Stroke Assessment Scales Overview

Taken from “Post-Stroke Rehabilitation: Assessment, Referral, and Patient Management Quick Reference Guide Number 16” published by the US Agency for Health Care Policy and Research.

Type Name and Source Approximate Time to Administer Strengths Weaknesses
Level-of-consciousness scale Glasgow Coma Scale [a] 2 minutes Simple, valid, reliable. None observed.
Stroke deficit scales NIH Stroke Scale [b] 2 minutes Brief, reliable, can be administered by non-neurologists. Low sensitivity.
Canadian Neurological Scale [c] 5 minutes Brief, valid, reliable. Some useful measures omitted.
Global disability scale Rankin Scale [d, e] 5 minutes Good for overall assessment of disability. Walking is the only explicit assessment criterion. Low sensitivity.
Measures of disability/activities of daily
living (ADL)
Barthel Index [f] 5-10 minutes Widely used for stroke. Excellent validity and reliability. Low sensitivity for high-level functioning.
Functional Independence Measure
(FIM) [g]
40 minutes Widely used for stroke.  Measures
mobility, ADL, cognition, functional communication.
“Ceiling” and “floor”
Mental status screening Folstein Mini-Mental State Examination [h] 10 minutes Widely used for screening. Several functions with summed score. May
misclassify patients with aphasia.
Cognition Status Exam (NCSE) [i]
10 minutes Predicts gain
in Barthel Index scores.  Unrelated to age.
Does not distinguish
right from left hemisphere. No reliability studies in stroke.
No studies of factorial structure. Correlates with  education.
Assessment of motor function Fugl-Meyer [j] 30-40 minutes Extensively evaluated measure. Good validity and reliability
for assessing sensorimotor function and balance.
Considered too complex and time-consuming by many.
Motor Assessment Scale [k] 15 minutes Good, brief assessment of movement
and physical mobility.
Reliability assessed only in stable
patients. Sensitivity not tested.
Motricity Index [l] 5 minutes Brief assessment of motor function
of arm, leg, and trunk.
Sensitivity not tested.
Balance assessment Berg Balance Assessment [m] 10 minutes Simple, well established with stroke patients,
sensitive to change.
None observed.
Mobility assessment Rivermead Mobility Index [n] 5 minutes Valid, brief, reliable test of physical mobility. Sensitivity not tested.
Assessment of speech and
language functions
Boston Diagnostic
Aphasia Examination [o]
1-4 hours Widely used, comprehensive,
good  standardization data, sound theoretical rationale.
Time to administer
long; half of patients cannot be classified.
Porch Index of
Communicative Ability (PICA) [p]
1/2-2 hours Widely used, comprehensive,
careful test development and standardization.
Time to administer
long. Special training required to administer. Inadequate sampling
of language other than one word and single sentences.
Western aphasia
Battery [q]
1-4 hours Widely used, comprehensive. Time to administer
long. “Aphasia quotients” and “taxonomy”
of aphasia not well validated.
Depression scales Beck Depression Inventory (BDI) (BDI) [r] 10 minutes Widely used, easily administered. Norms available.  Good
with somatic symptoms.
Less useful in elderly and in patients with aphasia or neglect.High
rate of false positives.  Somatic items may not be due
to depression.
Center for Epidemiologic Studies
Depression (CES-D) [s]
< 15 minutes Brief, easily administered, useful
in elderly, effective for screening in stroke population.
Not appropriate for aphasic patients.
Geriatric Depression Scale (GDS)
10 minutes Brief, easy to use with elderly,
cognitively impaired, and those with visual or physical problems
or low motivation.
High false negative rates in minor
Hamilton Depression Scale [u] < 30 minutes Observer rated; frequently used
in stroke patients.
Multiple differing versions compromise
interobserver reliability.
Quick Inventory of Depressive Symptomatology (QIDS) 5-10 minutes Good internal consistency, correlates significantly with clinician ratings of depression severity, and is sensitive to change
Measures of instrumental
PGC Instrumental Activities of Daily Living
5-10 minutes Measures broad base of information necessary
for independent living.
Has not been tested in stroke patients.
Frenchay Activities
Index [w]
10-15 minutes Developed specifically
for  stroke patients; assesses broad array of activities.
Sensitivity and
interobserver reliability not tested; sensitivity probably limited.
Family assessment Family Assessment Device (FAD) [x] 30 minutes Widely used in stroke. Computer scoring available. Excellent
validity and reliability. Available in multiple languages.
Assessment subjective; sensitivity not tested; “ceiling”
and “floor” effects.
Health status/ quality of
life measures
Medical Outcomes Study (MOS) 36-Item Short-Form
Health Survey [y]
10-15 minutes Generic health status scale SF36 is improved
version of SF20. Brief, can be self – administered or administered
by phone or interview. Widely used in the United States.
Possible “floor” effect in seriously
ill patients (especially for physical functioning), suggests
it should be supplemented by an ADL scale in  stroke patients.
Sickness Impact
Profile (SIP) [z]
20-30 minutes Comprehensive
and well-evaluated. Broad range of items reduces “floor”
or “ceiling” effects.
Time to administer
somewhat long. Evaluates behavior rather than subjective health;
needs questions on well-being, happiness, and satisfaction.
[a] Teasdale G, Jennett B.

