J Clin Neurol.  2012 Sep;8(3):177-183. 10.3988/jcn.2012.8.3.177.

Validity and Reliability of a Korean Version of the National Institutes of Health Stroke Scale

• Oh MS
• Yu KH
• Lee JH
• Jung S
• Ko IS
• Shin JH
• Cho SJ
• Choi HC
• Kim HH
• Lee BC

• KMID: 2287588
• DOI: http://doi.org/10.3988/jcn.2012.8.3.177

Abstract

BACKGROUND AND PURPOSE
The National Institutes of Health Stroke Scale (NIHSS) is a clinical assessment tool that is widely used in clinical trials and practice to evaluate stroke-related neurological deficits. The aim of this study was to determine the validity and reliability of the Korean version of the NIHSS (K-NIHSS) for evaluating Korean stroke patients.
METHODS
The K-NIHSS was translated and adapted with regard to cultural and linguistic peculiarities. To examine its content validity, we quantified the Content Validity Index (CVI), which was rated by 11 stroke experts. The validity of the K-NIHSS was assessed by comparison with the Glasgow Coma Scale (GCS), the modified Rankin Scale (mRS), and the Barthel Index. The reliability of the K-NIHSS was evaluated using the unweighted kappa statistics for multiple raters and an intraclass correlation coefficient (ICC).
RESULTS
The CVI of the K-NIHSS reached 0.91-1.00. The median K-NIHSS score at baseline was 3 (interquartile range, 2-7), and the mean+/-SD score was 6.0+/-6.6. The baseline K-NIHSS had a significantly negative correlation with the GCS at baseline and the Barthel Index after 90 days. The K-NIHSS also had a significantly positive correlation with the mRS after 90 days. Facial paresis and dysarthria had moderate interrater reliability (unweighted kappa, 0.41-0.60); kappa values were substantial to excellent (unweighted kappa, >0.60) for all the other items. The ICC for the overall K-NIHSS score was 0.998. The intrarater reliability was acceptable, with a median kappa range of 0.524-1.000.
CONCLUSIONS
The K-NIHSS is a valid and reliable tool for assessing neurological deficits in Korean acute stroke patients.

Keyword

NIH Stroke Scale; validity; reliability

MeSH Terms

Dysarthria
Facial Paralysis
Glasgow Coma Scale
Humans
Linguistics
National Institutes of Health (U.S.)
Reproducibility of Results
Stroke

Reference

1. Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol. 1989. 46:660–662.

2. Albanese MA, Clarke WR, Adams HP Jr, Woolson RF. Ensuring reliability of outcome measures in multicenter clinical trials of treatments for acute ischemic stroke. The program developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Stroke. 1994. 25:1746–1751.

3. Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC, McGarvey ML, et al. Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke. 1999. 30:1534–1537.

4. Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999. 53:126–131.

5. Lyden P, Brott T, Tilley B, Welch KM, Mascha EJ, Levine S, et al. NINDS TPA Stroke Study Group. Improved reliability of the NIH Stroke Scale using video training. Stroke. 1994. 25:2220–2226.

6. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke. 1997. 28:307–310.

7. Lyden P, Raman R, Liu L, Grotta J, Broderick J, Olson S, et al. NIHSS training and certification using a new digital video disk is reliable. Stroke. 2005. 36:2446–2449.

8. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004. 363:768–774.

9. Lyden P, Lu M, Jackson C, Marler J, Kothari R, Brott T, et al. NINDS tPA Stroke Trial Investigators. Underlying structure of the National Institutes of Health Stroke Scale: results of a factor analysis. Stroke. 1999. 30:2347–2354.

10. Lyden PD, Lu M, Levine SR, Brott TG, Broderick J. NINDS rtPA Stroke Study Group. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke. 2001. 32:1310–1317.

11. Schlegel D, Kolb SJ, Luciano JM, Tovar JM, Cucchiara BL, Liebeskind DS, et al. Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke. 2003. 34:134–137.

12. Lyden P, Raman R, Liu L, Emr M, Warren M, Marler J. National Institutes of Health Stroke Scale certification is reliable across multiple venues. Stroke. 2009. 40:2507–2511.

13. Nilanont Y, Phattharayuttawat S, Chiewit P, Chotikanuchit S, Limsriwilai J, Chalernpong L, et al. Establishment of the Thai version of National Institute of Health Stroke Scale (NIHSS) and a validation study. J Med Assoc Thai. 2010. 93:Suppl 1. S171–S178.

14. Sun TK, Chiu SC, Yeh SH, Chang KC. Assessing reliability and validity of the Chinese version of the stroke scale: scale development. Int J Nurs Stud. 2006. 43:457–463.

15. Domínguez R, Vila JF, Augustovski F, Irazola V, Castillo PR, Rotta Escalante R, et al. Spanish cross-cultural adaptation and validation of the National Institutes of Health Stroke Scale. Mayo Clin Proc. 2006. 81:476–480.

16. Cincura C, Pontes-Neto OM, Neville IS, Mendes HF, Menezes DF, Mariano DC, et al. Validation of the National Institutes of Health Stroke Scale, modified Rankin Scale and Barthel Index in Brazil: the role of cultural adaptation and structured interviewing. Cerebrovasc Dis. 2009. 27:119–122.

17. 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. 40:2557–2559.

18. Kang Y, Kim H, Na DL. Parallel short forms for the Korean-Boston Naming Test (K-BNT). J Korean Neurol Assoc. 2000. 18:144–150.

19. Waltz CF, Bausell RB. Nursing Research: Design, Statistics, and Computer Analysis. 1981. Philadelphia: Davis.

20. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986. 35:382–385.

21. Rowley G, Fielding K. Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet. 1991. 337:535–538.

22. Fischer J, Mathieson C. The history of the Glasgow Coma Scale: implications for practice. Crit Care Nurs Q. 2001. 23:52–58.

23. Wilson JT, Hareendran A, Hendry A, Potter J, Bone I, Muir KW. Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview. Stroke. 2005. 36:777–781.

24. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965. 14:61–65.

25. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2000. 2nd ed. Upper Saddle River: Prentice Hall Health;560–567.

26. Fleiss JL. Statistical Methods for Rates and Proportions. 1981. 2nd ed. New York: John Wiley & Sons.

27. Siegel S, Castellan NJ. Nonparametric Statistics for the Behavioral Sciences. 1988. 2nd ed. New York: McGraw-Hill.

28. Cheung RT, Lyden PD, Tsoi TH, Huang Y, Liu M, Hon SF, 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. 5:74–79.

29. Landis JR, Koch GG. An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics. 1977. 33:363–374.

30. Shoukri MM. Measures of Interobserver Agreement. 2004. Boca Raton: Chapman and Hall/CRC.

31. Lee KM, Jang YH, Kim YH, Moon SK, Park JH, Park SW, et al. Reliability and validity of Korean version of National Institutes of Health Stroke Scale: multi-center study. J Korean Acad Rehabil Med. 2004. 28:422–435.

32. Hills NK, Josephson SA, Lyden PD, Johnston SC. Is the NIHSS certification process too lenient? Cerebrovasc Dis. 2009. 27:426–432.

33. Schmülling S, Grond M, Rudolf J, Kiencke P. Training as a prerequisite for reliable use of NIH Stroke Scale. Stroke. 1998. 29:1258–1259.

34. Dewey HM, Donnan GA, Freeman EJ, Sharples CM, Macdonell RA, McNeil JJ, et al. Interrater reliability of the National Institutes of Health Stroke Scale: rating by neurologists and nurses in a community-based stroke incidence study. Cerebrovasc Dis. 1999. 9:323–327.