Orpington Prognostic Score (OPS)

Evidence Reviewed as of before: 05-12-2008
Author(s): Sabrina Figueiredo, BSc
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Orpington Prognostic Score (OPS), also known as Orpington Prognostic Scale, was developed from the Edinburgh Prognostic Score (Prescott, Garraway, & Akhtar, 1982) and the Hodkinson’s Mental Test Score (Qureshi & Hodkinson, 1974) as a means to evaluate stroke severity. The OPS enables clinicians and researchers to stratify clients into a good, intermediate or poor prognosis group by using established cut-offs. The OPS is also very effective in predicting functional outcomes (Kalra & Crome, 1993).

In-Depth Review

Purpose of the measure

The Orpington Prognostic Score (OPS), also known as Orpington Prognostic Scale, was developed from the Edinburgh Prognostic Score (Prescott, Garraway, & Akhtar, 1982) and the Hodkinson’s Mental Test Score (Qureshi & Hodkinson, 1974) as a means to evaluate stroke severity. The OPS enables clinicians and researchers to stratify clients into a good, intermediate or poor prognosis group by using established cut-offs. The OPS is also very effective in predicting functional outcomes (Kalra & Crome, 1993).

Available versions

The OPS was published by Kalra and Crome in 1993.

Features of the measure

Items:
The OPS is comprised of four subscales: Motor deficit in the arm, Proprioception, Balance and Cognition.

Motor deficit in the arm: The client is positioned lying in supine. The therapist asks the client to flex the shoulder of the most affected arm to 90 degrees against therapist’s manual resistance. If the client is not able to perform the movement, manual resistance is then removed and the therapist observes how the client flexes the shoulder only against gravity. Muscle power is then scored. In the presence of shoulder pain, the elbow extensors may be tested instead of the shoulder flexor (Kalra & Crome, 1993; Rieck & Moreland, 2005).

Proprioception: The client is instructed to close his/her eyes and locate the affected thumb by touching it with the other hand. The degree of difficulty in finding the affected thumb is scored (Kalra & Crome, 1993; Rieck & Moreland, 2005).

Balance: The therapist observes whether the client can successfully complete 3 balance tasks in the following order: 1) sit with feet unsupported for 20 seconds; 2) stand unsupported for 1 minute; 3) walk 10 feet without assistance. The client only attempts the next task after successful completion of a previous one. The highest balance-related ability is scored (Kalra & Crome, 1993; Rieck & Moreland, 2005).

Cognition: The clients are asked to verbally respond to the following 10 questions. In the presence of aphasia or dysarthria questions can be answered in writing (Kalra & Crome, 1993; Rieck & Moreland, 2005). A score of 1 point is given for each correct answer:

  1. Age of the client;
  2. Time (to the nearest hour);
  3. At this point the therapist instructs the client to memorize an address (42, West Street) that will be asked afterwards.
  4. Name of the hospital;
  5. Current year;
  6. Client’s date of birth;
  7. Current month;
  8. Year of the First World War;
  9. Name of the Monarch;
  10. Count backwards from 20 to 1;
  11. Recall previous address.

Note: Some studies have been adapting items 7 and 8 to Year of the Second World War and Name of the President, respectively.

It is recommended that the OPS be performed from day 2 post stroke. However, some authors advocate that outcomes are better predicted when administering the OPS in the second week (Kalra & Crome, 1993; Rieck & Moreland, 2005; Studenski, Wallace, Duncan, Rymer and Lai, 2001).

Scoring:
OPS scores range from 1.6 to 6.8. Higher scores indicate a more severe stroke and a worse prognosis. The OPS is scored as follows:

Subscales

Score

Motor Deficit in arm:
Normal power (MRC grade 5)
Diminished power (MRC grade 4)
Movement against gravity (MRC grade 3)
Movement with gravity eliminated or flicker when attempted movement (MRC grade 1-2)
No movement (MRC grade 0)
Note: MRC = Medical Research Council for grading power

 
0
0.4
0.8
1.2
1.6

Proprioception (eyes closed)
Locates affected thumb accurately
Locates affected thumb with slight difficulty
Locates affected thumb via arm
Unable to locate affected thumb

 
0
0.4
0.8
1.2

Balance
Walks 10 feet without help
Maintains standing position
Maintains sitting position
No sitting balance

 
0
0.4
0.8
1.2

Cognition (one point for each corrected answer)
Mental Test Score 10 out of 10
Mental Test Score 8-9 out of 10
Mental Test Score 5-7 out of 10
Mental Test Score 0-4 out of 10

