Protocol - Signs of Essential Tremor
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.
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.
Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale protocol for Videotaped Examination
While subject is seated:
- Hands resting in lap for 15 s
- Arms held at 90° for 15 s (arm sustention)
- Arms held in wing position for 15 s
- Pouring water from one cup to another (cups should be standard size and at least three quarters filled; 8 transfers)
- Bring a spoon of water from lap level up to mouth and back again; repeat 7 additional times
- Drinking water from a full glass; repeat 7 times with each hand
- Finger-nose-finger on right 8 times
- Finger-nose-finger on left 8 times
- Open and close right hand 10 times
- Open and close left hand 10 times
- Alternatively pronate and supinate right hand 10 times
- Alternatively pronate and supinate left hand 10 times
- Tap right foot 10 times
- Tap left foot 10 times
- Jaw at rest for 5 s
- Mouth open for 5 s
- Sustained phonation: first "AAA" for 10 s, then "EEE"
- Head while patient is seated for 10 s
- The examiner will test the passive tone of each arm and leg and comment on this on the videotape
- Drawing 2 Archimedes spirals with each hand (subject should make at least 6 full circular motions)
While subject is standing:
- Hands hanging at sides for 10 s; videotape legs too
- Walking 20 ft and turning
- Tandem gait for 10 steps
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.
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.
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.
|Specialized requirements for biospecimen collection||No|
|Average time of greater than 15 minutes in an unaffected individual||No|
Mode of Administration
Adult, aged 18 years or older
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.
|caDSR 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|
|Human Phenotype Ontology||Kinetic Tremor||HP:0030186||HPO|
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
Protocol Name from Source
Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET) Tremor Rating Scale
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.
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.
|Variable Name||Variable ID||Variable Description||dbGaP Mapping|
|PX131301200000||Drawing 2 Archimedes spirals with each hand more||N/A|
|PX131301020000||Arms held at 90? for 15 s (arm sustention)||N/A|
|PX131301030000||Arms held in wing position for 15 s||N/A|
|PX131301240000||Dominant Hand||Variable Mapping|
|PX131301060000||Drinking water from a full glass; repeat 7 more||N/A|
|PX131301050000||Bring a spoon of water from lap level up to more||N/A|
|PX131301080000||Finger-nose-finger on left 8 times||N/A|
|PX131301070000||Finger-nose-finger on right 8 times||N/A|
|PX131301230000||Tandem gait for 10 steps||N/A|
|PX131301210000||Hands hanging at sides for 10 s; videotape more||N/A|
|PX131301010000||Hands resting in lap for 15 s||N/A|
|PX131301180000||Head while patient is seated for 10 s||N/A|
|PX131301150000||Jaw at rest for 5 s||N/A|
|PX131301160000||Mouth open for 5 s||N/A|
|PX131301100000||Open and close left hand 10 times||N/A|
|PX131301090000||Open and close right hand 10 times||N/A|
|PX131301190000||The examiner will test the passive tone of more||N/A|
|PX131301040000||Pouring water from one cup to another (cups more||N/A|
|PX131301120000||Alternatively pronate and supinate left hand more||N/A|
|PX131301110000||Alternatively pronate and supinate right more||N/A|
|PX131301170000||Sustained phonation: first "AAA" for 10 s, more||N/A|
|PX131301140000||Tap left foot 10 times||N/A|
|PX131301130000||Tap right foot 10 times||N/A|
|PX131301220000||Walking 20 ft and turning||N/A|
Signs of Essential Tremor
May 12, 2010
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.
This measure can be used to screen a general population for the signs of essential tremor.
Neurology, tremor, movement disorder, gerontology, aging, geriatrics