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TRG Essential Tremor Rating Assessment Scale (TETRAS©) v 3.2

TRG Essential Tremor Rating Assessment Scale (TETRAS©) v 3.2 - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Tremor Research Group 1 of 6 US copyright October 21, 2008
TRG ESSENTIAL TREMOR RATING ASSESSMENT SCALE (TETRAS©) V 3.2
Activities of Daily Living Subscale

Rate tremor’s impact on activities of daily living (0 - 4 scoring).

1. Speaking
0 = Normal.
1 = Slight voice tremulousness, only when "nervous".
2 = Mild voice tremor. All words easily understood.
3 = Moderate voice tremor. Some words difficult to understand.
4 = Severe voice tremor. Most words difficult to understand.

2. Feeding with a spoon
0 = Normal
1 = Slightly abnormal. Tremor is present but does not interfere with feeding with a spoon.
2 = Mildly abnormal. Spills a little.
3 = Moderately abnormal. Spills a lot or changes strategy to complete task such as using two hands or
leaning over.
4 = Severely abnormal. Cannot feed with a spoon.

3. Drinking from a glass
0 = Normal.
1 = Slightly abnormal. Tremor is present but does not interfere with drinking from a glass.
2 = Mildly abnormal. Spills a little.
3 = Moderately abnormal. Spills a lot or changes strategy to complete task such as using two hands or
leaning over.
4 = Severely abnormal. Cannot drink from a glass or uses straw or sippy cup.

4. Hygiene
0 = Normal.
1 = Slightly abnormal. Tremor is present but does not interfere with hygiene.
2 = Mildly abnormal. Some difficulty but can complete task.
3 = Moderately abnormal. Unable to do most fine tasks such as putting on lipstick or shaving unless
changes strategy such as using two hands or using the less affected hand.
4 = Severely abnormal. Cannot complete hygiene activities independently.

5. Dressing
0 = Normal.
1 = Slightly abnormal. Tremor is present but does not interfere with dressing.
2 = Mildly abnormal. Able to do everything but has difficulty due to tremor.
3 = Moderately abnormal. Unable to do most dressing unless uses strategy such as using Velcro,
buttoning shirt before putting it on or avoiding shoes with laces.
4 = Severely abnormal. Cannot dress independently.




Tremor Research Group 2 of 6 US copyright October 21, 2008




6. Pouring
0 = Normal.
1 = Slightly abnormal. Tremor is present but does not interfere with pouring.
2 = Mildly abnormal. Must be very careful to avoid spilling but may spill occasionally.
3 = Moderately abnormal. Must use two hands or uses other strategies to avoid spilling.
4 = Severely abnormal. Cannot pour.

7. Carrying food trays, plates or similar items
0 = Normal
1 = Slightly abnormal. Tremor is present but does not interfere with carrying food trays, plates or similar
items.
2 = Mildly abnormal. Must be very careful to avoid spilling items on food tray.
3 = Moderately abnormal. Uses strategies such as holding tightly against body to carry.
4 = Severely abnormal. Cannot carry food trays or similar items.

8. Using Keys
0 = Normal
1 = Slightly abnormal. Tremor is present but can insert key with one hand without difficulty.
2 = Mildly abnormal. Commonly misses target but still routinely puts key in lock with one hand.
3 = Moderately abnormal. Needs to use two hands or other strategies to put key in lock.
4 = Severely abnormal. Cannot put key in lock.

9. Writing
0 = Normal
1 = Slightly abnormal. Tremor present but does not interfere with writing.
2 = Mildly abnormal. Difficulty writing due to the tremor
3 = Moderately abnormal. Cannot write without using strategies such as holding the writing hand with
the other hand, holding pen differently or using large pen.
4 = Severely abnormal. Cannot write.

10. Working. If patient is retired, ask as if they were still working. If the patient is a housewife, ask
the question as it relates to housework:
0 = Normal .
1 = Slightly abnormal. Tremor is present but does not affect performance at work or at home.
2 = Mildly abnormal. Tremor interferes with work; able to do everything, but with errors. .
3 = Moderately abnormal. Unable to continue working without using strategies such as changing jobs or
using special equipment.
4 = Severely abnormal. Cannot perform any job or household work.






Tremor Research Group 3 of 6 US copyright October 21, 2008
11. Overall disability with the most affected task (Name task, e.g. using computer mouse, writing,
etc)
Task _______________________________
0 = Normal.
1 = Slightly abnormal. Tremor present but does not affect task.
2 = Mildly abnormal. Tremor interferes with task but is still able to perform task.
3 = Moderately abnormal. Can do task but must use strategies.
4 = Severely abnormal. Cannot do the task.

12. Social Impact
0 = None
1 = Aware of tremor, but it does not affect lifestyle or professional life.
2 = Feels embarrassed by tremor in some social situations or professional meetings.
3 = Avoids participating in some social situations or professional meetings because of tremor.
4 = Avoids participating in most social situations or professional meetings because of tremor.







