Canadian Neurological Scale (CNS)

Evidence Reviewed as of before: 09-01-2012
Author(s)*: Katie Marvin, MSc. PT (Candidate)
Editor(s): Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Dr. Robert Cote, MD

Purpose

The Canadian Neurological Scale (CNS) was developed as a simple tool to be used in the evaluation and monitoring of neurological status of patients with stroke in the acute phase (Cote, Hachinski, Shurvell, Norris & Wolfson, 1986).

In-Depth Review

Purpose of the measure

The Canadian Neurological Scale (CNS) was developed as a simple tool to be used in the evaluation and monitoring of neurological status of patients with stroke in the acute phase (Cote, Hachinski, Shurvell, Norris & Wolfson, 1986). The CNS evaluates 10 clinical domains, including mentation (level of conciousness, orientation and speech) and motor function (face, arm and leg).

Features of the measure

Items :

The CNS is comprised of 8-items measuring the level of consciousness, orientation, speech, motor function and facial weakness.

  • If patient is alert or drowsy: monitor with CNS (sections A1 and A2)
  • If patient is stuporous or comatose: monitor with Glasgow Coma Scale

MENTATION

Level of Consciousness

  • Alert 3.0
    Spontaneous eye opening, normal level of consciousness
  • Drowsy 1.5When stimulated verbally patient remains awake and alert but tends to doze

Orientation

  • Oriented 1.0
    1. Where are you? (City and Hospital)
    2. What is the month and year?

    Speech can be slurred but must be intelligible.

  • Disoriented 0.0Patient cannot state both place and time or cannot express answers in words or intelligible speech.

It is acceptable for patient to write answer to questions of orientation

Speech

  • Receptive deficit 0.0Ask pt. 1) to close eyes; 2) Point to ceiling; 3) Does a stone sink in water?If pt. does not complete the above 3, go to Section A2.
  • Expressive deficit 0.5
  • Normal Speech 1.0

Adapated from Canadian Neurological Scale Cheat Sheet by Brown, M.and Li, J available from: http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.5385163/k.5CDC/HCP__Canadian_Neurological_Scale_CNS.htm

SECTION A1 – No Comprehension Deficit

Face: Ask pt. to smile:
None 0.5 No weakness – 0.5
Present 0.0 Weakness – 0.0 (Record L or R)
Arm: Proximal Ask pt. to lift arms to shoulder level and apply resistance above elbows bilaterally
None 1.5 No weakness – 1.5
Mild 1.0 Movement to 90°, unable to oppose pressure – 1.0
Significant 0.5 Movement < 90° – 0.5
Total 0.0 Absence of motion – 0.0
Arm: Distal Ask pt. to bend wrist back. Apply pressure on back of the hand.
None 1.5 No weakness – 1.5
Mild 1.0 Can bend wrist, unable to oppose pressure – 1.0
Significant 0.5 Some movement of fingers – 0.5
Total 0.0 Absence of movement – 0.0
Leg: Proximal Ask pt. to flex knee to 90°. Push down on each thigh one at a time.
None 1.5 No weakness – 1.5
Mild 1.0 Can lift leg, unable to oppose pressure – 1.0
Significant 0.5 Lateral movement but no power to lift leg – 0.5
Total 0.0 Absence of movement – 0.0
Leg: Distal Ask pt. to point toes and feet upward. Push down on each foot one at a time.
None 1.5 No weakness – 1.5
Mild 1.0 Can point foot & toes upward, unable to oppose pressure-1.0
Significant 0.5 Some movement of toes, but cannot lift toes or foot – 0.5
Total 0.0 Absence of movement – 0.0

SECTION A2 – Comprehension Deficit

Face: Ask pt. to mimic your grin (if unable, apply pressure to sternum).
Symmetrical 0.5 Symmetrical – 0.5
Asymmetrical 0.0 Asymmetrical – 0.0
Arms: Demonstrate/place pt. arms in front of pt. at 90° (if unable, apply finger nail bed pressure bilaterally and compare response)
Equal 1.5 Equal motor response – 1.5
Unequal 0.0 Unequal motor response – 0.0 (record L or R)
Legs: Thighs flexed to 90° (if unable, apply toenail bed pressure bilaterally and compare response)
Equal 1.5 Maintain position or withdraw equally – 1.5

Scoring and Score Interpretation:

  • Mentation: Comprised of evaluating consciousness, orientation and speech.
  • Motor function evaluations are separated into sections A1 and A2. A1 is administered if the patient is able to understand and follow instructions. A2 is administered in the presence of comprehension deficits (Cote et al., 1986, 1989). Each motor item is rated for severity and each rating is weighted “according to the relative importance of a particular neurological deficit” (Cote et al., 1989).
  • It should be noted that assessment using the CNS focuses on limb weakness over other possible neurological impairments (Muir, Weir, Murray, Povey & Lees, 1996).
  • The CNS scores only the motor strength of the weakest limb. For patients with a comprehension deficit, asymmetry in strength is scored. Therefore, in addition to using the CNS, clinicians may wish to further evaluate and document the upper and lower extremity strength and power in patients with comprehensive deficit (O’Farrell & Yong Zou, 2008).
  • Scores from each section are summed to provide a total score out of a possible 11.5. Lower scores are representative of increasing severity.

Nilanont et al. (2010) developed and validated a conversion model that allows clinicians and researchers to predict NIHSS scores for patients based on their CNS score in order to allow for comparability between the two scales. CNS scores can be reliably converted into NIHSS scores using the following conversion: NIHSS = 23 – (2 x CNS score).

Time:

The CNS takes approximately 5 to 10 minutes to complete (Cote et al., 1986, 1989; O’Farrell & Yong Zou, 2008).

Training requirements:

It is advised that the CNS be completed by a healthcare professional trained in its administration. The CNS does not need to be completed by a neurologist.

A trained observer rates the patent’s ability to answer questions and perform activities. Training is minimal and is available through participation in a 2-hour workshop or a self-directed learning package and review video. For more details on training requirements please visit the following website: http://www.heartandstroke.on.ca/site/c.pvI3IeNWJwE/b.5385163/k.5CDC/HCP__Canadian_Neurological_Scale_CNS.htm

Subscales:

The subscale items encompass level of consciousness, orientation, speech, motor function and facial weakness.

Equipment:

None typically reported.

Alternative forms of the assessment

None typically reported

Client suitability

Can be used with:

  • Patients in the acute phase of stroke who are either alert or drowsy (Cote et al., 1986).

Should not be used with:

  • As the CNS was designed as an observational scale, measurement by self-report or by telephone is not possible.

Languages of the measure

None reported.

Summary

What does the tool measure? The CNS measures neurological status.
What types of clients can the tool be used for? Patients with stroke in the acute phase who are either alert or drowsy.
Is this a screening or assessment tool? Assessment
Time to administer Approximately 5 to 10 minutes.
Versions There are no alternative versions reported.
Other Languages No information reported.
Measurement Properties
Reliability Internal consistency:
One study examined the internal consistency of the CNS and reported excellent internal consistency.
Inter-rater:
Two studies investigated the inter-rater reliability and found adequate to excellent inter-rater reliability.
Validity Criterion:
Concurrent:
One study evaluated the concurrent validity of the CNS and found excellent concurrent validity between the CNS and global neurological examination.
Predictive:
Two studies evaluated the predictive validity of the CNS and found initial CNS scores to predict death within 3 to 6 months, morbidity, and recovery of ADL within 3 to 5-months.
Construct:
Discriminant:
One study evaluated the discriminant validity of the CNS and found excellent correlation between total CNS scores and standard neurological examinations.
Floor/Ceiling Effects Floor/ceiling effects have not yet been examined.
Does the tool detect change in patients? The CNS can be used to monitor change in neurological status in patients with acute stroke.
Acceptability The CNS is short and simple. Patient burden associated with its use should be minimal.
Feasibility A trained healthcare professional should administer the CNS. It may be used both prospectively and retrospectively.
How to obtain the tool? The CNS is available from strokecenter.org.
A full version of the measure can be found in the following article: Cote, R., Hachinski, V., Shurvell, B., Norris, J. & Wolfson, C. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the CNS.

Floor/Ceiling Effects

Floor/ceiling effects have not yet been examined.

Reliability

Internal Consistency:
Cote et al. (1986) examined the internal consistency of the CNS in 34 patients with acute stroke. Four raters (one neurologist, one resident in neurology and two nurses) evaluated the patients. Internal consistency, as calculated using Cronbach’s alpha, was excellent for all domains (leg weakness 0.896; facial weakness 0.934; distal arm weakness 0.969; orientation 0.979; proximal arm weakness 0.98; and speech 1.00). No differences between professionals were found.

Test-retest:
Test-retest reliability has not been reviewed.

Intra-rater:
Intra-rater reliability has not been examined.

Inter-rater:
Cote et al. (1986) examined the inter-rater reliability of the CNS in 34 patients with acute stroke. Four raters (one neurologist, one resident in neurology and two nurses) evaluated the patients within two to four hours of each other using the CNS. Inter-rater reliability, as calculated using kappa statistics, was adequate to excellent for all domains (leg weakness 0.722-0.842; facial weakness 0.535-1.00; distal arm weakness 0.758-0.974; orientation 0.744-1.00; proximal arm weakness 0.788-1.00; and speech 0.934-1.00).

Brushnell, Johnston and Goldstein (2001) looked at the retrospective inter-rater reliability scoring of both the CNS and the National Institute of Health Stroke Scale (NIHSS). They compared data from academic medical centers to data from community hospitals with neurologists and community hospitals without neurologists. Inter-rater reliability for the CNS, as calculated using Intraclass correlation coefficient (ICC), was found to be excellent for all charts reviewed (academic medical center ICC=0.97; community hospital with neurologists 0.88; community hospital without neurologists 0.78). The inter-rater reliability for the NIHSS was excellent for the charts reviewed from the academic medical centre and the community hospital with a neurologist (ICC=0.93; 0.89 respectively), however only adequate agreement was found for charts reviewed from the community hospital without a neurologist (ICC=0.48). More data was missing for the NIHSS in comparison to that missing for the CNS likely due to the fact that the NIHSS requires a more detailed neurological examination. These results suggest that scoring the CNS retrospectively is reliable regardless of whether the medical record contains evaluation material from a neurologist.

Validity

Content :

Content validity has not been reviewed.

