What is a rating scale?
A rating scale is a means of providing information on a particular feature by assigning a value to it. In Parkinson’s, rating scales require the ‘rater’ (the person deciding on the points scored) to put a value to the feature or symptom in question, according to a set scale. The rater may be the person with Parkinson’s or a healthcare professional.
Parkinson’s rating scales are a means of assessing the symptoms of the condition. They provide information on the course of the condition and/or assess quality of life. They may also help to evaluate treatment and management strategies, which can be useful to researchers as well as to people with Parkinson’s, their carers and medical team.
A number of rating scales are used in Parkinson’s, and often more than one scale is used to give a broader picture. Motor (movement) scales are the best-known and most widely used, but non-motor symptom scales are equally important. Combined with a motor scale, these give a more balanced picture of how a person is affected by the condition. A low motor score may suggest that a person has mild Parkinson’s but, at the same time, the person may have disabling non-motor symptoms, which impact on quality of life.
Unified Parkinson's Disease Rating Scale (UPDRS)
The UPDRS combines elements of several scales to produce a comprehensive and flexible tool to monitor the course of Parkinson’s and the degree of disability. The scale was introduced in 1987 and has since been updated by specialists from the Movement Disorder Society (MDS) to include new assessments of non-motor symptoms.
The scale has three sections which evaluate key areas of disability, together with a fourth section that evaluates any complications of treatment. The UPDRS is often used with two other Parkinson’s rating scales: the Hoehn and Yahr, and the Schwab and England Activities of Daily Living (ADL) Scale.
Part I: Evaluation of mental activity, behaviour and mood:
- Intellectual impairment
- Thought disorder
- Motivation / initiative
- Bladder and bowel problems
Part II: Self-evaluation of activities of daily living:
- Cutting food
- Turning in bed
- Sensory difficulties
Part III: Evaluation of motor function:
- Facial expression
- Tremor at rest
- Action tremor
- Finger taps
- Hand movements
- Rotation of hands and forearms so palms face downward
- Rotation of hands and forearms so palms face upward
- Toe taps
- Leg agility
- Rising from chair
- Postural stability
Part IV: Evaluation of complications of therapy
- Early morning
- 'Off-period' deterioration, including the duration of 'off' periods, predictability based on dosage, and whether onset is sudden or gradual
- Anorexia (including nausea and/or vomiting)
- Sleep disturbance
Part V: Hoehn and Yahr Scale
Part VI: Schwab and England Activities of Daily Living Scale
- Low blood pressure on standing
For further details on the UPDRS see Movement Disorder Society (MDS).
The UPDRS testing is carried out by a healthcare professional. Points are assigned to every item based on the person’s response, as well as observation and physical examination. The total cumulative score will range from 0 (no disability) to 199 (total disability).
Hoehn and Yahr Scale
The Hoehn and Yahr Scale is used to measure how Parkinson’s symptoms progress and the level of disability. Originally published in 1967 in the journal Neurology by Melvin Yahr and Margaret Hoehn, it included stages 1 to 5. Since then, stage 0 has been added and stages 1.5 and 2.5 have been proposed and are widely used.
- Stage 0 - No signs of disease
- Stage 1 - Symptoms on one side only (unilateral)
- Stage 1.5 - Symptoms unilateral and also involving the neck and spine
- Stage 2 - Symptoms on both sides but no impairment of balance
- Stage 2.5 - Mild symptoms on both sides, with recovery when the ‘pull’ test is given (the doctor stands behind the person and asks them to maintain their balance when pulled backwards)
- Stage 3 - Balance impairment, mild to moderate disease, physically independent
- Stage 4 - Severe disability, but still able to walk or stand unassisted
- Stage 5 - Needing a wheelchair or bedridden unless assisted.
For full details of the original publication see: Parkinsonism: onset, progression, and mortality by Margaret Hoehn and Melvin Yahr - view article.
Schwab and England Activites of Daily Living (ADL) Scale
The Schwab and England ADL Scale is a means of measuring a person’s ability to perform daily activities in terms of speed and independence through a percentage figure. The rating may be made by a professional or by the person being tested. High percentages indicate a high level of independence while low percentages indicate dependence:
- 100% - Completely independent. Able to do all activities without slowness, difficulty or impairment
- 90% - Completely independent. Able to do all activities with some slowness, difficulty or impairment. Activities may take twice as long to complete
- 80% - Independent in most activities, but activities take twice as long. Conscious of difficulty and slowing
- 70% - Not completely independent. More difficulty with activities, which may take three to four times as long. May take large part of day for chores
- 60% - Some dependency. Can do most activities, but very slowly and with much effort, but some chores are impossible
- 50% - More dependent. Help required with half of chores. Difficulty with everything
- 40% - Very dependent. Can assist with all chores but can manage few alone
- 30% - With effort, now and then does a few chores alone or begins alone. Much help needed
- 20% - Cannot do anything alone. Can give some slight help with some chores. Severe invalid
- 10% - Totally dependent, helpless
- 0% - Vegetative functions such as swallowing
This self-administered questionnaire consists of 39 questions relating to eight key areas of health and daily activities, including both motor and non-motor symptoms. It is scored on a scale of 0-100, with lower scores indicating better health and high scores more severe symptoms.
Find out more and view the full questionnaire.
PD NMS Questionnaire
This 30-point questionnaire measures non-movement difficulties experienced by people with Parkinson’s that impact on quality of life. Areas covered include sleep, constipation, vision, smell, sexual problems and memory. The inclusion of these topics in the questionnaire may encourage discussion of subjects that might otherwise be ignored or considered embarrassing.
This survey is divided into nine different areas of non-motor symptoms, with 30 questions in total. Responses help doctors to quantify symptoms according severity (using a scale of 0-3) and frequency (using a scale of 0-4).
A number of other scales can help to assess a wide range of conditions, including Parkinson’s:
- King's PD Pain Scale - A scale that grades the frequency and severity of various types of pain - view scale
- Parkinson's Disease Sleep Scale - PDSS-2 - A scale that assesses the nature and frequency of sleep disturbances in Parkinson's - view scale
- Lindop Parkinson's Assessment Scale - A measurement of mobility in Parkinson's, which when used at intervals helps a physiotherapist determine if problems have developed
- Short-Form 36 (SF-36) – A relatively brief but comprehensive questionnaire to assess health status
- Sickness Impact Profile (SIP) – A general quality of life scale which measures 12 different factors, including walking, movement and mobility, body care, communication and social interaction
- Mini Mental State Examination (MMSE) – A simple means of assessing cognitive function (mental ability) using a brief 30-point questionnaire - view scale
- Caregiver Strain Index (CSI) – A 13-point questionnaire for carers that measures the burden of different aspects of caring, and identifies areas of concern.
In addition, symptom specific scales include the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Apathy Evaluation Scale.