SARA Scale GDL

GUIDE DETAILS

Description:	Scale of the Assessment and Rating of Ataxia (SARA) is a clinical scale that is based on a semiquantitative assessment of cerebellar ataxia on an impairment level. SARA has 8 items that are related to gait, stance, sitting, speech, finger-chase test, nose-finger test, fast alternating movements and heel-shin test. Although the cerebellum is directly involved in the coordination of eye movements, oculomotor functions are not considered, as the validation trials indicated that they are determined by other factors than appendicular and midline ataxia. SARA underwent a rigorous validation procedure involving three large multi-center trials in SCA and non-SCA ataxia patients, as well as controls.
Purpose:	The purpose of this tool is to model all the rules that are related to SARA scale to: 1. Calculate the total score 2. Interpret the total score 3. Link each scale item with its corresponding phenotypic abnormality and to determine its severity level 4. Infer the hierarchical relationships between phenotypic abnormalities
Use:
Misuse:
References:

AUTHOR DETAILS

Name:	Haitham Maarouf
Email:	h_maarouf@hotmail.com
Organisation:	KEAM-University of Santiago De Compostela
Date:	22/04/2017
Authorship lifecycle:
Copyright:

KEYWORDS

SARA, HPO

CONTRIBUTORS

María Taboada , María Jesús Sobrido

RULE LIST

Rule Initialization
When
    Element Gait severity value does not exist
    Element Stance severity value does not exist
    Element Sitting severity value does not exist
    Element Midline severity value does not exist
    Element Finger chase right severity value does not exist
    Element Finger chase left severity value does not exist
    Element Nose finger test right severity value does not exist
    Element Nose finger test left severity value does not exist
    Element Fast alternating hand movements right severity value does not exist
    Element Fast alternating hand movements left severity value does not exist
    Element Heel-shin slide right severtiy value does not exist
    Element Heel-shin slide left severity value does not exist
    Element Appendicular right severity value does not exist
    Element Appendicular left severity value does not exist
    Element Counter does not exist
Then
    Set element Gait severity value to 0
    Set element Stance severity value to 0
    Set element Sitting severity value to 0
    Set element Midline severity value to 0
    Set element Finger chase right severity value to 0
    Set element Finger chase left severity value to 0
    Set element Nose finger test right severity value to 0
    Set element Nose finger test left severity value to 0
    Set element Fast alternating hand movements right severity value to 0
    Set element Fast alternating hand movements left severity value to 0
    Set element Heel-shin slide right severtiy value to 0
    Set element Heel-shin slide left severity value to 0
    Set element Appendicular right severity value to 0
    Set element Appendicular left severity value to 0
    Set element Counter to 0

Rule Counter check gait
When
    Element "Gait_VALUE" is greater than 0
    Element Gait does not exist
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Gait to Gait

Rule Counter check stance
When
    Element Stance does not exist
    Element "Stance_VALUE" is greater than 0
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Stance to Stance

Rule Counter check sitting
When
    Element "Sitting_VALUE" is greater than 0
    Element Sitting does not exist
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Sitting to Sitting

Rule Counter check speech disturbance
When
    Element Speech Disturbance does not exist
    Element "Speech Disturbance_VALUE" is greater than 0
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Speech Disturbance to Speech Disturbance

Rule Counter check finger chase right
When
    Element "Finger chase-right hand_VALUE" is greater than 0
    Element Finger chase-right hand does not exist
Then
    Set element Finger chase-right hand to Finger chase-right hand
    Set element "Counter_MAGNITUDE" to (Counter + 1)

Rule Counter check finger chase left
When
    Element Finger chase-left hand does not exist
    Element "Finger chase-left hand_VALUE" is greater than 0
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Finger chase-left hand to Finger chase-left hand

Rule Counter Nose finger test right
When
    Element Nose-finger test-right hand does not exist
    Element "Nose-finger test-right hand_VALUE" is greater than 0
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Nose-finger test-right hand to Nose-finger test-right hand

