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Successful management of any disabling disease, including stroke,
should benefit from the use of a classification system to judge the
impact of treatment, particularly emerging therapies. Participants in
the Methodologic Issues in Stroke Outcome
Symposium2 determined that the complex nature of
stroke recovery demands clarification of its natural history and
classification of the variable patterns of functional recovery. For
stroke survivors to receive the best care, a comprehensive stroke
outcome classification system is needed to direct appropriate
therapeutic interventions.3 Building on the work
and recommendations of the Stroke Outcome Symposium, the American Heart
Association Classification of Stroke Outcome Task Force has worked to
develop a valid and reliable global classification system that
accurately summarizes the neurological impairments, disabilities, and
handicaps that occur after stroke.
The development of a stroke outcome classification system is predicated
on the belief that neurological deficits often lead to permanent
impairments, disabilities, and compromised quality of
life.4 5 6 Although a person's ability to
complete daily functional tasks is thought to be largely dependent on
and often limited by the type and degree of impairment, additional
factors are often relevant in the ultimate determination of functional
outcome.7 8 9 Thus, a classification of stroke
outcome should include the broad range of disabilities and impairments
as well as the relationship of disability and impairment to independent
function.
It is important to underscore that impairment alone does not
define level of disability. In a study of stroke
survivors10 it was determined that although a
disability is most directly influenced by impairments, current stroke
scales that measure impairments only partially explained the level of
disability, handicap, or quality of life for those surviving at least 6
months. Some persons adapt well to many and/or severe impairments
caused by stroke. Others with only minimal neurological impairments can
be severely disabled. Many factors determine function, including the
influence of poststroke rehabilitation training and the physical and
social environments.
Potentially affected neurological domains are
The domains of stroke impairments are documented both in the
number and severity of the neurological deficits observed. When >1
domain is affected, severity is defined by the most impaired domain.
The categories for the number of domains involved after stroke are
Level 0, no domains impaired; Level 1, 1 domain impaired; Level 2, 2
domains impaired; and Level 3, >2 domains impaired. For stroke
severity, impairment is classified as being either Level A, minimal or
no neurological deficit due to stroke in the above domains; Level B,
mild/moderate deficit due to stroke; or Level C, severe deficit due to
stroke.
The neurological examination is the basis for determining
neurological impairments in the AHA.SOC score. However, the task force
recommends that clinicians support their rating decisions by using
standardized assessment measures whenever possible. The Appendix
describes several available, well-documented assessment instruments
that have been tested in stroke populations. This listing is suggestive
and not all-inclusive of other available measures.
Neurological Impairment Scales
Following is an example of the use of a standardized assessment,
such as the NIHSS, to determine the neurological impairment-severity
part of the score. To translate the NIHSS scores into the AHA.SOC, it
is necessary to collapse the NIHSS scores. For example, patients with a
motor deficit and an NIHSS score of 4 in 1 limb would receive an
impairment rating of C=severe. Patients with any detectable weakness in
an arm or a leg (NIHSS score 1 to 3) would receive an impairment rating
of B=mild/moderate. Patients with no detectable weakness (NIHSS score
0) would receive a rating of A=no impairment. Patients with a sensory
deficit and an NIHSS score of 2 would receive an impairment rating of
C=severe. Patients with any detectable sensory loss (NIHSS score 1)
would receive an impairment rating of B=mild/moderate. Patients without
sensory loss would receive a rating of A=no impairment. Patients with
severe aphasia or who are mute (NIHSS aphasia score 3) would receive an
impairment rating of C=severe. Patients with mild or moderate aphasia
(NIHSS aphasia score 1 or 2) would receive an impairment rating of
B=mild/moderate. Patients without aphasia would receive a rating of
A=no impairment. Visual deficit can be collapsed similarly (NIHSS
visual score 2=C, severe impairment; NIHSS visual score 1=B,
mild/moderate impairment; NIHSS visual score 0=A, no impairment). If
the patient's NIHSS scores are motor=2 (B), sensory=2 (C), aphasia=0
(A), and visual=1 (B), the AHA.SOC severity score is C.
