 Hello, I am Dr. Patrick Leiden, Professor of Neuroscience at the University of California San Diego Medical Center and staff physician at the VA Medical Center. I'll be giving you basic instruction in examining and scoring patients using the NINDS NIH Stroke Scale. After each set of demonstration and scoring instructions, I will guide you through some subtleties we've learned over the years. If that's helpful to you, feel free to click on the special features section of the menu page. They are excerpts from interviews with other stroke scale experts who provide excellent tips on scoring various items. First, let's discuss important general guidelines and ideal conditions for giving the exam. The value of stroke scale assessments depends on uniform examiner-patient interactions. Anyone who gives the exam needs to stick closely to the testing and scoring methods to ensure reliability and reproducibility of the results. Remember, the stroke scale is designed to measure the deficits seen in a group of patients, so some of the scoring rules may seem odd to you as experienced clinicians. If you follow these scoring rules, then the reliability of scores obtained in varying places by different examiners will be very comparable. All scale items must be scored. Record a score for each scale item before going on to the next one. If any item is left untested, a detailed explanation must be clearly written on your stroke scale form. It is important to use only the validated form available from the NIH. In the package you received with this disc, several websites are listed where you may download the correct version of the scale. Generally, we record the patient's first effort, even if follow-up efforts are better, to optimize the reproducibility of the scoring. Don't go back and change scores. The most reproducible score will be your first impression. Work methodically and quickly. An experienced examiner will be able to complete the NIH stroke scale evaluation in about five minutes for uncomplicated cases, though a difficult patient may require a bit more time. Each scale item is judged independently from the previous items. There are some exceptions, and we'll highlight those as we go. Now, here are some important conventions used to assure the excellent reproducibility of the NIH stroke scale. Administer the scale items in their exact order. When coaching the patient, even though this may be counter to usual clinical practice of trying to elicit the best performance, accept the patient's first effort. Score only what the patient does, not what you think they can do. During the course of testing, you may develop an impression of level of function or lesion. Those impressions must not influence your scoring. Again, score only observed performance. Sometimes these rules don't make sense, but if all examiners do the scale the same way, the scores will be consistent. Be sure to include all deficits in your scoring, including those deficits that may result from previous strokes. Not all decisions are simple. When you're having trouble deciding on a score, try ruling out the extreme score and then weigh the mid-scale scores. You should keep the stroke scale reference material, such as the scoring guide, nearby when you administer and score the NIH stroke scale. However, at the bedside in a critical situation, all you need is the proper scoring sheet, the naming sheets, and a pin. These are the overall conventions. Now let's focus on each item of the scale. I will describe and perform each item of the scale for you and then go over scoring. Item 1A is the examiner's overall impression of patient alertness. Normally, you'll get enough information when taking the patient's history to make this assessment. Ask the patient two or three questions about the circumstances of the admission. Stimulate the patient by patting or tapping the patient, or on occasion, more noxious stimuli such as pinching may be needed to check the level of consciousness. Good morning. Good morning. Are you having any pain today? A little pain. A little pain? Are you comfortable now? No. Yes. Okay. For scale item 1A, this patient scored a zero. Let's look at how this scale item is scored. Score a zero if the patient is alert and keenly responsive. Score a one when the patient is not alert but can be aroused with minor verbal stimulation. Score a two for the patient who is not alert and requires repeated stimulation to attend or who requires strong, painful, or noxious stimulation to make movements. Score a three if the patient makes only reflexive posturing movements in response to repeated painful stimuli. A patient with a three on this scale item is generally considered to be in a coma. A patient suspected to be in a coma should be stimulated by rubbing on the chest or by using a painful stimulus. A three is scored only if the patient makes no movement other than reflexive posturing in response to noxious stimulation. If it's difficult to choose between a score of one or two, continue with medical history questions until you're confident in assigning a score. This is the only time you are allowed to go back and change a score. A score of three requires particular attention because it has an impact on how you'll score other scale items. In patients who appear to be in a coma and who score less than three, you must attempt all items, but realistically, you will likely fall back on the predefined default values