User:Pfeibelman/sandbox

The National Institute of Health Stroke Scale, or NIH Stroke Scale, is a tool utilized by healthcare providers to objectively quantify the impairment caused by a stroke. The NIH Stroke Scale (NIHSS) is composed of 11 items, each of which scores a specific ability between a 0 and 3. 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. The individual scores from each item are summed in order to calculate a patients total NIHSS. The maximum possible score is 42, with the minimum score being a 0.

Notes for performing NIHSS

 * For each item it is important that the examiner not coach or help the patient with the assigned task. The examiner may demonstrate the commands to patients unable to comprehend verbal commands, however the score should reflect the patient's own ability.
 * For each item the examiner should score the patients first effort, repeated attempts should not affect the patient's score.
 * Exceptions to this rule exist in the language assessment (Item 9)

A) LOC Responsiveness
Scores assigned by medical practitioner based on stimuli required to arouse patient.


 * Notes
 * If patients scores a 3 in this factor, the default coma scores should be used when applicable

B) LOC Questions
Patient is asked his or her age and for the name of the current month
 * Scores
 * 0= Correctly answers both questions
 * 1= Correctly answers one question
 * 2= Does not correctly answer either question


 * Default Coma Score: 2


 * Notes
 * 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, dysarthia, 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
 * Scores
 * 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
Assess ability for patient to track a pen or finger from side to side only using his or her eyes.This is to asses motor ability to gaze towards hemisphere opposite of injury.
 * Scores:
 * 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: Forced deviation; 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, asses the horizontal eye movement via the oculocephailic 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
Asses the patients visual fields. Each eye is tested individually, by covering one eye and then the other. Each upper and lower quadrant is tested 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 visuals test. 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.
 * Scores
 * 0: No visual loss
 * 1:Partial hemianopia or complete quadrantopia, meaning one quarter of one eye's visual field is completely blind.
 * 2: Complete hemianopia, meaning one half one one eye's visual field is completely blind
 * 3: Bilateral Blindness, includes blindness from any cause


 * Notes
 * If patient is non-verbal, he or she can be allowed to hold up the number of fingers the investigator is presenting
 * If patient is not responsive, the visual fields can be tested by visual threat.
 * Visual threat involves the investigator moving an object towards the eye and observing any response by the patient.

4. Facial Palsy
Investigator 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 should then be instructed to raise his or her eyebrows.
 * Scores
 * 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 at least 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 patients arm in position should not be considered downward drift. Repeat this test for the opposite arm.
 * Scores (One Score for each arm, recorded as scores 5a and 5b)
 * 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 rely 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


 * Default Coma Score: 8
 * Notes
 * Test the non paralyzed arm first is 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 place 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 patients leg in position should not be considered downward drift. Repeat this test for the opposite leg.
 * Scores (One Score for each leg, recorded as scores 6a and 6b)
 * 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 does not at any point hit the bed
 * 2: Limited effort against gravity; the leg is able to obtain the starting position, but drifts down from the initial position to the bed 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


 * Default Coma Score: 8
 * Notes
 * Test the non paralyzed leg first is 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

7.Limb Ataxia
This test for presence of unilateral cerebellar lesion, and distinguish difference between general weakness and incoordination. The patient should be instructed to first touch his or her finger to the investigator'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.
 * Scores
 * 0: Normal coordination; smooth and accurate movement
 * 1: [Ataxia] present in 1 limb, rigid and inaccurate movement
 * 2: [Ataxia] present in 2 or more limbs


 * 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 in pinpricks, the investigator should ask wether 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.
 * Scores
 * 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; patient is not aware he or she is being touched in all extremities.


 * Default Coma Score: 2
 * Notes
 * 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 patients 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.
 * Scores
 * 0: Normal; no obvious speech deficit
 * 1: Mild-to-moderate aphasia; detectable loss in fluency or comprehension. The examiner should still be able to extract the provided content from the patients 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
 * Default Coma Score: 3
 * Notes
 * 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.Dysarthria
The patient should 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.
 * Scores
 * 0: Normal; clear and smooth speech
 * 1: Mild-to-moderate aphasia; some slurring of speech, however the patient can be understood
 * 2: Severe dysarthria; speech is so slurred that he or she cannot be understood, also patients that cannot produce any speech.


 * Default Coma Score:2
 * Notes
 * 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 double simultaneous stimulation. This is performed by having the patient to close his or her eyes and asking him or her 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.
 * Scores
 * 0: Normal; patient correctly answers all questions
 * 1: Inattention in one modality; visual, tactile, auditory, or spatial.
 * 2: Hemi-inattention, or extinction in more than one modality


 * Default Coma Score:2
 * Notes
 * Patient with severe vision loss that correctly identifies all other stimulations scores a 0

Usage of NIHSS
The NIHSS was originally designed with the goal of providing researchers with a standardized metric for quantifying the deficits incurred from a stroke, however the NIHSS has become a more clinical tool. A patient's baseline score is obtained as soon as possible after the stroke as occurred. Regular NIHSS scorings are performed post-stroke to detect any trends in the patients level of impairment. This allow for clinicians to detect and quantify subtle improvements or setbacks over extended periods of time. The NIHSS may also be used to analyze the effect of various treatments or rehabilitation methods.

Accuracy of NIHSS
NIHSS has been found to be an extremely accurate predictor of patient outcome, particularly when combined with other prognostic indicators. Research as found the NIHSS to be such a solid prognostic indicator that a 1 point increase in a patients initial NIHSS score increases the patients chance at a excellent outcome at 3 months by 17%.