Unifying Concepts

MDS Clinical Diagnostic Criteria for Parkinson’s Disease (PD)

The prerequisite to apply the Movement Disorder Society (MDS-PD) criteria is the diagnosis of parkinsonism, which is based on three cardinal motor manifestations. Parkinsonism is defined as bradykinesia, in combination with either rest tremor, rigidity, or both. These features must be clearly demonstrable and not attributable to confounding factors.
MDS Clinical Diagnostic Criteria for Parkinson’s Disease
The first essential criterion is parkinsonism, which is defined as bradykinesia, in combination with at least 1 of rest tremor or rigidity. Examination of all cardinal manifestations should be carried out as described in the MDS–Unified Parkinson Disease Rating Scale. Once parkinsonism has been diagnosed:

Diagnosis of Clinically Established PD requires:
1. Absence of absolute exclusion criteria
2. At least two supportive criteria, and
3. No red flags

Diagnosis of Clinically Probable PD requires:
1. Absence of absolute exclusion criteria
2. Presence of red flags counterbalanced by supportive criteria

If 1 red flag is present, there must also be at least 1 supportive criterion
If 2 red flags, at least 2 supportive criteria are needed
No more than 2 red flags are allowed for this category

Supportive criteria
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 metaiodobenzylguanidine (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 within the first 5 y of disease
  4. Parkinsonian features restricted to the lower limbs for more than 3 y
  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 5 y of onset
  2. A complete absence of progression of motor symptoms or signs over 5 y or more y 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 5 y
  4. Inspiratory respiratory dysfunction: either diurnal or nocturnal inspiratory stridor or frequent inspiratory sighs
  5. Severe autonomic failure in the first 5 y of disease. This can include:
    a) Orthostatic hypotension: orthostatic decrease of blood pressure within 3 min of standing by at least 30 mm Hg systolic or 15 mm Hg 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 5 y of disease (excluding long-standing or small amount stress incontinence in women), that is not simply functional incontinence. In men, urinary retention must not be attributable to prostate disease, and must be associated with erectile dysfunction
  6. Recurrent (>1/y) falls because of impaired balance within 3 y of onset
  7. Disproportionate anterocollis (dystonic) or contractures of hand or feet within the first 10 y
  8. Absence of any of the common nonmotor features of disease despite 5 y 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



  1. Postuma RB, Berg D, Stern M, Poewe W, Olanow CW, Oertel W, Obeso J, Marek K, Litvan I, Lang AE, Halliday G, Goetz CG, Gasser T, Dubois B, Chan P, Bloem BR, Adler CH, Deuschl G. MDS clinical diagnostic criteria for Parkinson’s disease. Mov Disord. 2015 Oct;30(12):1591-601. [Medline]
  2. Mahlknecht P, Gasperi A, Willeit P, Kiechl S, Stockner H, Willeit J, Rungger G, Sawires M, Nocker M, Rastner V, Mair KJ, Hotter A, Poewe W, Seppi K. Prodromal Parkinson’s disease as defined per MDS research criteria in the general elderly community. Mov Disord. 2016 Sep;31(9):1405-8. [Medline]

Created Mar 16, 2018.

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