NIH Stroke Scale Study Exam How many items on the NIH stroke scale? - ✔-11 NIH Stroke scale is - ✔-an 11-item clinical evaluation instrument widely used in clinical trials and practice to assess neurologic outcome and degree of recovery from stroke. NIH Stroke Scale is used to quantify the effects of acute cerebral ischemia on levels of ... (7 items) - ✔-levels of: consciousness vision motor function (facial and extremities) cerebellar function sensation language extinction or inattention NIH SS is used to measure patient's status after a stroke and to assess the outcome after - ✔-treatment Should the patient be coached? Should you go back and rethink a particular assessment? - ✔-NO Having what when using NIH scale is important? - ✔-reference materials DO NOT RATE what you think the patient wants to do or what you think they can do, RATE ONLY - ✔-rate only what they actually do use patient"s first response? - ✔-YES - DO NOT USE SUMMARY OF RESPONSES re ataxia score 1-if real weak, assume ataxia score is... 2-if they can hold leg or arm up w/ minimal drift but are all over place when trying finger to nose test, that's probably... 3) Important to know if ataxia is present or not and if present in _____ or _______ limbs 4) if patient very weak or paralyzed, the ataxia score is... - ✔-1) 0 2) ataxia 3) 1 or 2 4) 0 You should only score loss of sensation if you can really demonstrate... - ✔-that they have loss of sensation
if patient has sensory loss from neuropathy, do you count thatt? - ✔-no, but you do if there's loss on top of the neuropathy aphasia is difficult because it can take a while to go through the battery and it can be subjective as to whether it is one of which classification? - ✔-mild, mod, severe start to recognise aphasia when you meet them and start talking and you don't get a history of... - ✔-what happened dysarthria is interesting because there are many cultural things about slurred ________? - ✔-speech. Score is associated with prognosis? - ✔-YES Is NIH scale a measure of disability? - ✔-NO. The NIH scale is a measure of impairments. The NIH scale creates a common currency so that everybody understands the patient's level of... - ✔-deficit, by giving a number that communicates to other professionals how sick the patient is how much time to budget to perorm NIH scale - ✔-7-10 mins What effort should be recorded? Do not do what? - ✔-The patient's first effort. Don't go back and change scores. IMPORTANT CONVENTIONS IN ADMINISTRATION: Administer scale items in their exact ______ -Avoid ______ing patient -Accept patient's _______ effort -Score only what the patient _______ -Be consistent -Include all _________s into scoring, including those that may be from _________s ______s - ✔--order -coaching -first -does -Be consistent -previous strokes ITEM 1a and how to get it - ✔--examiner's overall impression of patient alertness -ask 2-3 questions about circumstances of admission, stimuate patient by patting or tapping, occasionally pinching NIH Item 1a Scoring:
0 1 2 3 - ✔--Alert -Not alert, aroused w/ minor verbal stim -Not alert, requires strong or painful stim -Only reflexive movements or totally unresponsive ITEM 1a - patient w/ 3 on this item is generally considered to be in... 3 is scored ONLY if patient makes no movement other than.... - ✔-a coma reflexive posturing in response to noxious stimulation If difficult to determine 1 vs 2 in item 1a, continue with... - ✔-medical hx qs until confident in assigning a score - THIS IS ONLY TIME IN NIH scale where you can go back EVEN IF PRESENTED WITH OBSTACLES OR BARRIERS, YOU MUST CHOOSE A ✔-SCORE NIH Item 1B based on responses to two items: When? -What about patient - ✔--month of year -patient's age ITEM 1B SCORING 0 1 2 - ✔--answers both qs correctly -answers 1 q correctly OR patients unable to communicate d/t intubation, oral-tracheal trauma, severe dysarthria from any cause, language barrier, or any issue not secondary to aphasia -answers neither question correctly --> a 3 on 1a must be a 2 on 1b A patient that cannot speak but is otherwise able to communicate can be allowed to convey the answer how? - ✔-writing If the patient answers incorrectly first and then corrects self, how is the answer scored? - ✔-it is still scored as incorrect What if patient gives DOB as answer to question asking for their age? How is this scored? Is there credit for partial answers that are close like being off a month when answering what month it is? - ✔-This is scored as a WRONG answer. NO
