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The Movement Disorder Society Task Force for Rating Scales for Parkinson's Disease prepared a critique of the Unified Parkinson's Disease Rating Scale (UPDRS). Strengths of the UPDRS include its wide utilization, its application across the clinical spectrum of PD, its nearly comprehensive coverage of motor symptoms, and its clinimetric properties, including reliability and validity. Weaknesses include several ambiguities in the written text, inadequate instructions for raters, some metric flaws, and the absence of screening questions on several important non-motor aspects of PD.
The Task Force recommends that the MDS sponsor the development of anew version of the UPDRS and encourage efforts to establish its clinimetric properties, especially addressing the need to define a Minimal Clinically Relevant Difference and a Minimal Clinically Relevant Incremental Difference, as well as testing its correlation with the current UPDRS.
2 = Moderate memory loss, with disorientation and moderate difficulty handling complex problems. Strengthsculturally unbiased and be tested in different racial, gender, andof the UPDRS include its wide utilization, its application acrossage-groups. The Task Force recom-includes other, more detailed, and optionally used scales tomends that the MDS sponsor the development of a new versiondetermine severity of these impairments.
Themendation on maintaining or modifying currently avail-development of the UPDRS involved multiple trial ver-able scales.
All unpublished data thatthe UPDRS is often accompanied by and reported withwere used for the critique were shared with the entiresuch scales as the Schwab and England and Hoehn andTask Force membership.
The final document was assembled by the(Caley Kleczka, Director) sent a questionnaire on UPDRSchairperson and approved by all Task Force membersutilization patterns to all MDS members (see Appendixbefore submission to the MDS International Executive2). This Task Force document has been ap-tions), 185 members from all continents respondedproved by the MDS Scientific Issues Committee prior to(12%). Ninety-six percent of responders had personalsubmissionforjournalpeer-reviewinMovementexperience with the UPDRS, 87% using it in clinicalDisorders.trials, 70% in clinical practice, and 69% in other researchvenues.
Combination scores based on sums of differentwas developed as a compound scale to capture multipleparts were often used, I II III (37%) and II III (41%).aspects of PD. In addition, Part I addresses mentaltiple purposes, including research and clinical practice.dysfunction and mood, and Part IV assesses treatment-Parts II and III are most widely used for both clinical andrelated motor and non-motor complications. Questions compiled by the Writing Committeeself-administration of the Mentation and ADL sectionswere addressed to all Expert Consultants with the requestby patients in the waiting room. There is good inter-raterto furnish a written document to respond to each pointreliability between patients who self-complete the histor-with suitable references from the articles provided orical sections (Part I, Mentation, and Part II, ADL) of theMovement Disorders, Vol.
UPDRS scores,interventions for PD, both related to intracerebral trans-however, correlate with the Hoehn and Yahr scale andplantation and deep brain surgery, have employed thethe Schwab and England scale.13 Furthermore, within theUPDRS. To address thisamount of measurement error in a scale, while validityissue, some studies have permitted the inclusion of 0.5evaluations assess the degree to which a scale measuresratings or other designations based on such anchors aswhat it is purported to measure.
The UPDRS has shownstudies indicate that the UPDRS is responsive to thera-excellent internal consistency across multiple stud-peutic interventions.
Significant improvements in totalies13,37,38 and retains this consistency across stages ofUPDRS scores, individual subscales (Parts II and III),disease severity as measured by the Hoehn and YahrMovement Disorders, Vol.
Inter-raterAdditional validity studies have been conducted toreliability appears adequate for the total UPDRS13,18 asassess the ability of the UPDRS to detect changes inwell as the Activities of Daily Living14 and the Motorfunction in either untreated or treated states.



