The use of the Simpson Angus Scale for the assessment of movement disorder: A training guide

CJ HAWLEY1,2, N FINEBERG1,2,

AG ROBERTS1, D BALDWIN3,

A SAHADEVAN1 AND V SHARMAN1

1Department of Psychiatry, QEII Hospital,

Welwyn Garden City, UK; 2University of

Hertfordshire, Hatfield, UK; 3University of

Southampton, Royal South Hants Hospital,

Southampton, UK

Correspondence Address

Professor CJ Hawley, Department of Psychiatry,

QEII Hospital, Welwyn Garden City,

Hertfordshire AL7 4HQ, UK

Tel: �/(44) 1707 365073 Fax: �/(44) 1707 365169 E-mail: C.1.Hawley@herts.ac.uk

The Simpson Angus Scale is commonly used for the assessment of

Parkinsonian Movement Disorder related to psychiatric drug treatment.

The authors present a practical guide to the use of the scale to assist both

the learner and the teacher. (Int J Psych Clin Pract 2003; 7: 249�/257)

Keywords

Simpson Angus

guide movement disorder

measurement Received 26 March 2003; accepted for

publication 3 July 2003

INTRODUCTION

T he Simpson Angus Scale (SAS) was designed to measurethe Parkinsonian effects caused by classic, dopamine- blocking, anti-schizophrenic drugs. The scale is reported to

have good inter-rater reliability with a total score correlation

of 0.87,1 although replication studies on reliability are

lacking. The scale has been successfully used in many studies

of anti-schizophrenic agents and possesses discriminative

validity.2 The brevity of the scale, and that it is in the public

domain, make it an attractive option for the measurement of

medication-related Parkinsonian features in routine clinical

practice.3

However, our experience has been that non-medical staff

do not find the scale intuitive to use and that the best way to

perform the examination cannot be easily deduced from the

rating legends. With the systematic evaluation of medication-

induced movement disorders now assuming greater impor-

tance,4 we thought it timely to publish a guide to the use of

the Simpson Angus scale. This draws on the authors’ clinical

experience in both using the scale and in providing training

about it.

The guide, which follows, is intended to help both

learners and teachers. Although the guide is quite detailed

and specific we would not presume to say that our method is

exclusive or best. As the clinician gains experience with the scale they may find ways of performing the procedure which

are different to, and better than, our approach. Nonetheless

we hope that the guide is a useful starting point from which

the user can develop further experience.

THE GUIDE

The use of the scale assumes familiarity with the neurological effects of anti-schizophrenic agents and, more generally, with

the neurology of the common movement disorders seen in

psychiatric practice (i.e. Parkinsonism, akathisia, dystonias

and tardive dyskinesias). Such familiarity can be broadly

assumed for all medical practitioners. However, for other

potential users of the SAS, familiarity with these conditions

must first be established. Reading relevant sections of a

comprehensive textbook of psychiatry is recommended as a

# 2003 Taylor & Francis International Journal of Psychiatry in Clinical Practice 2003 Volume 7 Pages 249�/257 249

DOI: 10.1080/13651500310002986

starting point. Kaplan and Saddock’s Comprehensive Text-

book of Psychiatry5 can be recommended.

Becoming skilled in the use of any measurement tool

requires practice and experience. There has been no research

into the SAS to indicate how much practice is required before

sufficient competence is attained. We would suggest that, for

the novice rater, a total of 15 practice examinations will be

sufficient and that these can be divided up as follows:

1. Five examinations on patients or normal volunteers to

practise the process of examination. That is to say; while

performing the examination the novice examiner fo-

cuses on how the examination is done in order to

achieve fluency, but does not pay too much attention to

the actual scoring. Any person can be examined for this

purpose, irrespective of what treatment they are receiv- ing, if any.

2. Five examinations to gain experience in making the

rating judgements. Assuming that the novice examiner

is now fluent in the process of examining the patient,

attention is turned to considering the actual ratings. It is

desirable to perform these examinations on patients

being treated with classic antipsychotic drugs so that

there is the prospect of a certain level of movement disorder being present for the examiner to evaluate.