for coma patients. I will discuss these default values as we go along. They're also summarized in the scoring manual. You must choose a score even if confronted with obstacles, for example, endotracheal tube, language barrier, orotracheal trauma or bandages. A score of consciousness, item 1b, is based on the patient's answers to two specific questions, the month of the year and the patient's age. Would you please tell me your age? How old are you? Fifty-three. Okay. And tell me what month it is right now? February. Okay. For scale item 1b, this patient scored a zero. Let's look at how this scale item is scored. Score a zero if both questions are answered correctly. Score a one if only one question is answered correctly. By definition, patients unable to communicate because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, a language barrier, or any other problem not secondary to aphasia are scored a one. Score a two if neither question is answered correctly. A patient who scores a three on level of consciousness 1a must be scored a two on this scale item. Aphasic and stuporous patients who do not comprehend the questions will score a two. If the patient is in a coma, a score of two would be assigned. Because this is a standardized test and to ensure reproducibility of results, other measures of orientation such as time of day, location, etc., are not asked as part of this examination. But a patient who cannot speak may be allowed to write the answer. If the patient has aphasia, you need to judge his responses to questions in light of the language impairment. Like always, only score the initial answer. If the patient first gives an incorrect answer and then corrects himself, it is nevertheless scored as an incorrect answer. Many patients will give you their date of birth when you ask for their age. This is scored as a wrong answer. There is no partial credit for answers that are closed like being off by a month. For the third part of item one, or 1c, you ask the patient to perform two tasks. Before beginning this assessment, be sure to position the eyes and hands in a testable position, then ask the patient to do these actions. Close your eyes for me. Now open. Now make a fist with your hand. You may repeat the command once, but do not coach or encourage. To improve reproducibility, score what the patient does, not what you think they are capable of doing. In general, you should try to pantomime the command so the patient receives your verbal as well as visual input. Close your eyes and open them up. That's terrific. Make your left hand and make a fist. And now open it up. That's great. For scale item 1c, this patient scored a zero. Let's look at how this scale item is scored. Score a zero if both tasks are performed correctly. Score a one if one task is performed correctly. If the patient does not speak English, a friend or family member can be asked to translate. Now ask her to close her eyes. Cierra tus ojos. Ábrelos. You're going to take this hand and make a fist. This hand? This hand. Make a fist. Ah, aprieta tu mano así. As tu mano así. Make a fist. Score a two if neither task is performed correctly. I want you to take your hand and I want you to make a fist. I want you to make a fist. I want you to close your eyes. Close your eyes. A two is scored for patients with a comprehension deficit and who perform incorrectly. Some subtleties here. Give credit if a real attempt is made but not completed simply due to weakness. Only score the first attempt. Again, do not coach or teach. By the time this scale item is tested, you will have already interacted sufficiently with the patient to judge whether or not the patient will actually comprehend your verbal commands. If you're dealing with patients with trauma, amputation, or other physical impediments, you'll need to substitute other one-step commands. The best gaze item, number two on the NIH Stroke Scale, tests voluntary horizontal eye movements. Disorders of vertical gaze, nystagmus, and skew deviation are not measured. First look at the position of the eyes at rest. Make sure to note any spontaneous eye movements to the left or right. The next test is to move your finger or other target horizontally, asking the patient to track your finger from side to side by moving the eyes only. Make sure to keep asking the patient to follow the target. If the patient does not accurately follow your finger, a stronger test is needed. Use the oculosephalic maneuver, eye fixation, or tracking of the examiner's face. This is an exception to the rules of using the first observable response for scoring and not coaching the patient. In patients with poor attention spans, establish eye contact and move your face around the patient from side to side. This may clarify the presence of a partial gaze palsy. Now I'm going to test your gaze. I'd like you to look at my finger and follow it all the way over this way and all the way over that way. For scale item two, this patient scored a zero. Let's look at how this scale item is scored. Score a zero if the tasks are performed correctly. If a patient has ocular rotary problems, such as astrabismus, but leaves the midline and attempts to look both right and left, the patient should be considered to have a normal response. Score a one for partial gaze palsy. I want you to look at me, look at me, look here. I want you to look over here. Look over here. All right. I'm going to help you