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Protocol - Signs of Essential Tremor

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Description:

The Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale is a 23-item videotaped examination that assesses rest, postural, and kinetic tremor severity. Rated tasks include arm extension, pouring water between cups, drinking from a spoon, drinking from a cup, drawing Archimedes spirals, and touching a finger to the nose. The protocol includes scoring and classification instructions. A teaching videotape is also available to aid in training raters.

Protocol:

Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale protocol for Videotaped Examination

While subject is seated:

  1. Hands resting in lap for 15 s
  2. Arms held at 90° for 15 s (arm sustention)
  3. Arms held in wing position for 15 s
  4. Pouring water from one cup to another (cups should be standard size and at least three quarters filled; 8 transfers)
  5. Bring a spoon of water from lap level up to mouth and back again; repeat 7 additional times
  6. Drinking water from a full glass; repeat 7 times with each hand
  7. Finger-nose-finger on right 8 times
  8. Finger-nose-finger on left 8 times
  9. Open and close right hand 10 times
  10. Open and close left hand 10 times
  11. Alternatively pronate and supinate right hand 10 times
  12. Alternatively pronate and supinate left hand 10 times
  13. Tap right foot 10 times
  14. Tap left foot 10 times
  15. Jaw at rest for 5 s
  16. Mouth open for 5 s
  17. Sustained phonation: first "AAA" for 10 s, then "EEE"
  18. Head while patient is seated for 10 s
  19. The examiner will test the passive tone of each arm and leg and comment on this on the videotape
  20. Drawing 2 Archimedes spirals with each hand (subject should make at least 6 full circular motions)

While subject is standing:

  1. Hands hanging at sides for 10 s; videotape legs too
  2. Walking 20 ft and turning
  3. Tandem gait for 10 steps

Scoring Instructions

Criteria for ET:

1. On examination, a +2 postural tremor of at least 1 arm (a head tremor may also be present, but is insufficient for the diagnosis)

2. On examination, there must be

a. a +2 kinetic tremor during at least 4 tasks or

b. a +2 kinetic tremor on 1 task and a +3 kinetic tremor on a second task; tasks include: pouring water, using a spoon to drink water, drinking water, finger-to-nose, and drawing a spiral

3. If on examination the tremor is present in the dominant hand, then by report it must interfere with at least 1 activity of daily living (eating, drinking, writing, use of hands); if on examination, the tremor is not present in the dominant hand, this criterion is irrelevant.

4. Medications, hyperthyroidism, alcohol, or dystonia are not potential etiologic factors

5. Not psychogenic (bizarre features, inconsistent in character, changing, subject is distractable, other psychiatric features on examination)

Criteria for probable ET (1 and 3-5 must be true; also, either 2a or 2b must be true):

1. On examination, a +2 postural tremor of arms may or may not be present

2. (a) Same as 2 above

(b) Head tremor is present on examination

3. Tremor in the dominant hand may or may not interfere with at least 1 daily activity

4. Medications, hyperthyroidism, dystonia, or alcohol are not potential etiologic factors

5. Not psychogenic

Criteria for possible ET:

1. On examination, a +2 kinetic tremor must be present on 3 tasks

2. No other stipulations

Tremor Ratings (0 to +3):

0 = no visible tremor

+1 = low-amplitude/barely perceivable tremor or intermittent tremor

+2 = tremor is of moderate amplitude (1-2 cm) and usually present; it is clearly oscillatory

+3 = large-amplitude (>2 cm), violent, jerky tremor resulting in difficulty completing the task due to spilling or inability to hold a pen to paper

Note from the Neurology Working Group: Please see Louis et al. (2001) for discussion on the addition of a tremor rating of 4.

Protocol Name from Source:

Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale

Availability:

Publicly available

Personnel and Training Required

Personnel should be trained to administer the test by a licensed neurologist or other trained medical professional experienced with the Washington Heights-Inwood Genetic Study of Essential Tremor Rating Scale (WHIGET) or similar examination and should watch the teaching videotape that is available for learning to administer the protocol. Additionally, investigators are encouraged to have quality control procedures (e.g., videotaping sessions) in place to maintain consistency across examiners.

Equipment Needs

Investigators will need basic supplies to administer the test, such as standard-sized cups, spoons, and paper and pencil. Investigators will need a video recorder to tape the examination.

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Physical Examination

Life Stage:

Adult

Participants:

Adult, aged 18 years or older

Specific Instructions:

A teaching videotape is available for learning to administer the Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale (Louis et al., 2001).Several items of the WHIGET Tremor Rating Scale are designed to assess and rule out features of parkinsonism:

• Bradykinesia - items 9-14

• Rigidity - item 19

• Reduced arm movements - item 22

Additionally, although item 23 (tandem gait) can be abnormal in essential tremor, this item is not used to make a diagnosis.

Selection Rationale

The Washington Heights-Inwood Genetic Study of Essential Tremor Rating Scale (WHIGET) was vetted against similar protocols and selected because it is a relatively short (10 minutes or less), widely used, validated protocol that is relatively easy to administer.