3. Five examinations to verify reliability. Examinations are

performed jointly with an experienced rater, but scored

individually. The scoring is then discussed and learning

takes place through discussing the differences. Although

there is insufficient literature to indicate how close the

agreement should be between raters, the authors suggest

that disagreement in the scoring of individual items in the scale should not generally be greater than one point.

If the novice rater does not have access to an

experienced rater for a joint rating process, the next

best thing is for two novice raters to jointly examine

patients and discuss the scoring on a peer-to-peer basis.

Although this is a less than ideal situation, it nonetheless

promotes a degree of discussion and reflection that is

distinctly better than learning entirely unaided.

We recommend that the SAS is suitable for use by all medical

practitioners and suitably experienced psychiatric nurses. We

would not recommend that mental health professionals other than these use the scale.

PERFORMING THE EXAMINATION

GENERAL ISSUES

Setting

A suitably large examination space is needed. Both the

examiner and the patient should be able to fully outstretch

their arms at the same time without touching walls, furniture,

fittings or each other. The examination room must have an

examination couch, or similar, on which the patient can sit

with the feet at least 15 cm from the floor. Although a stout

table can suffice for this purpose, much office furniture is not

strong enough to support a person’s weight on a repeated

basis.

Confidence

Many novice examiners report an initial sense of embarrass-

ment when applying the SAS to patients given that the physical maneuvers are not usual for a psychiatric consulta-

tion. Such an emotion, which may communicate itself to the

patient, should be suppressed. Indeed, the whole examina-

tion should be performed with an air of confidence. Novice

raters may tend towards a conservative approach to the

examination, in particular, being too tentative on the

examination of items 3, 4, 5 and 7. While learning, a useful

guide is to aim to do everything twice as large as initially feels natural.

Consent

As with any examination, consent should be obtained from

the patient. Given the non-invasive nature of the examination

for the SAS, a simple verbal exchange suffices.

RATING THE INDIVIDUAL ITEMS

In the following section the rating instructions from the scale

itself are presented in the boxes in italic text. The text

following each box is the authors’ expansion on the rating

process for that item.

Item 1 �/ Gait The patient is examined as he walks into the examining room;

his gait, the swing of his arms, his general posture, all form the

basis for an overall score for this item. This is rated as follows:

0�/normal 1�/diminution in swing while the patient is walking 2�/marked diminution in swing with obvious rigidity in the arm 3�/stiff gait with arms held rigidly before the abdomen 4�/stooped shuffling gait with propulsion and retropulsion

The examination for this item should be performed

covertly, e.g. as the patient walks down the corridor to

the consultation room (Figure 1). The door-to-chair distance

in the average consulting room is too short for the examiner

to observe the gait sufficiently. If a person is asked to

demonstrate their gait this causes it to be rigid and artificial,

and hence covert observation is recommended.

250 CJ Hawley et al

Item 2 �/ Arm Dropping The patient and the examiner both raise their arms to shoulder height and let them fall to their sides. In a normal subject, a

stout slap is heard as the arms hit the sides. In the patient with

extreme Parkinson’s syndrome, the arms fall very slowly. The

scoring is as follows:

0�/normal, free fall with loud slap and rebound 1�/fall slowed slightly with less audible contact and little rebound

2�/fall slowed, no rebound 3�/marked slowing, no slap at all 4�/arms fall as though against resistance, as though through glue

The patient is to be positioned standing, facing the examiner

full on, and also so that their arms won’t accidentally hit any

nearby object as they fall (Figure 2). Thus plenty of free space

is needed to perform this item.

A practical tip for this item is to ‘show one, share one, see one’. First demonstrate to the patient arm dropping while

asking them not to copy you; this helps to diminish any

embarrassment. Then ask them to do one with you. Finally

one can use a prompt such as ‘now let me see you do that’

and make the rating accordingly.

Often, if the patient’s arms don’t fall freely, then one may

have the impression that the instruction has not been

understood. The patient may seem to deliberately move the arms down gradually rather than letting them free fall. One

can repeat the process using a clarifying prompt such as ‘Let

your arms flop, like a rag doll’. If there is still slowness of

dropping, then this should be rated accordingly.

