Expanded and Independent Spanish Validation of the MDS‐Non Motor Rating Scale

Expanded and Independen Spanish Valida ion o he MDS-Non Mo o Ra ing Scale Es he Cubo, MD, PhD, 1,2, *Sheng Luo, PhD, 3 Pablo Ma ínez-Ma ín, MD, PhD, 4 Glenn T. S ebbins, PhD, 5 Je ey Lin, PhD, 3 Dong ak Choi, PhD, 3 Al a o Ga cía-Bus illo, PhD, 6 Pablo Mi , MD, PhD, 4,7,8 Diego San os-Ga cia, MD, PhD, 9 Ma cos Se ano-Dueñas, MD, PhD, 10 Mayela Rod iguez-Violan e, MD, 11 Ca los Singe , MD 12 and he Spanish MDS-NMS Valida ion S udy G oup Abs ac : Backg oundBackg ound: The Mo emen Diso de Socie y-sponso ed Non-mo o Ra ing Scale (MDS-NMS) assess he se e i y and disabili y caused by non-mo o symp oms (NMS) in Pa kinson’s disease (PD). Objec i eObjec i e: This a icle encapsula es he o mal p ocess o comple ing his p og am and he da a on he fi s o ficially app o ed non-English e sion o he MDS-NMS (Spanish). Me hodsMe hods: The MDS-NMS ansla ion p og am in ol es ou s eps: ansla ion and back- ansla ion; cogni i e p e- es ing o ensu e ha a e s and pa ien s unde s and he scale and a e com o able wi h i s con en ; field es ing o he finalized e sion; analysis o he ac o s uc u e o he es ed e sion agains he o iginal English language e sion o he nine domains ha could be analyzed in a confi ma o y ac o analysis. To be designa ed an “O ficial MDS ansla ion,” he confi ma o y ac o analysis Compa a i e Fi Index had o be ≥0.90. Resul sResul s: The Spanish MDS-NMS was es ed in 364 na i e-Spanish-speaking pa ien s wi h PD om se en coun ies. Fo all subjec s wi h ully compu able da a wi h all domains o he MDS-NMS (n=349), he Compa a i e Fi Index was ≥0.90 o he nine eligible domains. Missing da a we e negligible and mode a e floo e ec (42.90%) was ound o he Non-Mo o Fluc ua ions subscale. I em homogenei y coe ficien was adequa e, and he co ela ion o he MDS-NMS domains wi h o he measu es o ela ed cons uc s was accep able ( s ≥0.50). ConclusionsConclusions: The Spanish e sion o he MDS-NMS ollowed he IPMDS T ansla ion P og am p o ocol, eached he c i e ion o be designa ed as an O ficial T ansla ion, and is now a ailable on he MDS websi e. Non-mo o symp oms (NMS) a e an impo an ac o o he de e io a ion o he heal h- ela ed quali y o li e (QoL) o pa ien s wi h Pa kinson’s disease (PD). 1,2 NMS bu den inc eases in hei se e i y o e ime, impac ing on pa ien s’disabili y, ca e- gi e s’bu den, and socie al cos s. 3 Assessmen o NMS in PD a e now c ucial o alue-based heal h ca e and ecommended by pa ien -led o ganiza ions and he In e na ional Pa kinson and Mo emen Diso de Socie y (IPMDS). 4 The IPMDS non-Mo o PD S udy G oup ecen ly de eloped and alida ed he In e na- ional Pa kinson and Mo emen Diso de Socie y-Non Mo o Ra ing Scale (MDS-NMS) in English, an upda ed e sion o he Non-Mo o Symp om Scale (NMSS). 5,6 The MDS-NMS was alida ed o use in PD using a sample o 402 English-speaking PD pa ien s om Ame ica and England. 1 Neu ology Depa men , Complejo Asis encial Uni e si a io de Bu gos, Bu gos, Spain; 2 Heal h Science Depa men , Uni e si y o Bu gos, Bu gos, Spain; 3 Depa men o Bios a is ics & Bioin o ma ics, Duke Uni e si y, Du ham, No h Ca olina, USA; 4 CIBERNED (Cen o de In es igacion Biomédica en Red En e medades Neu odegene a i as), Mad id, Spain; 5 P o esso Eme i us, Neu ological Sciences Rush Uni e si y Medical Cen e , Chicago, Illinois, USA; 6 Resea ch Uni , Complejo Asis encial Uni e si a io de Bu gos, Bu gos, Spain; 7 Unidad de T as o nos del Mo imien o, Se icio de Neu ología y Neu ofisiología Clínica, Ins i u o de Biomedicina de Se illa, Hospi al Uni e si a io Vi gen del Rocío/CSIC/Uni e sidad de Se illa, Se illa, Spain; 8 Depa amen o de Medicina, Facul ad de Medicina, Uni e sidad de Se illa, Se illa, Spain; 9 Complejo Hospi ala io Uni e si a io de A Co uña (CHUAC), A Co uña, Spain; 10 Facul ad de Medicina, Pon ificia Uni e sidad Ca olica del Ecuado , Qui o, Ecuado ; 11 Mo emen Diso de s Clinic, Na ional Ins i u e o Neu ology and Neu osu ge y, Mexico Ci y, Mexico; 12 Leona d M. Mille School o Medicine, Uni e si y o Miami, Miami, Flo ida, USA *Co espondence o: D . Es he Cubo, Neu ology Depa men . Hospi al Uni e si a io Bu gos, A da Islas Balea es 3, Bu gos, 09006, Spain; E-mail: [email p o ec ed] Keywo ds: non-mo o symp oms, a ing scale, Pa kinson’s disease. This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion-NonComme cial-NoDe i s License, which pe mi s use and dis ibu- ion in any medium, p o ided he o iginal wo k is p ope ly ci ed, he use is non-comme cial and no modifica ions o adap a ions a e made. Recei ed 2 No embe 2022; accep ed 8 Janua y 2023. Published online 13 Ma ch 2023 in Wiley Online Lib a y (wileyonlinelib a y.com). DOI: 10.1002/mdc3.13658 586 MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 © 2023 The Au ho s. Mo emen Diso de s Clinical P ac ice published by Wiley Pe iodicals LLC on behal o In e na ional Pa kinson and Mo emen Diso de Socie y. RESEARCH ARTICLE CLINICAL PRACTICE Gi en he impo ance o NMS bu den in PD, ha ing a scale ha is alida ed in mul iple non-English languages is pi o al o in e na ional e o s o ea NMS. To ob ain equi alen and locally alida ed non-English e sions o he MDS-NMS, a T ansla ion P og am P o ocol has been es ablished by he IPMDS (www.mo emen diso de s.o g). 