Movement Disorder Society clinical diagnostic criteria for Parkinson Disease – Executive summary/completion form

The first essential criterion is parkinsonism, which is defined as bradykinesia, in combination with at least one of rest tremor or rigidity. Examination of all cardinal manifestations should be carried out as described in the MDS-Unified Parkinson Disease Rating Scale.^[1] Once parkinsonism has been diagnosed:
Diagnosis of clinically established PD requires:
Absence of absolute exclusion criteria At least two supportive criteria, and No red flags
Diagnosis of clinically probable PD requires:
Absence of absolute exclusion criteria Presence of red flags counterbalanced by supportive criteria If one red flag is present, there must also be at least one supportive criterion If two red flags, at least two supportive criteria are needed No more than two red flags are allowed for this category
Supportive criteria (check box if criteria met)
1. Clear and dramatic beneficial response to dopaminergic therapy. During initial treatment, patient returned to normal or near-normal level of function. In the absence of clear documentation of initial response a dramatic response can be classified as: a. Marked improvement with dose increases or marked worsening with dose decreases. Mild changes do not qualify. Document this either objectively (>30% in UPDRS III with change in treatment), or subjectively (clearly-documented history of marked changes from a reliable patient or caregiver) b. Unequivocal and marked on/off fluctuations, which must have at some point included predictable end-of-dose wearing off
2. Presence of levodopa-induced dyskinesia
3. Rest tremor of a limb, documented on clinical examination (in past, or on current examination)
4. The presence of either olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy
Absolute exclusion criteria: The presence of any of these features rules out PD:
1. Unequivocal cerebellar abnormalities, such as cerebellar gait, limb ataxia, or cerebellar oculomotor abnormalities (eg, sustained gaze evoked nystagmus, macro square wave jerks, hypermetric saccades)
2. Downward vertical supranuclear gaze palsy, or selective slowing of downward vertical saccades
3. Diagnosis of probable behavioral variant frontotemporal dementia or primary progressive aphasia, defined according to consensus criteria^[2] within the first five years of disease
4. Parkinsonian features restricted to the lower limbs for more than three years
5. Treatment with a dopamine receptor blocker or a dopamine-depleting agent in a dose and time-course consistent with drug-induced parkinsonism
6. Absence of observable response to high-dose levodopa despite at least moderate severity of disease
7. Unequivocal cortical sensory loss (ie, graphesthesia, stereognosis with intact primary sensory modalities), clear limb ideomotor apraxia, or progressive aphasia
8. Normal functional neuroimaging of the presynaptic dopaminergic system
9. Documentation of an alternative condition known to produce parkinsonism and plausibly connected to the patient's symptoms, or, the expert evaluating physician, based on the full diagnostic assessment feels that an alternative syndrome is more likely than PD
Red flags
1. Rapid progression of gait impairment requiring regular use of wheelchair within five years of onset
2. A complete absence of progression of motor symptoms or signs over five or more years unless stability is related to treatment
3. Early bulbar dysfunction: severe dysphonia or dysarthria (speech unintelligible most of the time) or severe dysphagia (requiring soft food, NG tube, or gastrostomy feeding) within first five years
4. Inspiratory respiratory dysfunction: either diurnal or nocturnal inspiratory stridor or frequent inspiratory sighs
5. Severe autonomic failure in the first five years of disease. This can include: a. Orthostatic hypotension^[3]-orthostatic decrease of blood pressure within three minutes of standing by at least 30 mmHg systolic or 15 mmHg diastolic, in the absence of dehydration, medication, or other diseases that could plausibly explain autonomic dysfunction, or b. Severe urinary retention or urinary incontinence in the first five years of disease (excluding long-standing or small amount stress incontinence in females), that is not simply functional incontinence. In males, urinary retention must not be attributable to prostate disease, and must be associated with erectile dysfunction
6. Recurrent (>1/year) falls because of impaired balance within three years of onset
7. Disproportionate anterocollis (dystonic) or contractures of hand or feet within the first 10 years
8. Absence of any of the common nonmotor features of disease despite five years disease duration. These include sleep dysfunction (sleep-maintenance insomnia, excessive daytime somnolence, symptoms of REM sleep behavior disorder), autonomic dysfunction (constipation, daytime urinary urgency, symptomatic orthostasis), hyposmia, or psychiatric dysfunction (depression, anxiety, or hallucinations)
9. Otherwise-unexplained pyramidal tract signs, defined as pyramidal weakness or clear pathologic hyperreflexia (excluding mild reflex asymmetry and isolated extensor plantar response)
10. Bilateral symmetric parkinsonism. The patient or caregiver reports bilateral symptom onset with no side predominance, and no side predominance is observed on objective examination
Criteria application:
1. Does the patient have parkinsonism, as defined by the MDS criteria?	Yes	No
If no, neither probable PD nor clinically established PD can be diagnosed. If yes:
2. Are any absolute exclusion criteria present?	Yes	No
If yes, neither probable PD nor clinically established PD can be diagnosed. If no:
3. Number of red flags present ______
4. Number of supportive criteria present ______
5. Are there at least two supportive criteria and no red flags?	Yes	No
If yes, patient meets criteira for clinically established PD. If no:
6. Are there more than two red flags?	Yes	No
If yes, probable PD cannot be diagnosed. If no:
7. Is the number of red flags equal to, or less than, the number of supportive criteria?	Yes	No
If yes, patient meets criteria for probable PD

MDS: Movement Disorder Society; PD: Parkinson disease; MIBG: metaiodobenzylguanidine; REM: rapid eye movement.

References:

Goetz CG, Tilley BC, Shaftman SR, et al. Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord 2008; 23:2129.
Rascovsky K, Hodges JR, Knopman D, et al. Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain 2011; 134:2456.
Gilman S, Lost D, Low PA, et al. Second consensus statement on the diagnosis of multiple system atrophy. Neurology 2008; 71:670.

From: Postuma RB, Berg D, Stern M, et al. MDS clinical diagnostic criteria for Parkinson's disease. Mov Disord 2015; 30:1591. http://onlinelibrary.wiley.com/doi/10.1002/mds.26424/abstract. Copyright © 2015 International Parkinson and Movement Disorder Society. Reproduced with permission of John Wiley & Sons, Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared, or emailed. Please contact Wiley's Permissions Department either via email: permissions@wiley.com or use the RightsLink service by clicking on the Request Permission link accompanying this article on Wiley Online Library (www.onlinelibrary.wiley.com).

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