Parkinson’s Disease Staging – Neurosurgical Service – Massachusetts General Hospital

Hoehn and Yahr Staging of Parkinson’s Disease, Unified Parkinson Disease Rating Scale (UPDRS), and Schwab and England Activities of Daily Living

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Disclaimer: The information and reference materials contained herein are intended solely to provide background information. They were written for an audience of physicians. They are in no way intended to constitute medical advise. For medical advise a physician must, of course, be consulted.

Address for Correspondence:
Emad N. Eskandar, M.D.
Massachusetts General Hospital
15 Parkman St. ACC # 331
Boston, MA 02114

E-mail: eeskandar@partners.org
Patient Appointments: 617.724.6590
FAX: 617.724.0339

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Hoehn and Yahr Staging of Parkinson’s Disease

  1. Stage One
    1. Signs and symptoms on one side only
    2. Symptoms mild
    3. Symptoms inconvenient but not disabling
    4. Usually presents with tremor of one limb
    5. Friends have noticed changes in posture, locomotion and facial expression
  2. Stage Two
    1. Symptoms are bilateral
    2. Minimal disability
    3. Posture and gait affected
  3. Stage Three
    1. Significant slowing of body movements
    2. Early impairment of equilibrium on walking or standing
    3. Generalized dysfunction that is moderately severe
  4. Stage Four
    1. Severe symptoms
    2. Can still walk to a limited extent
    3. Rigidity and bradykinesia
    4. No longer able to live alone
    5. Tremor may be less than earlier stages
  5. Stage Five
    1. Cachectic stage
    2. Invalidism complete
    3. Cannot stand or walk
    4. Requires constant nursing care

This rating system has been largely supplanted by the Unified Parkinson’s Disease Rating Scale, which is much more complicated.

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Unified Parkinson Disease Rating Scale (UPDRS)

The UPDRS is a rating tool to follow the longitudinal course of Parkinson’s Disease. It is made up of the 1) Mentation, Behavior, and Mood, 2) ADL and 3) Motor sections. These are evaluated by interview. Some sections require multiple grades assigned to each extremity. A total of 199 points are possible. 199 represents the worst (total) disability), 0–no disability.