7 The objec i e o his s udy was o o ganize and pe o m an independen alida ion o he MDS-NMS Spanish e sion ollowing he IPMDS me hod- ology o he ansla ion and alida ion p ocess. 8 Me hods S udy Design and Pa ien s This was an in e na ional, mul icen e , obse a ional, c oss- sec ional s udy. We in i ed o pa icipa ion, Spanish-speaking pa ien s om 14 Mo emen Diso de s Uni s om Spain, and eigh cen e s om No h, Cen al, and Sou h Ame ica (Mexico, A gen ina, Colombia, Ecuado ) and Uni ed S a es (Miami Flo - ida and Boca Ra on, Flo ida) a any age and disease s age, diag- nosed wi h idiopa hic PD as pe he MDS-PD c i e ia, 9 and wi hou significan cogni i e impai men acco ding o he judg- men o he e alua ing neu ologis and a Mon eal Cogni i e Assessmen (MOCA) sco e > 21. 10 E hical Aspec s Each si e con ibu ing o he s udy ecei ed app o al o i s espec i e e hics commi ee/IRB o pa icipa ion, and he s udy was conduc ed acco ding o Good Clinical P ac ice. 11 Pa ien s p o ided signed in o med consen be o e pa icipa ing in his s udy. Ra e s Neu ologis s, membe s o he IPMDS, we e in i ed by email o pa icipa e in his p ojec . Sample Size The sample size o he ansla ion s udy was based on he need o fi e subjec s pe i em o he ques ionnai e o pe o m he s a- is ical analysis. 12 Because he e a e 60 i ems (52 MDS-NMS i ems and 8 nonmo o fluc ua ions i ems) on he MDS-NMS, a sample o a leas 300 was equi ed. Assessmen s Socio-demog aphic, p edominan hemi-body a ec ed by PD, cu en use o an ipa kinsonian d ugs including he le odopa- equi alen daily dose (LEDD), 13 and o he ea men s, and PD his o ical da a we e ob ained h ough an ad hoc ques ionnai e. In addi ion, he ollowing a ing scales we e adminis e ed: 1. MDS-NMS (see Appendix): A e he pilo s udy, 5 he final e sion o he MDS-NMS has 52 i ems, g ouped acco ding o clinical con en in o 13 domains: (A) Dep ession (5 i ems), (B) Anxie y (4 i ems), (C) Apa hy (3 i ems), (D) Psychosis (4 i ems), (E) Impulse Con ol and Rela ed Diso de s (4 i ems), (F) Cogni ion (6 i ems), (G) O hos a ic Hypo ension (2 i ems), (H) U ina y (3 i ems), (I) Sexual (2 i ems), (J) Gas oin es inal (4 i ems), (K) Sleep and Wake ulness (6 i ems), (L) Pain (4 i ems), and (M) O he (5 i ems; unin en ional weigh loss, dec eased smell, physical a igue, men al a igue, and excessi e swea ing). I ems a e sco ed o equency ( om 0 [ne e ] o 4 [majo i y o ime]) and se e i y ( om 0 [no p esen ] o 4 [se e e]), which a e mul iplied o gene a e he i em o al sco e. Sco es o each domain and he o al a ing scale (maximum, 832 poin s) a e cal- cula ed by summing he co esponding i ems. The Non-Mo o Fluc ua ions (NMF) subscale has eigh i ems: dep ession, anxie y, hinking o cogni i e abili ies, bladde symp- oms, es lessness, pain, a igue, and excessi e swea ing. Each i em is sco ed o ypical deg ee o change om “on” o “o ” pe iods, om 0 (no change) o 4 (la ge). The sum o deg ee o change o he eigh i ems is mul iplied by he amoun o ime spen in he “o ”s a e wi h NMS, which anges om 1 ( a ely) o 4 (majo i y o ime). Maximum possible sco e is 128. 2. MDS-Unified Pa kinson’s Disease Ra ing Scale (MDS- UPDRS): The MDS-UPDRS includes ou pa s: pa I, Non- mo o Aspec s o Expe iences o Daily Li ing (nM-EDL); pa II, Mo o Aspec s o Expe iences o Daily Li ing (M-EDL); pa III, Mo o Examina ion (ME); and pa IV, Mo o Complica ions (MCompl). In addi ion, i con ains he Hoehn and Yah scale (HY), a ool o s aging he se e i y o PD. 14 3. Wea ing O Ques ionnai e-19 (WOQ-19): This ques ionnai e includes nine i ems assessing mo o fluc ua ions including emo , di ficul y in speech, weakness, p oblems wi h balance, slowness, educed dex e i y, gene al s i ness, muscle c amps, di ficul y ge - ing ou o he chai (WOQ-19 Mo o sco e); and 10 i ems e al- ua ing non-mo o fluc ua ions including anxie y, swea ing, mood changes, numbness, panic a acks, cloudiness o mind, abdominal discom o , eeling ho and cold, aches and pain (WOQ-19 Non-mo o sco e). 