Objective. To determine the National Institutes of Health Stroke Scale’s (NIHSS’s) association with upper extremity (UE) impairment and functional outcomes. Design. Secondary, retrospective analysis of randomized controlled trial data. Setting. Not applicable. Participants. 146 subjects with stable, chronic stroke-induced hemiparesis. Intervention. The NIHSS, the UE Fugl-Meyer (FM), and the Arm Motor Ability Test (AMAT) were administered prior to their participation in a multicenter randomized controlled trial. Main Outcome Measures. The NIHSS, FM, and AMAT. Results. The association between the NIHSS and UE impairment was statistically significant but explained less than 4% of the variance among UE FM scores. The association between NIHSS total score and function as measured by the AMAT was not statistically significant . Subjects scoring a “zero” on the NIHSS exhibited discernible UE motor deficits and varied scores on the UE FM and AMAT. Conclusion. While being used in stroke trials, the NIHSS may have limited ability to discriminate between treatment responses, even when only a relatively narrow array of impairment levels exists among patients. Given these findings, NIHSS use should be restricted to acute stroke studies and clinical settings with the goal of reporting stroke severity. 1. Introduction Upper extremity (UE) hemiparesis remains one of the most frequent stroke-induced impairments [1] and considerably undermines performance of valued activities. Yet, despite weeks of rehabilitation, 50% of patients retain some degree of UE weakness [2] and up to seventy percent remain unable to functionally use their paretic UEs [3] in the months after stroke. Scores on the National Institute of Health Stroke Scale [4] (NIHSS) are associated with stroke outcomes [5–7], causing the NIHSS to be recommended for determining “appropriate treatment and predicting patient outcome” [8]. However, the “functional” measures with which the NIHSS has been associated in stroke trials [7, 9, 10] (e.g., Glasgow Coma Scale; Barthel Index) do not directly assess active UE movement or functional UE activity performance. For example, the Barthel Index ascertains the level of help that a patient requires to carry out various daily activities, but not the actual level of movement that the patient exhibits or how active movements conspire to facilitate participation in valued activities. These levels of help may be related to adaptive equipment use, available care partner support, or other factors, but do not tell the user how the client has actually responded to treatment
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