Cognitive Scales
Language Scales
Depression Scales
Classification of Functional Disabilities and Handicap
Basic Activities of Daily Living Scales
The Functional Independence Measure (FIM)(TM) is
another widely used disability measure.36 The FIM
contains 13 items related to self-care, bowel and bladder continence,
mobility, and ambulation, and 5 items related to communication, social
functioning, and cognition. The first 13 items are summed to develop a
motor score, and the last 5 items are summed to develop a
social/cognition score. Many studies have evaluated the reliability and
validity of the FIM37 38 and its sensitivity to
change.39 40
Instrumental Activities of Daily Living Scales
Case 1: A 62-year-old man has an ischemic
infarct in the left hemisphere. Neurologically he is cognitively
intact, not depressed, and able to communicate. He has no residual
weakness or sensory loss. Three months after the stroke he is living
independently at home without healthcare assistance for basic daily
activities. He manages routine household maintenance and needs
assistance only with community activities such as shopping and banking.
The stroke classification score for this patient is number of
domains impaired=0; stroke severity=A; functional classification=Level
II. AHA.SOC score=0.A.II.
Case 2 is a 74-year-old woman with a large-vessel infarct in
the right hemisphere. Neurologically she has the following residual
impairments: partial hemianopia, facial palsy, and sensory loss and
weakness in the upper and lower left extremities. She is not depressed
and is cognitively intact. She lives at home with professional home
healthcare assistance. She requires the assistance of another person to
access the community. She is unable to do housekeeping tasks or prepare
meals. She can take her own medications and use a telephone; however,
she cannot bathe independently or climb stairs. The stroke
classification score for this patient is number of domains
impaired=3; stroke severity=B; functional classification level=lll.
AHA.SOC score=3.B.III.
Case 3 is an 85-year-old woman with a right-hemisphere
infarct who lives in a skilled-nursing facility. She has paralysis of
the left upper and lower extremities, partial hemianopia, cognitive
impairment, and depression. She eats independently but is incontinent
and needs help with dressing, bathing, toileting, and mobility-related
activities. She cannot manage her medications, prepare her meals, use
the telephone, or access the community without special transportation
arrangements. The stroke classification score for this patient
is number of domains impaired=3; stroke severity score=C;
functional classification level=V. AHA.SOC score=3.C.V.
A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71–0141. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342, or
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© 1998 American Heart Association, Inc.
AHA Scientific Statement
The American Heart Association Stroke Outcome Classification
Key Words: AHA Medical/Scientific Statements • stroke • prognosis • stroke outcome • disability • evaluation
Introduction
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
Stroke remains one of
the major public health problems in the United States today, with
approximately 500 000 new or recurrent cases occurring each
year.1 About 4 000 000 persons alive today have
survived a stroke and have some neurological deficits. Although the
magnitude of healthcare resources used to treat and rehabilitate stroke
survivors is considerable, to date a standardized, comprehensive
classification system to document the resultant impairments and
disability has not been developed.
Approach to Stroke Assessment
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
The schema for the stroke outcome classification score
presented here is conceptually similar to the New York Heart
Association functional and therapeutic classification of patients with
diseases of the heart framework.11 However,
unlike heart disease, in which the primary limitation is impairment of
physical activity due to chest pain, shortness of breath, and fatigue,
stroke impairs many critical neurological functions, resulting in a
greater number and broader range of physical and social disabilities.
The AHA Stroke Outcome Classification (AHA.SOC) score
(Figure
) classifies the severity and
extent of neurological impairments that are the basis for disability.
The classification also identifies the level of independence of stroke
patients according to basic and more complex activities of daily living
both at home and in the community. The classification score is meant to
describe the limitations resulting from the current stroke. It is not
an evaluation of disabilities caused by other neurological events.
Furthermore, it is a summary score. The task force recommends that
clinicians support their rating decisions with standardized assessment
instruments whenever possible.