Rule Counter Nose finger test left
When
    Element Nose-finger test-left hand does not exist
    Element "Nose-finger test-left hand_VALUE" is greater than 0
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Nose-finger test-left hand to Nose-finger test-left hand

Rule Counter check fast alternating hand movements right
When
    Element Fast alternating hand movements-right hand does not exist
    Element "Fast alternating hand movements-right hand_VALUE" is greater than 0
Then
    Set element Fast alternating hand movements-right hand to Fast alternating hand movements-right hand
    Set element "Counter_MAGNITUDE" to (Counter + 1)

Rule Counter check fast alternating hand movements left
When
    Element Fast alternating hand movements-left hand does not exist
    Element "Fast alternating hand movements-left hand_VALUE" is greater than 0
Then
    Set element Fast alternating hand movements-left hand to Fast alternating hand movements-left hand
    Set element "Counter_MAGNITUDE" to (Counter + 1)

Rule Counter check heel shin slide right
When
    Element Heel-shin slide-right hand does not exist
    Element "Heel-shin slide-right hand_VALUE" is greater than 0
Then
    Set element Heel-shin slide-right hand to Heel-shin slide-right hand
    Set element "Counter_MAGNITUDE" to (Counter + 1)

Rule Counter check heel shin slide left
When
    Element "Heel-shin slide-left hand_VALUE" is greater than 0
    Element Heel-shin slide-left hand does not exist
Then
    Set element "Counter_MAGNITUDE" to (Counter + 1)
    Set element Heel-shin slide-left hand to Heel-shin slide-left hand

Rule Calculate finger chase mean
When
Then
Set element "Finger chase-mean of both sides_MAGNITUDE" to ((Finger chase-right hand + Finger chase-left hand) / 2.0)
Set element "Finger chase-mean of both sides_PRECISION" to 1

Rule Calculate nose finger test mean
When
Then
Set element "Nose-finger test-mean of both sides_PRECISION" to 1
Set element "Nose-finger test-mean of both sides_MAGNITUDE" to ((Nose-finger test-right hand + Nose-finger test-left hand) / 2.0)

Rule Calculate fast alternating hand movements mean
When
Then
Set element "Fast alternating hand movements-mean of both sides_PRECISION" to 1
Set element "Fast alternating hand movements-mean of both sides_MAGNITUDE" to ((Fast alternating hand movements-right hand + Fast alternating hand movements-left hand) / 2.0)

Rule Calculate Heel-shin mean
When
Then
Set element "Heel-shin slide-mean of both sides_PRECISION" to 1
Set element "Heel-shin slide-mean of both sides_MAGNITUDE" to ((Heel-shin slide-right hand + Heel-shin slide-left hand) / 2.0)

Rule Calculate total score
When
Then
Set element "Sara Total Score_MAGNITUDE" to (((((((Gait + Stance) + Sitting) + Speech Disturbance) + Finger chase-mean of both sides) + Nose-finger test-mean of both sides) + Fast alternating hand movements-mean of both sides) + Heel-shin slide-mean of both sides)
Set element "Sara Total Score_PRECISION" to 1

Rule Gait normal
When
    Element Gait equals to Normal, no difficulties in walking, turning and walking tandem (up to one misstep allowed)
Then
    Set element Gait to Gait
    Set element Gait Ataxia to Normal

Rule Gait Borderline
When
    Element Gait equals to Slight difficulties, only visible when walking 10 consecutive steps in tandem
Then
    Set element "Gait severity value_MAGNITUDE" to 1
    Set element Gait Ataxia to Borderline

Rule Gait mild
When
    Element Gait equals to Clearly abnormal, tandem walking >10 steps not possible
Then
    Set element "Gait severity value_MAGNITUDE" to 2
    Set element Gait Ataxia to Mild

Rule Gait moderate
When
    ((
        Element Gait equals to Considerable staggering, difficulties in half-turn, but without support
    )    or (
        Element Gait equals to Marked staggering, intermittent support of the wall required
    ))
Then
    Set element "Gait severity value_MAGNITUDE" to 3
    Set element Gait Ataxia to Moderate