NIH 1C is what? Make sure to position what in testable position - ✔-Commands Eyes and Hands NIH 1C ask patient to do how many actions and what are they? - ✔-3 commands "close your eyes for me" "now open them" "now make a fist with your hand" NIH 1C - may I repeat the commands? May I encourage? May I pantomime command? May I hold up arm for hand to make fist? - ✔-Yes, you can repeat command ONCE. No, no encouragement or coaching. Yes, you should try and pantomime command so that patient receives verbal and visual input. Yes, can hold up arm for hand command NIH scale 1C scoring: 0 1 2 - ✔-0 - both tasks performed correctly 1 - one task performed correctly 2 - neither task if performed correctly Can a friend/family member translate w/ NIH commands? - ✔-Yes NIH scale 1C -for patient who has comprehension deficit and perform incorreclty, what is scored? - ✔2 NIH scale 1C -for patient who gives a real attempt but not completed due to weakness, is credit given? - ✔-yes, give credit but ONLY score the first attempt NIH scale Number 2 item is... - ✔-Best Gaze what does the best gaze item test? - ✔-voluntary horizontal eye movements does NIH scale #2 measure distortions in vertical gaze, nystagmus or schew deviation ✔-NO, NIH scale #2 does not measure these visual issues NIH scale #2
-first test, noting what? -second test - ✔--look at position of eyes at rest, noting spontaneous eye movements to left or right -then move finger or other target from side to side and ask patient to track MOVING EYES ONLY, being sure to keep asking patient to follow the target If patient does not accurately follow finger, a stronger test is needed USE what other tests? - ✔-oculocephalic maneuver, eye fixation or tracking of the examiner's face Item 2 - if patient has ocular rotary problems, such as strabismus, but leaves mid-line in attempt to look both left and right, what should the response be considered? - ✔-normal Item 2 Best Gaze Scoring 0 1 2 - ✔-0 - normal 1 - partial gaze palsy 2- forced deviation If there is a conjugate deviation of eyes that can be overcome with voluntary or reflexive activity, score a - ✔-1 If patient has isolated cranial nerve paralysis such as ocular motor or abducens palsy, score a - ✔-1 Best Gaze - score a 2 if - ✔-there is forced deviation or total gaze paresis not overcome by the oculocephalic maneuver conjugate lateral deviation not overcome with reflexive movements, score a - ✔-2 tonic deviation such that eyes cannot be moved, score a - ✔-2 can a patient who scores a 3 on 1a LOC have palsy that can be overcome by moving head? if so, what should be performed? - ✔-yes use oculocephalic maneuver and score the result should caloric testing be used - ✔-No, tests involving water in the ear should not be used for eye tests in aphasic patients, is gaze testable? what makes it easier to study? - ✔-yes, establish eye contact and move around the bed, just as with confused patients
should patients with ocular trauma, bandages, pre-existing blindness, other disorders of visual acuity or fields be tested? if so, what should they be tested with? - ✔-yes they should be tested with reflexive movements and scored. NIH scale item 3 is - ✔-VISUAL FIELDS for item 3, have patient look where and tell them what should both eyes be open? - ✔-patient is to look in examiner's eyes and they are to be told that peripheral vision is being tested and that I may move a finger to the right, a finger to the left, or both - COVER ONE EYE when performing item 3, ask patient to do what - ✔-count fingers in all four quadrants Item 3 - if a patient scored 3 on item 1a, they are tested for 3 using what? and what is it? - ✔-bilateral threat NIH scale 3 scoring: 0 1 2 3 - ✔-0- no visual loss, upper and lower visual fields are normal 1- clear cut asymetry, including quadrantanopia or partial hemianopia 2-complete hemianopia 3-bilateral hemianopia (blindness of any cause including cortical blindness) item 3: if patient has severe monocular visual loss d/t