Items 3�/5, Shoulder Shaking, Elbow Rigidity and Wrist Rigidity, can be considered together. The aim is to perform

these three components of the examination as one fluid

process. As this is the first time that the examiner touches the

patient during the examination, a simple verbal explanation

should be provided and consent-to-touch obtained (although

in the vast majority of cases this can be implicit rather than

explicit).

Item 3 �/ Shoulder Shaking The subject’s arms are bent at a right angle at the elbow and

are taken one at a time by the examiner who grasps one hand

and also clasps the other around the patient’s elbow. The

subject’s upper arm is pushed to and fro and the humerus is

externally rotated. The degree of resistance from normal to

extreme rigidity is scored as follows:

0�/normal 1�/slight stiffness and resistance 2�/moderate stiffness and resistance 3�/marked rigidity with difficulty in passive movement 4�/extreme stiffness and rigidity with almost a frozen shoulder

Figure 1 Gait: the gait is best observed covertly as the patient walks toward

the examination room

Figure 2 Arm dropping: showing the patient the maneuver before observing

Use of the Simpson Angus Scale for the Assessment of Movement Disorder 251

To examine the patient’s right arm, the examiner takes hold of

the patient’s right wrist with their right hand. The examiner’s

hand should be just above patient’s wrist and semi-prone (i.e.

thumb uppermost). The full weight of the patient’s arm

should rest in the examiner’s palm. The examiner then grasps

the patient’s upper arm with their left hand with the fingers

over triceps and the thumb over biceps muscle (Figure 3).

The grip of the examiner’s hands must be firm and decisive so

that they have full control of the patient’s arm. The ‘dead-rat-

grip’ (Figure 4) does not provide sufficient control at the

wrist and should not be used.

The arm is then moved at the shoulder joint as stated in

the rating legend, but not allowing movement at the elbow

joint. Initial movements should be small and sensitive in case

the patient has any musculoskeletal disorder in the shoulder

joint. Thereafter the shoulder joint should be put through the

full range of movements with some vigor.

Item 4 �/ Elbow Rigidity The elbow joints are separately bent at right angles and

passively extended and flexed, with the subject’s biceps

observed and simultaneously palpated. The resistance to this

procedure is rated. (The presence of cogwheel rigidity is noted

separately). Scoring is from 0 to 4 as in Shoulder Shaking test.

The examiner keeps the same firm grip of the arm, and the

elbow is moved through the full range of extension and

flexion. As with shoulder shaking, the movements should be

sensitive initially proceeding, when one is reassured that

there is no joint pain, to full and vigorous movement.

It is emphasized that there is no lateral (side to side)

movement at the elbow joint. Apparent side-to-side move-

ments are due to rotational movement of the humerus at the

shoulder joint as covered in shoulder shaking.

Two types of rigidity may be felt, lead-pipe and cogwheel.

Lead-pipe rigidity refers to resistance that is felt evenly

throughout the range of movements as if one were indeed

bending a lead pipe. Cogwheel rigidity is felt in a succession

of ‘notches’ in the movement akin to a ratchet. Palpation of

biceps with the thumb is particularly revealing of cogwheel

rigidity.

Item 5 �/ Wrist Rigidity The wrist is held in one hand and the fingers held by the

examiner’s other hand, with the wrist moved to extension,

flexion and both ulnar and radial deviation. The resistance to

this procedure is rated as in items 3 and 4. Scoring is as

follows:

Figure 3 General view of the grip on the arm for

elbow and shoulder evaluation

252 CJ Hawley et al

Assessing the wrist requires a change in the examiner’s grip

on the arm. The left hand moves down to replace the right

hand that was supporting the patient’s wrist. The examiner

then takes hold of the patient’s hand with their right hand,

and mobilizes it through four movements: flexion, extension,

radial deviation and ulnar deviation (Figure 5).

Although there are three components to the examination

of the arm (i.e. shoulder shaking, elbow rigidity and wrist

rigidity), the aim is to perform them as one sequence so that

the patient has the experience of the arm being examined as a

whole rather than part by part. Also, the joints can be

examined in random order.