Rule Gait severe
When
    ((
        Element Gait equals to Severe staggering, permanent support of one stick or light support by one arm required
    )    or (
        ((
            Element Gait equals to Walking > 10 m only with strong support (two special sticks or stroller or accompanying person)
        )        or (
            Element Gait equals to Walking < 10 m only with strong support (two special sticks or stroller or accompanying person)
        ))
    ))
Then
    Set element Gait Ataxia to Severe
    Set element "Gait severity value_MAGNITUDE" to 4

Rule Gait profound
When
    Element Gait equals to Unable to walk, even supported
Then
    Set element Gait Ataxia to profound
    Set element "Gait severity value_MAGNITUDE" to 5

Rule Stance normal
When
    Element Stance equals to Normal, able to stand in tandem for > 10 s
Then
    Set element Stance to Stance
    Set element Standing Instability to Normal

Rule Stance borderline
When
    Element Stance equals to Able to stand with feet together without sway, but not in tandem for > 10s
Then
    Set element "Stance severity value_MAGNITUDE" to 1
    Set element Standing Instability to Borderline

Rule Stance mild
When
    ((
        Element Stance equals to Able to stand with feet together for > 10 s, but only with sway
    )    or (
        Element Stance equals to Able to stand for > 10 s without support in natural position, but not with feet together
    ))
Then
    Set element "Stance severity value_MAGNITUDE" to 2
    Set element Standing Instability to Mild

Rule Stance moderate
When
    Element Stance equals to Able to stand for >10 s in natural position only with intermittent support
Then
    Set element "Stance severity value_MAGNITUDE" to 3
    Set element Standing Instability to Moderate

Rule Stance severe
When
    Element Stance equals to Able to stand >10 s in natural position only with constant support of one arm
Then
    Set element "Stance severity value_MAGNITUDE" to 4
    Set element Standing Instability to Severe

Rule Stance profound
When
    Element Stance equals to Unable to stand for >10 s even with constant support of one arm
Then
    Set element Standing Instability to profound
    Set element "Stance severity value_MAGNITUDE" to 5

Rule Sitting normal
When
    Element Sitting equals to Normal, no difficulties sitting >10 sec
Then
    Set element Sitting Instability to Normal
    Set element Sitting to Sitting

Rule Sitting borderline
When
    Element Sitting equals to Slight difficulties, intermittent sway
Then
    Set element "Sitting severity value_MAGNITUDE" to 1
    Set element Sitting Instability to Borderline

Rule Sitting mild
When
    Element Sitting equals to Constant sway, but able to sit > 10 s without support
Then
    Set element "Sitting severity value_MAGNITUDE" to 2
    Set element Sitting Instability to Mild

Rule Sitting moderate
When
    Element Sitting equals to Able to sit for > 10 s only with intermittent support
Then
    Set element "Sitting severity value_MAGNITUDE" to 3
    Set element Sitting Instability to Moderate

Rule Sitting severe
When
    Element Sitting equals to Unable to sit for >10 s without continuous support
Then
    Set element "Sitting severity value_MAGNITUDE" to 4
    Set element Sitting Instability to Severe

Rule speech disturbance normal
When
    Element Speech Disturbance equals to Normal
Then
    Set element Speech Disturbance to Speech Disturbance
    Set element Dysarthria to Normal

Rule speech disturbance borderline
When
Element Speech Disturbance equals to Suggestion of speech disturbance
Then
Set element Dysarthria to Borderline

Rule speech disturbance mild
When
Element Speech Disturbance equals to Impaired speech, but easy to understand
Then
Set element Dysarthria to Mild

Rule speech disturbance moderate
When
    ((
        Element Speech Disturbance equals to Occasional words difficult to understand
    )    or (
        Element Speech Disturbance equals to Many words difficult to understand
    ))
Then
    Set element Dysarthria to Moderate

Rule speech disturbance severe
When
Element Speech Disturbance equals to Only single words understandable
Then
Set element Dysarthria to Severe

Rule speech disturbance profound
When
Element Speech Disturbance equals to Speech unintelligible / anarthria
Then
Set element Dysarthria to Profound