Criterion :

Concurrent:
Cote et al. (1989) evaluated the concurrent validity of the CNS in the original validation study involving 157 patients with acute stroke. Patients were evaluated by staff neurologists or neurology residents upon admission to the hospital and were classified as either having no, mild, moderate or severe deficit resulting from acute stroke. Nurses then evaluated the patients using the Glascow Coma Scale (GCS) and the CNS. An average interval of 3.71 hours occurred between assessments. Concurrent validity was evaluated by correlating CNS item with the appropriate components of the neurological examination, and the total score of the CNS with the global assessment on the neurological examination (no, mild, moderate or severe). Concurrent validity, as measured by Spearman rank correlation, was found to be excellent between the global neurological examination and the total CNS score (0.775). The concurrent validity between the neurological components and CNS was found to be excellent for orientation (0.716), speech (0.691) and weakness (0.767); and adequate for level of consciousness (0.574).

Predictive:
Cote et al. (1989) evaluated the predictive validity of the CNS in 157 patients with acute stroke. Three outcomes were evaluated: 1) death at 6 months; 2) any vascular event within 6 months (for example, MI, CVA or vascular death); and 3) independence in ADL at 5 months or beyond. Initial CNS scores were found to significantly predict death within 6 months, morbidity, and recovery of ADL within 5-months. For patients with scores of ≥ 11, only 2.1% had died at 6 months, 2.1% experienced another vascular event, approximately 90% were independent in ADLS at 5 months or beyond; compared to those that scored <9 initially where 13.2% had died at 6 months, 20.6% experienced another vascular event and <50% were independent in ADLS at 5 months or beyond.

Muir et al. (1996) compared the CNS, National Institute of Health Stroke Scale (NIHSS) and the Middle Cerebral Artery Stroke Score (MCANS) to see which scale best predicted good (alive at home) or poor (alive and requiring in care or dead) outcome at 3-months in 373 patients with acute stroke. Predictive accuracy of the variables was compared by ROC curves and stepwise logistic regression. Logistic regression showed that the NIHSS added significantly to the predictive value of all other scores. The overall accuracy for the CNS, NIHSS and MCANS as stand alone measures was adequate (0.79, 0.79 and 0.83 respectively).

Sensitivity/Specificity:
The sensitivity/specificity has not been examined.

Construct :

Convergent/Discriminant:
Cote et al. (1989) evaluated the discriminant validity of the CNS and the Glascow Coma Scale (GCS) by comparing results with a standard neurological examination. Results from the GCS and the CNS evaluation of 157 patients with acute stroke were compared with a standard neurological examination. Excellent correlation was found between the total CNS score and the standard neurological examination (r2=0.769), however only adequate correlation was found between the GCS and the standard neurological examination (r2=0.563). These results suggest that the CNS may better discriminate neurological deficit.

Known Groups:
The known groups validity has not been examined.

Responsiveness

Cote et al. (1989) evaluated the responsiveness of the CNS in 79 patients with acute stroke. The CNS was administered on admission and throughout the first 48 hours. Patients were classified as either 1) remaining stable over first 48 hours or 2) status changed over first 48 hours. A change in score ≥ 1 yielded the highest negative predictive value (0.969), with a sensitivity of 0.933 and specificity of 0.508). The results of this study suggest that the CNS can be used to monitor clinically significant differences in neurological status.

Hagen, Bugge, and Alexander (2003) examined the responsiveness of the CNS and other commonly used outcome measures in 136 patients in the early post-stroke period. The outcomes measures were administered at 1, 3 and 6 months after stroke onset. The sensitivity of the CNS to detect change from 1 to 3 months and 3 to 6 months, as calculated using Standardized Response Mean, was small (SRM=0.2860 and 0.2849 respectively). These results suggest that the CNS has some ability to detect change in patients with stroke in the subacute phase of recovery.

References

  • Bushnell, C.D., Johnston, D.C.C. & Goldstein, L. B. (2001). Retrospective assessment of the initial stroke severity: Comparison of the NIH Stroke Scale and the Canadian Neurological Scale. Stroke, 32, 656-660.
  • Cote, R., Battista, R.N., Wolfson, C., Boucher, J., Adam, J., Hachinski, V. (1989). The Canadian Neurological Scale: Validation and reliability assessment. Neurology, 39, 638-643.
  • Cote, R., Hachinski, V., Shurvell, B., Norris, J. & Wolfson, C. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.
  • Cuspineda, E., Machado, C., Aubert, E., Galan, L, Liopis, F, Avila, Y. (2003). Predicting outcome in acute stroke: A comparison between QEEG and the Canadian Neurological Scale. Clinical Electroencephalography, 34(1), 1-4.
  • Muir, K.W., Weir, C.J., Murray, G.D., Povey, C., Lees, K.R. (1996). Comparison of neurological scales and scoring systems for acute stroke prognosis. Stroke, 27, 1817-1820.
  • Nilanont, Y., Komoitri, C., Saposnik, G., Cote, R., Di Legge, S., Jin, Y. et al. (2010). The Canadian Neurological Scale and the NIHSS: Development and validation of a simple conversion model. Cerebrovascular Disease, 30(2), 120-126.
  • Shinar, D., Gross, C.R., Mohr, J.P., Caplan, L.R., Price, T.R., Wolf, P.A. et al. (1985). Interobserver variability in the assessment of neurologic history and examination in the stroke data bank. Archives of Neurology, 42, 557-565.

See the measure

How to obtain the CNS?

The CNS is available from strokecenter.org.

A full version of the measure can be found in the following article: Cote, R., Hachinski, V., Shurvell, B., Norris, J. & Wolfson, C. (1986). The Canadian Neurological Scale: A preliminary study in acute stroke. Stroke, 17(4), 731-737.

A training video has been produced by the Heart & Stroke Foundation of Canada using the Canadian Neurological Scale.

Table of contents

Charlson Comorbidity Index (CCI)

Evidence Reviewed as of before: 03-02-2009
Author(s)*: Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Charlson Comorbidity Index (CCI) assesses comorbidity level by taking into account both the number and severity of 19 pre-defined comorbid conditions. It provides a weighted score of a client’s comorbidities which can be used to predict short term and long-term outcomes such as function, hospital length of stay and mortality rates. The CCI is the most widely used scoring system for comorbities used by researchers and clinicians (Charlson, Pompei, Ales, & Mackenzie, 1987; Elixhauser, Steiner, Harris, & Coffey, 1998).

In-Depth Review

Purpose of the measure

The Charlson Comorbidity Index (CCI) assesses comorbidity level by taking into account both the number and severity of 19 pre-defined comorbid conditions. It provides a weighted score of a client’s comorbidities which can be used to predict short term and long-term outcomes such as function, hospital length of stay and mortality rates. The CCI is the most widely used scoring system for comorbities used by researchers and clinicians (Charlson, Pompei, Ales, & Mackenzie, 1987; Elixhauser, Steiner, Harris, & Coffey, 1998).

Available versions

The CCI was published by Charlson, Pompei, Ales, and Mackenzie in 1987.

Features of the measure

Items:
The CCI is comprised of 19 comorbid conditions: myocardial infarct, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, connective tissue disease, ulcer disease, mild liver disease, diabetes, hemiplegia, moderate or several renal disease, diabetes with end organ damage, any tumor, leukemia, lymphoma, moderate or severe liver disease, metastatic solid tumor, AIDS. Each disease is given a different weight based on the strength of its association with 1-year mortality as follows (Charlson et al., 1987):

Assigned weights for diseases Comorbid Conditions
1 Myocardial infarct, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, connective tissue disease, ulcer disease, mild liver disease, diabetes
2 Hemiplegia, moderate or several renal diseases, diabetes with end organ damage, any tumor, leukemia, lymphoma
3 Moderate or severe liver disease
6 Metastatic solid tumor, AIDS

The CCI can be completed from medical records, administrative databases, or interview-based questionnaires (Bravo, Dubois, Hebert, De Wals, & Messier, 2002).

Scoring:
The total score in the CCI is derived by summing the assigned weights of all comorbid conditions presented by the client. Higher scores indicate a more severe condition and consequently, a worse prognosis (Charlson, Szatrowski, Peterson, & Gold, 1994).

Time:
Not reported

Subscales:
None

Equipment:
Not applicable.

Training:
No specific training is available.

Alternative forms of the CCI

The CCI has a weighted age version, two adaptations to be used with ICD-9 databases, and one version to be used with clients with amputations (Charlson et al., 1994; Deyo, Cherkin, & Ciol, 1992; Melchiore, Findley, & Boda, 1996; Romano, Roos, & Jollis, 1993).

Client suitability

Can be used with:

  • Clients with stroke.
  • The CCI is a general scoring system allowing for its use with a variety of populations (Groot, Beckerman, Lankhorst, & Bouter, 2003).

Should not be used in:

  • To date, there is no information on restrictions for using the CCI.

In what languages is the measure available?

Not applicable

Summary

What does the tool measure? The CCI measures comorbidity level.
What types of clients can the tool be used for? The CCI can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Screening.
Time to administer Not reported.
Versions Age CCI; ICD-9-CM; CCI for clients with amputations.
Other Languages Not applicable
Measurement Properties
Reliability Internal consistency:
No studies have examined the internal consistency of the CCI.
Test-retest:
One study has examined the test-retest reliability of the CCI and reported excellent test-retest reliability using Intraclass Correlation Coefficient (ICC) and Spearman’s Rank Correlation.
Intra-rater:
No studies have examined the intra-rater reliability of the CCI.
Inter-rater:
One study examined the inter-rater reliability of the CCI and reported adequate inter-rater reliability using ICC.
Validity Content:
One study examined the content validity of the CCI by reporting the steps for generating the weighted comorbidity index.
Criterion:
Concurrent:
No studies have examined the concurrent validity of the CCI.
Predictive:
Four studies have examined the predictive validity of the CCI and reported that the CCI was able to predict function at 3 months post-stroke, poor outcomes on the modified Rankin Scale at discharge, and mortality after 1 year. In contrast, the CCI was not able to predict length of stay, Functional Independence Measure scores, and modified Rankin Scale scores at 4 months post-stroke.
Construct:
Convergent:
Three studies examined the convergent validity of the CCI and reported excellent correlations between the CCI and the Functional Comorbidity Index, poor to adequate correlations between the CCI and total numbers of medication consumed, numbers of hospitalization, length of stay, total costs, laboratory studies, therapeutic interventions, consultations and days of interruption of the rehabilitation program using Spearman rank correlation.
Known Groups:
No studies have examined the known groups validity of the CCI.
Floor/Ceiling Effects No studies have examined floor/ceiling effects of the CCI.
Sensitivity/ Specificity No studies have examined the sensitivity/specificity of the CCI.
Does the tool detect change in patients? No studies have examined the responsiveness of the CCI.
Acceptability The CCI is the most widely used index to assess comorbidity.
Feasibility The CCI can be completed from medical records, administrative databases, or interview-based questionnaires.
How to obtain the tool? The CCI can be obtained from its original publication: (Charlson, Pompei, Ales, & Mackenzie, 1987)

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Charlson Comorbidity Index (CCI) in individuals with stroke. We identified 6 studies.

