Table 2.
Category and sub category of stroke scale with different items
| Cut point | Grading | item | Authors | scale | Category |
|---|---|---|---|---|---|
| Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services | Joseph Harbison et al. | FAST | DIAGNOSTIC SCALES | ||
| Normal: Both sides of face move equally. Abnormal: One side of face does not move as well as the other. |
Facial Droop | National Institutes of Health Stroke Scale | CPSS | ||
| Normal: Both arms move the same, or both arms do not move at all. Abnormal: One arm either does not move, or one arm drifts down compared to the other. | Arm Drift | ||||
| Normal: The patient says correct words with no slurring of words. Abnormal: The patient slurs words, says the wrong words, or is unable to speak |
Speech | ||||
| Positive answers to all 6 questions above: Contact hospital en-route Alert hospital of possible stroke patient Test Sensitivity: 93% Test Specificity: 97% |
Yes, No, unknown | Age over 45 years | Department of Health Services, County of Los Angeles | LAPSS | |
| Yes, No, unknown | History of seizures or epilepsy absent | ||||
| Yes, No, unknown | Symptom duration less than 24 hours | ||||
| Yes, No, unknown | At baseline, patientis not wheelchairbound or bedridden | ||||
| Yes, No | Blood glucose between 60 and 400 | ||||
| Facial droop, Grip weakness or absence, Arm weakness | Exam: Look for obvious asymmetry Based on exam | ||||
| A score ≥4 is highly predicted of large artery occlusion | Absent (0) Present (1) |
Facial Droop | Jeffrey Saber et al | LAMS | |
| Absent (0) Drifts down (1) Falls rapidly (2) |
Arm Drift | ||||
| Absent (0) Weak grip (1) No Grip (2) |
Grip Strength | ||||
| PASS ≥2 | Yes No |
level of consciousness (month/age), | Somerville et al | PASS | |
| Yes No |
gaze palsy/deviation | ||||
| Yes No |
arm weakness | ||||
| ≥5 predicts LVO | Facial droop (1) | Face | Ollikainen et al(10) | FPSS | |
| Weakness of 1 or more extremities (1) | Extremity | ||||
| Difficulty of understanding or producing speech, including slurring (1) |
Speech | ||||
| Field cut or blindness (1) | Vision | ||||
| Partial or fixed gaze or head deviation away from the paretic side (4) | Gaze | ||||
| If total score > 0 (1 to 6) a diagnosis of acute stroke is likely. If total scores 0, -1 or -2 stroke unlikely but is not excluded and patient should be discussed with the stroke team. DECT phone 21616 – Stroke Specialist Nurse 9-5. Medical SpR – Out of hours. |
Yea (-1), no (0) | LOC/syncope | Azlisham Mohd Nor | ROSIER | |
| Yea (-1), no (0) | Seizure activity | ||||
| Yea (+1), no (0) | Asymmetric facial weakness | ||||
| Yea (+1), no (0) | Asymmetric arm weakness | ||||
| Yea (+1), no (0) | Asymmetric leg weakness | ||||
| Yea (+1), no (0) | Speech disturbance | ||||
| Yea (+1), no (0) | Visual field defect | ||||
| Alert (or awakens easily and stays awake) (0) Drowsy (Responds to minor stim. but falls back asleep) (1) Obtunded (Responds only to deep pain or vigorous stim) (2) Comatose (No response) (3) |
Level of Consciousness (LOC) | Patrick D. Lyden | NIHSS | IMPAIRMENT | |
| Mild 1-5 Mild to moderate severe 5-14 Severe 15-24 Very severe ˃25 |
Both questions answered correctly (0) One question answered correctly (1) Neither question answered correctly (2) |
LOC- Questions Month? Age? | |||
| Both commands performed correctly (0) One command performed correctly (1) Neither command performed correctly (2) |
LOC– Commands Opens/closes eyes Opens/closes hands | ||||
| Normal (0) Mild gaze paralysis (can bring eyes only over to midline) (1) Complete gaze paralysis (deviated & unable to bring eyes over) (2) |
Eye Movements: Horizontal eye movements | ||||
| Normal (0) Partial hemianopia (upper OR lower quadrant) (1) Complete hemianopia (upper AND lower quadrants) (2) Bilateral hemianopia (total blindness) (3) |
Visual fields: Sees objects in Four quadrants | ||||
| Normal (0) Minor paralysis (flattening of nasolabial folds) (1) Partial paralysis (near or total paralysis lower face) (2) Complete paralysis (Of upper and lower face) (3) |
Facial: Facial movements | ||||
| Normal (No drift at all) (0) Drift (Drifts downward but NOT to bed before 10 sec.) (1) Drifts to bed within 10 sec (2) Movement, but not against gravity (3) Complete paralysis (No movement at all) (4) Amputation or joint fusion (N/A) |
