| NIH
Stroke Scale Item |
Function |
Score |
| 1a.
Level of Consciousness |
Alert |
0 |
| (alert,
drowsy, etc.) |
Drowsy |
1 |
|
Stuporous
(requires repeated stim) |
2 |
|
Coma
(reflex responses only) |
3 |
| 1b.
LOC Questions |
Both
Correct |
0 |
|
(Month, Age) |
One
Correct |
1 |
|
Incorrect |
2 |
| 1c.
LOC Commands |
Obeys
both Correctly |
0 |
|
(Open, close eyes, make fist, let go) |
Obeys
one correctly |
1 |
|
Incorrect |
2 |
| 2.
Best Gaze |
Normal |
0 |
|
(Eyes open- patient follows examiners finger or face.) |
Partial
Gaze Palsy |
1 |
|
Forced
Deviation |
2 |
| 3.
Visual |
No
Visual Loss |
0 |
| (Introduce
visual stimulus/ threat to patients visual field quadrants) |
Partial
Hemianopia |
1 |
|
Complete
Hemianopia |
2 |
|
Bilateral
Hemianopia |
3 |
| 4.
Facial Palsy |
Normal |
0 |
| (Show
teeth, raise eyebrows and squeeze eyes shut.) |
Minor
asymmetry |
1 |
|
Partial
(lower face paralysis) |
2 |
|
Complete |
3 |
| 5a.
Motor Arm-Left |
No
Drift |
0 |
|
(Elevate extremity 90¡ and score drift/movement) |
Drift |
1 |
|
Some
Effort Against Gravity |
2 |
|
No
Effort Against Gravity |
3 |
|
No
Movement |
4 |
|
Amputation,
Joint fusion |
9 |
| 5b.
Motor Arm-Right |
No
Drift |
0 |
|
(Elevate extremity 90¡ and score drift/movement) |
Drift |
1 |
|
Some
Effort Against Gravity |
2 |
|
No
Effort Against Gravity |
3 |
|
No
Movement |
4 |
|
Amputation,
Joint fusion |
9 |
| 6a.
Motor Leg-Left |
No
Drift |
0 |
|
(Elevate extremity 30¡ and score drift/movement) |
Drift |
1 |
|
Some
Effort Against Gravity |
2 |
|
No
Effort Against Gravity |
3 |
|
No
Movement |
4 |
|
Amputation,
Joint fusion |
9 |
| 6a.
Motor Leg-Right |
No
Drift |
0 |
|
(Elevate extremity 30¡ and score drift/movement) |
Drift |
1 |
|
Some
Effort Against Gravity |
2 |
|
No
Effort Against Gravity |
3 |
|
No
Movement |
4 |
|
Amputation,
Joint fusion |
9 |
| 7.
Limb Ataxia |
Absent |
0 |
| (Finger-Nose,
Heel down shin.) |
Present
In one limb |
1 |
|
Present
In two limbs |
2 |
|
Complete |
3 |
| 8.
Sensory |
Normal |
0 |
| (Pin
prick to face, arm, trunk, and leg- Compare side to side) |
Partial
Loss |
1 |
|
Dense
Loss |
2 |
| 9.
Best Language |
No
Aphasia |
0 |
| (Name
items, describe a picture and read sentences.) |
Mild
-Mod Aphasia |
1 |
|
Severe
Aphasia |
2 |
|
Mute |
3 |
| 10.
Dysarthria |
Normal
Articulation |
0 |
| (Evaluate
speech clarity by patient repeating listed words) |
Mild-Moderate
Slurring |
1 |
|
Severe
Near Unintelligible Or Worse |
2 |
|
Intubated
or Other Physical barrier |
9 |
| 11.
Extinction and Inattention |
No
Neglect |
0 |
| (Use
information from prior testing to identify neglect or double simultaneous
stimuli testing.) |
Partial
Neglect |
1 |
|
Profound
Neglect |
2 |
Produced by SNR
Resources, a Division of The Stroke Group, Inc.
|