Reliability

Test-retest:
Katz, Chang, Sangha, Fossel, and Bates (1996) evaluated the test-retest reliability of the questionnaire format of the CCI in 25 inpatients with different diagnoses including stroke. Participants were evaluated by the same rater twice within 24 hours. Test-retest reliability was excellent as calculated using Intraclass Correlation Coefficient (ICC = 0.92) and Spearman’s Rank Correlation (rho = 0.94).

Inter-rater:
Liu, Domen and Chino (1997) assessed the inter-rater reliability of the CCI in 10 clients with stroke. The CCI was administered by two examiners blinded to each other’s scores. Inter-rater reliability, as calculated using Intraclass Correlation Coefficient, was adequate (ICC = 0.67).

Validity

Content:
Charlson et al. (1987) identified the comorbid conditions of 559 inpatients with breast cancer. They then calculated the relationship of potential prognostically important variables to survival using Cox’s regression analysis. Finally, the adjusted relative risk was estimated to each comorbid condition.

Criterion:
Concurrent:
No gold standard exists against which to compare the CCI.

Predictive:
Liu et al. (1997) estimated the ability of the CCI at hospital admission to predict length of stay and the Functional Independence Measure (FIM) score (Keith, Granger, Hamilton, & Sherwin, 1987) at discharge. Predictive validity was calculated in 106 clients with Spearman’s Rank Correlation. Correlation between the CCI and the FIM was poor(rho = -0.19) as was the correlation between the CCI and length of stay (rho = 0.16). These results suggest that the CCI measured at hospital admission may not be predictive of length of stay or the FIM at discharge.

Goldstein, Samsa, Matchar, and Horner (2004) examined in 960 clients with acute stroke whether the CCI measured at admission was able to predict the modified Rankin Scale (mRS) (Rankin, 1957) at hospital discharge, and, 1-year mortality rates. Predictive validity was analyzed using logistic regression. The CCI was dichotomized into low comorbidity (scores <2) and high comorbidity (scores <2) and the mRS into good outcomes (scores <2) and poor outcomes (scores ≥2). Higher CCI scores were associated with a 36% increased odds of having poor outcomes on the modified Rankin Scale and 72% greater odds of death at 1 year post-stroke.

Fischer, Arnold, Nedeltchev, Schoenenberger, Kappeler, Hollinger et al. (2006) verified in 259 clients the ability of the CCI, as measured at admission to a stroke unit, to predict poor outcomes on the modified Rankin Scale (mRS – Rankin, 1957) at 4 months after hospital discharge. The mRS was dichotomized into good outcomes (scores ≤ 2) and poor outcomes (scores >2). Logistic regression analyses revealed that the CCI was not able to predict poor outcomes on the mRS. In this study, the predictors of the mRS score at 4 months post-stroke were stroke severity, atrial fibrilation, coronary artery disease and diabetes.

Tessier, Finch, Daskalopoulou, and Mayo (2008) examined, in 672 participants, the ability of the CCI, the Functional Comorbidity Index (Groll, Bombardier, & Wright, 2005), and a stroke-specific comorbidity index (developed by the same authors) to predict function 3 months post-stroke. Predictive validity was calculated by use of c-statistics to calculate the area under the Receiver Operating Characteristic (ROC) curve. The ability of the CCI (AUC = 0.76), the Functional Comorbidity Index (AUC = 0.71) and the stroke-specific comorbidity index (AUC = 0.71) to predict function at 3 months post-stroke were all adequate. These results suggest that the percentage of patients correctly classified according to their function at 3 months post-stroke is slightly higher when using the CCI over these other comorbidity measures.

Construct:
Convergent/Discriminant:

Katz et al. (1996) tested the convergent validity of the CCI by comparing it to self-reported number of prescription medications consumed, number of hospitalizations, length of stay and total financial costs in 170 hospital inpatients, including those with stroke. Correlations, as calculated using Spearman’s Rank Correlation, were all poor between the CCI and self-reported number of prescription medications (rho = 0.06), number of hospitalizations (rho = 0.22), length of stay (rho = 0.20) and total costs (rho = 0.26).

Liu et al. (1997) measured the convergent validity of the CCI in 106 clients with stroke, by comparing it to the number of medication consumed, laboratory studies, therapeutic interventions, number of consultations during hospital’s stay, and days of interruption of participation in rehabilitation due to complications. Adequate correlations were found between the CCI and the total number of medications consumed (rho = 0.48) and poor correlations were found between the CCI and laboratory studies (rho = 0.28), therapeutic interventions (rho = 0.19), consultations (rho = 0.25), and days of interruption of rehabilitation participation (rho = 0.22).

Tessier et al. (2008) analyzed the convergent validity of the CCI by comparing it to the Functional Comorbidity Index (Groll et al., 2005) in 437 clients with Correlations were found to be excellent (rho = 0.62).

Known groups:
No studies have examined known groups validity of the CCI.

Responsiveness

No studies have examined the responsiveness of the CCI.

References

  • Bravo, G., Dubois, M.F., Hebert, R., De Wals, P., & Messier, L. (2002). A perspective evaluation of the Charlson Comorbidity Index for use in long-term care patients. JAGS, 50, 740-745.
  • Charlson, M., Pompei, P., Ales, M.L., & Mackenzie C.R. (1987). A new method of classifying comorbidity in longitudinal studies: Development and validation. J Chronic Dis, 40, 373-393.
  • Charlson, M., Szatrowski, T.P., Peterson, J., & Gold, J. (1994). Validationof a Combined Comorbidity Index. Journal of Clinical Epidemiology, 47(11), 1245-1251.
  • De Groot, V., Beckerman, H., Lankhorst, G.J., & Bouter, L.M. (2003). How to measure comorbidity: A critical review of available methods. Journal of Clinical Epidemiology, 56, 221-229.
  • Deyo, R.A., Cherkin, D.C., & Ciol, M.A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal Clinical Epidemiology, 45, 613-619.
  • Elixhauser, A., Steiner, C., Harris, D.R., & Coffey, R.M. (1998).Comorbidity measures for use with administrative data. Medical Care, 36(1), 8-27.
  • Fischer, U., Nedeltchev, K., Schoenenberger, R.A., Kappeler, L., Hollinger, P.,Schroth, G. et al. (2006). Impact of comorbidity on ischemic stroke outcome. Acta Neurol Scand, 113, 108-113.
  • Goldstein, L.B., Samsa, G.P., Matchar, D.B., & Horner, R.D. (2004). Charlson Index Comorbidity Adjustment for Ischemic Stroke Outcome Studies. Stroke, 35, 1941-1945.
  • Groll, D., Bombardier, C., & Wright, J. (2005). The development of a comorbidity index with physical function as the outcome. Journal of Clinical Epidemiology, 58, 595-602.
  • Hall, W. H., Ramachandran, R., Narayan, S., Jani, A. B., & Vijayakumar, S. (2004). An electronic application for rapidly calculating Charlson comorbidity score. BMC Cancer, 4, 94.
  • Katz, J., Chang, L., Sangha, O., Fossel, A., & Bates, D. (1996). Can comorbidity be measured by questionnaire rather than medical record review? Medical Care, 34(1), 73-84.
  • Keith, R.A., Granger, C.V., Hamilton, B.B., & Sherwin, F.S. (1987). The functional independence measure: A new tool for rehabilitation. Adv Clin Rehabil, 1, 6-18.
  • Liu, M., Domen, K., & Chino, N. (1997). Comorbidity measures for stroke outcome research: A preliminary study. Arch Phys Rehabil, 78, 166-172.
  • Melchiore, P.J., Findley, T., Boda, W. (1996). Functional outcome and comorbidity indexes in the rehabilitation of the traumatic versus the vascular unilateral lower limb amputee. Am J Phys Med Rehabil, 75, 9-14.
  • Rankin, J. (1957). Cerebral vascular accidents in patients over the age of 60. Scott Med J, 2, 200-215.
  • Romano, P.S., Roos, L.L., & Jollis, J.G. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. Journal of clinical epidemiology, 46 (10) 1075-1079.
  • Tessier, A., Finch. L., Daskalopoulou, S.S., Mayo, N.E. (2008). Validation of the Charlson Comorbidity Index for Predicting Functional Outcome of Stroke. Arch Phys Med Rehabil, 89, 1276-1283.

See the measure

How to obtain the CCI

An electronic application for rapidly calculating Charlson Comorbidity Index score

The following link will allow you to download an Excel Spread sheet calculator for Charlson Comorbidity Index: Excel calculator Charlson Index

Table of contents

Glasgow Coma Scale (GCS)

Evidence Reviewed as of before: 29-09-2008
Author(s)*: Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Glasgow Coma Scale (GCS) was developed to describe the depth and duration of impaired consciousness or coma. In this measure, three aspects of behaviour are independently measured: motor responsiveness, verbal performance, and eye opening. The GCS can be used with individuals with traumatic brain injury, stroke, non-traumatic coma, cardiac arrest, and toxic ingestions.

In-Depth Review

Purpose of the measure

The Glasgow Coma Scale (GCS) was developed to describe the depth and duration of impaired consciousness or coma. In this measure, three aspects of behaviour are independently measured: motor responsiveness, verbal performance, and eye opening. The GCS can be used with individuals with traumatic brain injury, stroke, non-traumatic coma, cardiac arrest, and toxic ingestions.

Available versions

The GCS was published in 1974 by Graham Teasdale and Bryan J. Jennett. In 1976, Teasdale and Jennett distinguished between “normal” and “abnormal” flexion, which increased the “best motor response” item by one point.

Features of the measure

Items:

The GCS is comprised of three components: 1) Best eye response, which is believed to indicate whether the arousal mechanisms in the brainstem are active; 2) Best verbal response, which is believed to be the most common definition of the end of a coma, or the recovery of consciousness; and 3) Best motor response, which is thought to be associated with central nervous system functioning. Each component has a number of grades starting with the most severe. Best eye response has 4 grades; Best verbal response has 5 grades; Best motor response has 6 grades.

