Assessment scales in stroke: clinimetric and clinical considerations

Abstract

As stroke care has developed, there has been a need to robustly assess the efficacy of interventions both at the level of the individual stroke survivor and in the context of clinical trials. To describe stroke-survivor recovery meaningfully, more sophisticated measures are required than simple dichotomous end points, such as mortality or stroke recurrence. As stroke is an exemplar disabling long-term condition, measures of function are well suited as outcome assessment. In this review, we will describe functional assessment scales in stroke, concentrating on three of the more commonly used tools: the National Institutes of Health Stroke Scale, the modified Rankin Scale, and the Barthel Index. We will discuss the strengths, limitations, and application of these scales and use the scales to highlight important properties that are relevant to all assessment tools. We will frame much of this discussion in the context of "clinimetric" analysis. As they are increasingly used to inform stroke-survivor assessments, we will also discuss some of the commonly used quality-of-life measures. A recurring theme when considering functional assessment is that no tool suits all situations. Clinicians and researchers should chose their assessment tool based on the question of interest and the evidence base around clinimetric properties.

Keywords: Barthel Index; National Institutes Health Stroke Scale; clinical trial; clinimetrics; disability; methodology; modified Rankin Scale; outcomes; scales; stroke.

Figure 1

Scales used at various points in the stroke survivor’s journey. Notes: Note how scale domains move from impairment to activity and participation as the subject progresses. Note also the various agencies that may use scales in their assessment. Abbreviations: ED, emergency department; GCS, Glasgow Coma Scale; NIHSS, National Institutes of Health Stroke Scale; E-ADL, extended activities of daily living; mRS, modified Rankin Scale; QOL, quality of life; MRC, Medical Research Council.

Figure 2

World Health Organization international classification.

Figure 3

Examples of commonly used stroke scales at differing levels of function. Abbreviation: QOL, quality of life.