【Tremor Rating Scale】

【Tremor Rating Scale】

1) HEAD TREMOR

Subjects are seated upright. The head is rotated fully left and right and then observed for 10 seconds in mid position. Rate worst amplitude during exam.

0 = no tremor

1 = slight tremor seen or felt only

    during/after provocative maneuvers.

2 = mild tremor

3 = moderate tremor

4 = severe tremor

2) FACE (Including JAW) TREMOR

Smile, close eyes, open mouth. The highest amplitude of the most involved facial anatomy is scored, regardless of whether it occurs during rest or activation.

0 = no tremor

1 = barely perceptible

2 = mild tremor

3 = moderate tremor

4 = severe tremor

3) TONGUE TREMOR:

Subjects are seated upright. They open their mouths for 5 seconds and protrude their tongue for 5 seconds.

0 = no tremor

1 = barely perceptible

2 = mild tremor

3 = moderate tremor

4 = severe tremor

4)  VOICE TREMOR:

First assess speech during normal conversation [for video, count from one to ten] then ask subject to produce an extended "aaa" sound and eee" sound for 5 seconds each.

0 = no tremor

1 = barely perceptible tremor only during aaa, and eee but not during speech

passage

2 = mild but clear tremor present with speaking

3 = moderate tremor (no voice breaks)

4 = severe tremor (with voice breaks or unintelligible speech)

5)  ARM TREMOR:

Subjects are seated upright. Tremor is assessed during three arm maneuvers (forward horizontal reach posture, lateral "wing beating" posture and kinesis). Each arm is assessed for 5 seconds in each posture. Left and right arms may be assessed simultaneously. Amplitude assessment should be estimated using the maximally displaced point of the hand at the point of greatest displacement along any single plane. For example, the amplitude of a pure supination-pronation tremor, pivoting around the wrist would be assessed at either the thumb or fifth digit.

a. Forward outstretched postural tremor: Subjects should bring their arms forward, slightly lateral to midline and parallel to the ground. The wrist should also be straight and the fingers maximally abducted so that they do not touch each other.

b. Lateral "wing beating" postural tremor: Subjects will abduct their arms parallel to the ground and flex the elbows so that the two hands do not quite touch each other. The fingers are maximally abducted so that they do not touch each other, with the pointer finger at shoulder height.

c. Kinetic tremor: Subjects extend only their index finger. They then touch a set object or the examiners finger located to the full extent of their reach, which is located at the same height (parallel to the ground) and slightly lateral to the midline. Subjects then touch their own nose or chin and repeat this back and forth motion five times. Only the position along the trajectory of greatest tremor amplitude is assessed. This will typically be either at the nose/chin or at the point of full finger.

0  = no tremor

1  = tremor is barely visible

1.5 = tremor is visible, but less than 1 cm

2  = tremor is 1 – <3 cm amplitude

2.5  = tremor is 3 – <5 cm amplitude

3  = tremor is 5 – <10 cm amplitude

3.5  = tremor is 10 – <20 cm amplitude

4  = tremor is > 20 cm amplitude

6)  LEG TREMOR ACTION:

Subjects are comfortably seated. They are then asked to raise each individual leg horizontally parallel to the ground for 5 seconds each. They then perform a standard heal to shin maneuver with each leg three iterations. The maximum tremor in either maneuver is scored.

0 = no tremor

1 = barely perceptible

2 = obvious but mild tremor

3 = moderate tremor, less than 5 cm at any point

4 = severe tremor, greater than 5 cm

7)  STANDING TREMOR: Subjects are standing, unaided if possible. The knees are 10–20 cm apart and are flexed 10–20°. The arms are down at the subject's side. Tremor is assessed at any point on the legs or trunk.

0 = no tremor

1 = barely perceptible

2 = obvious but mild tremor

3 = moderate tremor, less than 5 cm at any point

4 = severe tremor, greater than 5 cm

8)  SPIRAL DRAWINGS: (Takes up half the page)  

Ask the subject to copy an Archimede's spiral

(which approximately fills 1⁄4 of an 8" X 10" unlined page. Test each hand without allowing that hand or arm on table. Only use a ballpoint pen. Subjects may hold the paper with the other hand.

0 = normal

1 = very slight intermittent - barely visible

2 = nearly continuous, mild tremor < 1 cm

3 = moderate - accomplishes the task with great difficulty; figure largely illegible > 1 cm deviation from ideal track

4 = unable to complete drawing; figure not

recognizable

9)  HANDWRITING:

Have patient write the standard sentence "Today is a nice day" using their dominant hand, in their customary fashion; however use only cursive (i.e., no printing). They cannot hold (stabilize) their hand with the other hand — rate only for dominant hand.

0 = normal

1 = mildly abnormal; slightly untidy, tremulous

2 = moderately abnormal; legible, but with considerable tremor

3 = markedly abnormal, illegible

4 = severely abnormal; unable to keep pencil or pen on paper without holding down with the other hand

10)  HOLD PENCIL:

"As close as you can" to a point drawn on a sheet of paper "without touching it" (ideally approximately 1 mm) for 10 seconds.

0  = no tremor

1  = tremor is barely visible

1.5  = tremor is visible, but less than 1 cm

2  = tremor is 1<3 cm amplitude

2.5  = tremor is 3 – <5 cm amplitude

3  = tremor is 5 – <10 cm amplitude

3.5  = tremor is 10 – <20 cm amplitude

4  = tremor is > 20 cm amplitude

11) POUR WATER FROM ONE GLASS INTO ANOTHER:

Relatively firm paper cups approximately 10 cm in height are preferred. Fill the cup 1 cm from top. Rate the worst of three tries with each hand. The "receiving" cup is placed on table, not held. If that cup is knocked over then it is replaced upright and the subject continues. If the subject knocks over the cup with the water while initially grasping for it, they are allowed to start over with a new full cup. Subject may be seated or standing, but cups should be about mid thorax.

0 = absolutely no visible tremor

1 = more careful than a person without tremor; no water is spilled

2 = spills a small amount < 10%

3 = spills considerable amount, 10–50%

4 = unable to pour without spilling most

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