One more problem to correct. It bills itself as an objective scale. Testing secondary problems is not helpful. The best solution would be to quantify the dead area size and location, then quantify the penumbra size and location. The existing scale has absolutely no use in any type of comparison or usefulness in therapy. But our doctors continue down this stupidity. My score would have been 11 - moderate. That told no one anything useful.
http://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale
National Institutes of Health Stroke Scale
From Wikipedia, the free encyclopedia
The
National Institutes of Health Stroke Scale, or
NIH Stroke Scale (
NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a
stroke.
The NIHSS is composed of 11 items, each of which scores a specific
ability between a 0 and 4. For each item, a score of 0 typically
indicates normal function in that specific ability, while a higher score
is indicative of some level of impairment.
[1]
The individual scores from each item are summed in order to calculate a
patient's total NIHSS score. The maximum possible score is 42, with the
minimum score being a 0.
[2][3]
| Score [3] |
Stroke Severity |
| 0 |
No Stroke Symptoms |
| 1-4 |
Minor Stroke |
| 5-15 |
Moderate Stroke |
| 16-20 |
Moderate to Severe Stroke |
| 21-42 |
Severe Stroke |
Performing the scale
Throughout the NIHSS it is important that the examiner does not coach
or help with the assigned task. The examiner may demonstrate the
commands to patients that are unable to comprehend verbal instructions,
however the score should reflect the patient's own ability. It is
acceptable for the examiner to physically help the patient get into
position to begin the test, but the examiner must not provider further
assistance while the patient is attempting to complete the task. For
each item the examiner should score the patients first effort, and
repeated attempts should not affect the patient's score. An exception to
this rule exist in the language assessment (Item 9) in which the
patients best effort should be scored.
[1]
Some of the items contain "Default Coma Scores", these scores are
automatically assigned to patients that scored a 3 in item 1a.
1. Level of Consciousness
Level of consciousness testing is divided into three sections. The
first LOC items test for the patients responsiveness. The second LOC
item is based on the patients ability to answer questions that are
verbally presented by the examiner. The final LOC sub-section is based
on the patient's ability to follow verbal commands to perform simple
task. Although this item is broken into three parts, each sub-section is
added to the final score as if it is its own item.
[3]
A) LOC Responsiveness
Scores for this item are assigned by a medical practitioner based on
the stimuli required to arouse patient. The examiner should first assess
if the patient is fully alert to his or her surroundings. If the
patient is not completely alert, the examiner should attempt a verbal
stimuli to arouse the patient. Failure of a verbal stimuli indicates an
attempt to arouse the patient via repeated physical stimuli. If none of
these stimuli are successful in eliciting a response, the patient can be
considered totally unresponsive.
[3]
| Score |
Test Results |
| 0 |
Alert; Responsive |
| 1 |
Not alert; Verbally arousable or aroused by minor stimulation to obey, answer, or respond. |
| 2 |
Not alert; Only responsive to repeated or strong and painful stimuli |
| 3 |
Totally unresponsive; Responds only with reflexes or is areflexic |
Notes
- If patients scores a 3 in this factor, the default coma scores should be used when applicable
B) LOC Questions
Patient is verbally asked his or her age and for the name of the current month.
[3]
| Score |
Test Results |
| 0 |
Correctly answers both questions |
| 1 |
Correctly answers one question |
| 2 |
Does not correctly answer either question |
Notes
- Default Coma Score: 2
- The patient must answer each question 100% correct without help to get credit
- Patients unable to speak are allowed to write the answer
- Aphasic patients or patients in a stuporous state who are unable to understand the commands receive a score of 2
- Patients that are unable to talk due to trauma, dysarthria, language barrier, or intubation are given a score of 1
C) LOC Commands
The patient is instructed to first open and close his or her eyes and then grip and release his or hand
[3]
| Score |
Test Results |
| 0 |
Correctly performs both tasks |
| 1 |
Correctly performs 1 task |
| 2 |
Does not correctly perform either task |
Notes
- Commands can only be repeated once.
- The hand grip command can be replaced with any other simple one step command if the patient cannot use his or her hands.