out here a little bit so we can see your eyes. I want you to look over here. Now look over there, OK? If there is a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, also score a one. If the patient has an isolated cranial nerve paracys, such as an ocular motor or abducens palsy, also score a one. Score a two when there is forced deviation or total gaze paracys not overcome by the oculosephalic maneuver. I'm going to test your eye movements now. I want you to look at my hand. Can you look all the way over to your right? Look at my hand. And look all the way over at me. Look here at me. All the way here at my hand. Good. If there is a conjugate lateral deviation that is not overcome with reflexive movements, the score should be a two. The easiest way to score this item is to consider whether the eye movements are normal. If so, score a zero. If not, consider whether there is tonic deviation such that the eyes cannot be moved. If so, score a two. Everything else would be scored a one. Patients who score a three on level of consciousness, item 1A, are in a coma and may have gaze palsy that can be overcome by moving the head. So in these cases, you should use the oculosephalic maneuver and score the result. To keep the testing conditions standard, do not do caloric testing. With aphasic patients, gaze is testable. Just like with confused patients, it helps to establish eye contact and move about the bed. And finally, patients with ocular trauma, bandages, preexisting blindness, or other disorders of visual acuity or fields should be tested with reflexive movements and scored. This may mean removing the bandages. The third item in the NIH Stroke Scale tests the visual fields of both eyes. In the visual fields item, each eye is tested independently. Upper and lower quadrants are tested by confrontation. This means using finger movement, finger counting, or visual threat as appropriate. If a patient is unable to respond verbally, the examiner should check attention to responses to visual stimuli in all quadrants or have the patient hold up the number of fingers seen. Make sure the patient is looking directly into your eyes during the testing. Tell the patient you will be testing peripheral vision and that you may move a finger to the right or a finger to the left or both. Then you test by asking the patient to count fingers in all four quadrants. Patients who scored a three on the level of consciousness, 1A, are tested using bilateral threat. Now the next thing I'm going to do is I want to test your vision, all right? So I'm going to help you cover your right eye. How many fingers do you see? Two. OK. How many fingers do you see? Five. Good. How many fingers do you see? One. And how many up there? One or two. Now look at me. How many fingers down there? One. Level of five. One. One. For scale item number three, this patient scored a zero. Let's look at how this scale item is scored. Score the item zero if the upper and lower visual fields are normal. If the confused or language-impaired patient looks at the correct side of the moving finger, this is scored as normal. If a patient has severe monocular visual loss due to intrinsic eye disease and the visual fields in the other eye are normal, the examiner should score the visual fields as normal. Score a one only if you find a clear-cut asymmetry, including quadrantinopia or partial hemianopia. If there is an extinction, score the patient a one. And I want you to look at my nose and tell me, how many fingers do you see out of the corner of your eye? Two. One. OK, look right at my nose. Look at me. How many up there? Two. OK, look right at my nose. Look at me. One. OK. Two. The whole hand. Look at me. Look at me. Look at me. Three. Look right at my nose. Two. All right. Now switch hands and cover your left eye for me. All right. Again, look at my nose. One. The whole hand. One. Two. Look like three or four. OK. How about now? One. Look at my nose. Score a two for a complete hemianopia. Cover your right eye for me. When you see a finger, you tell me how many fingers you see. One. Good. One. One. All right, now I want you to switch eyes. And we'll try the same thing again. One. Good. Score a three for blindness of any cause, including cortical blindness, which requires a positive diagnosis, and double simultaneous stimulation testing. All right. Do you see my hands moving? Yes. How about now? Yes. OK. Do you see my hand moving now? Yes, I do. How about now? Yes, I do. All right. As soon as my hand moves, you say now. OK, one last thing. I want you to look right here at me. Look right here at me. Very good. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. The result of this item will have an impact on the last scale item, extinction, and inattention. And many of us check double simultaneous stimulation to visual input at this point. There is an arbitrary rule that if they extinguish, the visual field item is scored a one, even if the fields are intact to confrontation. This rule helps even out the variations that occur when inexperienced examiners encounter neglect so severe that the patient appears to have a visual field cut. The next item on the scale is an assessment of facial policy. To assess facial policy, you ask or use pantomime to encourage the patient to show me your teeth. If the teeth aren't in, ask them show me your gums. Open and close the eyes. You can say, squeeze your eyes shut as hard as you