Unifying Concepts

Diagnostic Criteria for Parkinson’s Disease (PD)

United Kingdom Parkinson’s Disease Society Brain Bank Diagnostic Criteria for Parkinson’s Disease

Step 1: Diagnosis of Parkinsonism

Bradykinesia and at least one of the following:

  • Muscular rigidity

  • 4–6 Hz resting tremor

  • Postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction

Step 2: Features tending to exclude Parkinson’s disease as the cause of Parkinsonism

  • History of repeated strokes with stepwise progression of parkinsonian features

  • History of repeated head injury

  • History of definite encephalitis

  • Neuroleptic treatment at onset of symptoms

  • >1 affected relatives

  • Sustained remission

  • Strictly unilateral features after 3 years

  • Supranuclear gaze palsy

  • Cerebellar signs

  • Early severe autonomic involvement

  • Early severe dementia with disturbances of memory, language and praxis

  • Babinski’s sign

  • Presence of a cerebral tumour or communicating hydrocephalus on computed tomography scan

  • Negative response to large doses of levodopa (if malabsorption excluded)

  • 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) exposure

Step 3: Features that support a diagnosis of Parkinson’s disease (three or more required for diagnosis of definite Parkinson’s disease)

  • Unilateral onset

  • Rest tremor present

  • Progressive disorder

  • Persistent asymmetry affecting the side of onset most

  • Excellent (70–100%) response to levodopa

  • Severe levodopa-induced chorea

  • Levodopa response for ?5 years

  • Clinical course of ?10 years

Criteria of diagnosis of Parkinson disease (Gelb et al, 1999) commissioned and supported by the Advisory Council of the National Institute of Neurological Disorders and Stroke, US National Institutes of Health.

Grouping of clinical features of Parkinson’s disease according to diagnostic utility

GROUP A: Features characteristic of Parkinson disease

  • Resting tremor

  • Bradykinesia

  • Rigidity

  • Asymmetric onset

GROUP B: Features suggestive of alternative diagnoses

  • Features unusual early in the clinical course

  • Prominent postural instability in the first 3 years after symptom onset

  • Freezing phenomena in the first 3 years

  • Hallucinations unrelated to medications in the first 3 years

  • Dementia preceding motor symptoms or in the first year

  • Supranuclear gaze palsy (other than restriction of upward gaze) or slowing of vertical saccades

  • Severe, symptomatic dysautonomia unrelated to medications

  • Documentation of a condition known to produce Parkinsonism and plausibly connected to the patient’s symptoms (such as suitably located focal brain lesions or neuroleptic use within the past 6 months)

Criteria for POSSIBLE diagnosis of Parkinson’s disease

At least 2 of the 4 features in Group A are present; at least 1 of these is tremor or bradykinesia

And either:

  • none of the features in Group B is present

  • or symptoms have been present for less than 3 years, and none of the features in Group B is present to date

And either:

  • substantial and sustained response to levodopa or a dopamine agonist has been documented

  • or patient has not had an adequate trial of levodopa or dopamine agonist

Criteria for PROBABLE diagnosis of Parkinson’s disease

At lest 3 of the 4 features in Group A are present

And none of the features in Group B is present (note: symptom duration of at least 3 years is needed to meet this requirement)

And substantial and sustained response to levodopa or a dopamine agonist has been documented

Criteria for DEFINITE diagnosis of Parkinson’s disease

All criteria for POSSIBLE Parkinson disease are met

And histopathological confirmation of the diagnosis is obtained at autopsy


Proposed criteria for histopathological confirmation of Parkinson disease

  • Substantial nerve cell depletion with accompanying gliosis in the substantia nigra

  • At least 1 Lewy body in the substantia nigra or in the locus coeruleus (note: it may be necessary to examine up to 4 non-overlapping sections in each of these areas before concluding that Lewy bodies are absent)

  • No pathological evidence for other diseases that produce Parkinsonism (eg progressive supranuclear palsy, multiple system atrophy, cortical–basal ganglionic degeneration) (Note: in excluding other diseases that produce Parkinsonism, published consensus criteria should be used when available)



  1. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992 Mar;55(3):181-4. [Medline]

  2. Gelb DJ, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease. Arch Neurol. 1999 Jan;56(1):33-9. [Medline]


Created: June 27, 2006

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