756 J Neurol Neurosurg Psychiatry 2000;68:756–760 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.756 on 1 June 2000. Downloaded from Evaluation of three diVerent ways of assessing tremor in multiple sclerosis S H Alusi, J Worthington, S Glickman, L J Findley, P G Bain Abstract scales have been deployed in therapeutic trials Objectives—To examine the comparative involving patients with multiple sclerosis reliability and validity of three simple tremor but these have not been tested for their ways of rating upper limb tremor in reliability and sensitivity to change. Most of patients with multiple sclerosis. these tremor scales are simple with four or five Methods—Three examiners independ- points.4–6 A valid, precise, and reliable scale ently rated severity of upper limb tremor (that ideally takes into account the various in patients with multiple sclerosis on a components of the complexities of multiple 0–10 scale by studying videotape record- sclerosis tremor) is required if comparisons ings of patients’ examinations, spiral between multiple centres and eYcacyofdiVer- drawings, and handwriting samples. The ent interventions are to be assessed accurately. correlations of the tremor severity scores The 0–10 clinical tremor severity score with scores from arm dexterity tests and a devised by Bain et al has been shown to be a tremor related disability scale were also reliable and valid method of measuring essen- assessed. tial and dystonic tremors.7 This 10 step grading Results—Rating tremor on posture had a system has the advantages of providing a good intrarater and interrater reliability. precise scale that can be easily used in a clinical However, these reliabilities decreased setting to assess tremor in a specific body part when kinetic tremor was assessed, in part during posture and movement.7 However, its because dysmetria was a confounding fac- use for scoring impairment caused by multiple tor. The intrarater reliabilities of rating sclerosis tremors, in which other ataxic ele- tremor from spirals and handwriting were ments may complicate the picture, has not also good but the interrater reliabilities been previously examined. This study evalu- were only fair to moderate. Tremor sever- ates the construct validity, intrarater, and inter- ity scored by all three methods correlated rater reliability of this scale when used in three highly with scores obtained from the nine diVerent ways to assess upper limb tremor in hole peg test, finger tapping test, and a patients with multiple sclerosis. The scale was tremor related activities of daily living applied by three raters scoring the severity of (ADL) questionnaire, indicating that all tremor in the upper limbs (1) during action three methods were valid ways of assess- (posture and movement), (2) in writing, and ing tremor in multiple sclerosis. (3) in spiral drawing. The comparative reliabil- http://jnnp.bmj.com/ Conclusion—Multiple sclerosis tremors in ity of rating multiple sclerosis tremor in these Department of posture can be scored using a clinical rat- three ways was determined. Neurosciences, ing scale in a valid and reliable way, and Imperial College from spirals and handwriting samples if School of Medicine, the ratings are carried out by the same London, UK examiner. However, scoring kinetic S H Alusi Patients and methods S Glickman tremor was less reliable. In addition, the Ethical approval for the project was obtained P G Bain nine hole peg and finger tapping tests pro- from the Riverside research ethics committee, on September 29, 2021 by guest. Protected copyright. vide useful objective assessments of upper London. Patients with a definite diagnosis of Multiple Sclerosis limb function in tremulous patients with multiple sclerosis (Poser, 1983) and associated Unit, Central multiple sclerosis. upper limb tremors were recruited for this Middlesex Hospital, (J Neurol Neurosurg Psychiatry 2000;68:756–760) London, UK study from outpatient clinics at Charing Cross J Worthington Keywords: tremor; multiple sclerosis; scale Hospital and the multiple sclerosis unit at S Glickman Central Middlesex Hospital. Patients with other known neurological problems and those Essex Neurosciences Unit, Oldchurch Upper limb tremor in multiple sclerosis was with tremor associated with other medical Hospital, Essex, UK present in 55 of 100 randomly selected patients problems were excluded from this study. L J Findley in a study conducted from a multiple sclerosis Patients with profound weakness of the upper unit in north west London and was disabling in limbs (power grade<3/5 MRC scale) were also Correspondence to: at least one third of these.1 Another study had excluded. Twenty six (65%) of the patients Dr Sundus Alusi, Department of Psychological found that