15 Fo each i em, pa ien s we e asked o check whe he symp oms we e p esen and whe he hey imp o ed a e he ollowing dose o dopamine gic ea - men : a cu o o 2 o he WOQ-19 To al sco e indica ed a diagnosis o gene ic wea ing o , 15 while a cu o o 1 o ei he he WOQ-19 Mo o o Non-mo o sco e specifically disclosed a diagnosis o mo o o non-mo o fluc ua ions, espec i ely. P ocedu e Assessmen s we e pe o med du ing he “on”s a e when possible, and pa ien assessmen s be ween all cen e s we e ha monized. Phases in he de elopmen o he Spanish e sion o he MDS-NMS ollowed he p esc ibed p o ocol es ablished by he IPMDS o o ficial ansla ions o he MDS-NMS: 1. T ansla ion, back- ansla ion, compa ison wi h he o iginal, and amendmen s o he scale ex . A o wa d ansla ion was de el- oped by a hi d-pa y ansla ion company expe ienced in he ansla ion o a ing scales and e iewed by he Spanish MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 587 CUBO E. ET AL. RESEARCH ARTICLE 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License T ansla ion Commi ee c ea ed o his p ojec . All wo ding was selec ed o mee he c i e ion o being a he 7 h g ade eading le el. Documen s we e e iewed by he adminis a- i e eam and e iewe s independen o he Spanish o ga- nize s, and a d a ansla ed scale was de eloped based on eedback. The back- ansla ion ob ained om a hi d-pa y ansla ion company was e iewed by he MDS T ansla ion S ee ing Commi ee, and he ansla ion was hen p o ision- ally app o ed o Cogni i e P e- es ing. 2. Cogni i e p e- es ing: This is a quali a i e app oach o assessing ins umen comple ion ega ding ask di ficul y o examine and esponden , and esponden in e es , a en ion span, dis- com o , and comp ehension. 16 The p o isionally app o ed ansla ion was adminis e ed o 20 PD pa ien s and ou a e s o cogni i e p e- es ing. This phase iden ifies po en ially cul- u ally sensi i e o complex i ems. 17 Based on he esul s o he ini ial cogni i e p e es ing, o he ound(s) o ansla ion, back ansla ion and cogni i e p e es ing could be equi ed. Once cogni i e p e es ing was comple ed and no u he p oblems we e no ed, he final ansla ion could be app o ed as “O ficial Wo king Documen ”. 3. Field es ing: I was conduc ed on a la ge sample o an in e na- ional sample o na i e Spanish speake s. 4. S a is ical analyses, including alidi y es ing, ac o and clinime ic analyses. Da a Analysis We conduc ed he ollowing analyses. P ima y Analyses Da a quali y which was es ablished a e checking o missing da a (accep able, <5%). 18 Cogni i e P e es ing: Da a om he esponden s ( a e s and pa ien s) we e analyzed using a amewo k app oach. 19 A ea o exp essed di ficul we e examined and changes o he scale we e made i necessa y. Fac o Analysis: R (Ve sion 4.2.0) packages la aan and psych we e used o do he p ima y confi ma o y and seconda y explo a o y ac o analyses, espec i ely. We used an adjus ed weigh ed leas squa e (WLSMV) app oach o ac o es ima ion ha minimizes he weigh ed sum o squa ed di e ences be ween obse ed and es i- ma ed co ela ion ma ices no coun ing diagonal elemen s. To assis in in e p e a ion o he ac o s we used an o hogonal VARIMAX o a ion ha cons ains he ac o s o be unco ela ed. Any pa icipan s wi h missing alues we e dele ed om analysis o ha domain only. Thus, he sample size om domain o domain could a y. The in es iga o s ob ained pa icipan s’app o al o col- lec he da a. Da a wi hou pa ien names o medical eco d num- be s we e ans e ed o he analy ic eam ia a secu e websi e. Confi ma o y ac o analysis (CFA): CFA was used o de e mine i he ac o s uc u e o he English language MDS-NMS 20 could be confi med in da a collec ed using he Spanish ansla ion. We e alua ed he CFA esul s based on he Compa a i e Fi Index (CFI) o only nine o he subscales wi h mo e han h ee i ems. 21 Because wo i ems (as in O hos a ic Hypo ension and Sexual sub- scales) and h ee i ems (as in Apa hy and U ina y subscales) lead o unde -iden ified and sa u a ed models, espec i ely, we could no ob ain alid model fi esul s. The e o e, CFAs we e conduc ed o each o he 10 subscales (nine domains o he MDS-NMS plus he NMF subscale) ha me his equi emen . Acco ding o he p o o- col, o es ablish a success ul ansla ion and o designa e ha ansla- ion as an O ficial MDS ansla ion o he MDS-NMS, we equi ed ha he CFI o each eligible subscale o he ansla ed MDS- NMS be 0.90 o g ea e ela i e o he English language e sion. Mean and a iance adjus ed weigh ed leas squa e (WLSMV) es ima o was used o confi m model fi . Seconda y Analysis Explo a o y Fac o Analysis (EFA): We conduc ed EFA o each o he subscales (13 domains o he MDS-NMS plus he NMF sub- scale) o explo e he unde lying ac o s uc u e wi hou he con- s ain o a p e-specified ac o s uc u e, and once he ac o s we e chosen, an i em was e ained in a ac o i he ac o loading o ha i em was 0.40 o g ea e . We used he o hogonal VARIMAX o a ion o assis he in e p e a ion o he ac o