intrinsic eye disease and visual fields in other eye are normal, examiner should score as - ✔-normal if there is unilateral blindness or enucleation, what is scored - ✔-visual fields in the remaining eye arbitrary rule that if they extinguish even if intact to confrontation, visual field item is scored as a... - ✔-1 NIH item 4 is... - ✔-facial palsy in NIH #4,you ask patient - ✔-"show me your teeth," if no teeth in say "show me your gums" "open and close your eyes" - can say "squeeze eyes shut as hard as you can" "raise the eyebrows" or "lift up your eyebrows as much as you can" for NIH 4, where MUST patient look? - ✔-directly at examiner
NIH 4: for aphasic, poorly responsive or noncomprehending patient, use what kind of stimulus? If using this stimulus, what is the basis for the scoring? - ✔-noxious -the symmetry of the grimace NIH Item #4 Scoring 0 1 2 3 - ✔-0 - normal symmetrical movement 1 - minor paralysis such as a flattened nasolabial fold or mild asymmetry while smiling proper score if function is less than clearly normal 2-paralysis of the lower face - appropriate for clear cut upper motor neuron facial palsy 3- complete paralysis of the upper and lower face - appropriate score for obtunded or comatose patient or one with unilateral-lower motor neuron facial weakness decreased spontaneous and forced facial movements are most prominent at what location? - ✔-the mouth if there is a clear cut asymmetry of the smile, the score is... - ✔-two, all other subtle asymmetries are scored as a one score of 3 re: face is reserved for unusual complete paralysis seen with some strokes of what kind? - ✔-some brain stem strokes NIH scale item 5 is... - ✔-Item 5 - Motor Arm what is proper positioning for item 5 motor arm movement? - ✔-extend arms 90 deg if sitting OR 45 deg if supine item 5 leg test always in what position and how many deg - ✔-leg motor test supine and extended 30 deg for item 5 motor arm, score a drift if arm does when and when? - ✔-if arm falls before 10 seconds as you count down out loud for motor leg, score a drift if leg does what and when - ✔-if leg falls before 5 seconds motor items: begin counting when? - ✔-immediately at the release of the limb how should the examiner be counting down? why? - ✔-verbally and with fingers in full view of the patient, so the patient receives verbal and visual input
watch for what upon release of the limb? what to consider about this? - ✔-watch for an initial dip after release of the limb, only score abnormal if there is a downward drift after the dip each arm is tested in turn beginning with the... - ✔-non-paretic arm when testing arms, what position for palms? - ✔-down can limbs be tested simultaneously? - ✔-NO in what cases are the motor items not scored? - ✔-only in the case of amputation or joint fusion of the shoulder or hip, BUT A WRITTEN NOTE OF THIS MUST BE NOTED - IF advised to score 9, do not use in calculating score Use what in voice when talking to aphasic patients? what else can be used - ✔-urgency in voice pantomime if patient has restricted limb function due to arthritis or non-stroke related limitations, does a score still need to be given? - ✔-yes - use best judgment to determine between effect of stroke and any other cause Scale item 5 has how many sections? What are they? - ✔-2, 5a and 5b NIH scale item 5 scoring 0 1 2 3 4 - ✔-0 - no drift 1 - drift: if arm jerks or drifts down to intermediate position without encountering support, such as a bed, before a full 10 seconds 2-some effort against gravity but the arm cannot get to or maintain the proper position and drifts down to some support 3-no effort against gravity and the arm falls 4-if patient is unable to make voluntary movements to differentiate between 3 and 4 on arm, you have to - ✔-encourage the patient and wait a second or two to observe movement in the paretic arm Any movement at all including small proximal movements such as shoulder shrug or hip flexion is enough to do what to the arm motor score? - ✔-lower from 4 to 3 a patient who scores 3 on 1a LOC is scored what on 5? - ✔-they are scored a 4
