The Essential Tremor Rating Assessment Scale Neuromed 1 1038
The Essential Tremor Rating Assessment Scale Neuromed 1 1038
The Essential Tremor Rating Assessment Scale Neuromed 1 1038
Article Notes The Essential Tremor Rating Assessment Scale was developed by the
Received: June 27, 2016 Tremor Research Group (www.tremorresearchgroup.org) to quantify essential
Accepted: July 27, 2016 tremor severity and its impact on activities of daily living. This scale requires
only a pen and paper, and can be completed in about 10 minutes. Upper
*Correspondence:
extremity action tremor is the main focus of this scale, but action tremor is also
Dr. Rodger J. Elble
Department of Neurology, Southern Illinois University School of assessed in the head, face, voice, and lower limbs. The scale has excellent face
Medicine, PO Box 19645 validity, inter- and intra-rater reliability, and sensitivity to change. The activities
Springfield, IL 62794-9645, USA of daily living section correlates strongly with the performance section, and
Telephone: 217-545-7194 this scale also correlates strongly with transducer measures of tremor and
E-mail: [email protected] with the Fahn-Tolosa-Marín tremor rating scale. In the Fahn-Tolosa-Marín
tremor rating scale, upper extremity tremor greater than 4 cm corresponds
© 2016 Elble RJ. This article is distributed under the terms of
the Creative Commons Attribution 4.0 International License
to a maximum rating of 4, while grade 4 tremor in the Essential Tremor Rating
Assessment Scale corresponds to an amplitude greater than 20 cm. Therefore,
Keywords the Essential Tremor Rating Assessment Scale is better suited for assessment
Essential Tremor of severe essential tremor.
Rating Scale
Action Tremor
Activities of daily living
Introduction
The Tremor Research Group (TRG) in the United States (www.
tremorresearchgroup.org) began developing the Essential Tremor
Rating Assessment Scale (TETRAS) in 2003. Until then, the most
widely used scale was the Fahn-Tolosa-Marín scale (FTM)1, which
had undergone limited validation in essential tremor (ET)2 and
which has upper extremity tremor amplitude anchors that are too
low for severe ET. TETRAS was therefore developed in a series of
several modifications and validation exercises, and it was ultimately
published in 20123. This review summarizes the strengths and
limitations of TETRAS and provides guidelines for its use by
individuals and by commercial entities.
Overview of TETRAS
TETRAS was designed to provide an accurate, comprehensive
quantification of ET in approximately 10 minutes, requiring only
a pen and paper. TETRAS has an activities of daily living (ADL)
section and a performance section3. Both sections emphasize
tremor in the upper limbs, which is the primary source of disability
in ET. A Microsoft Excel spreadsheet of TETRAS with instructions
and scoring are included in the on-line appendix. Instructions for
videotaping a TETRAS exam are available upon request from TRG
([email protected]).
The ADL section of TETRAS has 12 items, each rated 0, 1, 2, 3
or 4. The maximum total score is 48. Item 1 addresses speech; item
10 addresses occupational impairment; and item 12 assesses social
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Elble RJ. J Neurol Neuromed (2016) 1(4): 34-38 Journal of Neurology & Neuromedicine
impact. The other 9 items assess activities that are affected All items of the examination, except standing tremor and
primarily by upper limb tremor (see on-line appendix). heel-knee-shin testing, are performed with the patient
seated comfortably. Heel-knee-shin testing is performed in
The performance section of TETRAS has 9 items rated
the supine position. For each item, scoring is based on the
0-4 and a maximum total score of 64. Items 1 (head tremor),
highest peak-to-peak amplitude seen at any point during
2 (face tremor), 3 (voice tremor), 5 (lower limb tremor),
the exam. Patients are instructed not to suppress or control
7 (handwriting), and 9 (standing) have maximum scores
their tremor, but to simply perform the task in a manner
of 4. Lower limb tremor (item 5) is assessed bilaterally
that permits full expression of tremor severity.
