In a preliminary study, 10 members of TRG simultaneously rated 10 ET patients during the live administration of the TETRAS performance subscale. Excellent inter-rater reliabilities were found for head and upper limb tremor. In another preliminary study, ten members of TRG simultaneously rated three patients with mild, moderate and severe ET and rated the videos of these exams one month later. The correlations between video scores and live exam scores were greater than 0.87 for all items except face (0.67) and voice (0.63) tremor. We now estimate the inter- and intra-rater reliabilities of the TETRAS performance subscale and the correlation of this subscale with the ADL subscale, using 50 videotaped exams. Methods All studies were performed with the signed written informed consent of the patients and controls, approved by the institutional review board of each institution.
Jun 28, 2012 In an attempt to standardize the evaluation of tremor (particularly for clinical research purposes), a number of rating scales have been developed that optimize comparability between studies and patient populations. 5 One of the earlier tremor scales developed that is still in use today is the Fahn–Tolosa–Marin Tremor Rating Scale (TRS).
Patients with ET and controls with no history of tremor were recruited from the authors’ clinics. The patients were diagnosed using Tremor Investigation Group criteria. Nine of the authors, all movement disorder specialists, videotaped TETRAS exams of one control and at least four patients. Each specialist was asked to video patients with mild, moderate and severe ET so that the videos were evenly distributed over these levels of severity. The TETRAS ADL and performance subscales were performed during each videotaping. Fifty videos (44 patients and 6 controls) were compiled in random order to a set of DVDs and mailed to the same specialists and one other. Graphic bold font. Each specialist rated all 50 videos.
The same videos in different order were rated by the same specialists one to two months after the first rating. Due to omissions in some of the videos, some of the test items could not be scored for every video. Four of the ten video raters had no experience or training in TETRAS, and nearly all video omissions came from these four raters. Nevertheless, all raters scored 31 to 46 videos for each item, except the standing item for which only 19 were scored. Inter- and intra-rater reliability of the performance subscale were assessed with two-way random effects intraclass correlations (ICC), using an absolute agreement definition. Results The patients (mean 67, range 35–80) and controls (mean 50; range 27–82) had comparable ages, and 27 of 50 participants were men.
The average duration of tremor in the 44 patients was 30 years (range 6–72). The distribution of total TETRAS performance scores for the 50 participants was fairly uniform ().
The inter- and intra-rater ICCs were greater than 0.85 for all items except face tremor, voice tremor, lower limb tremor and trunk (standing) tremor (see and for details). The six experienced and four inexperienced raters did not differ statistically (repeated measures ANOVA) in their inter- and intra-rater reliabilities for any of the test items, but the biggest differences were for the face, lower extremity and trunk (standing) items. The raters performed live TETRAS assessments during the videotaping of the 50 TETRAS exams. The Pearson correlation between the total ADL scores and the total performance scores was 0.887 (p. Total ADL and performance scores for the 50 patients and controls Cronbach alpha for the live exams performed during the video tapings was 0.951, and it was 0.968 after removal of the face, lower limb and trunk items.
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Statistically identical results were obtained when Cronbach alpha was computed using the video ratings of each rater. The item-to-total score correlations ranged from 0.88 to 0.95 (mean 0.91) for all upper limb items except right upper limb postural tremor with the limb extended forward (0.75). Item-to-total correlations for the head (0.69), face (0.45), voice (0.68), lower limb (0.60) and trunk (0.46) were lower. Discussion Our use of performance ratings defined in terms of specific amplitude ranges (cm) resulted in exceptional inter- and intra-rater reliabilities, even for raters without prior experience or training with this scale. However, all raters were experienced movement disorder specialists, and it remains to be determined if raters with less expertise perform as well.
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