View larger version (45K):
[in a new window]
Figure 1. American Heart Association Stroke Outcome Classification
(AHA.SOC). BADL indicates Basic Activities of Daily Living:
feeding and swallowing, grooming, dressing, bathing, continence,
toileting, and mobility; and IADL, Instrumental Activities of
Daily Living: using the telephone, handling money, shopping, using
transportation, maintaining a household, working, participating in
leisure activities, etc.
Components of the AHA Stroke Outcome Classification Score
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
Classification of Neurological Impairments
The first area of assessment in the AHA.SOC score is the
evaluation of neurological impairment. A complete clinical examination
is the basis for documenting the major domains of neurological
impairment.12 In this classification schema the
number of affected domains is recorded as well as severity of
impairments.
The National Institutes of Health Stroke Scale
(NIHSS)14 and the Canadian Neurological
Scale15 evaluate many of the domains of
neurological deficits, including motor, sensory, and visual
impairments. In a study comparing the usefulness of the baseline NIHSS,
the Canadian Neurological Scale, the Middle Cerebral Artery
Neurological Score, and Guy's Prognostic Score, the NIHSS was the best
predictor of outcome at 3 months (alive at home, alive in care, or
deceased).16 The NIHSS is reproducible, easy, and
quick to perform (10 minutes) and correlates with infarct volume and
functional outcome 3 months after stroke.
About 15% to 25% of stroke patients develop significant
cognitive impairment after the acute ischemic
event.17 18 To screen for the presence of
cognitive changes, the task force recommends the Mini-Mental State
Examination (MMSE).19 The MMSE has been widely
used to screen for cognitive dysfunction in the stroke population. It
is an easily administered 30-item questionnaire that assesses
orientation, memory, attention, language, and construction functions.
Like other cognitive measures that include tests of arithmetic and
language, MMSE scores are highly correlated with educational
level.20 21 The Neurobehavioral Cognitive Status
Examination (NCSE)22 is another method for
assessing severity of dementia. The NCSE measures severity of
impairment in multiple domains, including consciousness, orientation,
memory, language, and reasoning.
Approximately 30% of stroke survivors have some language
dysfunction.12 Speech and language disorders may
interfere with a person's ability to return to a functional
independent life. Accurate assessment of the underlying deficits is
essential for treatment. Language impairments can best be documented by
the use of the American Speech-Language-Hearing Association Functional
Assessment of Communication Skills for Adults.23
This instrument measures adequacy, appropriateness, and promptness of
verbal responses. Some measures of language function, such as fluency,
naming ability, and comprehension, are also assessed in the NIHSS.
Other reliable language-assessment instruments are available, including
the Boston Diagnostic Aphasia
Examination.24
Depression, although common, is perhaps the least-treated
sequela of stroke. The prevalence of depression after stroke has been
estimated to range from 11% to 68%, a third of which is classified as
major depression.13 25 26 Depression can result
either from the direct biological effect of brain infarction, such as
that associated with left anterior cortex and basal ganglia
lesions,13 or a reaction to the significant
losses associated with the stroke. Symptoms of depression can be
manifested in cognitive deficits, including difficulty with
orientation, memory, language, and distractibility. It is sometimes
difficult to distinguish depression from dementia because they share
similar symptoms, including disorientation, memory loss, and
distractibility. Two assessment scales that reliably screen for
symptoms of depression in stroke populations are the CES-D
scale27 and the Geriatric Depression
Scale.28
The second major area of assessment in determining the stroke
outcome classification score is the evaluation of function in terms of
resultant disability. Disability is defined as "any restriction or
lack of ability to perform an activity in a manner or within the range
considered normal for a human being."4 The
basic self-care tasks are feeding; grooming; dressing; bathing;
toileting, including sphincter control; and mobility, including
transferring from place to place. These are called basic
activities of daily living (BADL). Independence in BADL
could enable the stroke patient to live at home with help from family
or community providers for meals and other household tasks as needed.
More complex activities of daily living are called instrumental
activities of daily living (IADL). These tasks are
performed to maintain independence in the home and community and
include shopping, using transportation, telephoning, preparing meals,
handling finances, and maintaining a household. Independence in these
activities enables the stroke patient to be discharged to home without
being dependent on others. Other instrumental activities of daily
living that affect quality of life are work skills, religious
activities, and leisure-time and recreational activities (see
Appendix).