Assessment of coma and impaired consciousness: a practical scale. Lancet 1974;2:81-3.
Teasdale G, Murray G, Parker L, Jennett B. Adding up the Glasgow Coma Scale. Acta Neurochir 1979; Suppl 28:13-6.

[b] Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, Rorick M, Moomaw CJ, Walker M.

Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20:864-70.

[c] Cote R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C.

The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke 1986; 17:731-7.

[d] Rankin J.

Cerebral vascular accidents in patients over the age of 60. Scott Med J 1957;2:200-15.

[e] Modification of Rankin Scale: Bonita R, Beaglehole R.

Recovery of motor function after stroke. Stroke 1988 Dec;19(12):1497-1500.

Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19(5):604-7.

[f] Mahoney FI, Barthel DW.

Functional evaluation: the Barthel Index. Maryland State Med J 1965;14:61-5.

Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 1988;10(2):64-7.

[g] Guide for the uniform data set for medical rehabilitation (Adult FIM), version 4.0 Buffalo, NY 14214: State University of New York at Buffalo; 1993.

Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwin FS. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1(3):59-74. Granger CV, Hamilton BB, Sherwin FS. Guide for the use of the uniform data set for medical rehabilitation. Uniform Data System for Medical Rehabilitation Project Office, Buffalo General Hospital, NY; 1986. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence measure: a new tool for rehabilitation. In: Eisenberg MG, Grzesiak RC (ed.). Advances in clinical rehabilitation volume 1. New York: Springer-Verlag; 1987. p. 6-18.

[h] Folstein MF, Folstein SE, McHugh PR.

“Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975 Nov;12(3):189-98.

[i] Kiernan RJ, Mueller J, Langston JW, Van Dyke C.

The Neurobehavioral Cognitive Status Examination: a brief but differentiated approach to cognitive assessment. Ann Intern Med 1987;107:481-5.

[j] Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S.

The post stroke hemiplegic patient. I. A method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31.

[k] Carr JH, Shepherd RB, Nordholm L, Lynne D.

Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985 Feb;65(2):175-80.
Poole JL, Whitney SL. Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys Med Rehabil 1988 Mar;69(3 Pt 1):195-7.

[l] Collin C, Wade D.

Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry 1990 Jul;53(7):576-9.
Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol 1980;19(6):382-9.

[m] Berg K, Maki B, Williams JI, Holliday P, Wood-Dauphinee S.

Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil 1992;73:1073-83.
Berg K, Wood- Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989;41:304-11.