One study usedthe determination of increases or decreases that representthe UPDRS and the other used a modified version of theclinically relevant changes in the disease under consid-scale applied to elderly community subjects without theeration. Among 400or handicap in a disease is known clinimetrically as theearly-stage PD subjects examined on two occasions,Minimal Clinically Relevant Difference (MCRD). First, PDor content validity, criterion validity, and construct va-signs vary throughout the day in parkinsonian patientslidity.
Theand rely on physician-based and patient-based assess-majority of validation studies have assessed the constructments, a single MCRD may not exist.
These studies have generallylike PD, different MCRD values may apply at differentfound satisfactory results regarding convergent validitydisease severities. MCRD has been par-the scale does not measure domains unrelated to PD, hasticularly well studied for pain assessment scales and to anot been well established. One factor structure, com-design of clinical trials involving groups of patients, aMovement Disorders, Vol. As such, though this portion is some-Allied to the concept of MCRD is the Minimal Clin-times used in clinical trials, most intervention studies forically Relevant Incremental Difference (MCRID). Ratherdyskinesias or motor-fluctuations currently rely primar-than comparing two assessments within a patient orily on other scales. Knowing theitems 40 – 42) can only be used as screening items to assessMCRID would allow clinicians to determine the thresh-presence or absence of select clinical problems. The Taskold UPDRS value that would discriminate two treat-Force members considered these items as insufficient toments. So far, there is no experimentally generated orassess severity of impairment or disability related to non-systematically analysed data on a MCRID for the total ormotor domains of PD.sub-component scores of the UPDRS. There is, however,Some items of the motor section have relatively poorlimited experience with this concept based on expertinter-rater reliability, including speech, facial expression,opinion or reliance on differences found in previousposture, body bradykinesia, action tremor, and rigidi-trials.
Becausethe few examples of an empirically used MCRID basedthe response of the patient and the assigned rating de-on experience and literature reviews, in one pallidotomypend directly on the force of the postural threat, stan-trial that enrolled advanced PD patients with high pre-dardized instructions and application of the test are es-operative UPDRS motor scores, a MCRID for Part III ofsential for consistent ratings. 7, 2003UPDRS: STATUS AND RECOMMENDATIONS743Additionally, there is some redundancy of items inand it has not been examined extensively in other ethnicboth the ADL and motor sections.
Efforts to reduce redundancy haveand the co-existence of other diseases like diabetes,led to the Short Parkinson’s Evaluation Scale (SPES),stroke, and arthritis can confound the evaluation of PD-based directly on the UPDRS, but with fewer items andrelated impairment and disability. Conversely,of numerical options clinimetrically diminishes the ca-correction of cataracts may improve overall patient func-pacity to discriminate change. The question of how the UPDRS shouldrelated items are overrepresented in terms of the numberaccommodate these various issues of co-morbidities isnot specifically detailed in the scale instructions. Items that overlap theseof focusing on PD itself, but it is highly subject totwo categories include the gait items that assess primaryinvestigator and patient bias. For accurate assessment ofparkinsonian features (freezing, falls), but impact onPart III, the rater would need to have a list of co-walking as an activity of daily living.
The second strategy deals with the reality of thecally, but not conceptually, resolve this ambiguity.


Itemspatient status without interpretation of underlying causeassessing function outside activities of daily living couldfor impairment, but will likely inflate ratings that havealternatively be reassigned to another section of theminimal or no direct relationship to PD. The Task Force members unanimouslyties and their impact on UPDRS scores can be minimizedconsidered the concept of a single clinical rating scale toby excluding patients with medical conditions that con-be an important tool for clear and consistent communi-found interpretation of the primary rating measure. Theternatively, some studies permit co-morbid conditions,strengths of the UPDRS are many, and the scale providesbut only when they are stable and of long duration. Ifa relatively comprehensive assessment of motoric as-these conditions do not overly elevate the baseline scorespects of PD.
Some items, however, havestudy.poor inter-rater reliability, and individual text anchors orinstructions for data acquisition are ambiguous.
TheImportant Elements Not CoveredUPDRS is less comprehensive in its assessment of non-Several key elements of PD are not covered by themotor features of the disease.UPDRS.
When the scale was formulated in the mid-The Task Force members agreed that the identified1980s, the developers were well aware of this limitation,weaknesses were substantive, but amenable to correc-but they made choices to delete questions on some par-tion.
They could be reduced or eliminated if the scalekinsonian impairments, mainly to create a scale that waswas retained in its basic structure and core elements, butreasonably simple and short (S. Modifications should focushowever, the Task Force members considered that theseon clarity, resolution of ambiguity, and also provideinitial choices should be re-considered. It was emphasized that any change inexist (Table I), though changes in all items may bethe place of a given existing item, any modification in theMovement Disorders, Vol.
Be tested by factor analysis to determine core im-would compromise already operative longitudinal stud-pairments that potentially could lead to a reducedies based on the current UPDRS version, statistical meth-number of items that would serve to form a shortods readily exist to compare the current version and aversion of the scale for everyday clinical practice.new version and could be conducted for total, section,3. The MDS should encourage efforts to conduct com-and individual item scores to address this dilemma. Retain the basic structure of the current UPDRS,panel of experts selected for this project should in-with sections that include both physician-derivedclude movement disorder specialists that represent ac-and patient-derived data and retain at least 0–4ademic and practice settings and statistical experts. Allratings for motor items assessing severity of impair-current members of the Task Force would be willingment or disability.to serve on this panel. Be responsive to concerns of cultural bias.all strong and useful assessment tool for evaluatingf.
Better characterize and rate dyskinesias, capturingAPPENDIX 1peak-dose and end of dose dyskinesia, both choreicand dystonic forms.Movement Disorder Society Task Force on Ratingh. Incorporate an appendix that lists officially recom-MD, Cristina Sampaio, MD, and Glenn T.
Stebbins, PhDmended additional scales applicable to each screen-Expert Consultants: Stanley Fahn, MD, Anthony E.



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