s, which se s he ac o s o be unco ela ed. Te ia y Analysis We used he IBM-SPSS .28 o hese s a is ical analyses. The p ima y a iables in he s udy had non-no mal dis ibu ion (Shapi o–Wilk Tes , all p < 0.001). To es ablish he homogene- i y o he included PD sample, we compa ed he main sociodemog aphic and clinical cha ac e is ics using he Fishe ’s exac and chi-squa ed es o ca ego ical a iables and T-S u- den , ANOVA, Mann–Whi ney U, and K uskall-Wallis es s, based on he no mal and non-no mal dis ibu ion o he nume i- cal a iables, espec i ely. P e alence o NMS was based on sco es ≥1 in each MDS- NMS i em, domain, and o al scale, deno ing he p esence o a symp om (0 =no symp om p esen ). Fo compa ison, he p e a- lence o NMS assessed wi h he MDS-UPDRS and WOQ-19 NMS was ob ained using he same me hod. Following he o iginal English alida ion p ocedu e, 6 we assessed he ollowing clinime ic p ope ies: Accep abili y:Floo and ceiling e ec (sa is ac o y h eshold, ≤15%) 22 ; skewness (c i e ion alues, om 1 o+1) 23 ; and ange o obse ed e - sus heo e ical alues; In e nal consis ency: Fo each domain (1) in e i em co ela ion (s anda d alues, 0.20–0.75) 24 ;(2)i em homogenei y coe ficien calcula ed as he a e age co ec ed i em- o al in e i em co ela ion by domain (s anda d, 0.15 o b oad domains) 25 ; (3) co ec ed i em- o al co ela ion (s anda d, ≥0.40) 18 ; and (4) C onbach’sα(s anda d, ≥0.70) 22 ;Hypo heses es ing: Fo con e gen alidi y, we hypo hesized ha MDS- NMS domains would be highly associa ed (Spea man ank co - ela ion coe ficien alue, s >0.50), 26 wi h co esponding com- ponen s o he MDS-UPDRS pa 1, and NMF subscale wi h heWOQ-19NMS,andmode a eo weakco ela ion ( s =0.20–0.50) wi h o he PD se e i y measu es. The known- 588 MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 RESEARCH ARTICLE MDS-NMS 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License g oups alidi y o he MDS-NMS and NMF was es ed by de e mining he di e ence in o al sco es o subg oups based on sex, age, PD du a ion, HY, p edominan hemibody a ec ed, and LEDD. To p o ide simila desc ip i e esul s compa ed wi h he o iginal alida ion, 6 we s a ified he popula ion in simila e iles. Resul s Sample Cha ac e is ics We included 364 PD pa ien s, 160 (44%) om Spain and 204 om No h, Cen al, and Sou h Ame ica (56%). Cen e s p o ided be ween 5 and 45 cases o he s udy coho . When he PD sample om Spain was compa ed o he Ame ican PD sam- ple, no significan di e ences we e ound in e ms o age (P=0.39), PD du a ion (P=0.11), educa ion (P=0.84), and gende (P=0.52), excep o highe HY s age in he Ame ican PD sample (P< 0.001). Sociodemog aphic and clinical cha ac- e is ics a e de ailed in Table 1. Cogni i e P e es ing The esponses om he 20 pa ien s and 4 a e s (samples o 5 pa ien s and 1 a e each om A gen ina, Mexico, Spain, and he Uni ed S a es) we e colla ed and subjec ed o amewo k analyses iden i ying common hemes and conce ns. No majo conce ns o p oblems we e iden ified, and he final ansla ion was designa ed an O ficial Wo king Documen and app o ed o use in he alida ion phase. P ima y Analyses Da a quali y: Fully compu able da a we e a ailable in 349 subjec s (96%) o all domains o he MDS-NMS, one subjec (0.3%) had missing da a in he dep ession domain, one subjec (0.3%) had missing da a in he impulsi e con ol and ela ed diso de s, TABLE 1 Demog aphic da a o Spanish speaking popula ion (N=364) Male, N(%) 211 (58.0) E hnici y, N(%) Ame ican Hispanic/Spania d 338 (92.9) Race, N(%) Whi e 243 (66.8) O he 118 (32.4) Ma ied (%) 263 (72.70) Li ing wi h amily (%) 315 (86.5) Age, yea s, Mean (SD) 64.12 (10.28) PD du a ion, yea s, Mean (SD) 8.80 (7.20) Educa ion, yea s, Mean (SD) 12.35 (4.89) To al le odopa daily equi alen dose, Mean (SD) 847.67 (457.44) An idep essan s, yes (%) 98 (26.90) Anxioly ics, yes (%) 78 (21.40) An ipsycho ics, yes (%) 10 (2.7) U ina y dis u bances ea men (%) 11 (3.00) Sleep dis u bances ea men (%) 32 (8.80) HY s age, N(%) 1 18 (4.9) 2 238 (65.3) 3 90 (24.7) 4 18 (4.9) MDS-NMS, Mean (SD) [ ange] Dep ession 8.44 (13.79) [0–80] Anxie y 8.62 (10.73) [0–64] Apa hy 4.34 (7.56) [0–48] Psychosis 1.65 (5.34) [0–60] Impulse con ol diso de 1.73 (4.31) [0–60] Cogni ion 8.75 (12.42) [0–88] O hos a ic Hypo ension 1.90 (3.74) [0–32] U ina y 8.94 (10.69) [0–48] Sexual 4.41 (7.46) [0–32] Gas oin es inal 7.82 (8.50) [0–38] Sleep 11.66 (11.64) [0–80] Pain 7.72 (8.59) [0–49] O he s 12.10 (10.86) [0–57] NMS To al 88.07 (73.47) [1–489] NMF To al 10.41 (14.55) [0–88] (Con inues) TABLE 1 Con inued MDS-UPDRS Mean (SD) [ ange] Pa 1 11.26 (7.55) [0–38] Pa 2 12.71 (9.59) [0–44] Pa 3 31.27 (18.63) [1–105] Pa 4 4.39 (4.48) [0–20] WOQ-19 To al Mean (SD) [ ange] 14.00 (2.49) [8–16] WOQ-19 