Rule Finger chase right normal
When
    Element Finger chase-right hand equals to No dysmetria
Then
    Set element Upper Limb Dysmetria Right to Normal
    Set element Finger chase-right hand to Finger chase-right hand

Rule Finger chase right mild
When
    Element Finger chase-right hand equals to Dysmetria, under/ overshooting target <5 cm
Then
    Set element "Finger chase right severity value_MAGNITUDE" to 2
    Set element Upper Limb Dysmetria Right to Mild

Rule Finger chase right moderate
When
    Element Finger chase-right hand equals to Dysmetria, under/ overshooting target < 15 cm
Then
    Set element "Finger chase right severity value_MAGNITUDE" to 3
    Set element Upper Limb Dysmetria Right to Moderate

Rule Finger chase right severe
When
    ((
        Element Finger chase-right hand equals to Dysmetria, under/ overshooting target > 15 cm
    )    or (
        Element Finger chase-right hand equals to Unable to perform 5 pointing movements
    ))
Then
    Set element "Finger chase right severity value_MAGNITUDE" to 4
    Set element Upper Limb Dysmetria Right to Severe

Rule Finger chase left normal
When
    Element Finger chase-left hand equals to No dysmetria
Then
    Set element Upper Limb Dysmetria Left to Normal
    Set element Finger chase-left hand to Finger chase-left hand

Rule Finger chase left mild
When
    Element Finger chase-left hand equals to Dysmetria, under/ overshooting target <5 cm
Then
    Set element "Finger chase left severity value _MAGNITUDE" to 2
    Set element Upper Limb Dysmetria Left to Mild

Rule Finger chase left moderate
When
    Element Finger chase-left hand equals to Dysmetria, under/ overshooting target < 15 cm
Then
    Set element "Finger chase left severity value _MAGNITUDE" to 3
    Set element Upper Limb Dysmetria Left to Moderate

Rule Finger chase left severe
When
    ((
        Element Finger chase-left hand equals to Dysmetria, under/ overshooting target > 15 cm
    )    or (
        Element Finger chase-left hand equals to Unable to perform 5 pointing movements
    ))
Then
    Set element "Finger chase left severity value _MAGNITUDE" to 4
    Set element Upper Limb Dysmetria Left to Severe

Rule nose finger test right normal
When
    Element Nose-finger test-right hand equals to No tremor
Then
    Set element Intention Tremor Right to Normal
    Set element Nose-finger test-right hand to Nose-finger test-right hand

Rule nose finger test righ mild
When
    Element Nose-finger test-right hand equals to Tremor with an amplitude < 2 cm
Then
    Set element "Nose finger test right severity value_MAGNITUDE" to 2
    Set element Intention Tremor Right to Mild

Rule nose finger test righ moderate
When
    Element Nose-finger test-right hand equals to Tremor with an amplitude < 5 cm
Then
    Set element "Nose finger test right severity value_MAGNITUDE" to 3
    Set element Intention Tremor Right to Moderate

Rule nose finger test righ severe
When
    ((
        Element Nose-finger test-right hand equals to Tremor with an amplitude > 5 cm
    )    or (
        Element Nose-finger test-right hand equals to Unable to perform 5 pointing movements
    ))
Then
    Set element "Nose finger test right severity value_MAGNITUDE" to 4
    Set element Intention Tremor Right to Severe

Rule nose finger test left normal
When
    Element Nose-finger test-left hand equals to No tremor
Then
    Set element Intention Tremor Left to Normal
    Set element Nose-finger test-left hand to Nose-finger test-left hand

Rule nose finger test left mild
When
    Element Nose-finger test-left hand equals to Tremor with an amplitude < 2 cm
Then
    Set element "Nose finger test left severity value_MAGNITUDE" to 2
    Set element Intention Tremor Left to Mild

Rule nose finger test left moderate
When
    Element Nose-finger test-left hand equals to Tremor with an amplitude < 5 cm
Then
    Set element "Nose finger test left severity value_MAGNITUDE" to 3
    Set element Intention Tremor Left to Moderate

