NIHSS scoring in practice: limb movement and ataxia, listen to what the experts say?

*For medical professionals only to read these details to know! The 2022 International Stroke Conference (ISC 2022) specially set up the National Institutes of Health Stroke Scale (NIHSS) scoring training topic to introduce some specific precautions in the application of the NIHSS score, which has been released Issue 2: After so many years, have you used your NIHSS score correctly? ｜2022 ISC gaze, visual field defect, see how international experts use NIHSS score NIHSS score includes assessment of limb movement and ataxia
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The importance of limb movement assessment is self-evident, but the assessment of ataxia is often overlooked
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Professor Laurie Schluter brings training on limb movement and ataxia assessment
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Ataxia Assessment - NIHSS Deficiencies First, we need to understand that the NIHSS has some deficiencies, namely, its poor assessment of posterior circulation stroke
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In the NIHSS score, the evaluation of posterior circulation stroke is mainly reflected in the ataxia score, which ranges from 0 to 2 points, that is, if the patient has ataxia, the highest score is only 2 points
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In contrast, if one side of the upper and lower limbs is hemiplegia, the highest score can reach 8 points
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A lower score setting for ataxia is prone to misjudge the severity of the disease, and the ataxia score only evaluates limb ataxia, not trunk ataxia
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Therefore, the speaker emphasized that the NIHSS score is only a part of the neurological examination, and a detailed neurological examination is still very necessary
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Using the NIHSS score, the limb movement (muscle strength) score should be used first, and then the ataxia score should be used on this basis
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Limb movement score NIHSS score When assessing limb movement, attention should be paid to the lifting angle and lifting time
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Items 5 and 6 are upper extremity motor scores, and the patient is asked to place the upper extremity in a suitable position
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In the supine position, you should lift at least 45°
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If sitting, lift at least 90°
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Hold time should be 10 seconds
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Items 7 and 8 are lower extremity motor scores.
The patient is asked to raise the lower extremity in a supine position, with a lifting angle of at least 30 degrees, and the adherence time should be 5 seconds
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In the NIHSS score, the range of the upper and lower limb movements on each side is 0-4 points, and the letter X (the domestic record number 9) is recorded in special cases, as shown in Figure 1
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Figure 1 NIHSS Score Limb Movement Score (Adapted from Speaker PPT) Ataxia Score Ataxia, the English word ataxia, is of Greek origin and means lack of order
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Checking for ataxia in the NIHSS score was done with the finger-nose test and the heel-knee-shin test
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Finger-nose test, ask the patient to stretch out the upper limb and use the index finger to touch the examiner's index finger first, and then touch the patient's own nose
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In patients with unilateral cerebellar lesions, the ipsilateral limb will exhibit intentional tremor when approaching the target
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This tremor is caused by overshooting or undershooting of the patient's index finger due to uncoordinated movements
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For the heel-knee-shin test, the patient lifts one lower limb, bends the knee so that the heel is placed on the knee first, and then slides down from the proximal end to the distal end against the tibia until it reaches the ankle
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If there is a unilateral cerebellar lesion, the patient will not be able to slide down the tibia in a straight line, and will shake as it slides down
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The precautions for ataxia examination are as follows: (1) When examining the upper extremity, the patient should fully extend the upper extremity, that is, the elbow joint should be extended
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(2) Patients should open their eyes for examination
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(3) If there is a visual field defect, make sure that the examination is performed within the visual field that the patient can see
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(4) If the patient is blind, ask the patient to point to the nose from the outstretched arm position
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(5) Not all tremors are ataxia, and attention should be paid to the identification
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(6) Both limbs should be checked
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If in doubt, check at least twice
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The ataxia score in the NIHSS score is shown in Figure 2
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Figure 2 NIHSS Ataxia Score (Speaker PPT) Ataxia or Paresis? Sometimes, ataxia and paresis can be difficult to differentiate
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The main difference between the two is that ataxia affects coordination but not muscle strength; paralysis only affects muscle strength
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Note the sequence of examinations, and score ataxia only if there is a disproportionate decrease in muscle strength
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The following few suggestions will help determine whether it is ataxia or paresis
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(1) If there is a stroke site shown by imaging, the localization will help to distinguish the two
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(2) If the patient has details such as tilting to one side, it may be ataxia
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(3) Ask the patient to hold the examiner with both hands at the same time to feel the muscle strength on both sides of the patient
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(4) Whether there are signs of hemiplegia on the ipsilateral limb or face, if so, it is more likely to be paralysis
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(5) Detailed examination of the patient can also help to judge, ask the patient to feel uncoordinated, clumsy, or feel weak
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Finally, the speaker emphasized that the NIHSS score is an evaluation tool for neurological examination, and the basic information of the patient should be paid attention to when using it
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For example, some patients have underlying diseases, and these underlying diseases themselves may have symptoms of ataxia.
At this time, the detection of ataxia does not necessarily point to ataxia caused by stroke
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