The above procedure is now performed on the patient’s

left arm. The degree of stiffness in a particular joint may be asymmetrical. If so, the rating is given for the more abnormal

side.

Item 6 �/ Leg Pendulousness The patient sits on a table with his legs hanging down and

swinging free. The ankle is grasped by the examiner and raised

until the knee is partially extended. It is then allowed to fall.

The resistance to falling and the lack of swinging form the basis

for the score on this item:

0�/the legs swing freely 1�/slight diminution in the swing of the legs 2�/moderate resistance to swing 3�/marked resistance and damping of swing 4�/complete absence of swing

The patient is seated on an examination couch or, failing that,

a stout table. The feet must be well clear of the ground and be

able to swing freely (it is therefore not sufficient for the patient to be seated on a chair). The examiner will need to

kneel to the patient’s right to perform the examination; a

comfortable posture for the examiner is to kneel on one knee,

the right, so that their right thigh does not obstruct the swing

of the patient’s right leg. The patient’s legs can be lifted with a

light touch behind the ankles, to about 458, and then released and allowed to swing (Figure 6).

It is common practice to supplement the observation of leg swinging with active examination of knee stiffness. The

Figure 4 The dead-rat grip at the wrist. This is

not to be used as it provides insufficient control of the

arm

Figure 5 Detail of the correct grip for examination of the wrist

Use of the Simpson Angus Scale for the Assessment of Movement Disorder 253

examiner places their left hand on the patient’s thigh and grasps

the leg, posteriorily, just above the ankle. The leg is then moved

through flexion and extension (Figure 7). Any stiffness felt to be

present can contribute to the scoring on this item. Both legs are

examined. Active examination of the ankle does not, in the

experience of the authors, usefully supplement evaluation of

this item.

Item 7 �/ Head Dropping The patient lies on a well-padded examining table and his head is raised by the examiner’s hand. The hand is then withdrawn

and the head allowed to drop. In the normal subject the head

will fall upon the table. The movement is delayed in

extrapyramidal system disorder, and in extreme parkinsonism

it is absent. The neck muscles are rigid and the head does not

reach the examining table. Scoring is as follows:

0�/the head falls completely with a good thump as it hits the table 1�/slight slowing in fall, mainly noted by lack of slap as head meets the table

2�/moderate slowing in the fall quite noticeable to the eye 3�/head falls stiffly and slowly 4�/head does not reach examining table

In one modified version of the SAS the head dropping

procedure has been replaced with head rotation. Once a

patient has had their head dropped once, the response on

subsequent occasions is to not let their head hit the couch

with a ‘good thump’. Even when using the original version of

the SAS (as reproduced here), it is standard practice to

perform head rotation rather than head dropping.

For the revised process the patient stands facing the examiner full on. The examiner places their hands firmly

over the occiput and mobilizes the head through extension,

flexion, left lateral flexion and right lateral flexion (that is:

forward, backward and side to side) and rotation (Figure 8).

The head should not be held with the tips of the examiner’s

fingers: the palm of the hands and flats of the fingers provide

better control.

The grading for stiffness is then made using the general meaning of the anchor point for items 3 to 5, i.e. normal,

slight stiffness and resistance, moderate stiffness and resis-

tance, marked rigidity with difficulty in passive movement,

extreme stiffness and rigidity.

It should be noted that the neck, unlike other joints in

the body, has a high resting tone. Thus the grading is given

for the degree of stiffness over and above that which is

normal. To establish what is ‘normal’ it is helpful to examine the necks of persons not on any psychiatric treatment.

Two additional points are worth noting before performing

head rotation:

1. Raising one’s arms to grasp a person’s head will naturally

evoke a fear response that may be unhelpful if the

patient is already paranoid. It is therefore valuable to

give a verbal prompt of your intended action. 2. Osteoarthritis of the neck is common, therefore, before

vigorously mobilizing the neck it is wise to ask the

patient whether they have any problems in this respect.

In the case of the patient being taller than the examiner, it

will be hard to perform this item in the standing position. In

this case ask the patient to sit with their knees together and

examine the neck standing to the front and right of the

patient.