Motor – Left Arm Hold arm straight out from chest | ||||
| Normal (No drift at all) (0) Drift (Drifts downward but NOT to bed before 10 sec.) (1) Drifts to bed within 10 sec (2) Movement, but not against gravity (3) Complete paralysis (No movement at all) (4) Amputation or joint fusion (N/A) |
Motor – Right Arm Hold arm straight out from chest | ||||
| Normal (No drift at all) (0) Drift (Drifts downward but NOT to bed before 10 sec.) (1) Drifts to bed within 10 sec (2) Movement, but not against gravity (3) Complete paralysis (No movement at all) (4) Amputation or joint fusion (N/A) |
Motor – Left leg Keep leg off bed | ||||
| Normal (No drift at all) (0) Drift (Drifts downward but NOT to bed before 10 sec.) (1) Drifts to bed within 10 sec (2) Movement, but not against gravity (3) Complete paralysis (No movement at all) (4) Amputation or joint fusion (N/A) |
Motor – Right leg Keep leg off bed | ||||
| Absent (no ataxia, OR pt cannot move arm/leg) (0) Presentinonelimb (1) Present in two or more limbs (2) (is absent if patient cannot understand or is too weak to do) |
Limb Ataxia Finger-Nose Heel-Knee-Shin | ||||
| Normal,nosensoryloss (0) Mildtomoderaeloss (1) Severe to total sensory loss (unaware of being touched) (2) |
Sensory Hemisensory loss: (Test on face, arm & thigh) | ||||
| Normal ability use words and follow commands (0) Mild to Moderate (Repeats / names with some difficulty) (1) Severe Aphasia (very few words correct or understood) (2) Mute (no ability to speak or understand at all (3) |
Language/Aphasia Repetition & Comprehension “Today is a bright sunny day” | ||||
| Normal (0) Mild to moderate slurred speech (some or most) (1) Severe (unintelligible - none understandable) (2) Intubated or other physical barrier (N/A) |
Dysarthria (slurred) Speech clarity (slurring | ||||
| No abnormality (0) Mild (either visual or tactile – partial neglect) (1) Profound (Visual and tactile – complete neglect) (2) |
Neglect Ignores touch or vision to one side | ||||
| 3 grade | Level of Consciousness | Ichord RN (16) | pedNIHSS | ||
| 3 grade | LOC Questions | ||||
| 3 grade | LOC Commands | ||||
| 3 grade | Best Gaze | ||||
| 4 grade | Visual | ||||
| 4 grade | Facial Palsy | ||||
| 6 grade | Motor Arm and Leg | ||||
| 3 grade | Limb Ataxia | ||||
| 3 grade | Sensory | ||||
| 4 grade | Best Language | ||||
| 6 grade | Level of consciousness | Hantson et al (30) | European Stroke Scale | ||
| 3 grade | Comprehension | ||||
| 5 grade | Speech | ||||
| 2 grade | visual field | ||||
| 4 grade | Gaze | ||||
| 3 grade | Facial movement | ||||
| 5 grade | Arm position, maintain | ||||
| 5 grade | Arm raising | ||||
| 5 grade | Wrist extension | ||||
| 3 grade | Finger strength | ||||
| 4 grade | Leg position, maintain | ||||
| 5 grade | Leg flexing | ||||
| 5 grade | Foot dorslflexion | ||||
| 6 grade | Gait | ||||
| Alert (3), Drowsy (1.5) | LEVEL CONSCIOUSNESS: | Cote et al | CNS | ||
| Oriented (1) Disoriented or Non Applicable (0) |
ORIENTATION | ||||
| Normal (1) Expressive Deficit (0.5) Receptive Deficit (0) |
SPEECH | ||||
| None (5) Present (0) |
FACE WEAKNESS | ||||
| None (1.5) Mild (1) Significant (5) Total (0) |
ARM:PROXIMAL WEAKNESS | ||||
| None (1.5) Mild (1) Significant (0.5) Total (0) |
ARM:DISTAL WEAKNESS | ||||
| None (1.5) Mild (1) Significant (0.5) Total (0) |
LEG WEAKNESS | ||||
| Symmetrical (5) Asymmetrical (0) |
FACE | ||||
| Equal (1.5) Unequal (0) |
ARM | ||||
| Equal (1.5) Unequal (0) |
LEG | ||||
| score 2–6 | consciousness | Askim et al (17) | Scandinavian Stroke Scale | ||
| score 0–4 | eye movement | ||||
| score 0–6 | arm motor power | ||||
| score 0–6 | hand motor power | ||||
| score 0–6 | leg motor power | ||||
| score 0–6 | orientation | ||||
| score 0–10 | speech | ||||
| score 0–2 | facial palsy | ||||
| score 0–12 | gait | ||||
| Unable to perform task (0) needs assistance (0) Fully independent (5) |
Personal hygiene | Mahoney et al (31) | BI | ||
| Unable to perform task (0) needs assistance (0) Fully independent (5) |
Bathing self | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Feeding | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Toilet | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Stair climbing | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Dressing | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Bowel control | ||||