NIH scale item 6 is... - ✔-motor leg NIH scale item 6 scoring 0 1 2 3 4 - ✔-0- no drift and leg holds 30 deg position for 5 seconds 1- if there is drift and leg falls before end of 5 sec period but does not hit support such as bed 2 - when there is some effort against gravity but leg falls to support within 5 sec 3- no effort against gravity and leg falls to support immediately but patient makes small movements such as hip flexion or adduction 4- if patient is unable to make voluntary movements what items are the most reproducible of the NIH scale? are they important to ultimate outcome? - ✔-5 and 6 yes, they are the most imporant watch limbs very carefully and compare to what to gauge whether the limb is drifting slightly? - ✔-compare to a marker behind the patient patients scoring a 3 on 1a are scored as what on item 6 - ✔-they are scored as a 4 NIH scale item is... - ✔-limb ataxia item 7 for limb ataxia is an assessment for evidence of... it attempts to distinguish a clinically significant incoordination from... - ✔-unilateral cerebellar lesion general weakness how do we perform item 7 tests - ✔-finger-nose-finger on both sides heel - shin on both sides finger nose finger - how - ✔-ask patient to touch my finger, their nose and my finger again, moving finger - enough times to thoroughly test for ataxia - THEN DO OTHER SIDE heel-shin test - how - ✔-instruct patient to move one heel down and up shin of opposite leg - THEN DO OTHER SIDE which side gets tested first? - ✔-unaffected side if visual field defect, attempt to pefrom test where? - ✔-perform test in the intact visual field
NIH scale item 7 scoring 0 - ✔-0 - absent, there is normal coordination - movements well performed, smooth accurate and not clumsy 1 - if ataxia, dysmetria, or dyssynergia is present in 1 limb 2-if any are present in 2 limbs, both arms, both legs or an arm and a leg on the same side of the body - also score 2 if bilateral signs if significant weakness, assume ataxia is ... - ✔-0 in the patient who cannot understand or is paralyzed, ataxia is scored as a ___ on this item - ✔-0 item 7 is scored a 1 or 2 only if ataxia is both _______ and out of proportion to ________ - ✔-present weakness for item 7, patients scoring a 3 on item 1a are scored only if what is present, otherwise are scored as what? - ✔-ataxia otherwise 0 NIH scale item 8 is - ✔-sensory perception item 8 is tested using a series of... for the obtunded or aphasic patient, withdrawal from... - ✔-pin pricks noxious stimulus is used for item 8, what should be used? what should not be used? - ✔-safety or seamstress pin DO NOT USE paperclips, broken sticks or ballpoint pins item 8: examine patient with pin in what areas of what? ask patient what? do eyes need to be closed ask patient if there is what between right and left sides - ✔-proximal portions of all 4 limbs ask if they feel the stimulus no, eyes do not need to be closed ask if there is asymmetry- DO NOT ASK IF SHARP OR DULL - as only to compare the sides and tell if there is a difference item 8 - in confused, obtunded or aphasic patients, look for symmetry of grimace in response to - ✔-noxious stimulus only sensation loss attributed to what is scored - ✔-stroke
should we test as many body areas as needed to assess for hemisensory loss? what areas? - ✔-yes arms, legs, trunk, face item 8 - what area should NOT be tested? why? - ✔-limb extremities: hands and feet these areas may have sensation confounded by unrelated neuropathy item 8 - test through clothing? - ✔-not unless absolutely necessary Item 8 Sensory Scoring 0 - ✔-0 - normal - no evidence of sensory loss 1- mild or moderate sensory loss 2- severe or total sensory loss - also patients with bilateral loss from brain stem stroke is item 8 ever not tested? what to do to determine 0 or 1 - ✔-NO, test stuporous of aphasic patients w/ vigorous noxious stimulus such as nail bed pressure and then decide between a one or zero based on whether any response appears if patient scores 3 on 1a, they automatically score what on item 8 - ✔-2 NIH item 9 is - ✔-Best Language what should examiner be doing throughout exam to determine item 9 score - ✔-listen to patient always wise to use what for item 9? - ✔-formal testing tools provided is item 9 an exception to rule of scoring only first impressions? what do we encourage? - ✔-yes we encourage (but not coach or stimulate) patient's best performance always determine if the patient wears what? - ✔-glasses when providing the card for item 9, the patient needs to be given adequate what to identify the objects? - ✔-adequate time ask patient to do what for each item on the card? ask the patient to describe the meaning and _________depicted on the cookie jar picture - ✔-name action ask the patient to read all the phrases on the ________ card - ✔-sentence