Item 8 �/ Glabellar Tap Subject is told to open his eyes wide and not to blink. The

glabella region is tapped at a steady rapid speed. The number

of times patient blinks in succession is noted:

0�/0�/5 blinks 1�/6�/10 blinks 2�/11�/15 blinks 3�/16�/20 blinks 4�/21 and more blinks

To elicit this feature, the glabellar region is tapped firmly with

the tip of the examiner’s right index finger (Figure 9). The

glabella is the region between the eyebrows, one centimeter

above the bridge of the nose. The taps should be delivered at approximately 1-s intervals.

Figure 6 Leg pendulousness: lifting and releasing the legs

Figure 7 Leg stiffness: the examiner flexes and extends the patient’s leg

254 CJ Hawley et al

The taps need to be delivered firmly. Medical practi-

tioners are usually skilled at this, as percussion is a core skill.

For non-medical professionals, some practice is required to

elicit taps of sufficient strength. One can practice by

percussing the back of one’s own hand; the taps are of

sufficient strength when they are strong enough to elicit mild

pain. It is only possible to perform the glabellar tap with

shortly cropped fingernails; attempting to tap with the pulp

of the fingertip is insufficient.

The examiner’s hand must not be in the patient’s line of

sight as this will elicit a blink reflex rather than glabellar

response. To achieve this: stand to the left side of the patient

and reach over the patient’s head with the right hand. If the

examiner is shorter than the patient, and therefore has

insufficient reach, then the patient can be seated. If this is the

case it may be convenient to perform glabellar tap at the same

time as head rotation.

A commonly asked question regards how many taps the

examiner should make. Sufficient taps should be applied until the blink reflex has stopped, except if the blink has not

extinguished by the 21st tap in which case no further

elicitation is required and a score of 4 is given. Opinion is

divided on whether partial blinks should be counted or only

full blinks. The authors adopt the practice that full blinks

should be counted while respecting the range of opinion on

this point.

Item 9 �/ Tremor Patient is observed walking into examining room and then is

re-examined for this item:

0�/normal 1�/mild finger tremor, obvious to sight and touch 2�/tremor of hand or arms occurring spasmodically 3�/persistent tremor of one or more limbs 4�/whole body tremor

The patient should be observed generally as they walk

toward the examination room, persistent tremor of the hands

or arms (e.g. scores of 3 or 4) will then be easily noticed.

For specific examination of less obvious tremor, the

patient stands facing the examiner straight on, approximately two arms length away. The patient is then asked to stretch

their arms out horizontally, palms downward, and to spread

their fingers. The examiner then raises their arms similarly so

that their finger tips are a couple of inches from the patient’s

(Figure 10). The examiner’s fingers are then used as the

normal reference point to decide if the patient has tremor or

not.

If it is equivocal whether the patient has mild tremor or

not (e.g. the decision between a score of 0 and 1) the observation can be supplemented by the examiner lightly

Figure 8 Detail of grip for head rotation. If the

patient is taller than the examiner (as illustrated)

the examination may be better performed with the

patient seated

Figure 9 The glabellar tap illustrated here with the patient seated

Use of the Simpson Angus Scale for the Assessment of Movement Disorder 255

running their fingers along the patient’s palm and fingers

while they are still outstretched. Mild tremor that may not

have been obvious to inspection may then be felt. If the examiner believes that tremor is due to some other

condition than medication-related movement disorder (e.g.

nervousness or the after effects of alcohol), the rating should

not be reduced or disregarded on this account. The general

rule for rating is that the features are rated irrespective of

putative cause, and the attribution is a matter for clinical

interpretation of the score, not how the scoring is made.

Item 10 �/ Salivation Patient is observed while talking and then asked to open his

mouth and elevate his tongue. The following ratings are given:

0�/normal 1�/excess salivation to the extent that pooling takes place if the mouth is open and the tongue raised

2�/when excess salivation is present and might occasionally result in difficulty in speaking

3�/speaking with difficulty because of excess salivation 4�/frank drooling

Excess salivation may arise for two reasons: either excess

saliva due to true hypersalivation (for example with cloza-

pine) or because there is stiffness of the oral and pharyngeal

musculature reducing the frequency of swallowing (for

example with a neuroleptic drug). No attempt is made to discriminate between these causes when making the rating.