 
0
0.4
0.8
1.2

TOTAL SCORE = 1.6 + Motor deficit score + Proprioception score + Balance score + Cognition score

Kalra and Crome (1993) established cut-off scores to categorize patients into prognostic groups. OPS scores <3.2 represent clients with mild neurological impairments and a good prognosis; OPS scores = 3.2-5.2 are representative of clients with moderate neurological impairments and an intermediate prognosis; OPS scores >5.2 are associated with severe neurological impairments and a poor prognosis. Early stratification assists in more appropriate allocation of stroke unit resources. Patients scoring <3.2 have a high likelihood of returning home. Patients scoring between 3.2 and 5.2 tend to respond better to rehabilitation. Patients scoring >5.2 are often severely dependent with an increased risk of institutionalization. (Kalra & Crome, 1993; Kalra & Eade, 1995).

Time:
The OPS takes approximately 5 minutes to administer (Celik, Aksel and Karaoglan, 2006; Studenski et al., 2001).

Subscales:
The OPS subscales items encompass Motor deficit, Proprioception, Balance and Cognition.

Equipment:
Only a pencil and the test are needed.

Training:
No specific training is available.

Alternative forms of the OPS

Not available.

Client suitability

Can be used with:

Clients with stroke, including those with aphasia, dysarthria and dementia (Kalra, Dale and Crome, 1994).

Should not be used in:

The OPS cannot be administered until neurological deficit and consciousness levels have stabilized (Kalra, Dale and Crome, 1994).

In what languages is the measure available?

English.

Summary

What does the tool measure?

The OPS measures stroke severity at baseline.

What types of clients can the tool be used for?

Clients with stroke, including those with aphasia, dysarthria and dementia.

Is this a screening or assessment tool?

Assessment and screening.

Time to administer

An average of 5 minutes.

Versions

None.

Other Languages

None.

Measurement Properties

Reliability

– One study examined the test-retest reliability of the OPS and reported excellent test-retest reliability using Intraclass Correlation Coefficient (ICC).
– Two studies examined the inter-rater reliability of the OPS and reported adequate to excellent inter-rater reliability using ICC and weighted kappa.

Validity

Content:
No studies have examined the content validity of the OPS.

Criterion:
Concurrent:
Three studies examined the concurrent validity of the OPS and reported excellent correlations between the OPS and the National Institute of Health Stroke Scale (NIHSS) as the gold standard using Spearman’s Rank Correlation.

Predictive:
Ten studies examined the predictive validity of the OPS. Nine studies reported that the OPS measured between the third and the fourteenth day after stroke was able to predict activities of daily living, length of stay, upper limb function, discharge destination, recovery rate and scores on the Barthel Index, the SF-36, the Rivermead Mobility Assessment, and the Oxford Handicap Scale either at discharge, 1, 3, 6 or 24 months after stroke. One study reported that the OPS measured between the fourth and the twelfth week was able to predict Functional Independence Measure and Nottingham Extended ADL Index scores at discharge from the rehabilitation program. 2 studies reported that the OPS was not able to predict the Timed Up and Go and the number of required follow-up sessions.

Four studies examined the sensitivity, specificity and predictive values of the OPS. Three studies reported that the OPS showed high to adequate sensitivity and positive predictive values, adequate negative predictive values, and adequate to low specificity at determining discharge destination. One study reported that the OPS showed high positive predictive values, moderate negative predictive values, and high to low sensitivity and specificity at predicting independence and death at 6 months.

Floor/Ceiling Effects

No studies have examined the floor or ceiling effects of the OPS.

Does the tool detect change in patients?

No studies have examined the ability of the OPS to detect change

Acceptability

The OPS cannot be administered until neurological deficit and consciousness levels have stabilized (Kalra, Dale and Crome, 1994).

Feasibility

The administration of the OPS is quick and simple.

How to obtain the tool?

The OPS can be obtained from its original publication: Kalra and Crome 1993 (1987). The following publications also present a description of the full tool: Lai et al., (1998); Pittock et al., (2003); Rieck & Moreland (2005). Wrigth et al., (2004).

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Orpington Prognostic Score (OPS) in individuals with stroke. We identified 13 studies.

Floor/Ceiling Effects

No studies have examined the floor or ceiling effects of the OPS.

