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
  • No studies have examined the internal consistency of the MRS.
  • Two studies have examined the test-rest reliability of the MRS and reported excellent test-retest.
  • 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.
  • Only one study has examined the intra-rater reliability of the MRS and reported excellent intra-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 5 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-rate:

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/

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