| Unable to perform task (0) needs assistance (5) Fully independent (10) |
Bladder control | ||||
| Unable to perform task (0) needs assistance (5-10) Fully independent (15) |
Ambulation | ||||
| Unable to perform task (0) needs assistance (0) Fully independent (5) |
Wheelchair (when unable to walk.) | ||||
| unable to perform task (0) needs assistance (5-10) Fully independent (15) |
Chair/bed transfers | ||||
| 7-ordinal scale Total assistance (complete dependence) to complete independence |
Eating, grooming, bathing, upper body dressing, lower body dressing, toileting, bladder management, bowel management, bed to chair transfer, toilet transfer, shower transfer, locomotion (ambulatory or wheelchair level), stairs, cognitive comprehension, expersion, social interaction, problem solving, memory | Chumney et al (32) | FIM | ||
| a summary score from 0 (low functioning) to 8 (high functioning) | Operates telephone on own initiative; looks up and dials numbers, Dials a few well-known numbers, Answers telephone, but does not dial (1) Does not use telephone at all (0) |
Ability to Use Telephone | Lawton et al (33) | IADL | |
| Takes care of all shopping needs independently (1) Shops independently for small purchases, Needs to be accompanied on any shopping trip, Completely unable to shop (0) |
Shopping | ||||
| Plans, prepares, and serves adequate meals independently (1) Prepares adequate meals if supplied with ingredients, Heats and serves prepared meals or prepares meals but does not maintain adequate diet, Needs to have meals prepared and served (0) |
Food Preparation | ||||
| Maintains house alone with occasion assistance (heavy work) (1) Performs light daily tasks such as dishwashing, bed making (1) Performs light daily tasks, but cannot maintain acceptable level of cleanliness (1) Needs help with all home maintenance tasks (1) Does not participate in any housekeeping tasks (0) |
Housekeeping | ||||
| Does personal laundry completely (1) Launders small items, rinses socks, stockings, etc (1) All laundry must be done by others (0) |
Laundry | ||||
| Travels independently on public transportation or drives own car (1) Arranges own travel via taxi, but does not otherwise use public transportation (1) Travels on public transportation when assisted or accompanied by another (1) Travel limited to taxi or automobile with assistance of another (0) Does not travel at all (0) |
Mode of Transportation | ||||
| Is responsible for taking medication in correct dosages at correct time (1) Takes responsibility if medication is prepared in advance in separate dosages (0) Is not capable of dispensing own medication (0) |
Responsibility for Own Medications | ||||
| Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income (1) Manages day-to-day purchases, but needs help with banking, major purchases, etc (1) Incapable of handling money (0) |
Ability to Handle Finances | ||||
| 0 | No symptoms at all | John van Swieten et al | mRS | HANDICAP | |
| 1 | No significant disability despite symptoms; able to carry out all usual duties and activities | ||||
| 2 | Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance | ||||
| 3 | Moderate disability; requiring some help, but able to walk without assistance | ||||
| 4 | Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance | ||||
| 5 | Severe disability; bedridden, incontinent and requiring constant nursing care and attention | ||||
| 6 | Dead | ||||
| Yes, no 5 |
Is the person bedridden? The patient is unable to walk even with another person’s assistance. May frequently be incontinent. May require constant care | Patel et al(20) | Rankin Focused Assessment | ||
| Yes, no 4 |
Is another person’s assistance essential for walking? | ||||
| Yes, no 3 |
Assistance to look after own affairs (5 question) | ||||
| Yes, no 2 |
USUAL DUTIES AND ACTIVITIES (4 questions) | ||||
| SPONTANEOUSLY REPORTED SYMPTOMS SYMPTOM CHECKLIST (8question) yes , no 1 |
SYMPTOMS AS A RESULT OF THESTROKE (2 category) | ||||
| 0 | Handicap None (life style none) | Perel et al (34) | Oxford Handicap Scale | ||
| 1 | Minor symptom ( no interference) | ||||