- A patient's attempt is regarded as successful if an attempt is made but is incomplete due to weakness
- If the patient does not understand the command, the command can be
visually demonstrated to him or her without an impact on his or her
score
- Patients with trauma, amputations, or other physical impediments can be given other simple one-step commands if these commands are not appropriate
2. Horizontal Eye Movement
Assesses ability for patient to track a pen or finger from side to
side only using his or her eyes. This is designed to assess motor
ability to gaze towards the
hemisphere opposite of injury. This item is tested because
Conjugated eye deviation
is present in approximately 20% of stroke cases. CED is more commons in
right hemispheric strokes and typically in lesions effecting the
basal ganglia and
temporoparietal cortex. Damage to these areas can result in decreased spatial attention and reduced control of eye movements.
[4]
| Score |
Test Results |
| 0 |
Normal; Able to follow pen or finger to both sides |
| 1 |
Partial gaze palsy; gaze is abnormal in one or both eyes, but gaze is not totally paralyzed. Patient can gaze towards hemisphere of infarct, but cant go past midline |
| 2 |
Total gaze paresis; gaze is fixed to one side |
Notes
- If patient is unable to follow the command to track an object, the
investigator can make eye contact with the patient and then move side to
side. The patients gaze palsy can then be assessed by his or her
ability to maintain eye contact.
- If patient is unable to follow any commands, assess the horizontal eye movement via the oculocephalic maneuver.
This is done by manually turning the patient's head from midline to one
side and assessing the eye's reflex to return to a midline position.
- If the patient has isolated peripheral nerve paresis assign a score of 1
3. Visual field test
Assess the patient's vision in each visual fields. Each eye is tested
individually, by covering one eye and then the other. Each upper and
lower quadrant is tested by asking the patient to indicate how many
fingers the investigator is presenting in each quadrant. The
investigator should instruct the patient to maintain eye contact
throughout this test, and not allow the patient to realign focus towards
each stimulus. With the first eye covered, place a random number of
fingers in each quadrant and ask the patient how many fingers are being
presented. Repeat this testing for the opposite eye.
[3]
| Score |
Test Results |
| 0 |
No vision loss |
| 1 |
Partial hemianopia or complete quadrantanopia; patient recognizes no visual stimulus in one specific quadrant |
| 2 |
Complete hemianopia; patient recognizes no visual stimulus in one half of the visual field |
| 3 |
Bilateral Blindness, including blindness from any cause |
Notes
- If patient is non-verbal, he or she can be allowed to respond by holding up the number of fingers the investigator is presenting
- If patient is not responsive the visual fields can be tested by
visual threat, this involves the investigator moving an object towards
the eye and observing the patient's response.
4. Facial Palsy
Facial palsy is partial or complete paralysis of portions of the
face. Typically this paralysis is most pronounced in the lower half of
one facial side. However, depending on lesion location the paralysis may
be present in other facial regions. While inspecting the
symmetry
of each facial expression the examiner should first instruct patient to
show his or her teeth (or gums). Second, the patient should be asked to
squeeze his or her eyes closed as hard as possible. After reopening his
or her eyes, the patient is then instructed to raise his or her
eyebrows.
[5]
| Score |
Test Results |
| 0 |
Normal and symmetrical movement |
| 1 |
Minor paralysis; function is less than clearly normal, such as flattened nasolabial fold or minor asymmetry in smile |
| 2 |
Partial paralysis; particularly paralysis in lower face |
| 3 |
Complete facial Hemiparesis, total paralysis in upper and lower portions of one face side |
Notes
- If the patient is unable to understand verbal commands, the instructions should be demonstrated to the patient.
- Patients incapable of comprehending an commands may be tested by applying a noxious stimulus and observing for any paralysis in the resulting grimace.
5. Motor Arm
With palm facing downwards, have the patient extend one arm 90
degrees out in front if the patient is sitting, and 45 degrees out in
front if the patient is laying down. If necessary, help the patient get
into the correct position. As soon as the patient's arm is in position
the investigator should begin verbally counting down from 10 while
simultaneously counting down on his or her fingers in full view of the
patient. Observe to detect any downward arm drift prior to the end of
the 10 seconds. Downward movement that occurs directly after the
investigator places the patient's arm in position should not be
considered downward drift. Repeat this test for the opposite arm. This
item should be scored for the right and left arm individually, denoted
as item 5a and 5b.
