Partial gaze palsy: can be overcome. Partial gaze palsy: corrects with oculocephalic reflex. Forced gaze palsy: cannot be overcome. No visual loss. Partial hemianopia. Complete hemianopia. Patient is bilaterally blind.
Bilateral hemianopia. Normal symmetry. Minor paralysis flat nasolabial fold, smile asymmetry. Partial paralysis lower face. Count out loud and use your fingers to show the patient your count.
No drift for 10 seconds. Drift, but doesn't hit bed. Drift, hits bed. Some effort against gravity. No effort against gravity. No movement. No drift for 5 seconds. No ataxia. Ataxia in 1 Limb. Ataxia in 2 Limbs. Does not understand. Normal; no sensory loss. Mild-moderate loss: can sense being touched.
Complete loss: cannot sense being touched at all. No response and quadriplegic. Describe the scene; name the items; read the sentences see Evidence. Normal; no aphasia. Mild-moderate aphasia: some obvious changes, without significant limitation. Severe aphasia: fragmentary expression, inference needed, cannot identify materials.
Read the words see Evidence. Mild-moderate dysarthria: slurring but can be understood. Severe dysarthria: unintelligible slurring or out of proportion to dysphasia. No abnormality. Extinction to bilateral simultaneous stimulation. Profound hemi-inattention ex: does not recognize own hand. Result: Please fill out required fields. More treated with thrombolysis recombinant tissue plasminogen activator.
Demchuk et al. More who were treated with alteplase a type of thrombolytic therapy. Muir et al. Predictive accuracy of the variables was compared by ROC curves and stepwise logistic regression.
Logistic regression showed that the NIHSS added significantly to the predictive value of all other scores. Adams et al. More trial. More when scores were 10 or more. More in patients. DeGraba et al. More progression. Frankel et al. More could be developed. More , it is possible to identify a subset of patients who are highly likely to have a poor outcome. Rundek et al. More , followed prospectively.
Polytomous logistic regression was used to determine predictors for rehabilitation and nursing home placement versus returning home. More care hospitalization, patients were discharged to their homes, to rehabilitation, and to nursing homes.
Bohannon, Lee, and Maljanian examined what variables predicted three hospital outcomes hospital length of stay, hospital charges, and hospital discharge destination.
Regression analysis showed that once post-admission Barthel Index scores were accounted for, no other variable added to the prediction of hospital length of stay or discharge destination, however the NIHSS score added to the explanation of hospital charges provided by post-admission Barthel Index scores. More treated by intravenous recombinant tissue plasminogen activator.
Univariate and multivariate logistic regression analyses were used to identify the predictors of clinical outcome. More recovery, which was tested in 63 patients. More recovery. Scores of 0 to 2 indicate low probability of recovery, 3 to 4 medium, and 5 to 7 high. More fared better by admission to a general ward or to the intensive care unit.
They found a general positive correlation The extent to which two or more variables are associated with one another. There was no obvious cutoff baseline NIHSS score that was predictive of better outcome lower Rankin in intensive care unit patients. There was no statistical difference in length of stay. More who received intravenous recombinant tissue plasminogen activator in the emergency department. Multivariate logistic regression analysis was used to identify the main predictors of 3-month stroke-related mortality.
Fischer et al. More who underwent arteriography. There was a significant association between NIHSS scores and the presence and location of a vessel occlusion. More Trial. More , the scale scores differentiated the two treatment groups at 24 hours and at 3 months.
More recombinant tissue plasminogen activator Trial to determine whether the NIHSS was valid in patients treated with tissue plasminogen activator. To assess the content validity Refers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. More , to derive an underlying factor structure.
The results from this analysis suggested that there were two factors, representing left and right brain function, underlying the NIHSS. The internal scale structure remained consistent in placebo and treated groups and when administered successively over time, confirming the content validity Refers to the extent to which a measure represents all aspects of a given social concept.
To prevent the confounding effects of time or treatment, the goodness of fit was calculated for data collected at 2 hours, 24 hours, 7 to 10 days, and 3 months after recombinant tissue plasminogen activator or placebo treatment.