[n] Collen FM, Wade DT, Robb GF, Bradshaw CM.

The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. Int Disabil Stud 1991;13:50-4.
Wade DT, Collen FM, Robb GP, Warlow CP. Physiotherapy intervention late after stroke and mobility. BMJ 1992 Mar 7;304(6827):609-13.

[o] Goodglass H, Kaplan E.

The assessment of aphasia and related disorders. Philadelphia: Lea and Febiger; 1972. Chapter 4, Test procedures and rationale. Manual for the BDAE. Goodglass H, Kaplan E. Boston Diagnostic Aphasia Examination (BDAE). Philadelphia: Lea and Febiger; 1983.

[p] Porch B.

Porch Index of Communicative Ability (PICA). Palo Alto: Consulting Psychologists Press; 1981.

[q] Kertesz A.

Western Aphasia Battery. New York: Grune & Stratton; 1982.

[r] Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J.

An inventory for measuring depression. Arch Gen Psychiatry 1961 June;4:561-71. Beck AT, Steer RA. Beck Depression Inventory: manual (revised edition). NY Psychological Corporation; 1987.

[s] Radloff LS.

The CES-D scale: a self-report depression scale for research in the general population. J Appl Psychol Meas 1977;1:385-401.

[t] Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO.

Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982-83;17(1):37-49.

[u] Hamilton M.

A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967;6:278- 96.

[v] Lawton MP.

Assessing the competence of older people. In: Kent D, Kastenbaum R, Sherwood S (ed.). Research planning and action for the elderly, New York: Behavioral Publications;1972.

[w] Holbrook M, Skilbeck CE.

An activities index for use with stroke patients. Age Ageing 1983 May;12(2):166-70.

[x] Epstein NB, Baldwin LM, Bishop DS.

The McMaster Family Assessment Device. J Marital and Fam Ther 1983 Apr;9(2):171-80.

[y] Ware JE, Sherbourne CD.

The MOS 36-Item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care 1992 Jun;30(6):473-83.

[z] Bergner M, Bobbitt RA, Carter WB, et al.

The Sickness Impact Profile: development and final revision of a health status measure. Med Care 1981; 19:787-805.
Instrument is available from the Health Services Research and Development Center, The Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, Baltimore, MD 21205.

NoteADL = activities of daily living. IADL = instrumental activities of daily living.

Other useful instruments for measuring disability/ADL include the following:

Katz Index of ADL. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW.

Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963 Sep 21:914-9.

Kenny Self-Care Evaluation. Schoening HA, Iversen IA.

Numerical scoring of self-care status: a study of the Kenny Self-Care Evaluation.
Arch Phys Med Rehabil 1968 Apr;49(94):221-9.

LORS/LAD. Carey RG, Posavac EJ.

Program evaluation of a physical medicine and rehabilitation unit: a new approach.
Arch Phys Med Rehabil 1978 Jul;59(7):330-7.

PECS. Harvey RF, Jellinek HM.

Functional performance assessment: a program approach.
Arch Phys Med Rehabil 1981;62:456-61.

Another useful instrument for assessing mental status is Motor Impersistence. Ben-Yishay Y, Diller L, Gerstman L, Haas A.

The relationship between impersistence, intellectual function and outcome of rehabilitation in patients with left hemiplegia.
Neurology 1968 Sep;18(9):852-61.

Another useful instrument for assessing depression is the Zung Scale. Zung WK.
A self-rating depression scale. Arch Gen Psychiatry 1965 Jan;12:63-70.

Other useful instruments for measuring IADL include:

OARS: Instrumental ADL. Duke University Center for the Study of Aging and Human Development.

Multidimensional functional assessment: the OARS methodology. Durham, NC: Duke University; 1978.

Functional Health Status. Rosow I, Breslau N.

A Guttman health scale for the aged.
J Gerontol 1966;21(4):556-9.