[3]
| Score |
Test Results |
| 0 |
No arm drift; the arm remains in the initial position for the full 10 seconds |
| 1 |
Drift; the arm drifts to an intermediate position prior to the end
of the full 10 seconds, but not at any point relies on a support |
| 2 |
Limited effort against gravity; the arm is able to obtain the
starting position, but drifts down from the initial position to a
physical support prior to the end of the 10 seconds |
| 3 |
No effort against gravity; the arm falls immediately after being
helped to the initial position, however the patient is able to move the
arm in some form (e.g. shoulder shrug) |
| 4 |
No movement; patient has no ability to enact voluntary movement in this arm |
Notes
- Default Coma Score: 8
- Test the non paralyzed arm first if applicable
- Score should be recorded for each arm separately, resulting in a maximum potential score of 8.
- Motor Arm assessment should be skipped in the case of an amputee,
however a note should be made in the scoring of the amputation.
- If patient is unable to understand commands, the investigator should deliver the instructions via demonstration
6. Motor Leg
With the patient in the
supine position,
one leg is placed 30 degrees above horizontal. As soon as the patient's
leg is in position the investigator should begin verbally counting down
from 5 while simultaneously counting down on his or her fingers in full
view of the patient. Observe any downward leg drift prior to the end of
the 5 seconds. Downward movement that occurs directly after the
investigator places the patient's leg in position should not be
considered downward drift. Repeat this test for the opposite leg. Scores
for this section should be recorded separately as 6a and 6b for the
left and right legs respectively.
[3]
| Score |
Test Results |
| 0 |
No leg drift; the leg remains in the initial position for the full 5 seconds |
| 1 |
Drift; the leg drifts to an intermediate position prior to the end
of the full 5 seconds, but at no point touches the bed for support |
| 2 |
Limited effort against gravity; the leg is able to obtain the
starting position, but drifts down from the initial position to a
physical support prior to the end of the 5 seconds |
| 3 |
No effort against gravity; the leg falls immediately after being
helped to the initial position, however the patient is able to move the
leg in some form (e.g. hip flex) |
| 4 |
No movement; patient has no ability to enact voluntary movement in this leg |
Notes
- Default Coma Score: 8
- This is performed for each leg, indicating a maximum possible score of 8
- Test the non paralyzed leg first if applicable
- Motor leg assessment should be skipped in the case of an amputee, however a note should be made in the score records
- If patient is unable to understand commands, the investigator should deliver the instructions via demonstration
7.Limb Ataxia
This test for the presence of a
unilateral
cerebellar lesion, and distinguishes a difference between general
weakness and incoordination. The patient should be instructed to first
touch his or her finger to the examiner's finger then move that finger
back to his or her nose, repeat this movement 3-4 times for each hand.
Next the patient should be instructed to move his or her heel up and
down the shin of his or her opposite leg. This test should be repeated
for the other leg as well.
[3]
| Score |
Test Results |
| 0 |
Normal coordination; smooth and accurate movement |
| 1 |
Ataxia present in 1 limb; rigid and inaccurate movement in one limb |
| 2 |
Ataxia present in 2 or more limbs: rigid and inaccurate movement in both limbs on one side |
Notes
- If significant weakness is present, score 0
- If patient is unable to understand commands or move limbs, score is 0
- Patient's eyes should remain open throughout this section
- If applicable, test the un-paretic side first
8.Sensory
Sensory testing is performed via pen pricks in the
proximal
portion of all four limbs. While applying pinpricks, the investigator
should ask whether or not the patient feels the pricks, and if he or she
feels the pricks differently on one side when compared to the other
side.
[3]
| Score |
Test Results |
| 0 |
No evidence of sensory loss |
| 1 |
Mild-to-Moderate sensory loss; patient feels the pinprick, however he or she feels as if it is duller on one side |
| 2 |
Severe to total sensory loss on one side; patient is not aware he or she is being touched in all unilateral extremities |
Notes
- Default Coma Score: 2
- The investigator should insure that the sensory loss being detected
is a result of the stroke, and should therefore test multiple spots on
the body.
