The NIHSS supplementary motor scale: a valid tool for multidisciplinary recovery trials.
BACKGROUND
There is a growing interest in therapies that may augment motor recovery that could be initiated in the acute stroke unit and maintained through the rehabilitation period. Homogenization of the currently fragmented stroke clinicometrics is necessary before such multidisciplinary trials can be conducted. The supplementary motor scale of the NIH Stroke Scale (SMS-NIHSS) is a simple and reliable scale for assessing proximal and distal motor function in the upper and lower extremities. We hypothesized that the currently underutilized SMS-NIHSS is a valid tool for assessing motor recovery with prognosticative value.


METHODS
We performed an analysis of SMS-NIHSS scores recorded in 1,281 patients enrolled in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). We plotted the probability of a favorable outcome (FO) and very favorable outcome (VFO) at 3 months based on the baseline SMS-NIHSS scores. In order to better study the relationship between SMS-NIHSS and 3-month functional outcome, we performed multivariate logistic regression analyses using both FO and VFO as outcome measures. Analyses were adjusted for potential confounders such as age, sex, side of the lesion, time from symptom onset to emergency room arrival, temperature, systolic blood pressure, blood glucose level and treatment group assignment (ORG 10172 vs. placebo). We also calculated the Spearman correlation coefficient between the SMS-NIHSS, Barthel Index (BI) and Glasgow Outcome Score (GOS) obtained at the 3-month visit.


RESULTS
The mean SMS-NIHSS scores were 8.18 at baseline and 4.68 at 3 months. The SMS-NIHSS scores showed a gradual improvement during the first 3 months after stroke. There was a linear relationship between the baseline SMS-NIHSS scores and the probability of an FO or VFO at 3 months. The SMS-NIHSS baseline score was an independent predictor of FO (OR = 0.86; 95% CI 0.84-0.87; p < 0.0001) and VFO (OR = 0.85; 95% CI 0.84-0.87; p < 0.0001) at 3 months after adjusting for confounders. The degree of improvement in the SMS-NIHSS scores from baseline to 3 months was also independently associated with FO and VFO (p < 0.0001). At 3 months, SMS-NIHSS scores showed a strong correlation with the BI (r = -0.70; p < 0.0001) and GOS (r = 0.73; p < 0.0001).


CONCLUSIONS
The SMS-NIHSS is a valid scale for assessing motor recovery with prognosticative value, and may be sensitive to changes during recovery. Given that the SMS-NIHSS is an extension of the widely accepted NIHSS, it could be easily implemented in trials conducted in a variety of clinical research settings, including acute stroke hospitals and rehabilitation units.
Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
Enrique C
EC
Leira
Christopher S
CS
Coffey
Ricardo E
RE
Jorge
Susanne M
SM
Morton
Michael T
MT
Froehler
Patricia H
PH
Davis
Harold P
HP
Adams
D000208:Acute Disease; D000925:Anticoagulants / Q000627:therapeutic use; D001925:Brain Damage, Chronic / Q000209:etiology / Q000503:physiopathology; D002545:Brain Ischemia / Q000188:drug therapy / Q000534:rehabilitation; D002809:Chondroitin Sulfates / Q000627:therapeutic use; D002986:Clinical Trials as Topic / Q000706:statistics & numerical data; D015986:Confounding Factors, Epidemiologic; D003871:Dermatan Sulfate / Q000627:therapeutic use; D005260:Female; D023261:Glasgow Outcome Scale; D006497:Heparan Sulfate / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009043:Motor Activity; D009069:Movement Disorders / Q000209:etiology / Q000503:physiopathology*; D015337:Multicenter Studies as Topic / Q000706:statistics & numerical data; D011379:Prognosis; D020127:Recovery of Function; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications; D000071939:Stroke Rehabilitation; D016896:Treatment Outcome
D000925:Anticoagulants; D002809:Chondroitin Sulfates; D003871:Dermatan Sulfate; D006497:Heparan Sulfate; C035838:danaparoid