally published in 1987 and is still one of the most commonly used tools for following the longitudinal course of Parkinson’s disease. A modified version, sponsored by the Movement Disorders Society, the MDS-UPDRS was published in 2007 as a copyrighted tool at a cost.

UPDRS scoring

The UPDRS scoring consists of 4 subscores of its sections, an overall score and 2 results of the scales:

UPDRS result	Scoring
UPDRS score (42 items)	Points out of 199
I. Mentation, Behavior And Mood (items 1 – 4)	Points out of 16
II. Activities Of Daily Living (items 5 – 17)	Points out of 52
III. Motor Examination (items 18 – 31)	Points out of 108
IV. Complications Of Therapy (32 – 42)	Points out of 23
The Hoehn and Yahr Staging	Stages 0 to 5
Schwab and England Activities of Daily Living Scale	0 to 100%

The lowest score on the overall UPDRS is 0, indicating an absence of signs and symptoms of Parkinson's disease, whilst the highest score is 199, indicating most severe level of disability due to Parkinson’s.

References

Original reference

Fahn S, Elton R, Members of the UPDRS Development Committee. In: Fahn S, Marsden CD, Calne DB, Goldstein M, eds. Recent Developments in Parkinson’s Disease, Vol 2. Florham Park, NJ. Macmillan Health Care Information 1987, pp 15 3-163, 293-304.

Validation

Ramaker C, Marinus J, Stiggelbout AM, Van Hilten BJ. Systematic evaluation of rating scales for impairment and disability in Parkinson's disease. Mov Disord. 2002; 17(5):867-876.

Other references

Goetz CG, Tilley BC, Shaftman SR, et al. Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord. 2008; 23(15):2129-2170.

Specialty: Neurology

Objective: Assessment

Year Of Study: 1987

Abbreviation: UPDRS

Article By: Denise Nedea

Published On: July 23, 2020 · 12:00 AM

Last Checked: July 23, 2020

Next Review: July 23, 2025

Unified Parkinson's Disease Rating Scale (UPDRS)

Jump to:

Mentation, Behavior And Mood

Intellectual Impairment

Thought Disorder (Due to dementia or drug intoxication)

Depression

Motivation/Initiative

Activities Of Daily Living (for both “on” and “off”)

Speech

Salivation

Swallowing

Handwriting

Cutting food and handling utensils

Dressing

Hygiene

Turning in bed and adjusting bed clothes

Falling (unrelated to freezing)

Freezing when walking

Walking

Tremor (Symptomatic complaint of tremor in any part of body.)

Sensory complaints related to parkinsonism

Motor Examination

Speech

Facial Expression

Tremor at rest (Head: face, lips, chin)

Tremor at rest (Right hand)

Tremor at rest (Left hand)

Tremor at rest (Right leg)

Tremor at rest (Left leg)

Action or Postural Tremor (Right hand)

Action or Postural Tremor (Left hand)

Rigidity (Neck)

Rigidity (Right hand)

Rigidity (Left hand)

Rigidity (Right leg)

Rigidity (Left leg)

Finger Taps (Right hand)

Finger Taps (Left hand)

Hand Movements (Right hand)

Hand Movements (Left hand)

Rapid Alternating Movements of Hands (Right hand)

Rapid Alternating Movements of Hands (Left hand)

Leg Agility (Right leg)

Leg Agility (Left leg)

Arising from Chair

Posture

Gait

Postural Stability

Body Bradykinesia and Hypokinesia

Complications Of Therapy (In the past week)

A. Dyskinesias

Duration: What proportion of the waking day are dyskinesias present?

Disability: How disabling are the dyskinesias?

Painful Dyskinesias: How painful are the dyskinesias?

Presence of Early Morning Dystonia

B. Clinical Fluctuations

Are “off” periods predictable?

Are “off” periods unpredictable?

Do “off” periods come on suddenly, within a few seconds?

What proportion of the waking day is the patient “off” on average?

C. Other Complications

Does the patient have anorexia, nausea, or vomiting?

Any sleep disturbances, such as insomnia or hypersomnolence?

Does the patient have symptomatic orthostasis?

Modified Hoehn And Yahr Staging

Schwab And England Activities Of Daily Living Scale

Send Us Your Feedback

Unified Parkinson's Disease Rating Scale Explained

UPDRS scoring

References

Original reference

Validation

Other references