Rule nose finger test left severe
When
    ((
        Element Nose-finger test-left hand equals to Tremor with an amplitude > 5 cm
    )    or (
        Element Nose-finger test-left hand equals to Unable to perform 5 pointing movements
    ))
Then
    Set element "Nose finger test left severity value_MAGNITUDE" to 4
    Set element Intention Tremor Left to Severe

Rule fast alternating hand movements right normal
When
    Element Fast alternating hand movements-right hand equals to Normal, no irregularities (performs <10s)
Then
    Set element Fast alternating hand movements-right hand to Fast alternating hand movements-right hand
    Set element Dysdiadochokinesis Right to Normal

Rule fast alternating hand movements right mild
When
    Element Fast alternating hand movements-right hand equals to Slightly irregular (performs <10s)
Then
    Set element "Fast alternating hand movements right severity value _MAGNITUDE" to 2
    Set element Dysdiadochokinesis Right to Mild

Rule fast alternating hand movements right moderate
When
    Element Fast alternating hand movements-right hand equals to Clearly irregular, single movements difficult to distinguish or relevant interruptions, but performs <10s
Then
    Set element Dysdiadochokinesis Right to Moderate
    Set element "Fast alternating hand movements right severity value _MAGNITUDE" to 3

Rule fast alternating hand movements right severe
When
    ((
        Element Fast alternating hand movements-right hand equals to Very irregular, single movements difficult to distinguish or relevant interruptions, performs >10s
    )    or (
        Element Fast alternating hand movements-right hand equals to Unable to complete 10 cycles
    ))
Then
    Set element "Fast alternating hand movements right severity value _MAGNITUDE" to 4
    Set element Dysdiadochokinesis Right to Severe

Rule fast alternating hand movements left normal
When
    Element Fast alternating hand movements-left hand equals to Normal, no irregularities (performs <10s)
Then
    Set element Dysdiadochokinesis Left to Normal
    Set element Fast alternating hand movements-left hand to Fast alternating hand movements-left hand

Rule fast alternating hand movements left mild
When
    Element Fast alternating hand movements-left hand equals to Slightly irregular (performs <10s)
Then
    Set element "Fast alternating hand movements left severity value_MAGNITUDE" to 2
    Set element Dysdiadochokinesis Left to Mild

Rule fast alternating hand movements left moderate
When
    Element Fast alternating hand movements-left hand equals to Clearly irregular, single movements difficult to distinguish or relevant interruptions, but performs <10s
Then
    Set element "Fast alternating hand movements left severity value_MAGNITUDE" to 3
    Set element Dysdiadochokinesis Left to Moderate

Rule fast alternating hand movements left severe
When
    ((
        Element Fast alternating hand movements-left hand equals to Very irregular, single movements difficult to distinguish or relevant interruptions, performs >10s
    )    or (
        Element Fast alternating hand movements-left hand equals to Unable to complete 10 cycles
    ))
Then
    Set element "Fast alternating hand movements left severity value_MAGNITUDE" to 4
    Set element Dysdiadochokinesis Left to Severe

Rule heel shin slide right normal
When
    Element Heel-shin slide-right hand equals to Normal
Then
    Set element Heel-shin slide-right hand to Nose-finger test-right hand
    Set element Lower Limb Dysmetria Right to Normal

Rule heel shin slide right mild
When
    Element Heel-shin slide-right hand equals to Slightly abnormal, contact to shin maintained
Then
    Set element "Heel-shin slide right severtiy value_MAGNITUDE" to 2
    Set element Lower Limb Dysmetria Right to Mild

Rule heel shin slide right moderate
When
    Element Heel-shin slide-right hand equals to Clearly abnormal, goes off shin up to 3 times during 3 cycles
Then
    Set element "Heel-shin slide right severtiy value_MAGNITUDE" to 3
    Set element Lower Limb Dysmetria Right to Moderate