can. Raise the eyebrows or lift up your eyebrows as high as you can. The patient needs to look directly at you while performing the requested tasks. For the aphasic, poorly responsive, or non-comprehending patient, use a noxious stimulus. In this case, the symmetry of the grimace is the basis of scoring. I'm going to examine your face. So I want you to show me your teeth. Good. And now relax. Close your eyes real tight. Tighter, tighter. Very good. Now open your eyes and raise your eyebrows up. That's great. For scale item four, this patient scored a one. Let's look at how this scale item is scored. Score the patient a zero for normal symmetrical movement. Normal function must be clearly demonstrated. Orbital and forehead musculature movements are normal. Score a one for minor paralysis, such as a flattened nasal labial fold, or mild asymmetry while smiling. This is the proper score if function is less than clearly normal. Score a two if there is paralysis of the lower face. This is the appropriate score for clear cut upper motor neuron facial palsy. Decrease spontaneous and forced facial movements are most prominent at the mouth. Open your eyes. Look at me. Thank you. Can you show me your teeth? There we go. Score a three when there is complete paralysis of the upper and lower face. This is the appropriate score for the uptunded or comatose patient, or one with unilateral lower motor neuron facial weakness. Now ask her to do what I do to show me her teeth. Show me your gums. Enseñar los ansios así. Good. Now close your eyes. Cierra tus ojos. Tightly. Fuerte. Fuerte. Tight. Tight. Fuerte. Good. And now raise the eyebrows up. Abre los ojos. And raise the eyebrows. Levanta tu ceja. Tu ceja, levanta la ceja. Good. Good. The easiest way to score this challenging item is to first decide if the face is normal. If so, score a zero. If the face is not normal, ask yourself if there's a clear cut asymmetry of the smile. If so, score a two. All other findings, including subtle asymmetries of the nasolabial fold, are scored a one. The score of three is reserved for the very unusual, complete facial paralysis seen with some brainstem strokes. Remember to include using noxious stimuli to score the symmetry of grimace in poorly responsive or non-comprehending patients. Also, in the event of facial trauma, remove the bandages, tape, or other physical barriers that might obscure the face. Scale items five and six assess arm motor movement and leg motor movement. For motor arm and leg scoring, make sure to appropriately position the limb. Extend the arms 90 degrees if the patient is sitting, or 45 degrees if the patient is supine. Always test the leg in the supine position by extending the leg 30 degrees. You score a drift if the arm falls before 10 seconds as you count down out loud, or if the leg falls before five seconds. Begin counting immediately at the release of the limb. You should also count down with your fingers in full view of the patient as you count out loud so that the patient receives verbal and visual input. You can help the patient in this item by placing the limb in the desired start position. Watch for an initial dip of the limb when you release it. Only score abnormal if there's a downward drift after the dip. Each limb is tested in turn beginning with the non-puretic arm. When testing the arms, the palms must be down. Do not test limbs simultaneously. Do not coach the patient. Only in the case of amputation or joint fusion at the shoulder or hip is this scale item not scored. But you need to make a written note of this. On some printed copies of the NIH Stroke Scale, you may be advised to score amputation as a nine when scoring motor arm, motor leg, or ataxia, but don't use the nines in calculating the total score. You'll have to use urgency in your voice or pantomime to encourage the aphasic patient. These patients may understand better what you are testing if you use the non-puretic limb first. If the patient has restricted limb function due to arthritis or non-stroke related limitations, you still need to give a score. Use your best judgment to differentiate between the effect of the stroke and any other cause. I'm gonna ask you to hold this arm up right here, spray it out for 10 seconds. One, two, three, four, five, six, seven, eight, nine, 10. That's terrific. Now let's try the other side. I'll hold it up and when I let go, you keep it up for 10 seconds. Can we get it to there? Okay. I don't know. Let's see. One, two, three, four, five, six, seven, eight, nine, 10. Okay. For scale item 5A, this patient scored a zero. For scale item 5B, the patient scored a one. Let's look at how this scale item is scored. Score a zero if there is no drift and the arm remains in position for a full 10 seconds after any initial dip. Score a one if the arm jerks or drifts down to an intermediate position without encountering support, such as a bed, before a full 10 seconds. Want you to hold your arm up for 10 seconds. You ready? One, two, three, four, five, six, seven, eight, nine, 10. That's terrific. Score a two when there is some effort against gravity, but the arm cannot get to or maintain the proper position and drifts down to some support. One, two, three, four, five, six, seven, eight, nine, 10. Score a three when there is no effort against gravity and the arm falls. Let me see if you can hold it up at all, okay? And shrug that shoulder for me. Show me that shoulder