MS Mean (SD) [ ange] 18.50 (3.72) [13–22] WOQ-19 NMS Mean (SD) [ ange] 33.00 (5.93) [25–38] Abb e ia ions: SD, s anda d de ia ion; PD, Pa kinson’s Disease; HY, Hoehn and Yah ; MDS-NMS, Mo emen Diso de Socie y–sponso ed Nonmo o Ra ing Scale; MDS-UPDRS, Mo emen Diso de Socie y–sponso ed Unified Pa kinson’s Disease Ra ing Scale; WOQ-19 =Wea ing O Ques ionnai e-19 i ems. MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 589 CUBO E. ET AL. RESEARCH ARTICLE 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License cogni ion, and o hos a ic hypo ension domains, h ee subjec s (0.8%) in he u ina y and sexual dys unc ion domains, and h ee subjec s (0.8%) in he sleep and wake ulness, pain and o he domains, espec i ely. Fac o analysis: Table S1 displays he CFA esul s o each o he10eligiblesubscales(9domainso heMDS-NMSplus he NMF subscale). All 10 subscales o he Spanish MDS- NMS sa isfied ou p e-specified c i e ion o Compa a i e Fi Index ≥0:90 in compa ison wi h he English-language ac o s uc u e. Seconda y Analyses Explo a o y Fac o Analysis: The esul s o he EFA displaying he ac o s uc u es o esul s o all domains o he MDS-NMS and heNMFsubscalea eincludedin heTableS2andFigu e1. Te ia y Analyses Da a Accep abili y: The MDS-NMS o al sco es showed no signi - ican floo and ceiling e ec s (0.50%, 0.30%, espec i ely), bu FIG 1. Sc ee plo s o i ems A o M o he MDS-NMS. 590 MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 RESEARCH ARTICLE MDS-NMS 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License TABLE 2 Da a Accep abili y Domains Mean (SD) Median ( ange) Skewness Floo (%) Ceiling (%)N=364 Dep ession 8.44 (13.79) 3.00 [0–80) 2.60 32.10 0.50 Anxie y 8.62 (10.73) 4.00 [0–64) 2.11 19.80 0.50 Apa hy 4.34 (7.56) 1.00 [0–48] 2.79 47.80 0.50 Psychosis 1.65 (5.34) 0.00 [0–60] 6.47 76.10 0.30 IC and ela ed diso de s 1.73 (4.31) 0.00 [0–60] 3.73 72.80 0.30 Cogni ion 8.75 (12.42) 4.00 [0–88] 2.85 21.40 0.30 O hos a ic hypo ension 1.90 (3.74) 0.00 [0–32] 3.75 57.10 0.30 U ina y 8.94 (10.69) 4.00 [0–48] 1.45 26.40 1.10 Sexual 4.41 (7.46) 0.00 [0–32] 2.09 57.70 3.00 Gas oin es inal 7.82 (8.50) 5.00 [0–38] 1.26 19.50 0.30 Sleep and wake ulness 11.66 (11.64) 8.00 [0–80] 1.85 8.00 0.30 Pain 7.72 (8.59) 6.00 [0–49] 1.71 21.70 0.30 O he s 12.10 (10.86) 9.00 [0–57] 1.14 11.80 0.30 MDS-NMS o al sco e 88.07 (73.47) 70.00 [1–489] 1.58 0.50 0.30 NMF change 4.77 (5.63) 3.00 [0–24] 1.21 42.90 0.80 NMF ime in “o ”1.22 (1.16) 1.00 (0–4) 0.41 39.30 2.20 NMF o al sco e 10.41 (14.55) 4.00 [0–88] 1.99 42.90 0.30 Abb e ia ions: SD, s anda d de ia ion; IC, Impulse Con ol; MDS-NMS, Mo emen Diso de Socie y–sponso ed Nonmo o Ra ing Scale; NMF, NonMo o Fluc ua ion. TABLE 3 Reliabili y Domain In e i em co ela ion I em homogenei y coe ficien I em- o al co ela ion C onbach’sαN=364 Dep ession 0.01–0.77 0.64 0.59–0.72 0.897 Anxie y 0.03–0.77 0.49 0.44–0.70 0.785 Apa hy 0.20–0.61 0.57 0.54–0.64 0.796 Psychosis 0.04–0.44 0.59 0.55–0.70 0.826 IC and ela ed diso de s 0.04–0.37 0.24 0.07–0.36 0.548 Cogni ion 0.17–0.49 0.51 0.41–0.66 0.861 O hos a ic hypo ension 0.43 0.43 0.43 a 0.556 U ina y 0.12–0.46 0.58 0.50–0.70 0.801 Sexual 0.66 0.66 0.66 a 0.545 Gas oin es inal 0.15–0.44 0.21 0.02–0.30 0.499 Sleep and wake ulness 0.12–0.47 0.23 0.08–0.37 0.625 Pain 0.20–0.46 0.22 0.10–0.31 0.497 O he s 0.12–0.44 0.15 0.009–0.18 0.429 NMF change* (n=208) 0.03–0.43 0.53 0.21–0.57 0.817 Abb e ia ions: IC, Impulse Con ol; MDS-NMS, Mo emen Diso de Socie y–sponso ed Nonmo o Ra ing Scale; NMF, NonMo o Fluc ua ion. a These domains ha e only wo i ems; he e o e, alues a e like in e -i em co ela ion. MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 591 CUBO E. ET AL. RESEARCH ARTICLE 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License he NMF showed a floo e ec (42.90%) and adequa e ceiling e ec (0.30%) (Table 2). The e we e no ceiling e ec s o indi- idual domains, bu floo e ec s anged om a low o 8.00% (sleep and wake ulness) o a high o 78.10% (impulse con ol dis- o de s and ela ed diso de s), in line wi h esul s om he alida ion sample. As a whole, he e was a posi i e skewness ha was highe han he s anda d, mi o ing he floo e ec . In e nal consis ency: These esul s a e shown in Table 3. Some i ems o he MDS-NMS and in he NMF subscale had an in e - i em (wi hin domain) and co ec ed i em- o al co ela ion coe fi- cien less han he 0.20 s anda d alue, bu he i em homogenei y coe ficien was mo e han he 0.15 h eshold alue o all domains. Hypo hesis es ing:Con e gen Validi y: MDS-NMS domains co ela ed 0.34–0.77 wi h he co esponding MDS-UPDRS i ems, and NMF subscales 0.32–0.50 wi h he co esponding WOQ-19 NMS i ems (Table 4). The co ela ion be ween he MDS-NMS and NMF o al sco es