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Instructions for the rater: Test each hand separately. Demonstrate the action to the patient, stopping the demonstration when the testing begins.
Instruct the patient to tap their thumb with their index finger 10 times with maximum amplitude and speed. Test each hand separately, assessing the speed of movement, amplitude, presence of hesitation and pauses, and any gradual decrease in amplitude.
Instructions for the evaluator: Test each hand separately. Demonstrate the action to the patient, and stop demonstrating when the patient begins testing.
Instruct the patient to bend their elbow and make a fist, with the palm facing the evaluator. Ask the patient to fully open their palm and rapidly clench and unclench their fist 10 times. If the patient does not clench their fist tightly or fully open their palm, remind them. Test each hand separately, evaluating the speed, amplitude, hesitation, pauses, and gradual reduction in amplitude of the movements.
Instructions for the rater: Test each hand separately. Demonstrate the action to the patient, and stop demonstrating when the patient begins testing.
Instruct the patient to extend their arms with palms facing down. Then, alternate flipping the palms up and down as quickly and broadly as possible for 10 repetitions. Test each side separately, assessing the speed, amplitude, any hesitations or pauses, and whether the amplitude gradually decreases.
Instructions for the evaluator: Have the patient sit in a chair with a straight back and armrests, with both feet on the ground. Test each foot separately. Demonstrate the movement to the patient and stop demonstrating when the test begins. Instruct the patient to place their heels on the ground in a comfortable position, then tap their toes on the ground with the maximum range and speed 10 times. Test each side separately, evaluating the speed, range, any hesitation and pauses, and any gradual reduction in range.
Instructions for the evaluator: Have the patient sit in a chair with a straight back and armrests. Both feet should be in a comfortable position on the ground. Test each leg separately. Demonstrate the movement to the patient and stop demonstrating when the test begins. Instruct the patient to place both feet comfortably on the floor, then raise and tap their foot on the ground with the maximum range and speed 10 times. Test each side separately, evaluating the speed, range, any hesitation and pauses, and any gradual reduction in range.
Instructions for the evaluator: Have the patient sit in a chair with a straight back and armrests, with both feet on the ground and leaning back. (If the patient is not too short.) Instruct the patient to cross their arms in front of their chest and then stand up. If the patient fails, they can repeat up to two more times. If still unsuccessful, have the patient scoot forward in the chair, cross their arms in front of their chest, and try to stand again. If they still cannot succeed, allow the patient to use the armrests to stand up. This action can be repeated a maximum of three times. If still unsuccessful, assist the patient in standing. After the patient stands up, observe the posture for item 3.13.
Instructions for the evaluator: The best way to test gait is to have the patient walk back and forth towards the evaluator, allowing them to easily see both sides of the patient's body. The patient should walk at least 10 meters (30 feet) and then turn around to walk back to the evaluator. This examination assesses multiple aspects of the patient, including stride length, walking speed, height of foot lift, heel contact while walking, turning, and arm swing, but does not include freezing. Observe for freezing gait during the patient's walk (next item 3.11). Also observe the posture for item 3.13.
Instructions for the evaluator: While assessing gait, evaluate whether the patient exhibits freezing gait. Observe if the patient has difficulty initiating movement and hesitates in their steps, especially when turning and approaching a target. As long as safety is ensured, do not use sensory stimuli to assist the patient in walking during the assessment.
Instructions for the evaluator: In this assessment, the patient should stand upright with their eyes open, feet appropriately apart, and standing parallel. After the evaluator quickly and forcefully pulls the patient’s shoulders back, evaluate the patient's postural stability by observing their backward reaction to the sudden shift of body position. During the assessment, the evaluator should stand behind the patient and inform them of what will happen next. Explain that they can step back to prevent falling. The wall behind the evaluator should be at least 1-2 meters away to observe how many steps the patient takes back. The first pull should be a guided demonstration, with light force and not counted in the scoring. The second pull should be quick and forceful, pulling the patient's shoulders toward the evaluator, with enough force to shift the patient's center of gravity so that the patient must step back to maintain balance. The evaluator should be prepared to catch the patient but must leave enough space to observe the number of steps taken back. The patient should not lean forward in an attempt to resist the pull. Observe the number of steps the patient takes back or whether they fall. Taking two steps back or fewer is a normal balance recovery response; taking three or more steps back is abnormal. If the patient does not understand this assessment, the evaluator may repeat it to confirm that the patient’s performance is due to their own limitations rather than misunderstanding or lack of readiness. Observe the patient’s standing posture and record it in item 3.13.
