MDS-UPDRS Part III (Motor Examination): 18 Items, Scoring and ON/OFF States
In short
The MDS-UPDRS Part III is the international standard motor assessment for Parkinson disease. Learn testing protocols, item scoring, rigidity grading and MCID values.
In this guide (4 sections)
What Is the MDS-UPDRS Part III?
The Movement Disorder Society-Unified Parkinson Disease Rating Scale (MDS-UPDRS) was revised by Goetz et al. in 2007 to provide a globally standardized clinical assessment for Parkinson disease.
Part III of the scale is the Motor Examination, consisting of 18 items (yielding 33 separate observational scores) evaluating tremor, rigidity, bradykinesia, postural stability, gait and facial expression.
The 5-Point Ordinal Scoring System
Each of the 33 motor observations is scored from 0 to 4:
0 = Normal (no impairment); 1 = Slight (detectable but no functional impact); 2 = Mild (noticeable impairment, mild fatigue); 3 = Moderate (significant impairment, difficulty executing); 4 = Severe (barely able or unable to execute).
| Item Number | Motor Feature Evaluated | Standard Clinical Examination Protocol | |
|---|---|---|---|
| 3.1 to 3.3 | Speech, Facial Expression, Rigidity | Evaluate hypophonia, hypomimia; passive rotation of neck, wrists, elbows, knees and ankles. | |
| 3.4 to 3.8 | Bradykinesia: Finger Taps, Hand Movements, Leg Agility | 10 rapid repetitions of index finger tapping, hand opening/closing, pronation/supination, heel tapping. | |
| 3.9 to 3.12 | Arising from Chair, Posture, Gait, Freezing | Arising from armless chair with crossed arms; evaluate stooped camptocormia, stride length and freezing episodes. | |
| 3.13 to 3.14 | Postural Stability (Pull Test), Body Bradykinesia | Sudden backward shoulder displacement; count retro-steps (normal <=2 steps). Global slowness of transitions. | |
| 3.15 to 3.18 | Postural, Action and Rest Tremor | Arms outstretched, finger-to-nose kinetic tremor, resting amplitude in all 4 limbs and jaw. |
ON vs OFF Medication States and MCID
To capture true motor fluctuations, the MDS-UPDRS Part III should document the patient medication state:
The defined OFF state occurs after withholding dopaminergic medications overnight (typically 12 hours). The ON state reflects peak therapeutic response (usually 45 to 60 minutes post-levodopa dose).
- Minimal Clinically Important Difference (MCID): Shulman et al. established that an improvement of 3.25 to 4.63 points represents a clinically meaningful difference.
- Dopaminergic responsiveness: An improvement of 30% or more between OFF and ON motor scores indicates marked levodopa responsiveness, typical of idiopathic Parkinson disease.
- Maximum Motor Score: 132 points. Most outpatient physiotherapy candidates score between 20 and 55 points in the ON state.
Frequently Asked Questions
How is rigidity scored if resting resistance is equivocal?
Use the Froment maneuver: ask the patient to perform voluntary movements with the contralateral limb (such as wrist circles or tapping). Contralateral activation unmasks cogwheel rigidity.
What is the correct protocol for the Pull Test (Item 3.14)?
Explain the test beforehand and allow one practice trial. Stand behind the patient, apply a quick, firm backward pull on the shoulders with sufficient force to displace the centre of gravity. Grade 0 is 1 to 2 recovery steps; Grade 1 is 3 to 5 steps; Grade 2 is >5 steps; Grade 3 requires examiner catch; Grade 4 is spontaneous fall.
How does high-amplitude physiotherapy (LSVT BIG) impact MDS-UPDRS scores?
Clinical trials demonstrate that 4 weeks of intensive amplitude-based training (LSVT BIG) reduces MDS-UPDRS Part III motor scores by an average of 5 to 7 points.
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