The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status
And yet it is constantly used, even with no objectivity.
Using the National Institutes of Health Stroke Scale A Cautionary Tale
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Introduction
The
National Institutes of Health Stroke Scale (NIHSS) is the most widely
used deficit rating scale in modern neurology: over 500 000 healthcare
professionals have been certified to administer it using a web-based
platform. Every clinical trial in vascular neurology—prevention, acute
treatment, recovery—requires a severity assessment, and the NIHSS became
the gold standard for stroke severity rating after the first successful
trial in acute stroke therapy, the NINDS r-tPA (National Institute of
Neurological Disorders and Stroke recombinant tissue-type plasminogen
activator) for Acute Stroke Trial (the Trial).1
As part of the Trial, detailed and rigorous training/certification
procedures were created for the NIHSS that facilitate wider use of the
scale outside of research.2
Today,
payers and regulators demand reportable data on patient outcomes, and
such outcomes must be adjusted for baseline severity: the NIHSS has
become the de facto metric for regulatory compliance. The Joint
Commission, as part of its certification program for Primary Stroke
Centers, now requires an NIHSS score within 12 hours of admission for
all stroke patients; this assessment is to be done by a certified
examiner.3,4 Federal agencies also require outcomes adjusted for baseline stroke severity—using the NIHSS.5
Despite widening regulatory requirements, considerable problems may
arise in using the NIHSS in clinical practice because the scale was
designed for research purposes.6
Given that the scale was not designed for such widespread—and
determinative—application, anyone using (or mandating use of) the NIHSS
must understand its development history, clinimetric properties, and its
proper bedside administration.
History/Development
During the late 1980s, several stroke-deficit rating scales were in use.7–10
For use in a National Institutes of Health–sponsored trial of naloxone
for acute stroke, investigators combined scales that had been developed
at the University of Cincinnati, Canadian neurological scale, the
Edinburgh-2 coma scale, and the Oxbury …
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