Letter to the editor National Institutes of Health Stroke Scale object naming test in a non-American Englishspeaking population Dear editor, The National Institutes of Health Stroke Scale (NIHSS) has become a standard means of assessing neurological impairment following stroke (1,2). The object naming component uses line drawings of a key, chair, glove, feather, hammock and cactuses to detect nominative aphasia. It is acknowledged that many people struggle to recognize some items. So many of our patients, although English-speaking like the original American derivation population, have difficulties with some items that we decided to perform a study to determine the generalizability of the test and to develop strategies to improve test performance. One hundred twenty-five nonaphasic, cognitively intact volunteers were shown each of the line drawings in turn and asked to name them. They were then
Correspondence: Joseph Harbison*, St James’s Hospital, Dublin 8, Ireland. E-mail: [email protected] DOI: 10.1111/ijs.12348
© 2014 World Stroke Organization
shown pictures of three further objects: an elephant, an umbrella, and a tractor. Proportion of incorrect answers was recorded. Participants were then shown photographs of the same objects to see if this improved recognition or made recognition easier. Proportions of correct identifications for each item were as follows: chair, 124 subjects (99%); key, 99%; glove, 94%; feather, 85%; cactuses, 83%; hammock, 82%; tractor, 98%; umbrella, 99%; and elephant, 99%. Subjects ≥70 years were less likely to identify the feather [9/33 (27·3%) vs. 10/92 (10·9%), P = 0·02], the cactuses (11/33 (33·3%) vs. 10/92 (10·9%), P = 0·003], and the hammock [10/33 (30·3%) vs. 12/92 (13·0%), P = 0·025]. Women were more likely to miss the feather [5/66 (7·6%) vs. 14/59 (23·7%), P = 0·02] and cactuses [7/66 (10·6%) vs. 14/59 (23·7%), P = 0·05]. Half of women >70 years (9/18) failed to identify the cactuses. Subjects reported finding recognition from photographs easier, but differences in rate of recognition were not significant. Several translations of the NIHSS, including the Italian, Chinese, Hindi, and Portuguese versions, have changed items in the object recognition test to more familiar objects. In our English-speaking population, substitution of more familiar
objects also improved performance in the test, and this should be considered in other populations. Meghan Burns1,2, Kate Somers1,2, Paul McElwaine1,2, and Joseph Harbison1,2* 1
Acute Stroke Service, St James’s Hospital, Dublin, Ireland 2 Trinity College Institute of Neurosciences, University of Dublin, Dublin, Ireland
References 1 Brott T, Adams HP Jr, Olinger CP et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20:964–70. 2 Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH Stroke Scale. Arch Neurol 1989; 46:660–2. 3 Pezzella FR, Picconi O, De Luca A, Lyden PD, Fiorelli M. Development of the Italian version of the National Institutes of Health Stroke Scale: it-NIHSS. Stroke 2009; 40:2557–9. 4 Prasad K, Dash D, Kumar A. Validation of the Hindi version of National Institute of Health Stroke Scale. Neurol India 2012; 60:40–4. 5 Cheung RT, Lyden PD, Tsoi TH et al. Production and validation of Putonghua- and Cantonese-Chinese language National Institutes of Health Stroke Scale training and certification videos. Int J Stroke 2010; 5:74–9.
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Correspondence: Joseph Harbison*, St James’s Hospital, Dublin 8, Ireland. E-mail: [email protected] DOI: 10.1111/ijs.12348
© 2014 World Stroke Organization
shown pictures of three further objects: an elephant, an umbrella, and a tractor. Proportion of incorrect answers was recorded. Participants were then shown photographs of the same objects to see if this improved recognition or made recognition easier. Proportions of correct identifications for each item were as follows: chair, 124 subjects (99%); key, 99%; glove, 94%; feather, 85%; cactuses, 83%; hammock, 82%; tractor, 98%; umbrella, 99%; and elephant, 99%. Subjects ≥70 years were less likely to identify the feather [9/33 (27·3%) vs. 10/92 (10·9%), P = 0·02], the cactuses (11/33 (33·3%) vs. 10/92 (10·9%), P = 0·003], and the hammock [10/33 (30·3%) vs. 12/92 (13·0%), P = 0·025]. Women were more likely to miss the feather [5/66 (7·6%) vs. 14/59 (23·7%), P = 0·02] and cactuses [7/66 (10·6%) vs. 14/59 (23·7%), P = 0·05]. Half of women >70 years (9/18) failed to identify the cactuses. Subjects reported finding recognition from photographs easier, but differences in rate of recognition were not significant. Several translations of the NIHSS, including the Italian, Chinese, Hindi, and Portuguese versions, have changed items in the object recognition test to more familiar objects. In our English-speaking population, substitution of more familiar
objects also improved performance in the test, and this should be considered in other populations. Meghan Burns1,2, Kate Somers1,2, Paul McElwaine1,2, and Joseph Harbison1,2* 1
Acute Stroke Service, St James’s Hospital, Dublin, Ireland 2 Trinity College Institute of Neurosciences, University of Dublin, Dublin, Ireland
References 1 Brott T, Adams HP Jr, Olinger CP et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20:964–70. 2 Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH Stroke Scale. Arch Neurol 1989; 46:660–2. 3 Pezzella FR, Picconi O, De Luca A, Lyden PD, Fiorelli M. Development of the Italian version of the National Institutes of Health Stroke Scale: it-NIHSS. Stroke 2009; 40:2557–9. 4 Prasad K, Dash D, Kumar A. Validation of the Hindi version of National Institute of Health Stroke Scale. Neurol India 2012; 60:40–4. 5 Cheung RT, Lyden PD, Tsoi TH et al. Production and validation of Putonghua- and Cantonese-Chinese language National Institutes of Health Stroke Scale training and certification videos. Int J Stroke 2010; 5:74–9.
Vol 9, October 2014, E35
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