move. There we go, all right. Score a four if the patient is unable to make voluntary movements. I'll hold it up for you right there. Now you hold it up. One, two, three, four, and it's hit the bed now, so what I'd like to know is can you move it at all? To differentiate a score of three from four, you have to encourage the patient and wait a second or two to observe movement in the peretic arm. Any movement at all, including small proximal movements, such as shoulder shrug or hip flexion, is enough to lower the score from four to three. A patient who scores three on level of consciousness, 1A, is scored four on this item. Scale items five and six assess arm motor movement and leg motor movement. For motor arm and leg scoring, make sure to appropriately position the limb. Extend the arms 90 degrees if the patient is sitting or 45 degrees if the patient is supine. Always test the leg in the supine position by extending the leg 30 degrees. You score drift if the arm falls before 10 seconds as you count down out loud, or if the leg falls before five seconds. Begin counting immediately at the release of the limb. You should also count down with your fingers in full view of the patient as you count out loud so that the patient receives verbal and visual input. You can help the patient in this item by placing the limb in the desired start position. Watch for an initial dip of the limb when you release it. Only score abnormal if there's a downward drift after the dip. Each limb is tested in turn beginning with the non-puretic arm. When testing the arms, the palms must be down. Do not test limbs simultaneously. Do not coach the patient. Only in the case of amputation or joint fusion at the shoulder or hip is this scale item not scored. But you need to make a written note of this. On some printed copies of the NIH Stroke Scale, you may be advised to score amputation as a nine when scoring motor arm, motor leg, or ataxia, but don't use the nines in calculating the total score. You'll have to use urgency in your voice or pantomime to encourage the aphasic patient. These patients may understand better what you are testing if you use the non-puretic limb first. If the patient has restricted limb function due to arthritis or non-stroke related limitations, you still need to give a score. Use your best judgment to differentiate between the effect of the stroke and any other cause. Let's lift this one up. And when I let go, you hold it up for one, two, three, four, five. Perfect, go ahead and relax. Now we'll try the other side. I'll lift it and you keep it up after I let go, right there. One, two, three, four, five. That's great. For scale item six A, this patient scored a zero. For scale item six B, the patient also scored a zero. Let's look at how this scale item is scored. Score a zero if there is no drift and the leg holds the 30 degree position for a full five seconds. Score a one if there is drift and the leg falls by the end of the five second period but does not hit a support such as a bed. When you hold it for one, two, three, four, five. Four, five, great. Score a two when there is some effort against gravity but the leg falls to the support within five seconds. Tell her to hold it up, up, up, up. One, two, three, four, five. Score a three when there is no effort against gravity and the leg falls to the support immediately but the patient makes small movements such as hip flexion or adduction. Now we'll hold this one up right there for one, okay, let's try it. Let's see you move it, all right? Let's see you move that leg. Okay. Score a four if the patient is unable to make voluntary movements. Hold that leg up, hold your leg up. Hold the leg up. One, two, can you move it at all? Can you move that leg? Try moving that leg for me. Items five and six are the most reproducible of the scale and carry the most import in determining ultimate outcome. Please watch the limb very carefully and compare to a marker behind the patient to gauge whether the limb is drifting slightly. If it is not possible to test the patient on this scale item because of an amputation or hip or shoulder joint fusion or any other reason, the item is not scored. We discourage you from doing this in any but the most extreme cases and the reason must be recorded on the form clearly. Patient scoring a three on level of consciousness 1A are scored four. The test for limb ataxia item seven is an assessment for evidence of a unilateral cerebellar lesion. This test attempts to distinguish a clinically significant incoordination from general weakness. Perform the finger nose finger and heel shin tests on both the right and left sides. Ask the patient to touch your finger with his index finger then back to his nose, then repeat enough times to thoroughly test for ataxia. Then perform the test on the other side. Then test coordination in the leg. Instruct the patient to move one heel down and up the shin of the opposite leg. Give the same test on both the right and left sides of the body. Test the normal side first, make sure the patient's eyes are open. In the event of a visual field defect, try to perform the test in the intact visual field. The next thing I'd like to do is check your coordination. Take your finger here and touch my finger. Now touch your nose. Now my finger. Now your nose. Now my finger. Now your nose. Good. Now on the other side, I don't know what we'll be able to do, but see if you can lift