  1. Mentation, Behavior, Mood
    • Intellectual Impairment
      0-none
      1-mild (consistent forgetfulness with partial recollection of events with no other difficulties)
      2-moderate memory loss with disorientation and moderate difficulty handling complex problems
      3-severe memory loss with disorientation to time and often place, severe impairment with problems
      4-severe memory loss with orientation only to person, unable to make judgments or solve problems
    • Thought Disorder
      0-none
      1-vivid dreaming
      2-“benign” hallucination with insight retained
      3-occasional to frequent hallucination or delusions without insight, could interfere with daily activities
      4-persistent hallucination, delusions, or florid psychosis.
    • Depression
      0-not present
      1-periods of sadness or guilt greater than normal, never sustained for more than a few days or a week
      2-sustained depression for >1 week
      3-vegetative symptoms (insomnia, anorexia, abulia, weight loss)
      4-vegetative symptoms with suicidality
    • Motivation/Initiative
      0-normal
      1-less of assertive, more passive
      2-loss of initiative or disinterest in elective activities
      3-loss of initiative or disinterest in day to say (routine) activities
      4-withdrawn, complete loss of motivation
  2. Activities of Daily Living
    • Speech
      0-normal
      1-mildly affected, no difficulty being understood
      2-moderately affected, may be asked to repeat
      3-severely affected, frequently asked to repeat
      4-unintelligible most of time
    • Salivation
      0-normal
      1-slight but noticeable increase, may have nighttime drooling
      2-moderately excessive saliva, hay minimal drooling
      3-marked drooling
    • Swallowing
      0-normal
      1-rare choking
      2-occasional choking
      3-requires soft food
      4-requires NG tube or G-tube
    • Handwriting
      0-normal
      1-slightly small or slow
      2-all words small but legible
      3-severely affected, not all words legible
      4-majority illegible
    • Cutting Food/Handing Utensils
      0-normal
      1-somewhat slow and clumsy but no help needed
      2-can cut most foods, some help needed
      3-food must be cut, but can feed self
      4-needs to be fed
    • Dressing
      0-normal
      1-somewhat slow, no help needed
      2-occasional help with buttons or arms in sleeves
      3-considerable help required but can do something alone
      4-helpless
    • Hygiene
      0-normal
      1-somewhat slow but no help needed
      2-needs help with shower or bath or very slow in hygienic care
      3-requires assistance for washing, brushing teeth, going to bathroom
      4-helpless
    • Turning in Bed/ Adjusting Bed Clothes
      0-normal
      1-somewhat slow no help needed
      2-can turn alone or adjust sheets but with great difficulty
      3-san initiate but not turn or adjust alone
      4-helpless
    • Falling-Unrelated to Freezing
      0-none
      1-rare falls
      2-occasional, less than one per day
      3-average of once per day
      4->1 per day
    • Freezing When Walking
      0-normal
      1-rare, may have start hesitation
      2-occasional falls from freezing,
      3-frequent freezing, occasional falls
      4-frequent falls from freezin
    • Walking
      0-normal
      1-mild difficulty, day drag legs or decrease arm swing
      2-moderate difficultly requires no assist
      3-severe disturbance requires assistance
      4-cannot walk at all even with assist
    • Tremor
      0-absent
      1-slight and infrequent, not bothersome to patient
      2-moderate, bothersome to patient
      3-severe, interfere with many activities
      4-marked, interferes with many activities
    • Sensory Complaints Related to Parkinsonism
      0-none
      1-occasionally has numbness, tingling, and mild aching
      2-frequent, but not distressing
      3-frequent painful sensation
      4-excruciating pain
  3. Motor Exam
    • Speech
      0-normal
      1-slight loss of expression, diction,volume
      2-monotone, slurred but understandable, mod. impaired
      3-marked impairment, difficult to understand
      4-unintelligible
    • Facial Expression
      0-Normal
      1-slight hypomymia, could be poker face
      2-slight but definite abnormal diminution in expression
      3-mod. hypomimia, lips parted some of time
      4-masked or fixed face, lips parted 1/4 of inch or more with complete loss of expression
    • Tremor at Rest
      • Face
        0-absent
        1-slight and infrequent
        2-mild and present most of time
        3-moderate and present most of time
        4-marked and present most of time
      • Right Upper Extremity (RUE)
        0-absent
        1-slight and infrequent
        2-mild and present most of time
        3-moderate and present most of time
        4-marked and present most of time
      • LUE
        0-absent
        1-slight and infrequent
        2-mild and present most of time
        3-moderate and present most of time
        4-marked and present most of time
      • RLE
        0-absent
        1-slight and infrequent
        2-mild and present most of time
        3-moderate and present most of time
        4-marked and present most of time
      • LLE
        0-absent
        1-slight and infrequent
        2-mild and present most of time
        3-moderate and present most of time
        4-marked and present most of time
    • Action or Postural Tremor
      • RUE
        0-absent
        1-slight, present with action
        2-moderate, present with action
        3-moderate present with action and posture holding
        4-marked, interferes with feeding
      • LUE
        0-absent
        1-slight, present with action
        2-moderate, present with action
        3-moderate present with action and posture holding
        4-marked, interferes with feeding
    • Rigidity
      • Neck
        0-absent
        1-slight or only with activation
        2-mild/moderate
        3-marked, full range of motion
        4-severe
      • RUE
        0-absent
        1-slight or only with activation
        2-mild/moderate
        3-marked, full range of motion
        4-severe
      • LUE
        0-absent
        1-slight or only with activation
        2-mild/moderate
        3-marked, full range of motion
        4-severe
      • RLE
        0-absent
        1-slight or only with activation
        2-mild/moderate
        3-marked, full range of motion
        4-severe
      • LLE
        0-absent
        1-slight or only with activation
        2-mild/moderate
        3-marked, full range of motion
        4-severe
    • Finger taps
      • Right
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
      • Left
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
    • Hand Movements (open and close hands in rapid succession)
      • Right
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
      • Left
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
    • Rapid Alternating Movements (pronate and supinate hands)
      • Right
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
      • Left
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
    • Leg Agility (tap heel on ground, amp should be 3 inches)
      • Right
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
      • Left
        0-normal
        1-mild slowing, and/or reduction in amp.
        2-moderate impaired. Definite and early fatiguing, may have occasional arrests
        3-severely impaired. Frequent hesitations and arrests.
        4-can barely perform
    • Arising From Chair (pt. arises with arms folded across chest)
      0-normal
      1-slow, may need more than one attempt
      2-pushes self up from arms or seat
      3-tends to fall back, may need multiple tries but can arise without assistance
      4-unable to arise without help
    • Posture
      0-normal erect
      1-slightly stooped, could be normal for older person
      2-definitely abnormal, mod. stooped, may lean to one side
      3-severely stooped with kyphosis
      4-marked flexion with extreme abnormality of posture
    • Gait
      0-normal
      1-walks slowly, may shuffle with short steps, no festination or propulsion
      2-walks with difficulty, little or no assistance, some festination, short steps or propulsion
      3-severe disturbance, frequent assistance
      4-cannot walk
    • Postural Stability (retropulsion test)
      0-normal
      1-recovers unaided
      2-would fall if not caught
      3-falls spontaneously
      4-unable to stand
    • Body Bradykinesia/ Hypokinesia
      0-none
      1-minimal slowness, could be normal, deliberate character
      2-mild slowness and poverty of movement, definitely abnormal, or dec. amp. of movement
      3-moderate slowness, poverty, or small amplitude
      4-marked slowness, poverty, or amplitude

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Schwab and England Activities of Daily Living

Gillingham FJ, Donaldson MC, eds., Third Symp. of Parkinson’s Disease, Edinburgh, Scotland, E&S Livingstone, 1969, pp.152-7.

Rating can be assigned by rater or by patient.

  • 100%-Completely independent. Able to do all chores w/o 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.

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One Response to Parkinson’s Disease Staging – Neurosurgical Service – Massachusetts General Hospital

  1. Pingback: I, uh… Forgot! — Parky Bill's Place

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