Protocol - Antipsychotic Medication Extrapyramidal Side Effects

Extrapyramidal Symptom Rating Scale (ESRS)

Summary of the ESRS examination procedure

1. Patient is asked to remove their shoes (omitted if judged clinically inappropriate or when patient hesitates, or delayed after patient has walked (after # 7). The patient is asked to remove anything from their mouth (except dentures). The patient is asked to sit facing the examiner on a chair with no armrests.

2. Observe facial expressiveness, speech, and dyskinesia while completing the questionnaire and while completing items 4, 5, and 6 below.

3. Patient is asked to extend both arms forward, with palms down and eyes closed.

4. The patient is asked to carry out pronation and supination of both hands as fast as possible, and to perform rapid alternate movements of both wrists. Repeat as necessary.

5. While the patient sits facing the examiner on a chair with no armrests about 1 foot (approx. 30 cm) from a table with his upper body turned, the patient is asked to copy a spiral with each hand and to write the name of his town, province/state and country.

6. Patient is asked to walk a distance of 12-15 feet (4-5 m) away from, and then back towards the examiner. Repeat as necessary.

7. Patient is asked to stand erect with eyes open with feet slightly apart (1-2 cm). The examiner pushes the patient on each shoulder, the back and pushes the chest or pulls from the back while asking the patient to keep his balance.

8. Carry out the examination of the muscular tonus of the four limbs.

In case of doubt score the lesser severity.

I. QUESTIONNAIRE: Parkinsonism, Akathisia, Dystonia and Dyskinesia. In this questionnaire, take into account the verbal report of the patient on the following: 1) the duration of the symptom during the day; 2) the number of days where the symptom was present during the last week; and, 3) the evaluation of the intensity of the symptom by the patient.

Enquire into the status of each symptom and rate accordingly

II. EXAMINATION: PARKINSONISM AND AKATHISIA

Items based on physical examinations for Parkinsonism

III. Examination: DYSTONIA

Based on examination and observation

IV. EXAMINATION: DYSKINETIC MOVEMENT

Based on examination and observation

Specify...……………………………………………………………………………………………………………..

* when activated or rarely spontaneous

** frequently spontaneous and present when activated

V. CLINICAL GLOBAL IMPRESSION OF SEVERITY OF DYSKINESIA

Considering your clinical experience, how severe is the dyskinesia at this time?

VI. CLINICAL GLOBAL IMPRESSION OF SEVERITY OF PARKINSONISM

Considering your clinical experience, how severe is the parkinsonism at this time?

VII. CLINICAL GLOBAL IMPRESSION OF SEVERITY OF DYSTONIA

Considering your clinical experience, how severe is the dystonia at this time?

VIII. CLINICAL GLOBAL IMPRESSION OF SEVERITY OF AKATHISIA

Considering your clinical experience, how severe is the akathisia at this time?

Scoring:

Questionnaire for Parkinsonism, akathisia, dystonia and dyskinesia:

• Each item is rated on a four point scale (0 = absent; 3 = severe). For subjective extra-pyramidal symptoms, severity is assessed over the last seven days and persistent symptoms are rated for the most typical day over the last seven.

Examination for Parkinsonism and akathisia (subscale II):

• Tremors and rigidity are scored on a seven-point scale (0 = none; 6 = severe) for each body part. Ratings for tremors account for amplitude and number of times the movement occurs during the interview.
• Total scores range from 0-102.
• A score of 3 or greater on any of the items is required to establish Parkinsonism for initiation of anti-Parkinsonism treatment.
• A score of 2 on 2 items or a score of 3 or greater on one item is required to establish the presence of Parkinsonism.
• Hypokinesia subscale scores (ranging from 0-42) are calculated from gait and posture, rigidity, expressive automatic movements, and bradykinesia.
• Hyperkinesia subscale scores (ranging from 0-54) are calculated from tremor and akathisia items.

Examination for dystonia:

• Acute and chronic movements are scored on a seven point scale (0 = none; 6 = most severe). Each body part is rated separately.
• Dystonia scores range from 0-60 and includes both acute and chronic dystonia.
• A score of three or greater on at least one item or a score of 2 on 2 items is required for presence of dystonia.

Examination for dyskinesia:

• Movements are scored on a seven-point scale (0 = none; 6 = severe) for each body part. Ratings account for amplitude and number of times the movement occurs during the interview.
• Dyskinesia scores range from 0-42 and is the total of all seven items.
• A score of three or greater on at least one item or a score of 2 on 2 items is required for presence of dyskinesia.
• Tardive dyskinesia subscale scores for each item separately
• Buccal-lingual-masticatory subscale is the total (0-18) from items 1, 2, 3 and an extremities score (0-12) from items 5 and 6.

Total Score:

• A total DMID score can be derived by adding together all 41 items.

Clinical global impressions of severity of Parkinsonism, akathisia, dystonia, and tardive dyskinesia:

• Results are rated according to results of the subjective questionnaire, examination subscales, and the evaluator’s clinical experience by applying an 8-point rating (0: absent; 1: borderline; 2: very mild; 3: mild; 4: moderate; 5: moderately severe; 6: marked; 7: severe; 8: extremely severe).

• The 4 clinical global impressions of severity subscales are analyzed as separate items.

Chouinard © 1979