it and touch my finger. I can't. Can't get up that high, okay. Let's see what happens with the legs, all right? I'm gonna take your right leg. I want you to put your heel on your knee and run it down your shin. Let's see what happens. Can you bend the knee? Put your heel right there and run it all the way down your shin and back up again. That's great. Now relax. Now let me try the right leg. I'll lift it up and you put the heel on your knee and slide it all the way down. And can you slide it back up? I can't do it. Okay, put it down and slide it down one last time. Very good. Okay. For scale item seven, this patient scored a zero. Let's look at how this scale item is scored. Score a zero if there is normal coordination. The movements should be well performed, smooth, accurate, and not clumsy. If there is significant weakness, assume ataxia is zero. Ataxia is scored only if present and out of proportion to weakness of the spastic limb. Ataxia is absent in the patient who cannot understand or is paralyzed and so is scored a zero on this item. Score a one if ataxia, dysmetria, or dysenergia is present in one limb. I want you to take the heel, put it on your knee and run it down your shin. Just take that heel and put it right there, run it down your shin and back up. And now do the same thing on the other side. Put the heel on the knee and run it all the way down and back up and run it all the way down to the end this time and back up. And that's terrific, relax. Score a two if ataxia is present in two limbs, both arms, both legs, or an arm and a leg on the same side of the body. Also score a two if you observe dysmetria or dysenergia in both the arm and the leg on one side or if there are bilateral signs. So take this finger right here and touch my finger. Now touch your nose, now my finger. Now your nose, now my finger, good. Now let's try that on the other side. Touch my finger as quick as you can and now your nose, back and forth, back and forth, back and forth. Yeah. There we go, okay. I want you to take your right leg, put the heel on your knee. So lift this heel up, put it on your knee there, and just run it straight down your shin. Straight down the shin and back up. Good, good. Now switch sides and put the left heel on the knee there, run it all the way down and back up. That's good. It's important to remember that this item is scored a one or a two only if ataxia is present and out of proportion to weakness. In the case of amputation or joint fusion, you may mark the item untestable, but make sure to write the reason on the form. Patient scoring a three on level of consciousness 1A are scored only if ataxia is present, otherwise give a zero. You test sensory perception with a series of pin pricks. Withdraw from noxious stimulus is used in the obtunded or aphasic patient. Do not use any object other than a safety or seamstress pin, no paper clips, broken sticks, or ballpoint pens. Examine the patient with a pin in the proximal portions of all four limbs and ask if the patient feels the stimulus. The patient's eyes do not need to be closed. Ask the patient if there is any asymmetry between the right and left sides. Asking if the patient feels sharp or dull only begs for confusion and misinterpretation. To optimize reproducibility, ask the patient only to compare the two sides and tell you if there is a difference. In confused, aphasic, or obtunded patients, observe for symmetry of grimace in response to the noxious stimulus. Only sensation loss attributed to stroke is scored. Test as many body areas, arms, legs, trunk, and face as needed to accurately assess for hemisensory loss. Do not test limb extremities like hands or feet when testing sensation since the response may be confounded by an unrelated neuropathy. Unless absolutely necessary, do not test through clothing. I'll touch you on the right or the left and you tell me if they're the same or if one side's sharper. Starting with your face, right, left, which one's sharper? Or are they the same? About the same. About the same, all right? Let's try your hands. Right, left, which one's sharper? Or are they the same? Dollar. Dollar on the right. Okay. Dollar on the right. Let's try your legs. Which one's sharper? Or are they the same? One's dollar on the right. For scale item number eight, this patient scored a one. Let's look at how this scale item is scored. Score a zero when there is no evidence of sensory loss. Score a one for mild or moderate loss. I'm gonna test how well you feel this pin now. I want you to tell me if the right side is sharper, the left side, or if they're the same. Okay. Starting with your face. Which side is sharper? Left. Which side is sharper? Left. Arms, which side is sharper? About the same. About the same, okay? I'm gonna go to the legs. The left side is sharper. Left side is sharper. Score a two when evidence confirms severe loss. Only give a two when a severe or total loss of sensation can be clearly demonstrated. Patients with brain stem stroke demonstrating bilateral loss of sensation also score a two. Now I'd like to see if you can feel any sensation. Gonna touch you with this pin. Can you tell me anything about that? Can you feel that? And I can't tell. So I'm gonna try something else. I'd like you to tell me if you feel this, if you feel that squeeze, all right? And how about on this side? Can you feel the squeeze on this side? Okay, I can see you pulling back on