wi h he MDS-pa 1–4 anged om 0.26 o 0.80, and 0.21 o 0.59, espec i ely. Wi h he WOQ-19 NMS and MS, co ela ions wi h MDS-NMS we e 0.42, and 0.33, and wi h he NMF: 0.54 and 0.18, espec- i ely (Table 5); Know-G oups Validi y: Using he MDS-NMS, 99.5% o he sample showed a leas one NMS, compa ed o he 90.9% wi h he MDS-UPDRS pa I. The MDS-NMF iden i- fied 57.1% o he sample wi h NMF, and 59.1% wi h he WOQ-19. The o al MDS-NMS and NMF subscale sco es showed no significan di e ences be ween subg oups defined by age, and p edominan a ec ed PD hemibody. Howe e , MDS-NMS and NMF sco es inc eased significan ly in emales, wi h highe HY s age, PD du a ion, and LEDD (Table S3). Likewise, in e ms o TABLE 4 I ems Con e gen Validi y MDS-NMS MDS-UPDRS Spea man R A.Dep esion 1.3Dep ession 0.68 B.Anxie y 1.4 Anxie y 0.62 C.Apa hy 1.5 Apa hy 0.69 D.Psychosis 1.2 Hallucina ions/ psychosis 0.44 E.IC and ela ed diso de s 1.6 Dopamine dys egula ion synd ome 0.55 F.Cogni ion 1.1 Cogni i e 0.64 G.O hos a ic hypo ension 1.12 Ligh headedness 0.59 H.U ina y 1.10 U ina y p oblems 0.77 I.Gas oin es inal 1.11 Gas oin es inal 0.59 I.Gas oin es inal 2.2 Sali a and d ooling 0.50 I.Gas oin es inal 2.3 Swallowing 0.48 K.Sleep and wake ulness 1.7 Sleep p oblems 0.44 K.Sleep and wake ulness 1.8 Day ime sleepiness 0.45 K.Sleep and wake ulness 2.9 Tu ning in bed 0.34 L.Pain 1.9 Pain 0.72 M.O he s 1.13 Fa igue 0.55 NMF WOQ-19 NMS Spea man R 2. Anxie y 3. Anxie y 0.50 3. Thinking o cogni i e abili ies 13. Cloudy mind 0.45 6. Pain 15. Muscle c amps 0.32 6. Pain 18. Pain 0.50 8. Excessi e swea ing 4. Swea ing 0.54 8. Excessi e swea ing 17. Feeling Ho and Cold 0.55 No e: Spea man ank co ela ion coe ficien s. All P alues <0.0001. Abb e ia ions: MDS-NMS, Mo emen Diso de Socie y–sponso ed Non- mo o Ra ing Scale; MDS-UPDRS, Mo emen Diso de Socie y–sponso ed Unified Pa kinson’s Disease Ra ing Scale; WOQ-19, Wea ing O Ques ionnai e-19 i ems; NMF, Nonmo o Fluc ua ion. TABLE 5 Hypo hesis Tes ing and Con e gen /Di e gen Validi y MDS-NMS To al Sco e NMF To al sco e Spea man R Spea man R Age 0.16 * 0.03** Age a onse 0.2 0.29 Educa ion (yea s) 0.06** 0.01** PD du a ion 0.18 0.27 LEDD 0.19 0.34 Hoehn & Yah 0.29 0.35 WOQ-19 NMS o al sco e 0.42 0.54 WOQ-19 MS o al sco e 0.33 & 0.18 & MDS-UPDRS pa I 0.80 0.59 MDS-UPDRS Pa II 0.58 0.48 MDS-UPDRS Pa III 0.26 & 0.21 & MDS-UPDRS Pa IV 0.45 0.61 No e: Spea man ank co ela ion coe ficien s. P alues a e <0.0001, excep o *=0.002, and **>0.05. & The Spea man R coe ficien s be ween he MDS- NMS/NMF wi h he WOQ-19 MS and MDS-UPDRS Pa III indica e di e gen alidi y. Abb e ia ions: LEDD, Le odopa equi alen daily dose; MDS-NMS, Mo e- men Diso de Socie y–sponso ed Nonmo o Ra ing Scale; MDS-UPDRS, Mo emen Diso de Socie y–sponso ed Unified Pa kinson’s Disease Ra ing Scale; WOQ-19, Wea ing O Ques ionnai e-19 i ems; NMF, Nonmo o Fluc ua ion. 592 MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 RESEARCH ARTICLE MDS-NMS 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License se e i y, a e adjus ing o mul iple compa isons, dep ession and anxie y domains, and o al NMS, MDS-UPDRS pa 1 and WOQ-19 NMS o al sco es we e highe in emales han males (Table S4). Compa isons o p e alence o NMS domains and MDS-UPDRS i ems a e shown in Table S5. Discussion The IPMDS has o ganized a wo ldwide p og am o p o ide o ficial and clinime ically alida ed e sions o se e al MDS-owned a ing scales. Se e al o ficial non-English e - sions a e cu en ly in p og ess o he MDS-NMS, bu he Spanish MDS-NMS is he fi s comple ed p og am o his scale. O no e, we ha e add essed he a ious cul u al di e - ences ha may be p esen in an in e na ional language such as Spanish. To achie e his in e na ional alida ion, we ha e achie ed ha moniza ion ac oss he majo Spanish-speaking cul u es in Spain and he Ame icas. Based on he esul s o his s udy, he Spanish e sion o he MDS-NMS ulfills he clinime ic c i e ia o be designa ed as an MDS-app o ed O ficial T ansla ion (h p://www.mo emen diso de s.o g/ publica ions/ a ing_scales). The o e all ac o s uc u e o he Spanish e sion was consis en wi h ha o he English e sion based on he high CFIs o he 10 eligible subscales o he MDS-NMS in he confi ma o y ac o analysis (CFI ≥0.90). We included a ep esen a i e sample o pa ien s wi h mild– mode a e PD se e i y acco ding o he HY s age. In e es ingly, conside ing he high p e alence (99.5%) and bu den o NMS (mean: 88.07 73.47, ange: 1–489), in addi ion o le odopa and o he dopamine gic d ugs, e y ew pa ien s we e ecei ing specific ea men o NMS, mos ly an idep essan s (26.90%) and anxioly ics (21.40%). Conce ning he alida ion aspec s, he da a quali y was e y sa is ac o y o all sec ions o he MDS-NMS and NMF, consid- e