When used over time, and in placebo-treated versus active-treated groups, the mNIHSS values ranged from 0. Raters in this study also had to conclude whether patients changed neurologically from the previous examination and from baseline.
That is, the mNIHSS tends to predict response of patients to recombinant tissue plasminogen activator as well as the original scale, when used in the multivariable model.
Likewise, the mNIHSS predicts likelihood of hemorrhage after recombinant tissue plasminogen activator treatment as well as the original in the multivariable model of symptomatic hemorrhage. Within-patient responsiveness The ability of an instrument to detect clinically important change over time.
Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes — the person may continue to improve but the test does not capture that improvement.
Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect.
Pickard, Johnson, and Feeny compared five health-related quality of life measures administered at baseline and at 6 months. Thank you for taking less than two minutes to provide us with feedback on the content of the www.
The scale has 15 items in total which assess the following: Level of consciousness Responsiveness The ability of an instrument to detect clinically important change over time. Questions: Patients are asked to state the month and their age rated from 0 — 2. Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand hand not affected by partial motor paralysis rated from 0 — 2.
Best gaze Horizontal eye movements of patient rated from 0 — 2. Visual To assess the presence of hemianopia rated from 0 — 3. Facial palsy Patients are asked to show their teeth or raise their eyebrows and close their eyes. Look for symmetry rated from 0 — 3. Motor arm Left arm: Arm is extended palms down 90 degrees if sitting or 45 degrees if supine. Drift is scored if the arm falls before 10 seconds rated from 0 — 4, or UN if amputation or joint fusion. Right arm: Same as in a.
Motor leg Left leg: Leg is raised at 30 degrees supine. Drift is scored if the leg falls before 5 seconds rated from 0 — 4, or UN if amputation or joint fusion.
Right leg: Same as in a. Limb ataxia Finger-to-nose and heel-to-shin test rated from 0 — 2, or UN if amputation or joint fusion. Sensory function If level of consciousness is impaired, score if a grimace or an asymmetric withdrawal is observed rated from 0 — 2.
The Aphasia Institute, Canada Standard pictures are named rated from 0 — 3. Dysarthria Patient is asked to read or repeat words from a list rated from 0 — 2 , or UN if intubated or other physical barrier. Extinction and inattention formerly called neglect Sufficient information to detect neglect may be obtained from prior testing rated from 0 — 2.
Time: The examination requires less than 10 minutes to complete. More severity is further stratified in the following way: Source: Brott et al. More were: right leg, left leg, gaze, visual fields, language, level of consciousness, facial palsy, and dysarthria. In what languages is the measure available? More What types of clients can the tool be used for? Is this a screening Testing for disease in people without symptoms. Translated and validated in Chinese; German; Spanish.
Measurement Properties Reliability Reliability can be defined in a variety of ways. Internal consistency A method of measuring reliability. Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More : No studies have examined the Internal consistency A method of measuring reliability.
Test-retest: Only one study has examined the test-retest reliability A way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. Intra-rater: Only one study has examined the intra-rater reliability This is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions.
Inter-rater: — Out of 11 studies examining the inter-rater reliability A method of measuring reliability. Validity The degree to which an assessment measures what it is supposed to measure. Concurrent: Modified NIHSS: Excellent correlations between mNIHSS and the Modified Rankin Scale, the Barthel Index, and the Glasgow Outcome Scale were reported in a retrospective analysis, however, in a prospective analysis the mNIHSS had poor concurrent validity To validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time concurrently , so they both reflect the same construct.
Adequate to excellent correlations have been reported with infarct volumes using computed tomography and excellent correlations using MRI. More ; discharge destination; 3-month mortality; presence and location of a vessel occlusion. Does the tool detect change in patients? One study assessed the responsiveness The ability of an instrument to detect clinically important change over time.
The scale cannot be completed by proxy or by self-report as it is an observational scale. However, measurement by video telemedicine appears to be reliable and could offer a method for remote assessment. How to obtain the tool? Floor and Ceiling Effects Muir et al. References Adams, H. Neurology, 53, Albanese, M. Ensuring reliability of outcome measures in multicenter clinical trials of treatments for acute ischemic stroke.