Best eye response (E)

  1. No eye opening
  2. Eye opening in response to pain (patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used).
  3. Eye opening to speech (not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3).
  4. Eyes opening spontaneously

Best verbal response (V)

  1. No verbal response
  2. Incomprehensible sounds (moaning but no words).
  3. Inappropriate words (random or exclamatory articulated speech, but no conversational exchange).
  4. Confused (the patient responds to questions coherently but there is some disorientation and confusion).
  5. Oriented (patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.).

Best motor response (M)

  1. No motor response
  2. Extension to pain (decerebrate response: rigid adduction and extension of the arms, legs stiffly extended, downward pointing of the toes, backward arching of the head, wrists pronated and fingers flexed).
  3. Flexion in response to pain (decorticate response: arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended).
  4. Withdraws from pain (pulls part of body away when pinched; normal flexion)
  5. Localizes to pain (purposeful movements towards changing painful stimuli; e.g. hand crosses mid-line and gets above clavicle when supra-orbital pressure applied).
  6. Obeys commands (the patient does simple things as asked).

Scoring:

In the GCS, each of the component scores as well as the sum of the components are considered. The total score is out of 15-points, with lower scores indicating more severe impairment. The lowest possible GCS total score is 3, indicating deep coma or death, and the highest possible score is 15, indicating a fully awake individual. The total score of the GCS is calculated by summing E + V + M.

The score is expressed in the form GCS (total score) = score on E + score on V + score on M. For example, GCS 9 = E2 V4 M3 indicates a total score of 9, a score of 2 on Best eye response (E), a score of 4 on Best verbal response (V), and a score of 3 on Best motor response (M). Note: For a patient who is intubated, the V is expressed as V intubated.

Interpretation of the GCS total score is as follows:

  • Minor head injury = 13-15
  • Moderate head injury = 9-12
  • Severe head injury (coma) = 8 or less

Time:

Not reported.

Subscales:

The GCS has 3 subscales: Best eye response, Best motor response, and Best verbal performance.

Equipment:

Only a pencil and the test are needed.

Training of administrator:

Although no training is required to administer the GCS, one study examined whether the GCS can be used reliably and accurately by inexperienced examiners and found that experienced medical personnel can use the measure with extremely high levels of accuracy and reliability, but inexperienced examiners may create significant errors, especially in the intermediate levels of consciousness, when the detection of neurologic changes is critical to patient monitoring (Rowley & Fielding, 1991). Thus, it is recommended that the inexperienced examiner be supervised by an expert when completing the GCS.

Alternative form of the GCS:

The GCS cannot be used with children, especially below the age of 36 months. This is due to the verbal performance component which is likely to be poor in even a healthy child. Thus, the Pediatric Glasgow Coma Scale (Reilly, Simpson, Sprod, & Thomas, 1988) was developed as an alternative to the GCS.

The Pediatric Glasgow Coma Scale can be obtained at the following website:

https://www.mdcalc.com/pediatric-glasgow-coma-scale-pgcs

Client suitability

Can be used with:

The GCS can be used with clients with stroke. However, the National Institutes of Health Stroke Scale (NIHSS), developed specifically for use with a stroke population may be a more useful assessment of consciousness in this population.

Should not be used with:

  • Clients with dysphasia, aphasia, and clients who are intubated will have a reduced score on the verbal response scale resulting in a reduced total GCS score but a normal level of consciousness. This should be taken into account when interpreting the GCS results in these individuals. Although it has been suggested that the verbal score be omitted in these clients, and an 8-level (3 to 10) modified GCS be used (Prasad, 1996; Prasad & Menon, 1998), the results of a larger study has suggested that the verbal subscale still be included because it adds important prognostic information (Weir, Bradford, & Lees, 2003).
  • In clients with hemiparesis, ensure that the motor scale is being applied to the less affected arm so that a “best” response can be obtained.
  • The GCS should be administered prior to administration of a sedative or paralytic agent, or after these drugs have been metabolized. Airway, breathing, and circulation should be assessed and stabilized prior to administering the GCS.

In what languages is the measure available?

The GCS has been translated into Chinese and is available online at the following
website: http://www.coma.ulg.ac.be/medical/acute.html

Summary

What does the tool measure? To describe the depth and duration of impaired consciousness or coma.
What types of clients can the tool be used for? The GCS can be used with individuals with traumatic brain injury, cerebrovascular events, nontraumatic coma, cardiac arrest, and toxic ingestions.
Is this a screening or assessment tool? Assessment
Time to administer Not reported.
Versions Pediatric Glasgow Coma Scale
Other Languages Chinese
Measurement Properties
Reliability Internal consistency:
One study examined the internal consistency of the GCS and reported excellent internal consistency.

Inter-rater:
Two studies examined the inter-rater reliability of the GCS using kappa statistics. One study reported adequate inter-rater reliability and the other reported excellent inter-rater reliability for all three GCS subscales.

Validity Criterion:
Predictive:
Three studies examined the predictive validity of the GCS. One reported that the GCS adequately predicted stroke mortality. One study reported that the total GCS score predicted acute mortality with 87% accuracy using just the Best eye response and Best motor response subscales, and with 88% accuracy using all three subscales. One study reported that the GCS was able to predict both 2-week mortality and 3-month recovery from stroke.

Construct:
Convergent:
One study examined the convergent validity of the GCS with the 60-Second Test (SST) and reported an excellent correlation using Spearman’s rho.

Floor/Ceiling Effects No studies have examined floor/ceiling effects of the GCS in patients with stroke.
Sensitivity/Specificity Not reported.
Does the tool detect change in patients?

One study examined the responsiveness of the GCS and reported that it had poor sensitivity to change.

Acceptability Caution should be used in interpreting the scores of intubated clients, or clients with dysphasia or aphasia.
Feasibility The GCS is a short measure that requires no additional equipment. Although training is not required, it is recommended as the measure is more reliable when completed by an experienced clinician. The scale is simple to score and cutoffs are well established in this measure.
How to obtain the tool? The GCS is available free online from the following website: http://www.strokecenter.org/professionals/stroke-diagnosis/stroke-assessment-scales/

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the GCS in individuals with stroke. We identified only three studies specifically examining the GCS in stroke (Weir et al., 2003; Prasad & Menon, 1998; Weingarten, Bolus, Riedinger, Maldonado, Stein, & Ellrodt, 1990). Thus, in this review we will present psychometric data from studies examining neurological patients that include patients with stroke.

Floor/Ceiling Effects

Not reported.

Reliability

Internal consistency:
Mayer, Dennis, Peery, Fitsimmons, Du, Bernardini, Commichau, et al. (2003) examined the internal consistency of the GCS in 171 patients in the neurointensive care unit. Cronbach’s alpha was found to be excellent (alpha = 0.83).

Test-retest:
Not reported.

Inter-rater:
Gill, Reiley, and Green (2004) examined the inter-rater reliability of the GCS in 116 emergency department patients with various diagnoses (10 clients with stroke, 9% of the sample). Two attending emergency physicians independently assessed the GCS within 5 minutes of each other while blinded to each other’s scores. Kappa statistics were calculated for each of the GCS subtests and the total score. Best eye response had adequate inter-rater reliability (weighted k = 0.72) as did Best verbal response (weighted k = 0.48) and Best motor response (weighted k = 0.40). The agreement percentage for total GCS was 32% (Kendall’s T-b = 0.74; Spearman rho = 0.86; Spearman rho2 = 75%). Agreement percentage for GCS Best eye response was 74% (T-b = 0.72; Spearman rho = 0.76; Spearman rho2 = 57%), verbal 55% (T-b = 0.59; Spearman rho = 0.67; Spearman rho2 = 44%), and motor 72% (T-b = 0.74; Spearman rho = 0.81; Spearman rho2 = 65%).

Mayer et al. (2003) examined the inter-rater reliability of the CGS in 64 patients in the neurointensive care unit. The GCS was administered by 2 or 3 examiners within 5 to 10 minutes of each other. Examiners were blinded to each other’s scores. Inter-rater reliability was excellent for the total GCS (weighted k = 0.91), Best visual response (weighted k = 0.86), Best motor response (weighted k = 0.91) and Best verbal response (weighted kappa = 0.76).

Validity

Content:

Not available.

Criterion:

Concurrent:
No gold standard exists against which to compare the GCS.

Predictive:
Weingarten et al. (1990) examined whether the GCS was as accurate in predicting stroke mortality as APACHE II (Knaus, Draper, Wagner, & Zimmerman, 1985), a scale that consists of the GCS score plus 11 other physiological variables, age, and a chronic health evaluation. 246 patients hospitalized with stroke, including 49 oversampled mortalities were included in the study. The GCS was found to adequately predict stroke mortality, and was found to be as accurate as the APACHE II score in predicting stroke mortality with the oversampled mortalities (r = -0.50 and r = 0.50, respectively) and after excluding the oversampled mortalities (r = -0.40 and r = 0.39, respectively).

Prasad and Menon (1998) compared the predictive accuracy of three alternative strategies for verbal scoring in 275 patients with acute stroke who were either intubated or had dysphasia. The total GCS score predicted acute mortality with 87% accuracy using just the Best eye response and Best motor response subscales, versus 88% accuracy with all three subscales. Thus, the authors concluded that the verbal subscale could be excluded from the total GCS score without loss of predictive value in clients with stroke.

Weir, Bradford, and Lees (2002) examined the ability of the GCS to predict 2-week mortality and 3-month recovery (survival, living at home) in a large cohort of individuals with acute stroke. The results of 1217 patients with stroke (including 349 patients with dysphagia) were analyzed. Area under the receiver operating curve (AUC) was used by the authors to compare versions of the GCS. The results of the AUC calculations indicated that the total GCS score had a greater AUC than the GCS without the verbal score for predicting 2-week mortality. This was apparent for all participants together (AUC = 0.78 for the total GCS score; 0.76 for the GCS without the verbal score) and for only the participants with dysphasia (AUC = 0.72 for total GCS score; 0.71 for the GCS without the verbal score). Similarly, the total GCS score was also better than the GCS without the verbal score for predicting 3-month recovery in all participants (AUC = 0.71 for the total GCS score; 0.67 for the GCS without the verbal score) and in participants with dysphasia only (AUC = 0.74 for the total GCS score; 0.70 for the GCS without the verbal score). These results suggest that in contrast to the findings by Prasad and Menon (1998), the verbal subscale should not be excluded in clients with dysphasia since it adds important prognostic information. These results also suggest that the total GCS score can predict early mortality and 3-month recovery and that the GCS better predicted the outcome of early mortality than the outcome of 3-month recovery.