Reliability

Test-retest:
Note: From the descriptions provided of the following study it appears that the authors called the testing ‘test-retest reliability’ while others would call the same analysis ‘inter-rater reliability’.
Rieck and Moreland (2005) evaluated the test-retest reliability of the OPS in 27 clients with stroke. Participants were tested separately by 2 different raters within the same day. Test-retest reliability, as calculated using Intraclass Correlation Coefficient, was excellent (ICC = 0.95).

Inter-rater:
Weir, Counsell, McDowall, Gunkel and Dennis (2003) assessed the inter-rater reliability of the OPS items in 92 clients with acute stroke. Two examiners administered the OPS within 4 hours of each other. Examiners were blinded to each other’s scores. Inter-rater reliability on individual items was calculated using weighted kappa. Adequate inter-rater reliability was found on Proprioception (weighted kappa = 0.53), Cognition (weighted kappa = 0.64) and Arm motor deficit (weighted kappa = 0.72). Balance was the only item with excellent inter-rater reliability (weighted kappa = 0.84).

Rieck and Moreland (2005) evaluated the inter-rater reliability of the OPS in 65 clients with stroke. Two different raters following a 1-week interval tested participants separately. Inter-rater reliability, as calculated using Intraclass Correlation Coefficient, was excellent (ICC = 0.99).[/su_spoiler]

Validity

Content:
No studies have examined the content validity of the OPS

Criterion:
Concurrent:
In a study by Lai, Duncan, and Keighley (1998) the concurrent validity of the OPS was verified against the National Institute of Health Stroke Scale (NIHSS), considered as the gold standard (Brott, Adams, Olinger, Marler, Barsan, Biller et al., 1989), in 184 individuals with stroke. Correlation between the OPS and the NIHSS, as calculated using Spearman’s Rank Correlation, was excellent (rho = 0.83).

Wright, Swinton and Green (2004) assessed the concurrent validity of the OPS by comparing it with the NIHSS, which is considered as the gold standard (Brott et al., 1989), in 277 clients with stroke. An excellent correlation between the OPS and the NIHSS was found (rho = 0.60).

Celik, Aksel and Karaoglan (2006) examined the concurrent validity of the OPS against the NIHSS, considered as the gold standard (Brott et al., 1989), in 25 individuals with stroke. Correlation using Spearman’s Rank Correlation was excellent between the OPS and the NIHSS (rho = 0.76).

Predictive:
Kalra and Crome (1993) estimated the ability of the OPS and the Edinburgh Prognostic Score (Prescott, Garraway, & Akhtar, 1982), measured at 1 and 2 weeks after stroke, to predict Barthel Index ADL scores (Mahoney & Barthel, 1965) at discharge from hospital. Predictive validity was calculated using linear regression in 64 patients at week 1 and in 47 patients at week 2. The OPS measured at week 2 was a better predictor of Barthel Index scores (R² = 0.89), when compared to the Edinburgh Prognostic Score (R² = 0.57).

Kalra, Dale and Crome (1994) compared the sensitivity and specificity of the OPS versus the presence of urinary incontinence, measured 2 weeks after stroke, in determining independent living at discharge. Both measures, calculated on 217 patients, showed high sensitivity but low specificity. The OPS was more sensitive (96%) but slightly less specific (36%) than urinary incontinence (90% sensitivity, 39% specificity). Additionally, the authors analyzed the predictive values of the OPS categories (OPS <3.2; OPS >5.2) and continence status (continence versus incontinence). The positive predictive value of OPS scores <3.2 was 100% for discharge home and for OPS scores >5.2 was 82% for discharge to an institutional center. Continence status showed lower predictive values.

Lai et al. (1998) examined, in 184 individuals, whether the OPS and the National Institute of Health Stroke Scale – NIHSS (Brot et al., 1989) measured at admission to hospital were able to predict SF-36 (Ware & Sherbourne, 1992) and the Barthel Index (Mahoney & Barthel, 1965) scores at 1, 3 and 6 months post stroke. Predictive validity was analyzed using linear regression. The OPS, compared with the NIHSS, explained more variance for both measures at all times taken, suggesting that the OPS was a better predictor of physical function as measured by the SF-36 and ADL as measured by the Barthel Index.