Stroke, 25, Albers GW, Bates, V. JAMA, , Baird, A. A three-item scale for the early prediction of stroke recovery. This study was a secondary analysis of data from the Everest randomized controlled trial of implanted cortical stimulation for UE movement in chronic stroke [ 21 ]. Outcome measures had been administered before and after intervention as part of the above trial.
Subjects were recruited for the trial from the United States using several recruitment strategies, including print advertisements placed in clinics near enrolling sites, radio advertisements in the markets of enrolling sites, and print advertisements placed in national magazines whose primary subscribers were survivors of stroke.
As volunteers came forward, the following screening criteria were applied. Inclusion criteria are as follows. Scores on each item are then summed for a single, total score, with a higher score indicative of greater deficit and stroke severity. Stroke severity and neurologic status may be expressed in a myriad of ways in the paretic UE.
Thus, we administered established, frequently used measures of both UE impairment i. The measures were administered by blinded raters at participating centers at which the trial was being conducted. All raters were certified and recertified on the outcome measures every 3 months using standardized, live, and video-based interrater reliability checks at the main study center.
The nonnormal, heterogenous distributions that are commonly seen in stroke also led us to expect that data would be nonparametric. To corroborate findings from the above correlational analyses, several, additional subanalyses were performed. In addition to the numbers derived from the correlational analyses, these plots provided a pictorial representation of correlations or lack thereof between the NIHSS and our two UE functional variables, allowing the reader to graphically observe the relational trends between data points on the measures and visualize if relationships existed.
Due to growing prevalence of stroke risk factors and improved acute care methods, the number of stroke survivors exhibiting UE impairment is likely to increase. The NIHSS is commonly used to characterize neurologic status and stroke severity and reportedly predicts stroke outcomes.
The outcomes were assessed during the chronic period of recovery to reduce the impact of commonly occurring, extraneous factors during the acute period such as spontaneous neurologic recovery and concurrent pharmacologic and therapy treatments.
This hypothesis was not confirmed. We then deployed additional analyses to verify the validity of these findings and to provide insight as to why the results were negative. Taken together, these findings suggest that the NIHSS may have limited ability to discriminate between a range of UE levels, even given a relatively narrow array of impairment levels as was the case in this study.
As a result of our findings, the NIHSS may be suboptimal for use as an outcome measure in stroke rehabilitative trials, since its use could give rise to Type II errors i. In parallel to the adequacy of the measure, one should consider whether the evaluator is ideally qualified to systematically assess paretic UE deficits and whether raters will be able to ascertain how these deficits conspire to diminish functional performance. NIHSS training does not convey these skills, and clinicians using the NIHSS in the acute setting may not have learned this skill as part of their academic or subsequent training.
Given this and our study findings, it is suggested that NIHSS administration is restricted to use in acute stroke studies and clinical settings with the goal of characterizing stroke severity. In obtaining the above results, this study used a large study sample, and thus, a large number of observations were incorporated into the analyses.
Given that the impairment group enrolled in this study is eligible for several, recently developed, rehabilitative therapies [ 14 — 16 ], information from this study is expected to be useful in selecting the best outcome measures for studies enrolling patients from this group.
This study used highly specific inclusion criteria regarding stroke severity and time after stroke, which may not be generalizable to all stroke patients. This constitutes a possible study limitation. However, the application of these criteria also constitutes a strength, as their use resulted in a well-defined study population of patients who were neurologically stable and were not receiving concurrent interventions.
Future studies should seek to replicate these findings in acute stroke populations as well as in populations with greater stroke severity. Our findings indicate that, in a large cohort of stable stroke survivors, NIHSS total scores were not associated with scores on established measures of UE impairment and function.
Based on these findings, we conclude that the NIHSS should be restricted for use in acute settings to determine stroke severity and should not be used to predict or assess UE outcomes in the months and years after ictus. The authors certify that no party having a direct interest in the results of the research supporting this paper has or will confer a benefit on them or on any organization with which they are associated and, if applicable, certify that all financial and material support for this research e.
The authors declare that there is no conflict of interests regarding the publication of this paper. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles. Journal overview. Special Issues. A Erratum for this article has been published.
Brittany Hand, 1 Stephen J. Academic Editor: Steve Kautz. Received 03 Dec Accepted 05 Feb
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