Language

English

Standards
StandardNameIDSource
Common Data Elements (CDE) Neurology Essential Tremor Sign Assessment Description Text 3107307 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Signs of essential tremor proto 62784-4 LOINC
Derived Variables

None

Process and Review

Expert Review Panel 4 (ERP 4) reviewed the measures in the Neurology, Psychiatric, and Psychosocial domains.

Guidance from ERP 4 included the following:

· Revised description of measure

Source

Louis, E. D., Ottman, R., Ford, B., Pullman, S., Martinez, M., Fahn, S., & Hauser, W. A. (1997). The Washington Heights-Inwood Genetic Study of Essential Tremor: Methodologic issues in essential-tremor research. Neuroepidemiology, 16, 124-133.

General References

Louis, E. D., Barnes, L., Wendt, K. J., Ford, B., Sangiorgio, M., Tabbal, S., Lewis, L., Kaufmann, P., Moskowitz, C., Comella, C. L., Goetz, C. C., & Lang, A. E. (2001). A teaching videotape for the assessment of essential tremor. Movement Disorders, 16, 89-93.

Louis, E. D. (2016). Diagnosis and management of tremor. Continuum, 22, 1143-1158.

Louis, E. D. (2016). More time with tremor: The experience of essential tremor versus Parkinson’s disease patients. Movement Disorders Clinical Practice, 3, 36-42.

Sternberg, E. J., Alcalay, R. N., Levy, O. A., & Louis, E. D. (2013). Postural and intention tremors: A detailed clinical study of essential tremor vs. Parkinson’s disease. Frontiers in Neurology 4, 51.

Protocol ID:

131301

Variables:
Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX131301_Archimedes_Spirals PX131301200000 Drawing 2 Archimedes spirals with each hand (subject should make at least 6 full circular motions) 4 N/A
PX131301_Arms_Sustention PX131301020000 Arms held at 90? for 15 s (arm sustention) 4 N/A
PX131301_Arms_Wing_Position PX131301030000 Arms held in wing position for 15 s 4 N/A
PX131301_Dominant_Hand PX131301240000 Dominant Hand 4 N/A
PX131301_Drinking_Water PX131301060000 Drinking water from a full glass; repeat 7 times with each hand 4 N/A
PX131301_Drink_From_Spoon PX131301050000 Bring a spoon of water from lap level up to mouth and back again; repeat 7 additional times 4 N/A
PX131301_Finger_Nose_Finger_Left PX131301080000 Finger-nose-finger on left 8 times 4 N/A
PX131301_Finger_Nose_Finger_Right PX131301070000 Finger-nose-finger on right 8 times 4 N/A
PX131301_Gait PX131301230000 Tandem gait for 10 steps 4 N/A
PX131301_Hands_Hanging_At_Side PX131301210000 Hands hanging at sides for 10 s; videotape legs too 4 N/A
PX131301_Hands_Resting_In_Lap PX131301010000 Hands resting in lap for 15 s 4 N/A
PX131301_Head_While_Seated PX131301180000 Head while patient is seated for 10 s 4 N/A
PX131301_Jaw_At_Rest PX131301150000 Jaw at rest for 5 s 4 N/A
PX131301_Mouth_Open PX131301160000 Mouth open for 5 s 4 N/A
PX131301_Open_Close_Left_Hand PX131301100000 Open and close left hand 10 times 4 N/A
PX131301_Open_Close_Right_Hand PX131301090000 Open and close right hand 10 times 4 N/A
PX131301_Passive_Tone_Arms PX131301190000 The examiner will test the passive tone of each arm and leg and comment on this on the videotape 4 N/A
PX131301_Pouring_Water PX131301040000 Pouring water from one cup to another (cups should be standard size and at least three quarters filled; 8 transfers) 4 N/A
PX131301_Pronate_Supinate_Left_Hand PX131301120000 Alternatively pronate and supinate left hand 10 times 4 N/A
PX131301_Pronate_Supinate_Right_Hand PX131301110000 Alternatively pronate and supinate right hand 10 times 4 N/A
PX131301_Sustained_Phonation PX131301170000 Sustained phonation: first "AAA" for 10 s, then "EEE" 4 N/A
PX131301_Tap_Left_Foot PX131301140000 Tap left foot 10 times 4 N/A
PX131301_Tap_Right_Foot PX131301130000 Tap right foot 10 times 4 N/A
PX131301_Walking_Twenty_Feet PX131301220000 Walking 20 ft and turning 4 N/A
Research Domain Information
Measure Name:

Signs of Essential Tremor

Release Date:

June 30, 2010

Definition

This is an examination to assess essential tremor, which is a disease characterized by action tremor of one or more body parts, such as the head, arms, or legs.

Purpose

This measure can be used to screen a general population for the signs of essential tremor.

Keywords

Neurology, tremor, movement disorder