item 9 assessment is based on examiners overall sense of patient's language as well as on their responses to these tests - ✔-true scale item 9 language scoring - ✔-0-no aphasia 1 - mild to moderate aphasia evidenced by some obvious loss of fluency or facility of comprehension, but no significant limitation on ideas expressed or form of reductions A LIMITED REDUCTION will still allow the examiner to identify the picture or naming card content from the patient's responses 2- severe aphasia - all the patient's expressions are fragmentary or when you cannot identify card content from the patient's response 3-mute for any reason or for global aphasia OR if no usable speech or auditory comprehension is demonstrated item 9 - for patient w/ stupor or limited cooperation, examiner must choose what score? - ✔-3 intubated patient should be asked to do what in response to examiner's questions - ✔write down responses item 9 - if patient's visual loss interferes with testing this item, you can ask the patient to identify objects how? - ✔-by placing them in the hand hammocks are not common outside the americas, so patients from other cultures - ✔may not know the term visual impairment may have people misidentify feather and gloves and cactus as? - ✔leaf and hand and squirrel - usually score as correct if visual impairment item 9: if patient is a 3 on 1a, they are automatically this on item 9 - ✔-3 mute patients may have some cause other than aphasia for not speaking, but to optimize scoring reliability, you always give the mute patient a.... - ✔-3 - SCORE WHAT YOU SEE, NOT WHAT YOU THINK THE PATIENT CAN DO NIH item 10 is what are we testing for - ✔-dysarthria articulation and clarity of speech should the examiner explain purpose of item 10 exam? - ✔-no ask patient to read or repeat the words from what - ✔-the card provided w/ stroke scale scale item 10 dysarthria scoring 0 1
2 - ✔-0-normal speech, all words read without slurring 1-mild to mod speech defects with some slurring but can be understood 2-severe slurring - cannot be understood in any meaningful way or is mute item 10: what score does an unresponsive patient receive? - ✔-score of 2 item 10: patient w/ 3 on item 1a get what score - ✔-2 item 10: can it be untestable? if so, when? - ✔-yes, only if patient intubated or has other physical barriers to producing speech item 10 -patients don't read, do what? - ✔-have them repeat item 11 is - ✔-extinction and inattention by the time you get to item 11, you may have enough info to... - ✔-make a judgment how to assess item 11 - ask patient to do what? -then alternately touch and ask what? -after patient responds consistently, then do what? -the patient without neglect will identify what? -patients with cortical impairment may ______ one side - ✔-- ask to close their eyes -touch left or right side and ask what is being touched -touch the patient on both sides at once -pt without neglect will identify sensation on both sides -pt w/ cortical impair may extinguish one side is item 11 ever untestable? why? - ✔-NO - IT IS NEVER UNTESTABLE this is because neglect is only scored if present where will examiner tap ? order? - ✔-face forearms legs finger wave to visual sensation to each side - l, r, both scoring of NIH scale item 11 0 1 2 - ✔-0 - absence of neglect - also, if visual loss but cutaneous stim is normal, if aphasic and cutaneous stim is normal - score is normal 1 - inattention to only one modality: visual, tactile, auditory or spatial OR personal inattention
2- profound hemi-inattention or extinction to more than one modality - score a 2 if one side extinguishes to both visual and tactile stimuli using double simultaneous stimulation item 11 - person w/ 3 on item 1a is automatically a - ✔-2 when testing visual threat, what is an indicator of response? - ✔-blinking in response to visual threat