Instructions for the evaluator: While assessing the patient's ability to stand up from a chair, walk, and perform postural reflexes, the patient's posture can also be evaluated. If you observe that the patient's posture is abnormal, you should remind the patient to stand straight and see if there is any improvement in their posture (see option 2 below). Score based on the most abnormal posture observed among the three assessment points above. Observe whether the patient has a forward lean or lateral bend in their body.
Instructions for the evaluator: This assessment integrates observations from various aspects, including slowness of movement, hesitation, and an overall decrease in movement and amplitude, including reduced hand gestures and crossing of legs. This assessment is based on the overall impression given by the evaluator after observing the patient's hand gestures while seated, as well as their performance when standing up and walking.
Instructions for the evaluator: Include all tremors observed in this posture, including reproduced resting tremors, within the scoring range. Test both hands separately and record the largest tremor amplitude observed. Instruct the patient to extend their arms forward with palms facing down. The wrists should be straight, and the fingers should be separated without touching. Observe this posture for 10 seconds.
Instructions for the evaluator: This examination requires the patient to perform a finger-to-nose movement. The patient should first extend their arms straight out, reaching as far as possible to touch the evaluator's finger, then point to their nose. This action should be repeated at least three times. The movements should be slow to observe for any tremors, as rapid movements may mask the tremor. Test both hands separately. Tremors can occur during the entire movement or may appear as the patient's finger approaches the target (nose or evaluator's finger). Score based on the largest tremor amplitude observed.
Instructions for the evaluator: This item and the next are intentionally placed at the end of the movement examination. The evaluator can observe any resting tremors that may occur at any time during the movement assessment, including when the patient is sitting quietly, walking, and when certain body parts are moving while others are still. Record the largest tremor amplitude seen at any time as the final score. Only the amplitude of the tremor is assessed, without noting whether the tremor is continuous or intermittent.
Additionally, this examination requires the patient to sit in a chair for 10 seconds, with both hands resting on the armrests (rather than on their legs) and both feet comfortably on the ground. The limbs and lips/jaw should be scored for resting tremor separately. Record the largest tremor amplitude observed at any time as the final score.
Instructions for the evaluator: This assessment is a standardized scoring of all resting tremors observed during the examination, focusing on the persistence of resting tremors. This examination has been intentionally placed at the end so that the evaluator can arrive at a comprehensive score based on observations from the previous few minutes.
Overview and Instructions:
In this section, the rater should evaluate two types of motor complications: dyskinesia and motor fluctuations, including off-period dystonia, based on prior and objective information. Six questions regarding the patient’s functional status over the past week, including the day of assessment, should be answered using information gathered from the patient, caregivers, and clinical examinations. As in other sections, scores can only be whole numbers (no half points) and cannot be left blank. If an item cannot be scored, "UR" should be used to indicate it cannot be rated. For scoring, you will need to answer some questions using percentages, so you need to calculate approximately how many hours the patient is awake each day and use this number as the denominator for off periods and dyskinesia. For off-period dystonia, the entire off-period time is the denominator.
Definitions for Raters:
Dyskinesia: Involuntary voluntary movements.
Patients often describe dyskinesia using terms like “body shaking” or “twisting.” Please be sure to emphasize the difference between dyskinesia and tremor, as patients often confuse the two.
Dystonia: Twisted postures, often with a rotational component.
Patients often describe dystonia using terms like “spasms,” “cramps,” or “abnormal postures.”
Motor fluctuations: Variable drug responses.
Patients often mention terms related to motor fluctuations such as “wearing off,” “loss of effect,” “effect fluctuating like a roller coaster,” “on-off phenomenon,” or “unstable effect.”
Off-period: Refers to the functional state when the patient is on medication but the effect is poor, or when no anti-Parkinson’s disease medication is being taken. Patients often describe off-periods using terms like “low points,” “bad times,” “when I shake,” “when I’m slow,” or “when my medication doesn’t work.”
On-period: Refers to the functional state when the patient is taking medication and has a good response. Patients often describe on-periods using terms like “good times,” “when I can walk,” or “when the medication kicks in.”
Instructions for the rater: Determine the total awake time for the patient each day and the time during which dyskinesia occurs. Calculate the proportion based on this. If the patient exhibits dyskinesia in the clinic, please point out to the patient that these movements are dyskinesia to ensure the patient and caregiver understand what you are assessing. You may also demonstrate typical dyskinesia seen in this patient or other patients to the patient and caregiver. When assessing this item, exclude morning and nighttime painful dystonia.