Rule heel shin slide right severe
When
    ((
        Element Heel-shin slide-right hand equals to Severely abnormal, goes off shin 4 or more times during 3 cycles
    )    or (
        Element Heel-shin slide-right hand equals to Unable to perform the task
    ))
Then
    Set element "Heel-shin slide right severtiy value_MAGNITUDE" to 4
    Set element Lower Limb Dysmetria Right to Severe

Rule heel shin slide left normal
When
    Element Heel-shin slide-left hand equals to Normal
Then
    Set element Heel-shin slide-left hand to Heel-shin slide-left hand
    Set element Lower Limb Dysmetria Left to Normal

Rule heel shin slide left mild
When
    Element Heel-shin slide-left hand equals to Slightly abnormal, contact to shin maintained
Then
    Set element "Heel-shin slide left severity value_MAGNITUDE" to 2
    Set element Lower Limb Dysmetria Left to Mild

Rule heel shin slide left moderate
When
    Element Heel-shin slide-left hand equals to Clearly abnormal, goes off shin up to 3 times during 3 cycles
Then
    Set element "Heel-shin slide left severity value_MAGNITUDE" to 3
    Set element Lower Limb Dysmetria Left to Moderate

Rule heel shin slide left severe
When
    ((
        Element Heel-shin slide-left hand equals to Severely abnormal, goes off shin 4 or more times during 3 cycles
    )    or (
        Element Heel-shin slide-left hand equals to Unable to perform the task
    ))
Then
    Set element "Heel-shin slide left severity value_MAGNITUDE" to 4
    Set element Lower Limb Dysmetria Left to Severe

Rule Midline and Gait
When
    Element Gait severity value is greater than or equals to Stance severity value
    Element Gait severity value is greater than or equals to Sitting severity value
Then
    Set element Midline severity value to Gait severity value

Rule Midline and Stance
When
Element Stance severity value is greater than Midline severity value
Then
Set element Midline severity value to Stance severity value

Rule Midline and Sitting
When
Element Sitting severity value is greater than Midline severity value
Then
Set element Midline severity value to Sitting severity value

Rule Midline normal
When
    ((
        Element Midline severity value equals to 0
    )    or (
        Element Sara Total Score is less than 3
    ))
Then
    Set element Midline Ataxia to Normal

Rule Midline Borderline
When
    Element Sara Total Score is greater than or equals to 3
    Element Midline severity value equals to 1
Then
    Set element Midline Ataxia to Borderline

Rule Midline Mild
When
    Element Sara Total Score is greater than or equals to 3
    Element Midline severity value equals to 2
Then
    Set element Midline Ataxia to Mild

Rule Midline moderate
When
    Element Sara Total Score is greater than or equals to 3
    Element Midline severity value equals to 3
Then
    Set element Midline Ataxia to Moderate

Rule Midline severe
When
    Element Sara Total Score is greater than or equals to 3
    Element Midline severity value equals to 4
Then
    Set element Midline Ataxia to Severe

Rule Midline Profound
When
    Element Sara Total Score is greater than or equals to 3
    Element Midline severity value equals to 5
Then
    Set element Midline Ataxia to Profound

Rule Has Abasia yes
When
Element Gait equals to Unable to walk, even supported
Then
Set element Abasia to Yes

Rule Has Abasia no
When
Element Gait is not equal to Unable to walk, even supported
Then
Set element Abasia to No

Rule Has Astasia yes
When
Element Stance equals to Unable to stand for >10 s even with constant support of one arm
Then
Set element Astasia to Yes

Rule Has Astasia no
When
Element Stance is not equal to Unable to stand for >10 s even with constant support of one arm
Then
Set element Astasia to No

Rule Has Anarthria yes
When
Element Speech Disturbance equals to Speech unintelligible / anarthria
Then
Set element Anarthria to Yes

Rule Has Anarthria no
When
Element Speech Disturbance is not equal to Speech unintelligible / anarthria
Then
Set element Anarthria to No

Rule Cerebellar syndrome no
When
    ((
        Element Counter is less than or equals to 1
    )    or (
        Element Sara Total Score is less than or equals to 1
    ))
Then
    Set element Cerebellar Syndrome to No

