Lees, K.R.

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Training and consistency in stroke assessments

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Training and Consistency in Stroke Assessments

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       Lees, K.R. (2009) Training and consistency in stroke assessments. Stroke, 40 (7). p. 2297. ISSN 0039-2499  http://eprints.gla.ac.uk/18205/  Deposited on: 18 January 2012   Enlighten – Research publications by members of the University of Glasgow http://eprints.gla.ac.uk Kennedy R. LeesTraining and Consistency in Stroke AssessmentsISSN: 1524-4628 Copyright © 2009 American Heart Association. All rights reserved. Print ISSN: 0039-2499. OnlineStroke is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514doi: 10.1161/STROKEAHA.108.5415812009, 40:2297: originally published online June 11, 2009Stroke  http://stroke.ahajournals.org/content/40/7/2297located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprintsReprints: Information about reprints can be found online at    journalpermissions@lww.com410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters   http://stroke.ahajournals.org//subscriptions/Subscriptions: Information about subscribing to Stroke is online at  at GLASGOW UNIV LIB on January 18, 2012http://stroke.ahajournals.org/Downloaded from EditorialTraining and Consistency in Stroke AssessmentsKennedy R. Lees, MD, FRCPSee related article, pages 2507–2511 and 2557–2559.Stroke is a global disease. It needs global tools for descriptionand outcome assessment, common definitions for risk fac-tors, common definitions for complications such as symptomatichemorrhage, and common investigation protocols.Research into treatments for stroke depends on enrollmentof large numbers of patients, possible only through interna-tional cooperation. Wide variation in initial stroke severityrequires us to describe the population that we enroll. TheNational Institutes of Health Stroke Scale is now the mostwidely used scale for measuring stroke severity in clinicaltrials1 and lies second only to the modified Rankin Scale forchoice as a primary end point.2 This trend to homogeneity isimportant; consistency in language is required within trialsand to interpret their results. For example, use of commonscales allowed pooling of data from the National Institute ofNeurological Diseases and Stroke, Alteplase Thrombolysisfor Acute Noninterventional Therapy in Ischemic Stroke, andEuropean Cooperative Acute Stroke Study trials to examinethe influence of onset to treatment time with alteplase.3 Itassists selection of patients for routine care through transla-tion of trial results into practice. It lets us understand trends inclinical practice, facilitating comparisons over time andacross regions.4 With clinical trial data from 10s of thousandsof patients archived by groups such as the Virtual Interna-tional Stroke Trials Archive,5 it is now possible to examinetrends in natural history, to plan selection criteria for futuretrials, and perhaps to crossvalidate trial results using data thatwere collected in a consistent manner using common tools.These benefits that accrue from use of common scalesdepend on consistency of application across raters and overtime. There will be a temptation to modify the scale toimprove reliability, by adding or omitting items, and byadjusting the weighting given to components. This should beresisted. An imperfect scale applied consistently will be moreuseful than modifications intended to improve validity orreliability. The articles by Lyden and colleagues in thisjournal6,7 provide reassurance in this respect. By demonstrat-ing that even among general (nonexpert) users, the NationalInstitutes of Health Stroke Scale can achieve good interraterreliability, Lyden at al have given further support to thechoice of National Institutes of Health Stroke Scale as thepre-eminent stroke severity rating. Pezzella and colleagues7have found that with translation into Italian, the scale canachieve similar reliability as the English version. The lowerreliability of the scale in their hands among nurses contrastswith the more extensive analysis of the English version byLyden.6 He and colleagues find that nonneurologists are justas reliable in their application of the scoring rules. Trainingcan be robustly applied across multiple venues and special-ties. This pattern appears to be consistent with other scalessuch as modified Rankin Scale.8 Of course, language formsonly a component of National Institutes of Health StrokeScale both with regard to scoring and instructions; mostly thescoring is based on observation of physical performance.Validity of the National Institutes of Health Stroke Scale inother languages thus does not guarantee that interview-basedassessments such as the modified Rankin Scale will achievesimilar consistency after translation.It would be intriguing to re-examine trials to assess theextent to which the expertise or reliability of the individualrater contributes to the variation in severity ratings, tooutcome assessments, and perhaps even to the trial conclu-sion. This must be a topic for continued effort becausedescription of patients’ baseline characteristics and outcomesplays such a crucial role in determining whom we should treatand how effective are our interventions.We should congratulate Dr Lyden and colleagues fortaking an imperfect tool and guiding its use in a way that hasmade it an invaluable part of every modern stroke trial and amandatory skill for professionals in at least one country.DisclosuresNone.References1. Quinn TJ, Dawson J, Walters MR, Lees KR. Functional outcome measuresin contemporary stroke trials. Int J Stroke. In press.2. Quinn TJ, Lees KR, Hardemark HG, Dawson J, Walters MR. Initialexperience of a digital training resource for modified Rankin Scaleassessment in clinical trials. Stroke. 2007;38:2257–2261.3. The ATLANTIS, ECASS, and NINDS rt-PA Study Group Investigators.Association of outcome with early stroke treatment: pooled analysis ofATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–774.4. Ali M, Atula S, Bath PMW, Grotta JC, Hacke W, Lyden PD, Marler JR, SaccoRL, Lees KR; for the VISTA Investigators. Stroke outcome in clinical trialpatients deriving from different countries. Stroke. 2009;40:35–40.5. Ali M, Bath PMW, Curram J, Davis SM, Diener HC, Donnan GA, Fisher M,Gregson BA, Grotta J, Hacke W, Hennerici MG, Hommel M, Kaste M, MarlerJR, Sacco RL, Teal P, Wahlgren NG, Warach S, Weir CJ, Lees KR. TheVirtual International Stroke Trials Archive. Stroke. 2007;38:1905–1910.6. Lyden P, Ramani R, Liu L, Emr M, Warren M, Marler J. NIHSS certifi-cation is reliable across multiple venues. Stroke. 2009;40:2507–2511.7. Pezzella FR, Picconi, Pezzella FR, Picconi O, De Luca A, Lyden PD,Fiorelli M. Development of the Italian version of the NIH Stroke Scale:It-NIHSS. Stroke. 2009;40:2557–2559.8. Quinn TJ, Dawson J, Lees KR, Walters MR. Variability in modifiedRankin scoring across a large cohort of international observers. Stroke.2009;40:in press.KEY WORDS: NIHSS  outcome  scalesThe opinions in this editorial are not necessarily those of the editors orof the American Heart Association.From the Department of Medicine & Therapeutics, Faculty of Medi-cine, University of Glasgow, Western Infirmary, Glasgow, UK.Correspondence to Kennedy R. Lees, University of Glasgow, Depart-ment of Medicine & Therapeutics, Western Infirmary, 44 Church Street,Glasgow G11 6NT, UK. E-mail k.r.lees@clinmed.gla.ac.uk(Stroke. 2009;40:2297.)© 2009 American Heart Association, Inc.Stroke is available at http://stroke.ahajournals.orgDOI: 10.1161/STROKEAHA.108.5415812297 at GLASGOW UNIV LIB on January 18, 2012http://stroke.ahajournals.org/Downloaded from 

Functional outcome measures in contemporary stroke trials. Int J Stroke.

Initial experience of a digital training resource for modified Rankin Scale assessment in clinical trials.

Lees KR; for the VISTA Investigators. Stroke outcome in clinical trial patients deriving from different countries.

NIHSS certification is reliable across multiple venues.

NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials.

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Training and consistency in stroke assessments

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