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Patients Ask: What Are the Stages of Parkinson's Disease?

October 13, 2022Neelem Sheikh

Establishing clinical stages of diseases—particularly for those of degenerative nature—is important for understanding disease progression for a given patient depending on specific symptoms and abilities. Staging in Parkinson’s disease helps healthcare providers understand how well a patient can function, determine whether or not specific drugs or therapies are likely to be effective, and monitor response to medications. Staging scales can also allow caregivers to better understand a patient’s changing care needs.

So, what are the stages of Parkinson’s disease? While there is no single staging scale used in practice, two of the most common and highly regarded Parkinson’s disease staging scales are Hoehn and Yahr (H-Y) and the Movement Disorder Society-Sponsored Revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS).

What Are the Stages of Parkinson’s Disease: H-Y

The H-Y staging scale was first described in 1967 by Hoehn and Yahr based on the level of clinical disability and included five stages (1-5). A modified version of this staging scale has been widely adopted and includes the additional stages of 0, 1.5, and 2.5. The stages of Parkinson's disease, as described by the original and modified H-Y staging scale, are detailed below.

Original H-Y Parkinson’s Disease Staging Scale

0No clinical signs of Parkinson’s diseasen/a
1Unilateral involvement only During stage one, patients have mild symptoms that usually do not interfere with Activities of Daily Living (ADLs). Movement symptoms, such as tremor, occur unilaterally, meaning on one side of the body only.
2Bilateral involvement without impairment of balanceDuring stage two, movement symptoms—such as tremor, rigidity, and loss of facial expressions—become more severe and affect both sides of the body or the midline (trunk and neck). Speech abnormalities and slowness in ADLs are common during this stage.
3Mild to moderate bilateral disease; some postural instability; physically independentLoss of balance and slowed movement are hallmarks of stage three. Motor symptoms continue to become more severe, and falls become more common.
4Severe disability; still able to walk or stand unassistedDuring stage four, symptoms are severe, and significant assistance with ADLs is typically required, though the patient may still be able to walk or stand without assistance.
5Wheelchair-bound or bedridden unless aidedStage five is the most advanced stage and is characterized by confinement to a wheelchair or bed. Patients in this stage require around-the-clock care for all ADLs.

Modified H-Y Parkinson’s Disease Staging Scale

0No clinical signs of Parkinson’s disease
1Unilateral involvement only
1.5Unilateral and axial involvement
2Bilateral involvement without impairment of balance
2.5Mild bilateral disease with recovery on pull test
3Mild to moderate bilateral disease; some postural instability; physically independent
4Severe disability; still able to walk or stand unassisted
5Wheelchair-bound or bedridden unless aided

What Are the Stages of Parkinson’s Disease: MDS-UPDRS

The UPDRS was developed in 1987 to incorporate elements from existing scales and provide a more comprehensive tool to assess the vast range of symptoms, both motor- and non-motor-related. In 2001, the Movement Disorder Society updated the rating scale. This scale is referred to as the MDS-UPDRS and is commonly used by neurologists to monitor response to medications and decrease the signs of Parkinson’s disease.

The MDS-UPDRS consists of four parts:

  1. Non-Motor Aspects of Experiences of Daily Living (nM-EDL)
  2. Motor Aspects of Experiences of Daily Living (M-EDL)
  3. Motor Examination 
  4. Motor Complications
PartSymptoms Analyzed
  • Cognitive impairment
  • Hallucinations and psychosis
  • Depressed mood
  • Anxious mood
  • Apathy
  • Features of dopamine dysregulation syndrome
  • Sleep problems
  • Daytime sleepiness
  • Pain and other sensations
  • Urinary problems
  • Constipation problems
  • Lightheadedness on standing
  • Fatigue
  • 2
  • SpeechSaliva and drooling
  • Chewing and swallowing
  • Eating tasks
  • Dressing
  • Hygiene
  • Handwriting
  • Doing hobbies and other activities
  • Turning in bed
  • Tremor
  • Getting out of bed, a car, or a deep chair
  • Walking and balance
  • Freezing
  • 3
  • Speech
  • Facial expression
  • Rigidity
  • Finger tapping
  • Hand movements
  • Pronation-supination movements of hands
  • Toe tapping
  • Leg agility
  • Arising from a chair
  • Gait
  • Freezing of gait
  • Postural stability
  • Posture
  • Body bradykinesia
  • Postural tremor of the hands
  • Kinetic tremor of the hands
  • Rest tremor amplitude
  • Constancy of resting tremor
  • 4
  • Time spent with dyskinesias
  • Functional impact of dyskinesias
  • Time spent in the off state
  • Functional impact of fluctuations
  • Complexity of motor fluctuations
  • Painful off-state dystonia
  • Each category within each part is scored on a five-point scale to indicate severity:

    1. Normal
    2. Slight
    3. Mild
    4. Moderate
    5. Severe

    Scores are tallied up to provide insight into disease severity, with 199 points being total disability and zero points being no disability.

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