Construct:

Convergent/Discriminant:
Mayer et al. (2003) examined the convergent validity of the GCS with the 60-Second Test (SST) in 171 patients in the neurointensive care unit using Spearman’s rho. The GCS and SST had an excellent correlation (Spearman’s rho = 0.72).

Known groups:
Not examined.

Responsiveness

Mayer et al. (2003) examined the responsiveness of the GCS in 36 patients in the neurointensive care unit. Patients underwent a baseline testing, followed by 1-13 follow-up encounters performed every 12-24 hours. The neurologist performed a brief standardized examination and provided a global clinical impression of change in level of consciousness (better, the same, or worse) compared with the prior encounter. According to the global impression of a neurologist, patients improved in 24% and worsened in 26% of the 187 follow-up examinations. Sensitivity of the GCS to these changes in level of consciousness was poor (46%).

References

  • Gill, M. R., Reiley, D. G., & Green, S. M. (2004). Interrater Reliability of Glasgow Coma Scale Scores in the Emergency Department. Ann Emerg Med, 43, 215-223.
  • Knaus, W. A., Draper, E. A., Wagner, D. P., & Zimmerman, J. E. (1985). APACHE II: A severity of disease classification system. Crit Care Med, 13, 818-829.
  • Lenfant, F., Sobraques, P., Nicolas, F., Combes, J. C., Honnart, D., Freysz, M. (1997). Use of Glasgow Coma Scale by anesthesia and intensive care internists in brain injured patients. Ann Fr Anesth Reanim, 16, 239-243.
  • Mayer, S. A., Dennis, L. J., Peery, S., Fitsimmons, B. -F., Bernardini, G. L., Commichau, C., Eldaief. (2003). Quantification of lethargy in the neuro-ICU: The 60-Second Test, Neurology, 61(4), 543-545.
  • Prasad, K. (1996). The Glasgow Coma Scale: A critical appraisal of its clinimetric properties. Journal of Clinical Epidemiology, 49(7), 755-763.
  • Prasad, K. & Menon, G. R. (1998). Comparison of three strategies of verbal scoring of the Glasgow Coma Scale in patients with stroke. Cerebrovasc Dis, 8, 79-85.
  • Reilly, P., Simpson, D., Sprod, R., Thomas, L. (1988). Assessing the conscious level in infants and young children: A paediatric version of the Glasgow Coma Scale.Child’s Nerv Syst, 4(1), 30-33.
  • Rowley, G, Fielding, R. (1991). Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet, 337, 535-538.
  • Teasdale, G., Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. The Lancet, 2(7872), 81-84.
  • Teasdale, G. M., & Jennett, B. (1976). Assessment and prognosis of coma after head injury. Acta Neurochir (Wien), 34, 45-55.
  • Warlow, C. P., Dennis, M. S., van Gijn, D., Hankey, G. J., Sandercock, P., Bamford, J. M., et al. (2001). Stroke: A Practical Guide to Management (2nd ed.). Malden, MA: Blackwell Publishing.
  • Weir, C. J., Bradford, A. P., & Lees, K. R. (2003). The prognostic value of the components of the Glasgow Coma Scale following acute stroke. Q J Med, 96, 67-74.

See the measure

How to obtain the GCS:

The GCS is available at the following website:
http://www.strokecenter.org/trials/scales/glasgow_coma.html

Table of contents

Modified Rankin Scale (MRS)

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Sabrina Figueiredo, BSc

Purpose

The Modified Rankin Scale (MRS) is a single item, global outcomes rating scale for patients post-stroke. It is used to categorize level of functional independence with reference to pre-stroke activities rather than on observed performance of a specific task.

In-Depth Review

Purpose of the measure)

The Modified Rankin Scale (MRS) is a single item, global outcomes rating scale for patients post-stroke. It is used to categorize level of functional independence with reference to pre-stroke activities rather than on observed performance of a specific task.

Available versions

The original Rankin Scale was developed in Scotland in 1957 and was used to assess disability in patients with acute stroke (Rankin, 1957). It consisted of a single item, with five grades representing no, slight, moderate, moderately severe, and severe disability. The Rankin Scale was modified in 1988 as part of a study of aspirin in stroke prevention (UK-TIA Study Group, 1988) and renamed the MRS. This modification was not reported in the aspirin study, but was described subsequently by van Swieten, Koudstaal, Visser, Schouten, and van Gijn (1988). An additional grade was included (grade 0 = no symptoms at all) because of reported concerns about a lack of grading comprehensiveness. The wording of the definitions for grades 1 and 2 were also altered because of concerns of ambiguity (Bamford, Sandercock, Warlow, & Slattery, 1989). The changes were reportedly also made to accommodate language disorders and cognitive defects, to allow comparison between patients with different kinds of neurological deficits and to add a further dimension by referring to previous activities (van Swieten et al., 1988).

Features of the measure

Items:

The MRS is a single item scale.

The conventional method of administration for the MRS is a guided interview process. The assessment is carried out by asking the patient about their activities of daily living, including outdoor activities. Information about the patient’s neurological deficits on examination, including aphasia and intellectual deficits, should be obtained. All aspects of the patient’s physical, mental performance, and speech should be combined in the choice of a single MRS grade.

The categories within the MRS have been criticized as being broad and poorly defined, left open to the interpretation of the individual rater (Wilson et al., 2002). A structured interview format for the administration of the MRS is available (see section Alternative forms of the Modified Rankin Scale – MRS).

Scoring:

A single MRS grade should be assigned based on the following criteria (Dromerick, Edwards, & Diringer, 2003):

Rankin Grade Description
0 No symptoms
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

* It is unclear whether the term ‘without assistance’ allows for aids or modifications, or whether it refers only to assistance from another person.

Some studies have examined the ability of MRS scores to be dichotomized. de Haan, Limburg, Bossuyt, van der Meulen, and Aaronson (1995) suggested that MRS scores be dichotomized for the purposes of comparison in evaluating the effectiveness of an intervention. They suggested that a score of 0-3 indicate mild to moderate disability, and a score of 4-5 indicate severe disability. Currently, there is no standardized or consistent method of dichotomization (Sulter, Steen, & de Keyser, 1999), as there is a lack of consensus regarding favorable vs. unfavorable poor outcome in terms of Rankin score. Dichotomization has also been criticized as being associated with a loss of information when determining the benefits derived from a particular rehabilitation intervention. For example, Lai and Duncan (2001) reported that 62% of patients included in their study experienced recovery represented by a shift of 1 or more Rankin grades in the first 3 months following stroke. If these shifts were between grades 0 and 1 or between 4 and 5, for example, no change would be reported using a dichotomized system of outcomes where favourable outcome was defined as MRS = 0, 1, and 2 and unfavourable as MRS = 3, 4 or 5. In a study from Weisscher, Vermeulen, Roos, and de Haan (2008), 15% of patients were classified as having a favorable outcome when it was defined as MRS = 0-1. Among these patients, 84% were able to perform outdoor activities. When favorable outcome was defined as a MRS = 0-2, 37% were classified as having a favorable outcome. However, among this group, only 56% were able to perform outdoor activities. Lai and Duncan (2001) have suggested that transition in Rankin grades may be more appropriate in the assessment of intervention benefit. Weisscher et al. (2008) stated that defining favorable and unfavorable outcomes is an arbitrary decision.

The authors suggested that if favorable outcome is expressed by the ability to perform outdoor activities then the score 0-1 should be chosen. However, if complex ADL are considered as the main outcome, then a score of 0-2 on the MRS should be considered the best dichotomization option. Sulter et al. (1999) suggest that an appropriate definition may be that poor outcome exists if any of the following occur: death, institutionalization due to stroke, MRS score >3, or Barthel Index score <60.

Time:

5-15 minutes (New & Bushbinder, 2006)

Subscales:

There are no subscales to the MRS.

Equipment:

Administration of the MRS does not require any specialized equipment.

Training:

No formal training is required to administer the MRS.

Alternative form of the Modified Rankin Scale (MRS)

  • Modified Rankin Scale-Structured Interview (MRS-SI) (Wilson et al., 2002).
  • Wilson et al. (2002) developed a structured interview to improve the inter-rater reliability of the MRS. The structured interview differs from the conventional guided interview for the MRS by defining specific questions to grade each category. The structured interview developed for the study consisted of 5 sections: (1) constant care (e.g. does the person require constant care?), (2) basic ADL (e.g. is assistance essential for eating, using the toilet, daily hygiene, or walking?), (3) instrumental ADL (e.g. is assistance essential for preparing a simple meal, doing household chores, looking after money, shopping, or traveling locally?), (4) limitations in participation in usual social roles (e.g. has there been a change in the person’s ability to participate in previous social and leisure activities?), and (5) checklist for the presence of common stroke symptoms (e.g. does the person have difficulty reading/writing, speaking or finding the right word, problems with balance/coordination, visual problems, numbness, difficulty with swallowing, or other symptom resulting from stroke?). Inter-rater reliability improved significantly after training in the structured interview (Wilson et al., 2005). Furthermore, the extent of disagreement between raters on the MRS-SI was less than what has been observed with the MRS.

Client suitability

Can be used with:

  • Patients with stroke.

Should not be used with:

  • The MRS has not been evaluated for use with proxy respondents.

In what languages is the measure available?

The MRS is available in:

  • German (Berger et al., 1999)
  • Persian (Oveisgharan et al., 2006)
  • Dutch (e.g. Hop, Rinkel, Algra, & van Gijn, 1998).

Summary

What does the tool measure? Level of post-stroke functional independence.
What types of clients can the tool be used for? Patients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer The MRS takes 5-15 minutes to administer.
Versions Original Rankin Scale (RS), Modified Rankin Scale-Structured Interview (MRS-SI)
Other Languages German, Persian, Dutch
Measurement Properties
Reliability Internal consistency:
No studies have examined the internal consistency of the MRS.

Test-rest:
Two studies have examined the test-rest reliability of the MRS and reported excellent test-retest.

Intra-rater:
Only one study has examined the intra-rater reliability of the MRS and reported excellent intra-rater reliability.

Inter-rater:
Six studies have examined the inter-rater reliability of the MRS. Two reported adequate to excellent, three reported excellent inter-rater (note: one study used an expanded guidance scheme – guided interview format -, two reported systematic differences between raters using ANOVA), and one reported poor inter-rater reliability.