moderate and severe tremor were studied had normal power in the arms. The rest Medicine, Morrison present in 32% and 6% of patients had mild to moderate weakness (power 3–4/5 Hospital, Swansea SA6 6NL, respectively.2 Multiple sclerosis tremor mani- MRC scale). Sensory impairments were dem- UK [email protected] fests on action; including posture (postural), onstrated in one or both arms of half (20/40) during movement (kinetic) or both and can be the patients in the study (14 patients had Received 2 July 1999 and in embedded in a complex ataxic movement abnormal light touch and pinprick sensation, revised form 18 January 1999 disorder making accurate grading of tremor 11 reduced vibration sense, and five impaired Accepted 18 January 1999 diYcult.23 Various diVerent tremor rating joint position sense). Evaluation of three diVerent ways of assessing tremor in multiple sclerosis 757 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.756 on 1 June 2000. Downloaded from Table 1 Interpretation of Table 2 The intrarater and interrater reliability for rating were also rated on a 0–4 scale by looking at ê scores tremor in two postures (P1 and P2) and during movement patients’ movements while reaching out and (M) touching a target and performing alternating Strength of ê CoeYcient agreement Intrarater reliability Interrater reliability hand movement respectively (appendix 1). For (weighted ê values) (weighted ê values) the purposes of this study all rhythmic <0 Poor Tremor 0–0.20 Slight scoring Examiner 1 Examiner 2 1 v 2 1 v 3 2 v 3 tremulous movements were considered to be 0.21–0.40 Fair the result of tremor (defined as a rhythmic 0.41–0.60 Moderate P1 0.76* 0.82* 0.80* 0.32* 0.35* oscillation of a body part). Thus the raters were 0.61–0.80 Substantial P2 0.70* 0.69* 0.81* 0.49* 0.53* 0.81–1.00 Almost perfect M 0.37* 0.77* 0.76* 0.39* 0.42* asked to score the rhythmic oscillations of the upper limb or the manifestations of that move- *p<0.001. ment in writing or drawing specimens. RATING TREMOR AT REST, ON POSTURE, AND RATING TREMOR FROM SPIRAL DRAWINGS AND DURING MOVEMENT HANDWRITING SAMPLES Forty two video recordings were made from 30 Twenty three patients, seven men and 16 patients. Five patients had more than one women, provided spiral drawings and hand- recording (two or three) made after various writing samples. The patients’ average age was interventions, at least 3 months apart. There 43.0 years (SD 11.9), range (18–67), with an were 14 men and 16 women, average age was average disease duration of 17.3 years (SD 42.9 years (SD 10.3), range (23-70), and aver- 10.4). Median EDSS was 6.5 (range 1–9)). age disease duration was 17.4 years (SD 7.0). Twenty of the patients were right handed and The patients’ median expanded disability three left handed. status score (EDSS) was 6.5 (range 1- 9). The patients were asked to draw an Twenty four of the patients were right handed Archimedes spiral and to write the phrase and six were left handed. “Mary had a little lamb”. All samples were The patients were examined and videotaped performed with the patients seated and the in the sitting position. The rest component of forearm supported on a table. Spirals were tremor was examined with the arms relaxed drawn with both hands and handwriting and supported in the patient’s lap; however, samples were obtained from the dominant this was excluded from the analysis as none of hand only. Some patients with very severe the patients had rest tremor. The postural tremor were unable to perform all the tasks. component was examined in two postures: (1) Thus, 21 patients completed a spiral with the with the arms outstretched and the hands pro- right hand, 22 with the left hand, and 20 nated (P1), and (2) with the arms flexed at the patients provided a handwriting sample. All the elbows, and abducted at the shoulders to 90 samples obtained were photocopied twice, then degrees with the hands pronated and the the photocopies were individually number fingers held near to the nose ("the batswing” coded and shuZed. This produced a total of 86 position) (P2). The movement component was spirals and 40 handwriting samples. The three examined during a finger-nose-finger test (M). raters were then asked to score the spirals and The three clinicians were asked to rate tremor handwriting on the 0–10 scale while referenc- severity for each of these actions separately on ing the book “Assessing Tremor Severity” the 0–10 scale. Two of the raters repeated the (Bain and Findley 1993).8 The raters were http://jnnp.bmj.com/ scoring on the same video recordings 15 blinded to the fact that each sample had been months later to assess intrarater reliability. For duplicated to assess the intrarater reliability. this study only the right hand scores were used.