that one. This item is never marked not testable. You should test stuporous or aphasic patients with vigorous noxious stimuli, such as nail bed pressure, and then decide between a one or zero based on whether any response appears. Patients who score three on level of consciousness 1A will automatically score a two on the sensory item. For item nine, best language, we score the patient's language skills. Listen for this item as you perform the entire stroke scale examination. By this time, you'll know a lot about the patient's ability to comprehend language and you may be able to score the item. However, it's almost always wise to confirm your impressions developed to this point in the exam using the formal testing tools provided. This scale item is an exception to the rule of scoring only the first impressions. We encourage, but do not coach or stimulate the patient's best performance. The patient's language is tested by having the patient examine the cookie jar picture in the standard naming card and by reading a series of sentences. The objects and sentences are provided with the stroke scale exam. Always determine if the patient wears glasses. If so, they will be needed for the exam. Give the patient adequate time to identify the objects on the object card. Ask the patient to name each item on the card. Ask the patient to describe the meaning and action depicted on the cookie jar picture. Encourage, but do not coach the patient to be as complete as possible. Ask the patient to read all the phrases on the sentence card. The assessment is based on your overall sense of the patient's language as well as on their responses on these tests. I'd like you to put on your reading glasses here. Okay. All right. I'm gonna show you a card. I want you to tell me what you see in that picture. Socket, to hostess, and going outside, just washing, and falling down. Good. Now I have some pictures. Can you tell me what that is right there? Cloth. Okay. And that right there? Feather. Good. And this one? Amic. Good. And this one? Jare. Mm-hmm. And this one? Gexis. Uh-huh. Yeah. And this one? Key. Good. That's great. Can you read these sentences for me? You know how down to Earth, I got home from work near the table in the dining room. They heard him speak on the radio last night. For scale item nine, this patient scored a one. Let's look at how this scale item is scored. Score a zero if there is no aphasia. Score a one for 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 you as the examiner to identify the picture or naming card content from the patient's responses. What I'm gonna do is give you this picture here. And I'd like you to tell me what you see in that picture. Describe to me what you see there. Well, uh, boy, boy, boy, has, take, getting, c, cookie, good job. Mm-hmm. Mm-hmm. Now he's falling on this stool. Mm-hmm. Mm-hmm. Very good. Do you see anything else? Slippy people. Mm-hmm. Mm-hmm. Yeah. A little ladder. What else do you see? The lady has... ...wants to dish us and overflow the... ...the...thing. Excellent. Ok. Now what I'd like you to do... ...I have another picture... ...and I'd like you to take a look at this... ...and tell me what that object is right there. What is that right there? Can you tell me the name of that object? Excellent. How about this one? Key. How about this one? Chair. Cut. Cut. Cut. Cut. Cut. I cannot pronounce. Okay, how about that? Cut. Cut. Good. Alright. How about this one here? Feather. And this one here? Hammock. Okay. Score a two for severe aphasia when all the patient's expressions are fragmentary or when you cannot identify card content from the patient's response. Ask her if there's anything in that picture she can tell us. Amar. Mira el dibujo y ¿qué están haciendo ellos? A ver, trata de decir ¿qué es lo que están haciendo? No, aquí. Mira el dibujo. ¿Qué está haciendo ella? Tell you what, let's try a different one and see what I'd like her to do is look at the card and tell us if she can point to the chair. ¿Puedes apuntar dónde está la silla? La silla. Mira el dibujo. ¿Dónde está la silla? ¿Toca la silla con tu mano? Okay. Score a three if mute for any reason or for global aphasia or if no usable speech or auditory comprehension is demonstrated. The examiner must choose a score of three for the patient with a stupor or limited cooperation. Would you take a look at this card? Is there anything that you can tell me about it? I'll hold it where you can see it. Can you speak at all about that card? Let me try one more thing. I have a few pictures here. Can you tell me what this object is on the picture card? The intubated patient should be asked to write down responses to the examiner's questions. If a patient's visual loss interferes with testing this item, you may ask the patient to identify objects placed in the hand. You'll also need to elicit samples of speech. On the naming card test, it is very common for visually impaired patients to identify the feather as a leaf and the glove as a hand. Also, in some parts of the country, the cactus picture will be identified as animals in profile such as squirrels. I usually score these responses as correct. Hammocks are not common outside of the Americas, so patients from other cultural groups may not know the term. Patients scoring a 3 on level of consciousness 1A are scored 3 on this scale item. 