Validity Criterion:
Concurrent:
Excellent correlations with the Barthel Index, Frenchay Activities Index, the motor component of the Functional Independence Measure, Short Form-36 Physical Functioning subscale and the Euroqol 5D.Adequate correlations with the Stroke-Adapted Sickness Impact Profile-30 and the Glasgow Coma Scale as well as adequate to excellent correlations with Magnetic Resonance Imaging (MRI) findings.

Predictive:
The most relevant predictors were MRS scores before the stroke event, the presence of diabetes, and severity of left arm weakness.

Construct:
Convergent/Discriminant:
One study reported that the MRS was closely related to the Glasgow Outcome Scale, the NIH Stroke Scale, and the Barthel Index. One study reported an excellent correlation between the MRS and the Barthel Index. One study reported adequate to excellent correlations between the MRS and five impairment scales (the Orgogozo Scale, the NIH Stroke Scale, the Canadian Neurological Scale, the Mathew scale, and the Scandinavian Stroke Scale). Finally, one study reported a weak correlation between the MRS and the Sickness Impact Profile subscales of Cognitive Alertness and Social Interaction.

Floor/Ceiling Effects One study examined the floor effects of the MRS and reported an adequate floor effect.
Does the tool detect change in patients? One study examined the responsiveness of the MRS when administered to stroke rehabilitation inpatients at admission and discharge and reported that the MRS was poor at detecting change.
Acceptability The MRS has not been evaluated for use with proxy respondents.
Feasibility The MRS is single item, global outcomes rating scale that takes 5 -15 minutes to administer and does not require any formal training or specialized equipment. The categories of the MRS have been criticized for being broad, poorly defined and left open to rater interpretation. The MRS- Structured Interview (MRS-SI) differs from the conventional guided interview format of the MRS by defining specific questions to grade each category. Inter-rater reliability of the MRS has been shown to improve with the use of this structured interview format.
How to obtain the tool? Please click here to obtain a copy of the MRS.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MRS.

Floor/Ceiling Effects

Dromerick, Edwards, and Diringer (2003) administered the MRS to 95 stroke rehabilitation inpatients and reported that the MRS displayed an adequate floor effect (18%) at admission to rehabilitation.

Reliability

Test-retest:
Wolfe, Taub, Woodrow, and Burney (1991) examined the test-retest reliability of the MRS in 50 patients with stroke of varying severity. Two out of three research nurses interviewed patients on two occasions that were 2-3 weeks apart. The test-retest reliability using the weighted kappa statistic was excellent (kappa w = .95).

Wilson et al. (2005) examined the test-retest reliability of the MRS in patients at least 6 months post-stroke, using two raters who performed repeat assessments with a mean test-retest interval of 7 days. Agreement was measured using the kappa statistic. Comparison of Rankin grades showed that there was excellent agreement between the first and second assessments. Agreement between the first and second assessments was found in 85% of cases for rater 1 (kappa = 0.81; kappa w = 0.94), and in 96% for rater 2 (kappa = 0.95; kappa w = 0.99).

Intra-rater:
Wolfe et al. (1991) examined the intra-rater reliability of the MRS in a sample of 14 patients who were assessed twice by the same observer within a 2-week period at least 3 months post-stroke. Exact agreement was reported in 86% of observations (kappa w = 0.95). The intra-rater reliability of the MRS as reported in this study is considered to be excellent.

Inter-rater:
van Swieten et al. (1988) examined the inter-rater reliablity of the MRS in 100 patients who were interviewed by two physicians using kappa statistics. Physician agreement on the degree of handicap of the patients occurred for 65% of the patients. The physicians differed by one Rankin grade in 32% of the patients and by two grades in 3% of the patients. The kappa for all pairwise observations was adequate (kappa = 0.56; kappa w = 0.91). For the outpatient group, the kappa was excellent (kappa = 0.82). For the inpatient group, the kappa was adequate (kappa = 0.51).

Wolfe et al (1991) examined the inter-rater reliability of the MRS in 50 patients with stroke of varying severity. Two out of three research nurses interviewed patients. The kappa coefficients were excellent and ranged from kappa = 0.75 to kappa = 0.96. However, analysis of variance revealed that there was evidence of a systematic difference between the raters (F 2,48 = 6.02, p = 0.005), with raters 1 and 3 estimating the grade 0.42 and 0.33 points higher than rater 2.

Wilson et al. (2002) examined the inter-rater reliability of the MRS in 63 patients with stroke. The MRS was administered by two raters. Inter-rater reliability was measured with the kappa statistic and was found to be excellent (kappa w = 0.78). However, overall agreement between the 2 raters was only 57%, and one rater assigned significantly lower grades than the other (p = 0.048).

Wilson et al. (2005) examined the inter-rater reliability of the MRS in patients at least 6 months post-stroke. Fifteen raters were recruited for the study and pairs of raters assessed a total of 113 patients on the MRS. Agreement between raters was observed in only 43% of cases (kappa = 0.25, kappa w = 0.71).

Shinohara, Minematsu, Amano, and Ohashi (2006) examined the inter-rater reliability of the MRS when an expanded guidance scheme (a guided interview format) and corresponding questionnaire was used. Twenty raters (neurologists and nurses) watched videotapes of 30 patients interviewed and scored each patient. Inter-rater reliability was calculated using the intraclass correlation coefficient (ICC). In this study, inter-rater reliability was excellent (ICC = 0.95 for neurologists and ICC = 0.96 for nurses).

Quinn, Dawson, Walters, and Lees (2008) assessed the inter-rater reliability of the MRS among 2942 evaluators from 30 different countries. The evaluators rated 5 non-scripted videotaped interviews. Inter-rater reliability was calculated using Kappa statistics. The overall inter-rater reliability of the MRS was adequate (kappa = 0.67). The agreement level at each grade of the MRS was poor for a score of 0 (kappa = 0.19), adequate for a score of 2 (kappa = 0.48) and 3 (kappa = 0.74), and excellent for a score of 4 (kappa = 0.95). The agreement level for scores of 0 and 5 were not reported since the videotaped interviews did not include clients with a full range of disabilities. The inter-rater reliability by country was poor for Italy (kappa = 0.34), adequate for Belgium (kappa = 0.73), Czech Republic (kappa = 0.68), France (kappa = 0.64), Hungary (kappa = 0.70), Netherlands (kappa = 0.50), South Korea (kappa = 0.67), Sweden (kappa = 0.65), Unites States (kappa = 0.73) and the United Kingdom (kappa = 0.69) and excellent for Australia (kappa = 0.77), Germany (kappa = 0.78), Portugal (kappa = 0.80), Slovakia (kappa = 0.75) and Spain (kappa = 0.84). The agreement level was excellent for both native and non-native English speakers (kappa = 0.77; kappa = 0.76). Among assessors from the United Kingdom the inter-rater reliability was adequate for all professional backgrounds: general medicine (kappa = 0.66), geriatrics (kappa = 0.54), neurology (kappa = 0.56), and research assistants (kappa = 0.65).
Note: The inter-reliability by country was calculated only for countries with more than 50 certified evaluators.

Validity

Criterion:

Concurrent:
Cup, Scholte op Reimer, Thijssen, and van Kuyk-Minis (2003) examined the concurrent validity of the MRS with the Canadian Occupational Performance Measure (COPM), the Barthel Index (BI), the Frenchay Activities Index (FAI), the Stroke-Adapted Sickness Impact Profile-30 (SA-SIP30), and the Euroqol 5D (EQ-5D) in 26 patients post-stroke at their place of residence. The MRS had a statistically significant correlation with the BI, FAI, SA-SIP30 and the EQ-5D. Spearman’s rho correlation coefficients were excellent for the BI, FAI and EQ-56 (r = -0.81, -0.80, and 0.68, respectively). An adequate correlation was found between the MRS and the SA-SIP30 (r = 0.47).
Note: Some correlations are negative because a high score on the MRS indicates increased impairment whereas a low score on other measures indicates increased impairment.

Kwon, Harzema, Duncan, and Min-Lai (2004) examined the concurrent validity of the Barthel Index (BI), the motor component of the Functional Independence Measure (M-FIM), and the MRS using Spearman correlation coefficients. Excellent correlations were observed between the MRS and the BI (r = -0.89) and between the M-FIM and the MRS (r = -0.89).

Weimar et al. (2002) examined the concurrent validity of the MRS from a sample of 4,264 patients with acute ischemic stroke from 30 hospitals in Germany during a 1-year period. The patients were administered the Barthel Index (BI), the MRS, the Short Form-36 Physical Functioning subscale (SF-36 PF), and the Center for Epidemiologic Studies-Depression short form (CES-D). The MRS had an excellent correlation with the SF-36 PF (r = 0.84) and with the BI (r = 0.82).

Schaefer, Huisman, Sorensen, Gonzalez, and Schwamm (2004) examined whether diffusion-weighted Magnetic Resonance Imaging (MRI) findings (thought to demonstrate lesions that are not visualized with conventional MRI sequences) and conventional MRI findings correlate with discharge MRS and Glasgow Coma Scale scores in 26 patients with diffuse axonal injury. Using Spearman rank correlation coefficients, the results of this study showed that the strongest correlation was between signal-intensity abnormality volume on diffusion-weighted images and MRS score, which was excellent (r = 0.77). For lesion number, the strongest correlation was between lesion number on images acquired and all sequences and MRS score, which was also excellent (r = 0.66). For lesion location, the strongest correlation was between lesion location in the corpus callosum and MRS score, which was adequate (r = 0.51). There was an adequate correlation between the MRS and the Glasgow Coma Scale.

Predictive:
Weimar et al. (2002) identified the most important predictors of adverse outcomes on the Barthel Index (BI) and MRS following stroke. The most relevant predictors were MRS scores before the stroke event, the presence of diabetes, and severity of left arm weakness.
Note: Although MRS scores > 3 was an inclusion criterion in this study, it did not specify how the MRS scores were obtained before the stroke event.