ing he exis ence o 52 and 8-i em ques ionnai es, espec i ely, indica ing he scale’s excellen easibili y. In he p esen s udy, only 208 (57%) pa ien s expe ienced NMF, which migh explain he high floo e ec on he NMF o al sco e. Compa ed o he o iginal English e sion o he MDS-NMS, 6 simila i em homo- genei y coe ficien s and C onbach’s alpha alues we e ound, indica ing a good in e nal consis ency. As hypo hesized, con e gen alidi y be ween he MDS- NMS domains and o he scales measu ing simila cons uc s was sa is ac o y. The MDS-NMS iden ified a high p e alence o NMS and NMF in he included sample, simila o he MDS- UPDRS and WOQ-19 NMS. Due o di e ences be ween he a ing scales, hei componen s a e no equi alen , showing sligh di e ences in p e alence a es. MDS-NMS and NMF sco es co - ela ed mode a ely wi h indi idual MDS-UPDRS pa s I, II, IV, and WOQ-19 NMS. The co ela ion be ween mo o fluc ua- ions se e i y obse ed in he MDS-UPDRS pa IV wi h MDS- NMS and NMF, suppo ed ecen s udies epo ing he associa ion o mo o fluc ua ions wi h a g ea e inc ease in he NMS bu den. 27 The MDS-NMS domains also showed a sa is ac o y disc imi- na i e abili y o di e en ia e be ween pa ien s g ouped acco ding o he PD and HY s aging a a poin in ime. In ag eemen wi h o he au ho s, we ound a highe bu den o NMS in emales, 28,29 also wi h he MDS-UPDRS pa I, II, and WOQ- 19 NMS, indica ing simila capabili ies o de ec gende NMS bu den di e ences. The mos a ec ed NMS domains in emales we e dep ession and anxie y using he MDS-NMS. O no e, al hough no s a is ically significan in e ms o PD mo o asym- me y, we ound ha pa ien s wi h p edominan le ex emi ies a ec ed by PD ( igh b ain hemisphe e) had a highe NMS bu - den han he igh one. This finding was consis en wi h b ain asymme y, and i s associa ion wi h NMS se e i y ound in ano he PD coho , sugges ing inc eased suscep ibili y o awa e- ness in he igh hemisphe e o NMS. 30 Limi a ions o he s udy a e ela ed o po en ial sample selec- ion bias as da a come om specialized clinical uni s. Howe e , he mul icen e , in e na ional collabo a ion and wide sample a e ci cums ances bu e ing ha bias. As pe exclusion c i e ia excluding pa ien s wi h significan cogni i e impai men , he sample dis ibu ion showed a p edominance o pa ien s wi h mild/mode a e PD acco ding o he HY s age. Finally, da a abou longi udinal alidi y and in e p e abili y we e no a ailable. On he o he hand, he benefi s o ansla ing and alida ing he MDS-UPDRS in o Spanish will include he possibili y o eaching millions o indi iduals wo ldwide, including heal hca e p o essionals and PD pa ien s. App oxima ely 21 coun ies wo ldwide speak Spanish as hei o ficial language, and Spanish is spoken by mo e han 492 million indi iduals wo ldwide. 31 This alida ion will also uni y PD clinical assessmen s, e en ually imp o ing pa ien ou comes. I s a ailabili y now allows o la ge clinical ials ha use he MDS-NMS as a pi o al ou come o include s udy si es, in es iga o s, and pa ien s om hese coun- ies when new ea men p o ocols eme ge. In conclusion, he c oss-cul u al adap a ion o he scale and he confi ma ion ha he MDS-NMS Spanish e sion is s uc u - ally equi alen o he o iginal English measu e is ele an o u u e ansna ional s udies en olling pa ien s om Spanish- speaking coun ies. Au ho Roles (1) Resea ch p ojec : A. Concep ion; B. O ganiza ion; C. Execu ion. (2) Analysis: A. Design; B. Execu ion; C. Re iew and C i ique. (3) Manusc ip P epa a ion: A. W i ing o he fi s d a ; B. Re iew and C i ique. EC: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B. SL: 1A, 1B, 2A, 2B, 2C, 3B. PMM: 1A, 1B, 2A, 2B, 2C, 3B. GS: 1A, 1B, 2A, 2B, 2C, 3B. JL: 2B, 2C, 2C, 3B. MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 593 CUBO E. ET AL. RESEARCH ARTICLE 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License DC: 2B, 2C, 2C, 3B. AGB: 1C, 3B. PM:1C, 3B. DSG: 1C, 3B. MSD: 1C, 3B. MRV:1C, 3B. CS: 1B, 3C. Acknowledgmen s The au ho s acknowledge g an suppo om he In e na ional Pa kinson and Mo emen Diso de Socie y o plan, de elop, and alida e he Spanish e sion o he MDS-NMS in an in e na- ional s udy. Disclosu es E hical Compliance S a emen : Each si e ob ained i s IRB app o al sepa a ely. All pa icipan s p o ided in o med consen o he s udy. We confi m ha we ha e ead he Jou nal’s posi- ion on issues in ol ed in e hical publica ion and a fi m ha his wo k is consis en wi h hose guidelines. Funding Sou ces and Conflic s o In e es : G an suppo om he In e na ional Pa kinson and Mo emen Diso de Soci- e y. The au ho s epo no conflic s o in e es . Financial Disclosu es o P e ious 12 Mon hs: E.C.: has ecei ed hono a ia o educa ional p esen a ions and ad ice se - ice by Abb ie, I al a