| 2 | Minor handicap (some restrictions but able to look after self) | ||||
| 3 | Moderate handicap (significant restrictions, unable to lead a totally independent existence ---require some assistance) | ||||
| 4 | Moderate to severe handicap handicap (unable to live independently but does not require constant attention) | ||||
| 5 | Severe handicap (totally dependent, require constant attention day and night | ||||
| Penson D.F and Wei J.T (35) | HRQOL | QUALITY OF LIFE | |||
| Yes or no | Body Care and Movement (23) | Bergner et al (36) | Sickness Impact Profile | ||
| Ambulation (12) | |||||
| Mobility (10) | |||||
| Social interaction (20) | |||||
| Sleep and rest (7) | |||||
| Work (9) | |||||
| Recreation and pastimes (8) | |||||
| Eating (9) | |||||
| Home Management (10) | |||||
| Emotional Behavior (9) | |||||
| Alterness Behavior (10) | |||||
| Communication (9) | |||||
| Vitality (4) | Jenkinson C (37) | SF36 | |||
| Physical functioning (10) | |||||
| Bodily pain (2) | |||||
| General health perceptions (5) | |||||
| Physical role functioning (4) | |||||
| Emotional role functioning (3) | |||||
| Social role functioning (2) | |||||
| Mental health | |||||
| 6 grade | Vision | Horsman J et al (38) | Health Utilities Index | ||
| 6 grade | Hearing | ||||
| 5 grade | Speech | ||||
| 6 grade | Ambulation | ||||
| 6 grade | Dexterity | ||||
| 5 grade | Emotion | ||||
| 6 grade | Cognition | ||||
| 5 grade | Pain | ||||
| mobility | Brooks R (39) | EuroQol | |||
| self-care | |||||
| usual activities | |||||
| pain/discomfort | |||||
| anxiety/depression | |||||
| A lot of strength (5) Quite a bit of strength (4) Some strength (3) A little strength (2) No strength at all (1) |
physical problems (4 questions) | Duncan PW (40) | SIS | ||
| Not difficult at all (5) A little difficult (4) Somewhat difficult (3) Very difficult (2) Extremely difficult (1) |
memory and thinking (7 questions) | ||||
| None of the time (5) A little of the time (4) Some of the time (3) Most of the time (2) All of the time (1) |
mood, and emotions (9 questions) | ||||
| Not difficult at all (5) A little difficult (4) Somewhat difficult (3) Very difficult (2) Extremely difficult (1) |
ability to communicate with other people, as well as your ability to understand what you read (7 questions) | ||||
| Not difficult at all (5) A little difficult (4) Somewhat difficult (3) Very difficult (2) Could not do at all (1) |
Activities (10 questions) | ||||
| Not difficult at all (5) A little difficult (4) Somewhat difficult (3) Very difficult (2) Could not do at all (1) |
ability to be mobile,at home and in the community (9 questions) | ||||
| Not difficult at all (5) A little difficult (4) Somewhat difficult (3) Very difficult (2) Could not do at all (1) |
ability to use your hand that was MOST AFFECTED by your stroke (5 questions) | ||||
| None of the time (5) A little of the time (4) Some of the time (3) Most of the time (2) All of the time (1) |
ability to participate in the activities that you usually do, things that are meaningful to you, and help you to find purpose in life (8 questions) | ||||
| Total help - Couldn't do it at all - Strongly agree (1) A lot of help - A lot of trouble - Moderately agree (2) Some help - Some trouble - Neither agree nor disagree (3) A little help - A little trouble - Moderately disagree (4) No help needed - No trouble at all - Strongly disagree (5) |
Energy(3) | SS-QoL | |||
| Family Roles (3) | |||||
| Language (5) | |||||
| Mobility (6) | |||||
| Mood (5) | |||||
| Personality (3) | |||||
| Self-Care (5) | |||||
| Social Roles (5) | |||||
| Thinking (3) | |||||
| Upper Extremity Function (5) | |||||
| Vision (3) | |||||
| Work/Productivity (3) |
*Abbreviations: FAST: Face Arm Speech Test, CPSS: Cincinnati Prehospital Stroke Scale, LAPSS: Los Angeles Prehospital Stroke Screen, LAMS: Los Angeles Motor Scale, PASS: Prehospital Acute Stroke
Severity scale, FPSS: The Finnish Prehospital Stroke Scale, ROSIER: Recognition of Stroke in the Emergency Room, SIS :Stroke Impact Scale and SS-QoL: Stroke-Specific Quality of Life Scale
**HRQOL, SF36, Health Utilities Index, EuroQol considered as general quality of life scale. SIS, Stroke-Specific Quality of Life Scale and Stroke-Specific Quality of Life Scale considered as specific Quality of Life Scale.