A tongue wagging procedure is used to gain additional

information about muscular stiffness to supplement the

examination for salivation. For this procedure the patient is

asked to protrude the tongue and wag it from side to side,

initially slowly, then as quickly as possible (Figure 11). It is

usual for the examiner to demonstrate this to the patient first.

If significant slowness of tongue wagging is noticed, then

this will contribute to the scoring on this item (even if there

is no excess saliva). The grading for impaired movement is

made using the general meaning of the anchor points for

Figure 10 Examination for tremor

Figure 11 After observation for excess saliva the tongue wagging is

observed

256 CJ Hawley et al

items 3�/5, i.e. normal, slight, moderate, marked and extreme impairment of movement.

ORDER OF ITEMS

The items do not have to be performed in the order set out in

the scale. The clinician may modify the order of the items

according to personal preference and the convenience of the patient.

INTERPRETATION OF SCORES

According to the original report, the scale is scored by

summing the individual items and dividing the total by 10.

Thus the scale has a range from 0 to 4 points. In the majority

of research reports scores are reported in this way. However, for clinical purposes it is equally reasonable to report scale

values as simply the sum of item scores and the range of

values is then 0�/40. Providing one makes it clear which way one is documenting the score (e.g. as x /4 or y /40) then there

is no practical difference.

Simpson and Angus originally reported that scores below

0.3 (three-point raw score) can be considered normal. The

scale score cannot in itself be the decision maker in whether a patient’s pharmacotherapy needs modification; there will be

many other considerations that bear on whether the patient’s

treatment should, or can, be modified. However, in the

experience of the authors raw scores ]/6 represent a clinically significant degree of movement disorder such that

some elective revision of therapy should at least be

considered. Scores ]/12 should attract decisive attention

and a score ]/18 almost certainly dictates a modification of the pharmacotherapy on an expeditious basis.

UNPUBLISHED REVISIONS OF THE SAS

The scale is in the public domain and, consequently, there

are many informally revised versions in circulation. We would mention the modest revision of the scale published by

Rush et al3 which differs from the original scale in that the leg

pendulousness item is deleted, head rotation is specified in

place of head dropping and an item for akathisia is added. In

the absence of peer-reviewed validity and reliability data, it

would be hard to assert that any particular version of the SAS

is any better than another. However, we hope that this guide

is broadly applicable to the conduct of the SAS even in the face of minor revisions.

REFERENCES

1. Simpson GM, Angus JWS (1970) A rating scale for extrapyramidal side effects. Acta Psychiatr Scand (Suppl 212): 11�/9.

2. Zimbroff DL, Kane JM, Tamminga CA et al (1997) Controlled, dose- response study of sertindole and haloperidol in the treatment of schizophrenia. Sertindole Study Group. Am J Psychiatry 154: 782�/ 91.

3. Rush J (2000) Handbook of Psychiatric Measures . Washington: American Psychiatric Publishing.

4. National Institute for Clinical Excellence (2002) Schizophrenia: core

interventions in the treatment and management of schizophrenia in

primary and secondary care . London: NICE. 5. Saddock BJ, Saddock VA (eds) (2000) Kaplan and Saddock’s

Comprehensive Textbook of Psychiatry (7th ed) Philadelphia, PA:

Lippincott Williams and Wilkins.

KEY POINTS

. The Simpson Angus Scale is a tool for the evaluation of antipsychotic drug-induced parkinsonism.

. This article provides procedural guidance on the performance of the evaluation.

. The guide can be used as a learning or a teaching aid.

Use of the Simpson Angus Scale for the Assessment of Movement Disorder 257

The use of the Simpson Angus Scale for the assessment of movement disorder: A training guide

"Looking for a Similar Assignment? Get Expert Help at an Amazing Discount!"

Academic Writing Help

Quicl Links

Talk to Us