Studenski, Wallace, Duncan, Rymer and Lai (2001) assessed the ability of the OPS, measured in 413 clients, 3-to-14 days post stroke, to predict functional recovery rate at 3 and 6 months. Functional recovery rate was measured by independence levels in personal care, meal preparation, medication administration and mobility in the community. The predictive validity of OPS cut-offs <2.4 and >4.4 was calculated using Receiver Operating Characteristic (ROC) curves. At 3 months the percentage of patients correctly classified according to their functional recovery rate was adequate (AUC = 0.80-0.86). At 6 months the predictive validity was adequate but the percentage of patients correctly classified according to their functional recovery rate was slightly lower. At six months the area under the ROC curve for the 4 outcomes ranged from 0.74 to 0.80.

Pittock, Meldrum, Ni Dhuill, Hardiman and Moroney (2003) evaluated the predictive validity of the OPS in 117 individuals by comparing the results of the OPS at 2 and 14 days after stroke with that of the Rivermead Motor Assessment (Lincoln & Leadbitter, 1979); the Oxford Handicap Scale (Bamford, Sandercock, Warlow, & Slattery, 1989); Barthel Index (Mahoney & Barthel, 1965) and length of stay at 6 and at 24 months by use of Spearman’s Rank Correlation. Correlations between both scores of the OPS (day 2 and day 14) and all outcome measures were excellent at 6 months and adequate at 24 months. These results suggest that the OPS measured within the first 2 weeks after stroke is able to predict motor performance, disability level, ADL and length of stay, especially at 6 months. This study also examined the predictive values, sensitivity and specificity for OPS scores <3.2 and >5.2 in predicting independence and death at 6 months. Scores <3.2 measured at day 2 showed a positive predictive value of 87%, sensitivity of 85%, specificity of 85%, and negative predictive value of 84%. This same cut-off (<3.2) when measured at 2 weeks showed very high positive predictive value (92%) and sensitivity (92%), adequate negative predictive value (84%) and specificity (63%). OPS scores >5.2 at day 2 and day 14 demonstrated high positive predictive values (93%; 100%) and specificity (97%; 100%), adequate negative predictive values (68%; 68%) and low sensitivity (48%; 35%).

Meldrum, Pittock, Hardiman, Ni Dhuill, O’Regan and Moroney (2004) examined, in 114 patients, whether the OPS, Rivermead Motor Assessment arm scores to measure upper limb function (Lincoln & Leadbitter, 1979), Grip Strength (Mathiowetz, Kashman, Volland, Weber, Dowe, & Rogers, 1985), age, and arm sensation, measured at day 2 post-stroke were adequate predictors of upper limb function at 6 and 24 months. The predictive validity of the OPS was calculated using Spearman’s Rank Correlation and logistic regression analyses. The highest correlation was found between the OPS and upper limb function at 6 months (rho = -0.73) and 24 months (rho = -0.71). Logistic regression analyses revealed that the best predictor of upper limb function at 6 months was the OPS and arm sensation. The only predictor of upper limb function at 24 months was arm sensation.

Wright et al. (2004) studied 277 clients with stroke to identify whether the OPS and the National Institute of Health Stroke Scale – NIHSS (Brott et al., 1989) were able to predict discharge destination. The NIHSS was measured day 1 post-stroke and the OPS at day 7. The predictive validity was calculated by use of logistic regression and Receiver Operating Characteristic (ROC) curves. In the regression model, both prognostic measures were significant predictors of place of discharge. When analyzing the area under the ROC curve (AUC) the percentage of patients correctly classified according to their discharge destination was adequate using OPS cut-offs <3 and >5 (AUC = 77%) and NIHSS cut-offs (<5; 6-10; 11-15; 16-20; >20) (AUC = 0.81). The specificity of the OPS for the outcome discharge destination was high at 87.7% and even higher for the NIHSS at 97.7%.

Rieck and Moreland (2005) examined, in 81 clients, whether the OPS, measured at 7 and 14 days post-stroke, was able to predict the number of follow-up services at discharge. When analyzing the OPS as a predictor of discharge destination (home versus institution) the OPS score at day 14 showed higher sensitivity (84%) and specificity (42%) than scores at day 7 (sensitivity = 82%; specificity = 25%). The positive predictive value of the OPS scores <3.0 and =3.0-5.0 at predicting discharge home was 81% and 50%, respectively. The positive predictive value of the OPS cut-off >5.0 at predicting discharge to an institution was 68%.