Instructions for the patient (and caregiver): In the past week, how many hours did you usually sleep each day? This includes nighttime sleep and daytime naps. Okay, if you sleep for ___ hours, then your total awake time is ___ hours. During this awake time, how many hours do you experience body shaking or twisting? Please do not include the time for tremors, which are regular back-and-forth shaking, nor the time for painful foot cramps or spasms in the morning or at night; I will ask you about those symptoms later. Please focus on abnormal movements such as body shaking, twisting, and irregular movements. Please add up the time you experienced these movements during your awake time. Total ___ hours (use this number for calculation).
Instructions for the rater: Assess the extent of the impact of dyskinesia on the patient’s daily activities and social interactions. Please provide the best answer based on the responses from the patient and caregiver, as well as your observations of the patient in the clinic.
Instructions for the patient (and caregiver): In the past week, when you experienced body shaking or twisting movements, did these often affect your ability to do things or interact with others? Did these movements prevent you from doing things or interacting with others?
Instructions for the rater: Use the awake time derived from item 4.1 to determine the duration of daily off-periods. Calculate the proportion based on this. If the patient exhibits off-periods in the clinic, please point out to the patient that this is an off-period. You may also use information from the patient to describe typical off-periods. Additionally, you may demonstrate typical off-periods seen in this patient or other patients to the patient and caregiver. Please record the time of the patient's off-periods, as you will use this number to complete item 4.6.
Instructions for the patient (and caregiver): Some Parkinson’s disease patients respond well to medications and can maintain a good state during their awake time; we call this the “on” period. Some patients also take medications but still experience low points or poor states, or may experience slowness or tremors. Doctors refer to these low points as “off” periods. In the past week, you previously told me that you usually have __ hours of awake time each day. During this awake time, how many hours do you typically experience low points or are in an off state? A total of __ hours (use this number for calculation).
Guidance for the rater: Determine the extent to which motor fluctuations affect the patient's daily activities and social interactions. This question focuses on the different states of the patient during on and off periods. If the patient has no off periods, score 0. If the patient has very mild fluctuations that do not affect daily activities, score 0. Please provide the best answer based on the responses from the patient and caregivers, as well as your observations of the patient in the office.
Guidance for the patient (and caregivers): Please think about when in the past week you have experienced poor medication effectiveness or an "off" state. Is it generally more difficult for you to do things or interact with people during this time compared to when the medication is effective? Are there things you can do when the medication is working well, but have difficulty completing when it is not?
Guidance for the rater: Determine whether off periods can be predicted based on medication dosage, time of day, eating, or other factors. Use the information obtained from the patient and caregivers, along with your observations, to make a judgment. You need to ask whether the onset of off periods is always at a specific time, mostly at a specific time (in which case you need to further inquire to distinguish whether the complexity is mild or moderate), only sometimes at a specific time, or completely unpredictable? Exclude non-conforming options to find the correct answer.
Guidance for the patient (and caregivers): For some patients, poor medication effectiveness or "off" periods may occur at a specific time during the day or coincide with activities such as eating or exercising. In the past week, have you generally known when you would experience poor medication effectiveness? In other words, does the poor effectiveness always occur at a specific time? Or does it mostly occur at a specific time? Or does it only sometimes occur at a specific time? Or is it completely unpredictable?
Guidance for the assessor: For patients with motor fluctuations, assess the proportion of painful dystonia during off periods. You have already learned about the off period duration in item 4.3. During the off periods, how many hours does the patient experience dystonia? Calculate the proportion. If the patient has no off periods, score as 0.
Guidance for the patient (and caregiver): In the previous questions I asked you, you mentioned that you typically spend __ hours in the "off" period each day, during which your Parkinson's disease symptoms are poorly controlled. During these times when the medication is ineffective or you are in the "off" period, do you often experience painful spasms or cramps? In the __ hours of off period each day, how many hours do you experience painful spasms?
I have now completed the assessment of your Parkinson's disease. I know that these questions and examinations have taken up your valuable time, but I hope to conduct a comprehensive and complete evaluation of your Parkinson's disease. Therefore, I may have asked some questions you have never encountered or questions that you may not experience in the future. Although the questions I asked may not apply to every patient, it is important to ask all questions to every patient because they can indeed occur. Thank you for your valuable time and for patiently completing this scale with me.
Tip: Please take a screenshot to save the results
The MDS-UPDRS scale is the new comprehensive assessment scale for Parkinson's disease sponsored by the International Parkinson and Movement Disorder Society (MDS), mainly consisting of four parts: (Non-Motor Symptoms, Motor Symptoms, Motor Function Examination, Motor Complications). The higher the score, the more severe the patient's symptoms.