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. Remember, score what you see, not what you think the patient can do. In item 10, dysarthria, we test the patient's articulation and clarity of speech. It's important that you don't explain the purpose of this exam. Ask the patient to read or repeat the words from the word card provided with the stroke scale. I'd like you to pronounce these words for me. Mamba, tipped up, 50-50, Sphinx, aqua berry, baseball player. For scale item number 10, this patient scored a 1. Let's look at how this scale item is scored. Score a 0 for patients with normal speech who read all words without slurring. Score a 1 for patients with mild to moderate speech defects and some slurring, but who can be understood. Could you read those words for me, please? Mamba, tipped up, 50-50, Sphinx, aqua berry, baseball player. Very good. A score of 2 is reserved for the patient who cannot be understood in any meaningful way or who is mute. Would you ask her to say Mamba? Ask her to say Mamba. Mamba, tipped up, 50-50, Okay. An unresponsive patient receives a score of 2 on this item. Patients scoring a 3 on level of consciousness 1a are scored 2 on this scale item. The item is untestable only if the patient is intubated or has other physical barriers to producing speech. Remember to clearly document and explain this problem on the form. If phasic patients and patients who do not read may be scored based on listening to the speech they do produce or by asking them to repeat the words after you read them out loud. In some cases, the speech may be hard to understand due to dental or other non-neurological causes. Nevertheless, score the item a 1 to optimize reliability among examiners that might have varying degrees of experience. We come now to the last scale item, which tests for neglect or inattention. You may have enough information by the time you reach this point in the exam to make a judgment, but if abnormalities are not clear, the presence of neglect is examined by the patient's response to double simultaneous stimulation. Unless there is obvious neglect or anisognosia, it is wise to double-check. First, ask the patient to close their eyes. Alternately touch the patient's left or right side and ask the patient which side is being touched. After the patient responds consistently, then touch the patient on both sides at once. The patient without neglect will identify sensation on both sides. Patients with cortical impairment may extinguish one side, that is, they will only perceive sensation on one side. Since neglect is scored only if present, the item is never untestable. Now, the last thing I'd like to do is tap you on the right, left, or both. You tell me which it is, alright? Close your eyes. We'll start with your face. Right, left, or both? Okay. Can you say if it was left, right, or both? Okay, alright. You know what might be easier for you is if you take your finger and point to the side that I'm touching. Okay? Point to the side that I'm touching. Good. Alright. Left. Good. Both. Excellent. Now, you're able to pronounce it now, so let me try the hands. You tell me if this is right, left, or both. Right. Good. Okay. Left. Wait for me to touch it. Both. Both. Left. Right. Both. Beautiful. Keep your eyes closed and I'm going to tap your legs. Right. Left. Both. Left. Both. I'd like to do the same thing now in your vision. You can point to the finger that wiggles. It'll either be right, left, or both. Right. Left. Right. Both. Both. Good. For scale item number 11, this patient scored a zero. Let's look at how this scale item is scored. Score a zero for the absence of neglect. If the patient has a severe visual loss, preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia and cutaneous stimuli are normal, the score is normal. Score a one for inattention to only one modality, visual, tactile, auditory, or spatial. If the patient does not extinguish but shows other well-developed evidence of neglect, score a one. Tell me if you see a finger wiggling on the right side, left side, or both sides. Where's that? That's left. Right. Right. Right. Right. Left. Right. Right. Okay. A two is scored for profound hemi inattention or extinction to more than one modality. Score a two if one side extinguishes to both visual and tactile stimuli using double simultaneous stimulation. Score a two if there is inattention to more than one category, visual, tactile, auditory, or spatial inattention. A patient with a score of three on level of consciousness 1A is automatically scored a two. As soon as you finish, add up the scores from each item to derive the total. It is always wise to be sure that you have entered the scores correctly, especially on items 1B and 1C. People have a tendency to write a two when the patient scores both items correctly. We have completed basic instruction in the use of the NIH Stroke Scale. As you have seen, the scoring rules are rigid and arbitrary, and in some cases counter to typical neurological practice. However, if the scoring rules are followed, the scale scores will be highly reliable and reproducible. To help you master the art of scoring the NIH Stroke Scale, we have placed guided interactive patient assessments on this disc. Using these patient assessments, you will have the opportunity to observe again how each test is given and how patients respond, and to practice scoring performance on each item of the scale with the opportunity to compare your scoring judgments to those of experienced clinicians.