maco and g an s om he Spanish Minis y o Economy and Compe i i eness [PI19/0964], he Fundacion “la Caixa”and Fundacion “Caja de Bu gos”(Cou se 2019/2020), Ho izon 2020: Mul i-Domain Li es yle Ta ge s o Imp o ing P ogNOsis in Hun ing on’s Disease. DOMINO-HD. Ho izon 2020. S.L.: Consul ing and Ad iso y Boa d Membe ship wi h hono a ia: Na ional Ins i u es o Heal h, CHDI Managemen , Inc. G an s and Resea ch: Na ional Ins i u es o Heal h, CHDI, In e na ional Pa kinson and Mo emen Diso de Socie y, Pa kinson’s Founda- ion. Hono a ia: S . Jude Child en’s Hospi al. In ellec ual P ope y Righ s: None. Owne ship In e es s: None. Royal ies: None. Expe Tes imony: None. Sala y: Duke Uni e si y. P.M.M.: has ecei ed hono a ia om he In e na ional Pa kinson and Mo emen Diso de Socie y (MDS) o managemen o he Clinical Ou come Assessmen s P og am. G.T.S.: ecei ed hono a ia o consul ing and ad iso y boa d membe ship wi h Acadia Pha maceu icals, Adamas Pha maceu i- cals Inc., Biogen Inc., Ce egene Inc., CHDI Managemen Inc., Cle eland Clinic Founda ion, Ingenix Pha maceu ical Se ices (i3 Resea ch), MedGenesis The apeu ix Inc., Neu oc ine Biosci- ences Inc., Pfize Inc., Tools-4-Pa ien s, Ul agenyx Inc., and Sunshine Ca e Founda ion. He also ecei ed hono a ia om he In e na ional Pa kinson and Mo emen Diso de Socie y, Ame i- can Academy o Neu ology, Michael J. Fox Founda ion o Pa kinson’s Resea ch, Food and D ug Adminis a ion, Na ional Ins i u es o Heal h, Alzheime ’s Associa ion. He also ecei ed g an s and esea ch om Na ional Ins i u es o Heal h, Depa - men o De ense, Michael J. Fox Founda ion o Pa kinson’s Resea ch, Dys onia Coali ion, CHDI, Cle eland Clinic Founda- ion, In e na ional Pa kinson and Mo emen Diso de Socie y, CBD Solu ion. J.L.: Sala y: Duke Uni e si y. D.C.: Sala y: Duke Uni e si y. A.G.B.: Sala y: Resea ch Uni , Hospi al Uni e si a io Spain. P.M.: has ecei ed suppo o a ending mee ings and/o a el o hono a ium o lec u ing om Abbo , Alle gan, Abb ie. Bial, B i annia, I al a maco, Me z, UCB, Te a and Zambon and has ecei ed g an s om Spanish Minis y o Science and Inno a ion [RTC2019-007150- 1], he Ins i u o de Salud Ca los III-Fondo Eu opeo de Desa ollo Regional (ISCIII-FEDER) [PI19/01576], he Conseje ía de Salud y Bienes a Social de la Jun a de Andalucía [PE-0210-2018] and he Conseje ía de T ans o ma- cion Economica, Indus ia, Conocimien o y Uni e sidades de la Jun a de Andalucía [PY20_00903]. D.S.G.: has ecei ed hono a ia o educa ional p esen a ions and ad ice se ice by Abb ie, UCB Pha ma, Lundbeck, KRKA, Zambon, Bial, I al a maco, Te a, A chímedes, Es e e, S ada, Me z, and g an s om he Spanish Minis y o Economy and Compe i i eness [PI16/01575] co- ounded by ISCIII (Concesion de sub enciones de P oyec os de In es igacion en Salud de la con oca o ia 2020 de la Accion Es a égica en Salud 2017–2020 po el p oyec o “PROGRESIÓN NO MOTORA E IMPACTO EN LA CALIDAD DE VIDA EN LA ENFERMEDAD DE PARKINSON”). M.R.V.: has ecei ed hono a ia om Bos on Scien ific, E e Neu opha ma, Abbo , Fe e , Silanes and Dumon . M.S.D.: no disclosu es. C.S.: has ecei ed g an s om Suno ion, Re ance, Pha ma2B, Amneal and Adamas. He has ecei ed hono a ia om he Mo e- men Diso de s Socie y. ■ Re e ences 1. Ma inez-Ma in P, Rod iguez-Blazquez C, Ku is MM, Chaudhu i KR, G oup NV. The impac o non-mo o symp oms on heal h- ela ed quali y o li e o pa ien s wi h Pa kinson’s disease. Mo Dis- o d 2011;26:399–406. 2. San os-Ga cia D, de la Fuen e-Fe nandez R. Impac o non-mo o symp oms on heal h- ela ed and pe cei ed quali y o li e in Pa kinson’s disease. J Neu ol Sci 2013;332:136–140. 3. San os Ga cia D, De Deus FT, Paz Gonzalez JM, e al. S aging Pa kinson’s disease combining mo o and nonmo o symp oms co ela es wi h disabili y and quali y o li e. Pa kinsons Dis 2021;2021:8871549– 8871516. 4. Ma inez-Ma in P, Ray CK. Comp ehensi e g ading o Pa kinson’s dis- ease using mo o and non-mo o assessmen s: Add essing a key unme need. Expe Re Neu o he 2018;18:41–50. 5. Ma inez-Ma in P, Sch ag A, Wein aub D, Rizos A, Rod iguez- Blazquez C, Chaudhu i KR, on behal o he IPMDS Non Mo o PD S udy G oup. Pilo s udy o he In e na ional Pa kinson and Mo emen Diso de Socie y-sponso ed non-mo o a ing scale (MDS-NMS). Mo Diso d Clin P ac 2019;6:227–234. 6. Chaudhu i KR, Sch ag A, Wein aub D, Rizos A, Rod iguez- Blazquez C, Mamikonyan E, Ma inez-Ma in P. The mo emen 594 MOVEMENT DISORDERS CLINICAL PRACTICE 2023; 10(4): 586–595. doi: 10.1002/mdc3.13658 RESEARCH ARTICLE MDS-NMS 23301619, 2023, 4, Downloaded om h ps://mo emen diso de s.onlinelib a y.wiley.com/doi/10.1002/mdc3.13658 by Uni e sidad De Bu gos, Wiley Online Lib a y on [18/03/2024]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License