Rule Cerebellar syndrome no significant
When
    Element Counter is greater than 1
    Element Sara Total Score is greater than 1
    Element Sara Total Score is less than 3
Then
    Set element Cerebellar Syndrome to No Significant

Rule Cerebellar syndrome mild
When
    Element Counter is greater than 1
    Element Sara Total Score is greater than or equals to 3
    Element Sara Total Score is less than or equals to 8
Then
    Set element Cerebellar Syndrome to Mild

Rule Cerebellar syndrome moderate
When
    Element Counter is greater than 1
    Element Sara Total Score is greater than 8
    Element Sara Total Score is less than or equals to 15
Then
    Set element Cerebellar Syndrome to Moderate

Rule Cerebellar syndrome severe
When
    Element Counter is greater than 1
    Element Sara Total Score is greater than 15
Then
    Set element Cerebellar Syndrome to Severe

Rule Appendicular right and finger chase right
When
Element Appendicular right severity value is less than Finger chase right severity value
Then
Set element Appendicular right severity value to Finger chase right severity value

Rule Appendicular right and nose finger test right
When
Element Appendicular right severity value is less than Nose finger test right severity value
Then
Set element Appendicular right severity value to Nose finger test right severity value

Rule Appendicular right and fast alternating hand movements right
When
Element Appendicular right severity value is less than Fast alternating hand movements right severity value
Then
Set element Appendicular right severity value to Fast alternating hand movements right severity value

Rule Appendicular right and heel shin slide right
When
Element Appendicular right severity value is less than Heel-shin slide right severtiy value
Then
Set element Appendicular right severity value to Heel-shin slide right severtiy value

Rule Appendicular right normal
When
    ((
        Element Sara Total Score is less than 3
    )    or (
        Element Appendicular right severity value equals to 0
    ))
Then
    Set element Appendicular Ataxia Right to Normal

Rule Appendicular right mild
When
    Element Sara Total Score is greater than or equals to 3
    Element Appendicular right severity value equals to 2
Then
    Set element Appendicular Ataxia Right to Mild

Rule Appendicular right moderate
When
    Element Appendicular right severity value equals to 3
    Element Sara Total Score is greater than or equals to 3
Then
    Set element Appendicular Ataxia Right to Moderate

Rule Appendicular right severe
When
    Element Sara Total Score is greater than or equals to 3
    Element Appendicular right severity value equals to 4
Then
    Set element Appendicular Ataxia Right to Severe

Rule Appendicular left and finger chase left
When
Element Appendicular left severity value is less than Finger chase left severity value
Then
Set element Appendicular left severity value to Finger chase left severity value

Rule Appendicular left and nose finger test left
When
Element Appendicular left severity value is less than Nose finger test left severity value
Then
Set element Appendicular left severity value to Nose finger test left severity value

Rule Appendicular left and fast alternating hand movements left
When
Element Appendicular left severity value is less than Fast alternating hand movements right severity value
Then
Set element Appendicular left severity value to Fast alternating hand movements right severity value

Rule Appendicular left and heel shin slide left
When
Element Appendicular left severity value is less than Heel-shin slide left severity value
Then
Set element Appendicular left severity value to Heel-shin slide left severity value

Rule Appendicular left normal
When
    ((
        Element Sara Total Score is less than 3
    )    or (
        Element Appendicular left severity value equals to 0
    ))
Then
    Set element Appendicular Ataxia Left to Normal

Rule Appendicular left mild
When
    Element Sara Total Score is greater than or equals to 3
    Element Appendicular left severity value equals to 2
Then
    Set element Appendicular Ataxia Left to Mild

Rule Appendicular left moderate
When
    Element Appendicular left severity value equals to 3
    Element Sara Total Score is greater than or equals to 3
Then
    Set element Appendicular Ataxia Left to Moderate

Rule Appendicular left severe
When
    Element Sara Total Score is greater than or equals to 3
    Element Appendicular left severity value equals to 4
Then
    Set element Appendicular Ataxia Left to Severe