Tremor Research Group 4 of 6 US copyright October 21, 2008
Performance Subscale
Instructions
Scoring is 0 – 4. For most items, the scores are defined only by whole numbers, but 0.5 increments may
be used if you believe the rating is between two whole number ratings and cannot be reconciled to a
whole number. Each 0.5 increment in rating is specifically defined for the assessment of upper limb
postural and kinetic tremor and the dot approximation task (items 4 and 8). All items of the
examination, except standing tremor and heel-knee-shin testing, are performed with the patient seated
comfortably. For each item, score the highest amplitude seen at any point during the exam. Instruct
patients not to attempt to suppress the tremor, but to let it come out.

1. Head tremor: The head is rotated fully left and right and then observed for 10s in mid position.
Patient then is instructed to gaze fully to the left and then to the right with the head in mid
position. The nose should be used as the landmark to assess and rate the largest amplitude
excursions during the examination.

0 = no tremor
1 = slight tremor (< 0.5 cm)
2 = mild tremor (0.5- < 2.5 cm)
3 = moderate tremor (2.5-5 cm)
4 = severe or disfiguring tremor (> 5 cm)

2. Face (including jaw) tremor: Smile, close eyes, open mouth, purse lips. The highest amplitude
of the most involved facial anatomy is scored, regardless of whether it occurs during rest or
activation. Repetitive blinking or eye fluttering should not be considered as part of facial
tremor.

0 = no tremor
1 = slight; barely perceptible tremor
2 = mild: noticeable tremor
3 = moderate: obvious tremor, present in most voluntary facial contractions
4 = severe: gross disfiguring tremor

3. Voice tremor: First ask subject to produce an extended “aaah” sound and eee” sound for 5
seconds each. Then assess speech during normal conversation by asking patients “How do you
spend your average day?”.

0 = no tremor
1 = slight: tremor during aaah, and eee and no tremor during speech
2 = mild: tremor in “aaah” and “eee” and minimal tremor in speech
3 = moderate: obvious tremor in speech that is fully intelligible
4 = severe: some words difficult to understand

4. Upper limb tremor: Tremor is assessed during three maneuvers: forward horizontal reach
posture, lateral “wing beating” posture and finger-nose-finger testing. Each upper limb is
assessed and scored individually. The forward horizontal reach posture is held for 5 seconds.


Tremor Research Group 5 of 6 US copyright October 21, 2008
The lateral wing beating posture is held for 20 seconds. The finger-nose-finger movement is
executed three times. 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 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 and are at
the level of the nose. The fingers are abducted so that they do not touch each other. The
posture should be held for 20 seconds.
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 if the tremor is severe) and repeat this back and forth three times. Only
the position along the trajectory of greatest tremor amplitude is assessed. This will
typically be either at the nose or at the point of full limb extension.

For all three hand tremor ratings
0 = no tremor
1 = tremor is barely visible (< 0.5 cm)
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

5. Lower limb tremor: Raise each lower limb horizontally parallel to the ground for 5 seconds
each. Then perform a standard heel to shin maneuver with each leg, three times, with patient
in supine position. The maximum tremor in either maneuver is scored, and only the limb with
the largest tremor is scored. Tremor may exist in any part of the limb, including foot.
0 = no tremor
1 = slight: barely perceptible (< 0.5 cm)
2 = mild, less than 1 cm at any point
3 = moderate tremor, less than 5 cm at any point
4 = severe tremor, greater than 5 cm




Tremor Research Group 6 of 6 US copyright October 21, 2008
6. Archimedes spirals: Demonstrate how to draw Archimedes spiral that approximately fills ¼ of
an unlined page of standard (letter) paper. The lines of the spiral should be approximately 1.3
cm (0.5 inch) apart. Then ask the subject to copy the spiral. Test and score each hand
separately. Use a ballpoint pen. The pen should be held such that no part of the limb touches
the table. Secure the paper on the table in a location that is suitable for the patient’s style of
drawing. Score the tremor in the spiral, not the movement of the limb.

0 = normal
1 = slight: tremor barely visible.
2 = mild: obvious tremor
3 = moderate: portions of figure not recognizable.
4 = severe: figure not recognizable

7. Handwriting: Have patient write the standard sentence "This is a sample of my best
handwriting" using the dominant hand only. Patients must write cursively (i.e., no printing).
They cannot hold or stabilize their hand with the other hand. Use a ballpoint pen. Secure the
paper on the table in a location that is suitable for the patient’s style of writing. Score the
tremor in the writing, not the movement of the limb.

0 = normal
1 = slight: untidy due to tremor that is barely visible.
2 = mild: legible, but with considerable tremor.
3 = moderate: some words illegible.
4 = severe: completely illegible

8. Dot approximation task: The examiner makes a dot or X and instructs the subject to hold the
tip of the pen “as close as possible to the dot (or center of an X) without touching it, (ideally
approximately 1 mm) for 10 seconds”. Each hand is score separately.

0 = no tremor
1 = tremor is barely visible (< 0.5 cm)
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

9. Standing tremor: Subjects are standing, unaided if possible. The knees are 10-20 cm apart and
are flexed 10-20 θ. 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 tremor
2 = obvious but mild tremor, does not cause instability
3 = moderate tremor, impairs stability of stance
4 = severe tremor, unable to stand without assistance