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Schwab and England Activities of Daily Living Scale
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Supplemental - Highly Recommended: Parkinson's Disease (PD)
Recommendations for use: Indicated for studies requiring a global assessment of Parkinson's Disease.
Short Description of Instrument
The Schwab and England Activities of Daily Living Scale estimates the abilities of individuals living with a disease relative to a range of life activities spanning from a bedridden, vegetative state (the lowest score of 0%) to complete independence of function (the highest score of 100%). The percentage score is typically determined by an examiner based on the patient's description of abilities and limitations in routine life activities. Often the patient view is integrated with that of a corroborating informant like spouse or caregiver who participates in the activities, as well as with the examiner's clinical impression.
Comments/Special Instructions
The scale focuses on independence in practical, real-life activities with most gradations presented in the context of "chores". It also emphasizes movement with different levels of function distinguished by degree or nature of "slowness", supporting its utility in motor system disorders like Parkinson's disease and amyotrophic lateral sclerosis. However, it can be applied to non-motor disorders or dysfunction given that slowing can reflect disability from primary cognitive as well as movement disorders.
While the scale is typically a holistic estimate of the patient's current or recent ability to perform activities of daily living, pairs of scores can be determined for the range of their abilities that covers from "worst" to "best", or more commonly in Parkinson's disease, from "off" to "on" with respect to the beneficial effects of dopaminergic anti-parkinsonian medication.
Although scoring traditionally has been performed by clinical research or care staff member interviewing the patient - either as part of a research protocol or routine clinical care, it can also be performed by the patient, constituting a directly patient-reported outcome.
Scoring and Psychometric Properties
Scoring: Whereas the original scale publication alludes to ratings at any number between 0 and 100%, the scale is practically applied most often using scores at 5 or 10% increments, because specific written anchors are provided for each 10% change.  
Psychometric Properties: The standardization of the administration of the scale is not specifically addressed in the original document. Physicians, patients, and caregivers have participated to varying degrees in the final score.
The scale has adequate inter-rater reliability between physicians and patients (ICC=0.65) (McRae et al., 2002).
  • Simple and intuitive
  • Correlates with Unified Parkinson's Disease Rating Scale's (UPDRS) patient-reported Experiences of Daily Living, particularly the Motor subset (UPDRS M-EDL)
  • Part (VI) of the original UPDRS
  • Available in multiple languages
  • Uncertainty over key descriptors; e.g., "chores"
  • Limited standardization and variable application across studies with respect to:
    • who administers (physician, nurse, research coordinator, fellow, caregiver, patient, or no one specifically)
    • who determines the score (physician, nurse, research coordinator, fellow, caregiver, patient, or a combination)
    • whether or not scale increment descriptions are presented during score determinations
    • whether scores are determined on or off antiparkinsonian medication

Key Reference:
Schwab RS, England ACJ. (1969) Projection technique for evaluating surgery in Parkinson's disease. In: Gillingham FJ, Donaldson IML, editors. Third Symposium on Parkinson's Disease. Edinburgh, Scotland: E & S Livingstone, pp.152-157.
Additional References:
Bhidayasiri R, Martinez-Martin P. Clinical Assessments in Parkinson's Disease: Scales and Monitoring. Int Rev Neurobiol. 2017;132:129-182.
Bjornestad A, Tysnes OB, Larsen JP, Alves G. Reliability of Three Disability Scales for Detection of Independence Loss in Parkinson's Disease. Parkinsons Dis. 2016;2016:1941034.
Lang AE, Eberly S, Goetz CG, Stebbins G, Oakes D, Marek K, Ravina B, Tanner CM, Shoulson I; LABS-PD investigators. Movement disorder society unified Parkinson disease rating scale experiences in daily living: longitudinal changes and correlation with other assessments. Mov Disord. 2013 Dec;28(14):1980-6.
McRae C, Diem G, Vo A, O'Brien C, Seeberger L. Schwab & England: standardization of administration. Mov Disord. 2000 Mar;15(2):335-6.
McRae C, Diem G, Vo A, O'Brien C, Seeberger L. Reliability of measurements of patient health status: a comparison of physician, patient, and caregiver ratings. Parkinsonism Relat Disord. 2002 Jan;8(3):187-92.
Perlmutter JS. (2009) Assessment of Parkinson disease manifestations. Curr Protoc Neurosci. 2009 Oct; Chapter 10: Unit 10.1.
Document last updated August 2022