Hershkovitz, Gottlieb, Beloosesky and Brill (2006) assessed the predictive validity of the OPS in 103 individuals by comparing the results of the OPS measured at admission to a rehabilitation program (4-to-12 weeks post-stroke) with discharge scores (on average, 6 weeks after admission) on the Functional Independence Measure (Keith, Granger, Hamilton, & Sherwin, 1987); the Nottingham Extended ADL Index (Nouri & Lincoln, 1987) and the Timed Up and Go (Podsiadlo & Richardson, 1991). Correlations were calculated using Spearman’s Rank Correlation. Excellent correlations were found between the OPS and the Functional Independence Measure (rho = -0.73) and the Nottingham Extended ADL Index (rho = -0.67). The correlation between the OPS and the Timed Up and Go was adequate (rho = -0.44). These results indicated that the OPS, measured 4-to-12 weeks post-stroke, was able to predict function six weeks later as measured by the Functional Independence Measure and the Nottingham Extended ADL Index scores.

Celik, Aksel and Karaoglan (2006) analyzed whether the OPS and the National Institute of Health Stroke Scale – NIHSS (Brott et al., 1989) measured on the seventh day post-stroke predicted Barthel Index (Mahoney & Barthel, 1965) scores at 1,3 and 6 months. The predictive validity was calculated using logistic regression analyses. The OPS (R²1 month=0.58; R²3months = 0.41; R²6months = 0.38) compared to the NIHSS (R²1month = 0.50; R²3months = 0.23; R²6months = 0.20), explained more variance in the regression model at all times. Thus, the OPS was found to be a better predictor of function as measured using the Barthel Index than the NIHSS at all 3 points.

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.
  • Brott, T. G., Adams, H. P., Olinger, C. P., Marler, J. R., Barsan, W. G., Biller, J., Spilker, J., Holleran, R., Eberle, R., Hertzberg, V., Rorick, M., Moomaw, C. J., Walker, M. (1989). Measurements of acute cerebral infarction: a clinical examination scale. Stroke, 20, 864 -70.
  • Celik, C., Aksel, J., & Karaoglan, B. (2006). Comparison of the Orpington Prognostic Scale (OPS) and the National Institutes of Health Stroke Scale (NIHSS) for the prediction of the functional status of patients with stroke. Disability and Rehabilitation, 28(10), 609-612.
  • Hershkovitz A., Gottlieb, D., Beloosesky, Y., & Brill, S. (2006). Assessing the potential for functional improvement of stroke patients attending a geriatric day hospital. Archives of Gerontology and Geriatrics, 43, 243-248.
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  • Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: normative data for adults. Archives of Physical and Medicine and Rehabilitation, 66, 69-72.
  • Meldrum, D., Pittock, S.J., Hardiman, O., Ni Dhuill, C., O’Regan M., & Moroney, J.Y. (2004). Recovery of the upper limb post ischemic stroke and the predictive value of the Orpington Prognostic Score. Clin Rehabil, 18, 694-702.
  • Nouri, F. M., Lincoln, N. B. (1987). An extended activities of daily living scale for stroke patients. Clin Rehab, 1, 301-305.
  • Pittock, S.J., Meldrum, D., Ni Dhuill, C., Hardiman, O., & Moroney, J.T. (2003). The Orpington Prognostic Scale within the First 48 hours of Admission as a Predictor of Outcome in Ischemic Stroke. Journal of Stroke and Cerebrovascular Diseases, 12(4), 175-181.
  • Podsiadlo, E., Richardson, S. (1991). The Timed ‘Up & Go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc, 39, 142-148.
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  • Rieck, M., & Moreland, J. (2005). The Orpington Prognostic Scale for patients with stroke: Reliability and pilot predictive data for discharge destination and therapeutic services. Disability and Rehabilitation, 27(23), 1425-1433.
  • Studenski, S.A., Wallace, D., Duncan, P.W., Rymer, M., & Lai, S.M. (2001). Predicting Stroke Recovery: Three- and Six- Month Rates of Patient Centered Functional Outcomes Based on the Orpington Prognostic Scale. JAGS, 49, 308-312.
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  • Weir, N.U., Counsell, C.E., McDowall, M.,Gunkel, A.,& Dennis, M.S. (2003). Reliability of the variables in a new set of models that predict outcome after stroke. J Neurol Neurosurg Psychiatry, 74, 447 – 451.
  • Wright, C.J., Swinton, L.C., Green, H.. (2004). Predicting Final Disposition after Stroke using the Orpington Prognostic Score. Can. J. Neurol. Sci., 31, 494-498.

See The Measure

How to obtain the OPS?

The OPS can be obtained from its original publication: Kalra and Crome (1993). The following publications also present a description of the full tool : Lai et al., (1998); Pittock et al., (2003); Rieck & Moreland (2005); Wright et al., (2004).

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