Finding a clinical assessment scale - Physical Medicine and Rehabilitation

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Subject of the scale: Traumatic brain injury, coma, stroke

National Institutes of Health Stroke Scale (NIHSS)


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A scale enabling the initial assessment of patients having been victims of an acute ischemic cerebral-vascular incident, the objective being to associate this with a prognosis.

It can be used in carotid ischemic and vertebral-basilar incidents.

The time needed for the scale is 6 minutes and 30 seconds on average.

It is sub-divided into a total of 10 themes:

1. The level of consciousness (observed, responses to two questions, responses to two orders): each item must be noted even in acute conditions, where sometimes a complete response is impossible. The score of 3 is only applied when the patient makes no other movement than a posture reflex in response to painful stimulation. Use another order if the hands cannot be used. If the patient does not carry out the order, the tasks must be shown to him/her and it is the imitation which is evaluated (carry out one, two or no orders).

2. Oculomotor [eye movement]: ocular reflex movements can be used if the patient has a pre-existing ocular pathology or a traumatism during the incident.

3. The visual field.

4. For facial paralysis, use the Pierre Marie and Foix manoeuvre if the patient is not cooperating or shows difficulties in understanding.

5. motoricity of limbs (upper or lower limbs). The upper limb is placed in the appropriate position: arms extended (palms facing down) at 90° in a seated position, at 45° recumbent [decubitus], and for the legs at 30° while recumbent. A fall is taken into account if it happens within 10 seconds to the upper limb, and in 5 seconds for the lower limb. The aphasic patient is encouraged in a vigorous voice and by miming, but without using any nociceptive stimulation. Each limb is tested successively starting with the non-paretic arm. The score is 9 only in the case of amputation or arthrodesis of the shoulder or the hip, and the examiner must write the reason for this grading clearly.

6. Ataxia of the limbs: test the open eyes

7. sensitivity: sensitivity or a grimace for an injection when this is tested; a withdrawal reaction after nociceptive stimulation with a patient with obnubilation or aphasia.

8. language: if the patient is in a coma (item 1a = 3) the score is 3. The score of 3 is for mute patients not obeying any simple order.

9. Dysarthria: repetition of words from a list means that the patient has a maximal score. If the patient has severe aphasia, the precision of the articulation of spontaneous language can be assessed. A score of 9 is only applied if the patient has a tube inserted or if there is another physical barrier to the production of language, the examiner must provide a written explanation of this score. Don’t tell the patient that he/she is being tested.

10. Extinction or negligence. Sufficient information to identify negligence can be obtained during the previous tests.

A total score of 0 to 6 shows a light attack, from 7 to 90 a moderate one, while 20 is serious.

> Access to the scale is free

Psychometric properties:


Psychometric properties



Face validity


Content validity


Criterion validity

Concurrent validity


Predictive validity


Construct validity

Convergent validity


Divergent validity


Discriminant validity
(sensitivity and distinctiveness)



Intra-rater reliability


Inter-rater reliability

[1] [2]



Internal consistency (alpha)




General comment on reliability:

The inter-observer reproducibility has been improved by the development of an apprenticeship by video and the addition of orders [3] and has enabled evaluation of the inter-judge reproducibility with smart phones [4]. The initial score provides a more reliable prediction of the residual handicap of the patient than the other existing scales [5].

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More information:

For more details of the scale, the comments or the psychometric properties presented here, please contact Dr. François GENET :

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