during posture and heel-knee-shin movement, but only the
maximum tremor observed during the four assessments TETRAS does not provide a comprehensive
is scored, resulting in an obvious underweighting of lower characterization of patients with ET. In particular, there
limb tremor in the total performance score. By contrast, is no assessment of anxiety and depression, which are
item 4 is the sum of 0-4 ratings of right and left upper limb known to impact the quality of life in ET4,5, and there is no
tremor in three tasks: 1) postural tremor with upper limbs assessment of rest tremor, which is not a typical feature
held forward and horizontally, 2) postural tremor with of ET but may occur in severely affected people. Anxiety,
upper limbs extended laterally and horizontally, with the depression and quality of life can be assessed with scales
elbows flexed and hands positioned close to each other near designed for these purposes, as recently reviewed4-6.
the chin (“wing beating position”), and 3) kinetic tremor Rest tremor was not included because its determination
during finger-nose (or chin)-finger movements. The sum of is a common source of diagnostic uncertainty7. Postural
the three tasks and two extremities results in an item 4 score tremor in severe ET is often misconstrued as rest tremor
of 0-24. Similarly, the spiral drawing task (item 6) and the in a patient that is not given adequate opportunity to
dot approximation task (item 8; a test of upper limb tremor) relax the affected body part. For example, rest tremor is
are scored for the right and left upper limbs and summed often assessed while a patient sits in a chair with back
to produce item scores of 0-8. This scoring results in an unsupported and forearms supinated on the patient’s lap.
intentional overweighting of upper limb tremor in TETRAS. Inadequate support of the torso enables postural tremor
in the torso, and supination of the forearms requires active
For head, face, voice, lower limbs, spiral drawing,
contraction of the forearm supinator muscles. In contrast
handwriting, and standing (items 1, 2, 3, 5, 6, 7 and 9),
to rest tremor in Parkinson disease, rest tremor in ET does
the scores are defined by 0-4 whole numbers. However,
not subside when the muscles are activated for a voluntary
0.5-point increments may be used if a rating cannot be
movement and usually does not increase during walking7,8.
reconciled to the higher or lower whole number (e.g.,
a score of 1.5 when the rater is uncertain whether the TETRAS was designed for the clinical assessment of
score is 1 or 2). Each 0.5 increment in rating is explicitly ET in clinical trials and for routine clinical assessment of
defined for upper limb postural and kinetic tremor (item treatment effects and disease progression. It has excellent
4) and for the dot approximation task (item 8) (Table 1). face validity, and it correlates strongly with transducer
measures of upper limb9, 10 and head tremor11. TETRAS
Upper limb Lower limb also correlates strongly with the FTM (Figure 1). TETRAS
Rating Head tremor**
tremor* tremor**
0 none none none
0.5
1 < 0.5 cm < 0.5 cm < 0.5 cm
1.5 0.5 - < 1 cm
2 1 - < 3 cm 0.5 - < 1 cm 0.5 - < 2.5 cm
2.5 3 - < 5 cm
3 5 - < 10 cm 1 - < 5 cm 2.5 – 5 cm
3.5 10 - < 20 cm
4 ≥ 20 cm ≥ 5 cm > 5 cm
*These anchors are used for the assessment of upper limb tremor
in two postures, during finger-nose-finger testing, and in the dot
approximation task (TETRAS performance items 4 and 8; see on-line
appendix for a detailed description of TETRAS).
**Half point increments are used when the rater is uncertain
whether the rating fits the higher or lower whole number. A score of Figure 1: Linear regression and 95% confidence limits for FTM
0.5 is given when the rater is uncertain whether tremor is present. versus TETRAS total scores obtained from 13 patients (7 men) with
moderate-severe ET. The two exams were performed less than
Table 1: Metric anchors for TETRAS performance ratings of limb and
one hour apart by one of two experienced examiners.
head tremor.
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Elble RJ. J Neurol Neuromed (2016) 1(4): 34-38 Journal of Neurology & Neuromedicine
Conflicts of interest
The author is a member of the Tremor Research Group,
which holds the copyright on TETRAS.
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