 People need to be trained. They need to understand the rules. As I said having the reference materials when you're using the scale is I think very, very important and just being consistent. Don't coach the patient. Don't go back and rethink a particular assessment because patients can be coached and that in fact changes the physical sign itself. Another thing that happens is that as neurologists or as physicians we think we know what the patient should do and we very often will tend to want to code what we think they should do as opposed to what they actually do. When you're using a scale like this it's again very important to follow the rules and you don't coach the patient where you're not supposed to coach them and you don't rate what you think they want to do or what you think they can do, you rate what they actually do. Ataxia. There's some language items, dysarthria, things that you need to have a reasonable amount of experience with this patient population to make good decisions about. There are always the ones that people tend to screw up and score wrong but distinguishing an ataxic patient from a patient who has motor weakness takes a little of experience and insight and you need a good mentor to help you get through that decision making process and people to teach you that have that insight. I think the most difficult item to score on the stroke scale is the visual field score especially in patients that have non-dominant hemisphere strokes. Those patients tend to have neglect and when they're neglectful it can be very difficult to tell apart the neglect from our actual visual field deficit. I think the other item is facial weakness and facial asymmetry and sometimes when people have real subtle changes in their lower face saying is that something that's really there or not that's also a hard judgment. When it comes to doing the facial observation just really call it as it is which is no different to the advice that has been given. Don't try and interpret it on the basis of whether or not you've seen weakness in the arm or you're expecting a hemiplegia. Again just have a prime response that you've become used to in terms of assessing facial asymmetry. I think it's important when you address the motor part of the scale just like any part of the scale that you use the patient's first response. It's not a summary of responses over like say 5 or 10 minutes and that's a mistake that I think some people can do doing the scale. Any wavering if the patient's arm is up and it falls down and they bring it back up again that's abnormal. If to score a normal on the arm function they have to hold the arm in the same place and not let it drift down at any time. I actually think one of the really neatest parts of the scale was the part of the scale which looked at motor assessment. Before there was all these different ways of trying to see how weak a person was and all these scales had a lot of subjective feel to them. So the idea of having somebody hold up their arm and just usually taking 10 seconds for an arm or 5 seconds for a leg and counting and saying did it stay rock solid? Did it drift? Did it drift and hit the bed? Or did it not move at all? That was such a quantifiable way of looking at the motor function that I think that was one of the major advances I think in the scale and why the scale works so well. Well the most challenging aspect in my mind is the taxia question. But there are some other things that are somewhat more difficult to do. They're looking for inattention, starting out a haemonymous hemianopia from loss of vision to one side versus some neglect. Trying to decide whether it's neglect alone, whether it's visual field defect alone or whether it's both. That can be problematic. Deciding how bad the weakness is, is it a three or a four? That's points. That's the sort of judgment call that every physician just has to make. The thing to remember with the ataxia score is that if they're real weak, assume that the ataxia score is zero. If they got their arm or leg can be held up pretty well with just a minimal drift, but they're all over the map when they're trying to move their arm or leg when they do the finger to nose testing. That's probably ataxia. The ataxia is really, is it present or not? And then is it present in one limb or two limbs? And that's how you score it. So if you keep that in mind, remember that when they're very weak or they're paralyzed, it's always zero for the ataxia score. What it tries to reflect is that there's some people with stroke that damage a part of the brain where the strength is okay but the coordination is very affected. And that's particularly true in strokes that occur in the brainstem or the cerebellum part of the brains. The sensory item is easy to score. It's fairly straightforward. The patients that are most difficult to score are those that have non-dominant hemisphere strokes and have neglect. These patients may be neglectful of your attempts to score the sensory item, but in general it's a very straightforward exam with pinprick and light touch. It's difficult to be sure just how profound the sensory loss is or whether they even have sensory loss. And again, if you're not sure the patient has sensory loss, then don't give them the sensory loss. You should only score loss of sensation if you can clearly demonstrate that they have it. Somebody that comes in with sensory loss in their legs from neuropathy, you don't want to count that towards the stroke, but if they have sensory loss on top of the neuropathy, you do. Aphasia is a difficult thing to test, not so much because we don't know as physicians what an aphasia is, but it takes a longer time to go through the entire aphasia battery and then it's a little bit subjective as to is it a mild, moderate or severe aphasia. Obviously if the patient has global inability to comprehend or to speak so-called global aphasia, that's a very severe aphasia. I score a mild aphasia if the patient is still able to have functional speech. They're able to get their thoughts and meaning across and able to understand most things. There are several ways that you can test aphasia. You start to recognize that the patient has aphasia when you first meet them and you start talking to them and you're not getting a history as to what's happened. Right away we know there's a language impairment. Now we have formal things that we've asked them to do, the reading, the naming, the items, etc. Very quickly you recognize how bad the aphasia is. Disarthria is another one because there are many cultural things about slurried speech. It's hard sometimes to make a judgment on is this someone's normal speech or is this an impaired form of speech. Sometimes you just look over to the family to see if they always talk like this or is this an impaired slurred speech. Disarthria is generally quite easy to score. You should keep in mind that you will be scoring disarthria, so pay attention to your entire interaction with the patient. Using the words and the pictures that are supplied in the NIH Stroke Scale will clearly help you distinguish disarthria from aphasia. Disarthria is a very difficult thing to score because it's not difficult in the patient who has a normal language function. But in the aphasic patient it's difficult to know when somebody is not talking very well are they disarthric or is this all aphasia. And generally if the patient is mute, I give them a 2 for the disarthria scale. If they're able to talk and make some language function then I have to make my best assessment as to whether they have some element of disarthria or not Usually I wind up giving most aphasic patients a 1 for the disarthria scale.