Construct:

Convergent/Discriminant :
Tilley et al. (1996) found that the MRS was closely related to the Glasgow Outcome Scale (94% agreement; Φ = 0.88) and with impairment measured by the NIH Stroke Scale (86% agreement; phi coefficient = 0.67) and the Barthel Index (87% agreement; Φ = 0.76). These results raise concern about the construct validity of the MRS. The results of this study lends support to the assertion that the MRS is closer to a disability scale than a handicap scale.

de Haan, Horn, Limburg, van Der Meulen, and Bossuyt (1993) evaluated 87 patients who had a stroke 6 months prior to evalutation. Impairments were scored on five stroke scales: the Orgogozo Scale, the National Institutes of Health Stroke Scale, the Canadian Neurological Scale, the Mathew scale, and the Scandinavian Stroke Scale. Disability was assessed with the Barthel Index, handicap with the MRS, and quality of life with the Sickness Impact Profile. The correlations between MRS and the 5 impairment scales using Pearson’s coefficients ranged from adequate to excellent (ranging from r = -0.56 to r = -0.71).
Note: Some correlations are negative because a high score on the MRS indicates increased impairment whereas a low score on other measures indicates increased impairment.

de Haan, Limburg, Bossuyt, van der Meulen, and Aaronson (1995) reported a strong relationship (using Somers’ D) between activities of daily living as measured by the Barthel Index (0.73) and the subscales of the Sickness Impact Profile including Instrumental activities of daily living (0.65), Mobility (0.60) and Living arrangements (0.74) The weakest associations reported were between the MRS and the Sickness Impact Profile subscales of Cognitive Alertness (0.34) and Social Interaction (0.37).

Wolfe et al. (1991) administered the MRS and the Barthel Index (which assesses disability) to 50 patients post-stroke. The correlation between the MRS and the Barthel Index was measured using kappa statistics. There was an excellent correlation (kappa = 0.72; weighted kappa = 0.91) between the two scales, which lends support to the assertion that the MRS is closer to a disability scale than a handicap scale.

Responsiveness

Dromerick et al. (2003) examined the responsiveness of the MRS in comparison to 3 other disability scales (the International Stroke Trial Measure; the Barthel Index (BI); the Functional Independence Measure (FIM). The MRS was administered to 95 stroke rehabilitation inpatients at admission and at discharge. The MRS was poor at detecting change. When compared to the FIM, the receiver operating characteristics analysis showed that the MRS (C-statistic C = 0.59) was much less sensitivity to change compared with the BI (C-statistic C = 0.82), indicating a corresponding lower specificity for the MRS. The MRS detected change in 55 subjects, including all who changed on the International Stroke Trial Measure. The BI detected change in 71 patients and the FIM detected change in 91 patients. The results of this study suggest that the global scales (MRS and the International Stroke Trial Measure) are much less sensitive to changes in disability than the activities of daily living scales (the BI and the FIM).

References

  • Bamford, J. M., Sandercock, A. G., Warlow, C. P., Slattery, J. (1989). Interobserver agreement for the assessment of handicap in stroke patients (letter). Stroke, 20, 828.
  • Bamford, J. M., Vessey, M., Fowler, G., Molyneux, A., Hughes, T., Burn, J., et al. (1988). A prospective study of acute cerebrovascular disease in the community: The Oxfordshire Community Stroke Project 1981-1986. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry; 51, 1373-1380.
  • Berger, K., Weltermann, B., Kolominsky-Rabas, P., Meves, S., Heuschmann, P., Bohner, J., Neundorfer, B., Hense, H. W., Buttner, T. (1999). The reliability of stroke scales. The german version of the NIHSS, ESS and Rankin scales. Fortschr Neurol Psychiatr, 67(2), 81-93.
  • Cup, E. H. C., Scholte op Reimer, W. J. M., Thijssen, M. C. E., van Kuyk-Minis, M. A. H. (2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clin Rehabil, 17, 402-409.
  • de Haan, R., Horn, J., Limburg, M., van Der Meulen, J., Bossuyt, P. (1993). A comparison of five stroke scales with measurement of disability, handicap and quality of life. Stroke, 24, 1178-1181.
  • de Haan, R., Limburg, M., Bossuyt, P., van der Meulen, J., Aaronson, N. (1995). The clinical meaning of Ranking ‘handicap’ grades after stroke. Stroke, 26, 2027-2030.
  • Dromerick, A. W., Edwards, D. F., Diringer, M. N. (2003). Sensitivity to changes in disability after stroke: A comparison of four scales useful in clinical trials. Journal of Rehabilitation Research and Development, 40(1), 1-8.
  • Hop, J., Rinkel, G. J. E., Algra, A., van Gijn, J. (1998). Quality of life in patients and partners after aneurismal subarachnoid hemorrhage. Stroke, 29, 798-804.
  • Kwon, S., Harzema, A. G., Duncan, P. W., Min-Lai, S. (2004). Disability measures in stroke: Rehationship among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale. Stroke, 35, 918-923.
  • Lai, S. M., Duncan, P. W. (2001). Stroke recovery profile and the Modified Rankin Assessment. Neuroepidemiology, 20, 26-30.
  • New, P. W., Buchbinder, R. (2006). Critical appraisal and review of the Rankin Scale and its derivatives. Neuroepidemiology, 26, 4-15.
  • Oveisgharan, S., Shirani, S., Ghorbani, A., Soltanzade, A., Baghaei, A., Hosseini, S., Sarrafzadegan, N. (2006). Barthel Index in a middle-east country: Translation, validity and reliability. Cerebrovascular Diseases, 22, 350-354.
  • Quinn, T.J., Dawson, J., Walters, M.R., Lees, K.R. (2008). Variability in Modified Rankin Score across a large cohort of international observers. Stroke, 39, 2975-2979.
  • Rankin, J. (1957). Cerebral vascular accidents in patients over the age of 60. Scott Med J, 2, 200-215.
  • Schaefer, P. W., Huisman, T., Sorensen, G., Gonzalez, G., Schwamm, L. (2004). Diffusion-weighted MR Imaging in closed head injury: High correlation with initial Glasgow Coma Scale score and score on Modified Rankin Scale at discharge. Neuroradiology, 233, 58-66.
  • Shinohara, Y., Minematsu, K., Amano, T., Ohashi, Y. (2006). Modified Rankin Scale with expanded guidance scheme and interview questionnaire: interrater Agreement and Reproducibility of Assessment. Cerebrovasc Dis, 21, 271-278.
  • Sulter, G., Steen, C., De Keyser, J. (1999). Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke, 30, 1538-1541.
  • Tilley, B. C., Marler, J., Geller, N. L., Lu, M., Legler, J., Brott, T., et al (1996). Use of a global test for multiple outcomes in stroke trails with application to the National Institute of Neurological Disorders and Stroke t-PA stroke trial. Stroke, 27, 2136-2142.
  • UK-TIA Study Group. (1988). The UK-TIA aspirin trial: Interim results. Br Med J, 296, 316-320.
  • van Swieten, J. C., Koudstaal, P. J., Visser, M. C., Schouten, H. J., van Gijn, J. (1988). Interobserver agreement for the assessment of handicap in stroke patients. Stroke, 19, 604-607.
  • Weimar, C., Kurth, T., Kraywinkel, K., Wagner, M., Busse, O., Ludwig, R., Diener, H-C. (2002). Assessment of functioning and disability after ischemic stroke. Stroke, 33, 2053-2059.
  • Weisscher, N., Vermeulen, M., Roos, Y.B., de Haan, R.J. (2008). What should be defined as good outcome in stroke trials; a modified Rankin score of 0-1 or 0-2? J Neurol, 255, 867-874.
  • Wilson, L. J. T., Hareendran, A., Hendry, A., Potter, J., Bone, I., Muir, K. W. (2005). Reliability of the Modified Rankin Scale across multiple raters: Benefits of a structured interview. Stroke, 36, 777-781.
  • Wilson, L. J. T., Harendran, A., Grant, M., Baird, T., Schultz, U. G. R., Muir, K. W., Bone, I. (2002). Improving the assessment of outcomes in stroke: Use of a structured interview to assign grades on the Modified Rankin Scale. Stroke, 33, 2243-2246.
  • Wolfe, C. D., Taub, N. A., Woodrow, E.J., Burney, P. G. (1991). Assessment of scales of disability and handicap for stroke patients. Stroke, 22, 1242-1244.

See the measure

How to obtain the MRS?

Please click here to obtain a copy of the MRS and the MRS-SI.

The MRS is also available in New, P. W., Buchbinder, R. (2006). Critical appraisal and review of the Rankin Scale and its derivatives. Neuroepidemiology, 26, 4-15.

The MRS-SI can be found in Wilson, L. J. T., Harendran, A., Grant, M., Baird, T., Schultz, U. G. R., Muir, K. W., Bone, I. (2002). Improving the assessment of outcomes in stroke: Use of a structured interview to assign grades on the Modified Rankin Scale. Stroke, 33, 2243-2246.

On-line training can be obtained at http://www.rankinscale.org/ The training modules comprise an introductory description of the mRS followed by 4 brief patient interviews. These interviews should be scored anonymously for practice purposes before optional group discussion. Correct scores and their justification follow each case (20 minutes). A transcript of the interviews is available. Certification of successful training will depend on correct completion of 5 further scenarios under ‘test’ conditions. Certification lasts for one year, after which re-certification is recommended. scenarios.

Link to MRS training program: http://www.rankinscale.org/

Table of contents

Toronto Bedside Swallowing Screening Test (TOR-BSST©)

Evidence Reviewed as of before: 18-02-2019
Author(s)*: Annabel McDermott, OT
Expert Reviewer: Trixie Reichardt, MHSc, RD, Rosemary Martino, PhD
Content consistency: Gabriel Plumier

Purpose

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a screening tool which identifies patients at risk for dysphagia following stroke.

In-Depth Review

Purpose of the measure

The Toronto Bedside Swallowing Screening Test (TOR-BSST©) is a screening tool administered at the bedside by trained screeners which identifies patients at risk for dysphagia following stroke.

Available versions

There is one version of the TOR-BSST©. See https://swallowinglab.com/tor-bsst/.

Features of the measure

Items:

The TOR-BSST© is comprised of 5 items:

  1. Baseline vocal quality
  2. Tongue movement
  3. 50mL water test
  4. Cup sip
  5. Final judgment of vocal quality

Scoring:

The TOR-BSST© uses binary scoring (i.e. abnormal/normal) for each item. Failure on any item discontinues the screen and prompts referral to a Speech-Language Pathologist dysphagia expert.

What to consider before beginning:

The TOR-BSST© should only be used with patients who are alert, able to sit upright at 90 degrees, and are able to follow simple instructions. Patients who do not meet these guidelines should not be screened but, instead, be referred to a Speech-Language Pathologist for assessment.

International best practice guidelines advise that, following stroke, patients should undergo screening for swallowing difficulties before oral intake of food, fluids or oral medication. Screening should be performed by specially trained personnel, using a validated screening tool. Swallowing should be screened as soon as possible after admission provided that the patient is able to participate. Patients who fail the swallowing screening should be referred to a Speech-Language Pathologist for comprehensive swallowing assessment. For patients who are confirmed at high risk of aspiration and/or dysphagia should undergo an instrumental assessment such as videofluoroscopy swallowing study (VFS) and/or fibreoptic evaluation of swallowing (FEES).