- For patients unable to understand the instructions, the pinprick can
be replaced by a noxious stimulus and the grimace can be judged to
determine sensory score.
9.Language
This item measures the patients language skills. After completing
items 1-8 it is likely the investigator has gained an approximation of
the patient's language skills; however it is important to confirm this
measurement at this time. The stroke scale includes a picture of a
picture of a scenario, a list of simple sentences, a figure of assorted
random objects, and a list of words. The patient should be asked to
explain the scenario depicted in the first figure. Next, he or she
should read the list of sentences and name each of the objects depicted
in the next figure. The scoring for this item should be based on both
the results from the test performed in this item in addition to the
language skills demonstrated up to this point in the stroke scale.
[3]
| Score |
Test Results |
| 0 |
Normal; no obvious speech deficit |
| 1 |
Mild-to-moderate aphasia; detectable loss in fluency, however, the
examiner should still be able to extract information from patient's
speech |
| 2 |
Severe aphasia; all speech is fragmented, and examiner is unable to extract the figure's content from the patients speech. |
| 3 |
Unable to speak or understand speech |
Notes
- Default Coma Score: 3
- Patients with visual loss should be asked to identify objects placed in his or her hands
- This is an exception to recording only the patients first attempt.
In this item, the patients best language skills should be recorded
10.SPEECH
Dysarthria is the lack of motor skills required to produce
understandable speech. Dysarthria is strictly a motor problem, and is
not related to the patient's ability to comprehend speech. Strokes that
cause dysarthria typically effect areas such as the anterior opercular,
medial prefrontal and premotor, and anterior cingulate regions. These
brain regions are vital in coordinating motor control of the tongue,
throat, lips, and lungs.
[6]
To perform this item the patient is be asked to read from the list of
words provided with the stroke scale while the examiner observes the
patients articulation and clarity of speech.
[3]
| Score |
Test Results |
| 0 |
Normal; clear and smooth speech |
| 1 |
Mild-to-moderate dysarthria; some slurring of speech, however the patient can be understood |
| 2 |
Severe dysarthria; speech is so slurred that he or she cannot be understood, or patients that cannot produce any speech |
Notes
- Default Coma Score:2
- An intubated patient should not be rated on this item, instead make note of the situation in the scoring documents.
11.Extinction and Inattention
Sufficient information regarding this item may have been obtained by
the examiner in items 1-10 to properly score the patient. However, if
any ambiguity exist the examiner should test this item via a technique
referred to as "double simultaneous stimulation". This is performed by
having the patient close his or her eyes and asking him or her to
identify the side on which they are being touched by the examiner.
During this time the examiner is alternating between touching the
patient on the right and left side. Next, the examiner touches the
patient on both sides at the same time. This should be repeated on the
patients face, arms, and legs. To test extinction in vision, the
examiner should hold up one finger in front of each of the patient's
eyes and ask the patient to determine which finger is wiggling or if
both are wiggling. The examiner should the alternate between wiggling
each finger and wiggling both fingers at the same time.
[3]
| Score |
Test Results |
| 0 |
Normal; patient correctly answers all questions |
| 1 |
Inattention on one side in one modality; visual, tactile, auditory, or spatial |
| 2 |
Hemi-inattention; does not recognize stimuli in more than one modality on the same side |
Notes
- Default Coma Score: 0
- Patient with severe vision loss that correctly identifies all other stimulations scores a 0
Usage
The NIHSS was designed to be a standardized and repeatable assessment
of stroke patients utilized by large multi-center clinical trials.
[7]
Clinical researchers have widely accepted this scale due to high levels
of score consistency. Consistency of NIHSS scores has been demonstrated
in inter-examiner and in test-retest scenarios.
[8]
Clinical research use of the NIHSS typically involves obtaining a
baseline NIHSS score as soon as possible after onset of stroke symptoms
[9] .
[10]
The NIHSS is then repeated at regular intervals or after significant
changes in patient condition. This history of scores can then be
utilized to monitor the effectiveness of treatment methods and quantify a
patient’s improvement or decline.
[11][12]
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