The use of the Simpson Angus Scale for the assessment of movement disorder: A training guide
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,
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)
guide movement disorder
measurement Received 26 March 2003; accepted for
publication 3 July 2003
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
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
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 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
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
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
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.
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
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.
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 elbow
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
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
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 wrist
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
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
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
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
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
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
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
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
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
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
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.
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.
. 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