Time:

The TOR-BSST© takes less than 10 minutes to administer and score. Administration ceases immediately on failure of an item.

Training requirements:

The TOR-BSST© can be administered by health professionals who have undergone the requisite 4-hour didactic standardized training program. Didactic training is followed by individual training/competency observations. Training is provided by Speech-Language Pathologists who have completed the “TOR-BSST© Training for the SLP Dysphagia Expert” trainers course.

See The Swallowing Lab (https://swallowinglab.com/tor-bsst/) for details.

Equipment:

The TOR-BSST© is a one-page double-sided form that includes standardized instructions for administration

Client suitability

Can be used with:

  • The TOR-BSST© is suitable for use with individuals with stroke across the recovery continuum (Martino et al., 2009).
  • The TOR-BSST© is being validated for use with critically ill patients who have undergone prolonged intubation and may be at risk of swallowing problems.

Should not be used in:

  • Following stroke, patients should be assessed and managed according to best practice guidelines for dysphagia. The TOR-BSST© should not be used with individuals with decreased alertness or cognition, or those who are being tube-fed. Patients who are being tube-fed have already been identified to have dysphagia and therefore should be referred to a Speech-Language Pathologist for a comprehensive assessment and management.

In what languages is the screening tool available?

  • English
  • French
  • Chinese
  • German
  • Italian
  • Portuguese (Brazil)

Summary

What does the tool measure? Risk for dysphagia following stroke.
What types of clients can the tool be used for? The TOR-BSST© was developed for patients with stroke across the recovery continuum.
Is this a screening or assessment tool? Screening tool
Time to administer Ten minutes.
Versions There is one version of the TOR-BSST©.
Languages Chinese, English, French, German, Italian, Portuguese (Brazil)
Measurement Properties
Reliability Internal consistency:
No studies have reported on the internal consistency of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:
Two studies have reported excellent inter-rater reliability of the TOR-BSST©.

Validity Content:
Development of the TOR-BSST© involved item generation from systematic review and subsequent item reduction, in combination with consultation with expert Speech-Language Pathologists.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the TOR-BSST©.

Predictive:
One study has conducted a randomized controlled diagnostic study of the TOR-BSST© by comparison with videofluoroscopy.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent or discriminant validity of the TOR-BSST©.

Known Groups:
No studies have reported on the known group validity of the TOR-BSST©.

Floor/Ceiling Effects Not applicable
Does the tool detect change in patients? The TOR-BSST© is designed as a screening test and scored using binary responses, so is not intended to detect change.
Acceptability – The TOR-BSST© is quick to administer.
– The TOR-BSST© requires specialised training.
Feasibility The TOR-BSST© is suitable for administration across acute and rehabilitation settings. The screening is easily portable and is quick to administer, score and interpret.
How to obtain the tool? Click here for information regarding the TOR-BSST©.

Psychometric Properties

Overview

The TOR-BSST© was developed and validated by Dr. Martino of The Swallowing Lab, University Health Network, University of Toronto.

A literature search was conducted to identify all relevant publications on the psychometric properties of the TOR-BSST©. Four studies were identified.

Floor/Ceiling Effects

The TOR-BSST© is a 5-item screening test to determine risk of dysphagia. The screening should be discontinued as soon as an individual fails an item.

Reliability

Internal consistency:
No studies have reported on internal consistency of the TOR-BSST©.

Test-retest:
No studies have reported on the test-retest reliability of the TOR-BSST©.

Intra-rater:
No studies have reported on the intra-rater reliability of the TOR-BSST©.

Inter-rater:
Martino et al. (2009) established inter-rater reliability of the TOR-BSST© in the first 50 patients with stroke enrolled, using intraclass correlation coefficient (ICC) and 95% confidence intervals (CI). Results indicated excellent test-retest reliability (ICC=0.92; CI, 0.85 to 0.96).

Martino et al. (2006) examined 24-hour inter-rater reliability of the TOR-BSST© item and total screen scores in a sample of 286 patients with stroke (acute, n=78; subacute/chronic, n=208), using kappa statistics. Results indicated moderate reliability for the total score, with a higher reliability early after training (k = 0.90). Item reliability ranged from poor to adequate; the item ‘water swallowing’ including both the 50-ml and sip achieved the highest item reliability (k=0.82; CI, 0.66-0.98).

Validity

Content:

Initial item generation for the TOR-BSST© resulted from systematic review of the accuracy and benefit of non-invasive bedside dysphagia screening tests with patients with stroke (see Martino, Pron & Diamant, 2000). Two measures were shown to be accurate predictors of dysphagia by videofluroscopic assessment (VFS) of aspiration, and a further two were considered to show promising (although inconsistent) predictive ability:

  1. Dysphonia/coughing during the 50mL Kidd water swallow test
  2. Impaired pharyngeal sensation
  3. Impaired tongue movement
  4. General dysphonia – voice before or voice after water intake

The final measure, general dysphonia, was defined as two sub-items (voice before, voice after).

Item reduction was then performed, whereby positive results across the 5 items were compared with the total score. The item ‘water swallow’ contributed 25% to the total positive score, indicating that this item was the most frequent single item to identify dysphagia. The item ‘tongue movements’ contributed 8% to the total positive score. The remaining items contributed less than 5% each to the total positive score, and so were considered for elimination on review of practical application as determined by expert Speech-Language Pathologists. These expert clinicians considered the item ‘pharyngeal sensation’ to be impractical due to difficulty differentiating from a gag reflex in the clinical setting.

Martino et al. (2014) conducted item descriptive analysis in the original sample of 311 patients with stroke from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses. Items were eliminated individually to evaluate the impact of each item on the total score. Results showed that the ‘water swallow’ item contributed most significantly to identification of dysphagia, identifying 42.7% of patients in the acute setting and 29.0% of patients in the rehabilitation setting.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the TOR-BSST©.

Predictive:
Martino et al. (2009) examined predictive validity of the TOR-BSST© by comparison with gold standard VFS assessment identifying any abnormal swallow physiology including all severity. The randomized controlled diagnostic study design included four blinded Speech-Language Pathologists and 68 patients with stroke in acute and rehabilitation settings. Nine participants with stroke were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart as per a priori criteria for patient flow. VFS assessment was used to confirm findings obtained by TOR-BSST© screening; clinicians rated the VFS images using three standardized scales: (1) Penetration Aspiration Scale; (2) Mann Assessment of Swallowing Ability (MASA) dysphagia subscore; and (3) MASA aspiration subscore. Across the entire sample of acute and rehab patients, results showed that 61% (n=36) of patients were confirmed by experts to have no dysphagia vs. 39% (n=23) with dysphagia. These results indicate high accuracy to predict dysphagia using the TOR-BSST©, where dysphagia is defined by aspiration and/or physiological abnormality on VFS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the TOR-SST©.

Known Group:
No studies have reported on the known-group validity of the TOR-BSST(c).

Sensitivity & Specificity:

Martino et al. (2009) examined sensitivity of the TOR-BSST© by comparison with VFS assessment, in a sample of 68 patients with stroke in acute and rehabilitation settings. Nine patients were eliminated when the TOR-BSST© and VFS assessments were performed more than 24 hours apart. The TOR-BSST showed 91.3% sensitivity (CI, 71.9 – 98.7) and 66.7% specificity (CI, 49.0 – 81.4) among all patients. Sensitivity and specificity was 96.3% and 63.6% (respectively) among patients in an acute setting, and 80.0% and 68.0% (respectively) among patients in rehabilitation settings. The TOR-BSST© showed high negative predictive value of 93.3% and 89.5% in participants in acute and rehabilitation stroke settings, respectively.

Martino et al. (2014) conducted sensitivity analysis of the TOR-BSST© in the original sample of 311 patients with stroke from acute and rehabilitation settings. The TOR-BSST© was administered by trained nurses using the standard 10 teaspoons plus a sip of water. Positive screening occurred in 59.2% of patients in the acute setting (n=103) and 38.5% of patients in the rehabilitation setting (n=208).

Martino et al. (2014) further examined sensitivity of the TOR-BSST© when modifying administration according to water volume intake. Using the original sample from Martino et al. (2009), sensitivity was examined on administration of 1 to 10 teaspoons of water to determine the acceptable cut-point to identify dysphagia. Among all participants (n=311), sensitivity ranged from moderate to excellent for 5, 8 and 10 teaspoons of water (79%, 92%, 96% respectively). Among patients in the acute setting and rehabilitation settings, sensitivities were 84% and 75% (respectively) for 5 teaspoons of water, 93% and 92% (respectively) for 8 teaspoons, and 95% and 97% (respectively) for 10 teaspoons. Results indicate greater accuracy on administration of 10x 5mL teaspoons of water, as per the original assessment guidelines

References

  • Martino, R., Maki, E., & Diamant, N. (2014). Identification of dysphagia using the Toronto Bedside Swallowing Screening Test (TOR-BSST©): are 10 teaspoons of water necessary? International Journal of Speech-Language Pathology, 16(3), 193-8. https://www.ncbi.nlm.nih.gov/pubmed/24833425
  • Martino, R., Nicholson, G., Bayley, M., Teasell, R., Silver, F., & Diamant, N. (2006). Interrater reliability of the Toronto Bedside Swallowing Screening Test (TOR-BSST©) [Abstract]. Dysphagia, 21(4), 287-334. https://doi.org/10.1007/s00455-006-9044-5
  • Martino, R., Pron, G., & Diamant, N. (2000). Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia, 15, 19-30. https://www.ncbi.nlm.nih.gov/pubmed/10594255
  • Martino, R., Silver, F., Teasell, R., Bayley, M., Nicholson, G., Streiner, D.L., & Diamant, N.E. (2009). The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke. Stroke, 40, 555-61. https://www.ncbi.nlm.nih.gov/pubmed/19074483

See the measure

How to obtain the TOR-BSST©:

Click here for information regarding the TOR-BSST©.

Other measures of dysphagia:

Instrumental Assessments:

  • Videofluoroscopy swallowing study (gold standard)
  • Fiberoptic endoscopic examination of swallowing
  • Rosenbeck’s Penetration Aspiration Scale

Clinical Bedside Assessments:

  • The Modified Mann Assessment of Swallowing Ability (Modified MASA)

Screening Tools:

  • Massey Bedside Swallowing Screen Volume-Viscosity Swallowing Test (Clave et al., 2008)
  • The Gugging Swallowing Screen (GUSS) (Trapl et al., 2007)
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