To determine the extent of disability after stroke, self-care
activities and ability to live independently are assessed. The Barthel
Index is a measure of severity of disability and the most frequently
used stroke outcome measure. It has been repeatedly shown to be a
reliable and valid measure of BADL.29 30 31 32 33 34 A
limitation is that it does not capture significant losses in higher
levels of physical functions or activities that are necessary for
independence in the home and community. It is responsive to change but
has definite ceiling effects in persons with mild
stroke.34 35
Although several assessments measure BADL adequately, no
single assessment measures IADL or leisure-time and recreational
activities that a stroke patient may be asked to do or may want to do.
Therefore, it is incumbent on the rehabilitation professional to learn
what those tasks and activities are by interviewing and selecting the
most appropriate assessment(s) for that particular patient. Assessment
should be based on performance, not
capacity.2 Two assessments are recommended in
Post-Stroke Rehabilitation: Clinical Practice
Guideline.12 The Philadelphia Geriatric Center
(PGC) Instrumental Activities of Daily Living Scale measures IADL at
home and in the community.41 42 43 Using
self-reports by the patient and his or her
family,44 45 the Frenchay Activities Index
measures leisure, work, and outdoor activities as well as IADL at
home.
Psychometric Properties of the AHA Stroke Outcome
Classification
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
To test the psychometric properties of the AHA.SOC, cases
were selected from the Kansas City Stroke Study. This community-based
study follows acute hospitalized stroke cases in the Kansas City area
to determine measurable stroke outcomes and track recovery over time
using standardized assessment measures. For this project, 3-month
poststroke survivors were evaluated with the
NIHSS,14 the Barthel
Index,29 the Lawton IADL
score,41 the Geriatric Depression
Scale,28 and the MMSE.19
The task force identified 10 raters with experience in stroke trials,
including physicians, nurses, and allied health professionals. Each
rater used the AHA.SOC to evaluate the severity and impact of stroke on
10 patients for a total of 100 assessments. Interrater reliability was
calculated with weighted kappas, a composite measure of agreement
across all categories and raters. A weighted average of the individual
kappa values was used to calculate an overall kappa value. Kappa values
0.75 are considered an excellent agreement beyond chance; values
<0.40 are considered poor agreement beyond chance; values between 0.40
and 0.75 represent fair to good agreement beyond chance. The
overall kappa value for the stroke severity classification was 0.76.
The overall kappa value for the number of domains impaired was 0.56.
The kappa values for the various levels of the functional
classification ranged from 0.71 to 0.88. The overall kappa value for
the functional disability classification was 0.77. On the basis of the
data analysis, it was concluded that the AHA.SOC scores were
reproducible and that the AHA.SOC accurately classified neurological
impairments and stroke-related disability.
Application of the AHA Stroke Outcome Classification Score to
Sample Cases
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
The following cases illustrate the decision-making process and use
of the AHA.SOC in assessments of 3 stroke patients.
Conclusion
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
New therapies and improved survival after stroke provide an
opportune time to develop a stroke outcome classification system that
measures the full range of domains affected by stroke. The AHA.SOC
score provides a mechanism to comprehensively document stroke
impairments and disabilities in a single summary stroke score. The
system can be used by healthcare providers to reliably assess recovery,
measure responses to treatment, and describe the long-term impact of
stroke on
survivors.
View this table:
[in a new window]
Table 1. Appendix: Stroke Deficit Scales
View this table:
[in a new window]
Table 2. Appendix: Mental Status Screening Test
View this table:
[in a new window]
Table 3. Appendix: Language Scales
View this table:
[in a new window]
Table 4. Appendix: Depression Scales
View this table:
[in a new window]
Table 5. Appendix: BADL Scales
View this table:
[in a new window]
Table 6. Appendix: IADL Scales
Acknowledgments
We thank Sue Min Lai, PhD, for her statistical assistance with
this project.
Footnotes
"The American Heart Association Stroke Outcome Classification" was approved by the American Heart Association Science Advisory and Coordinating Committee in December 1997.
References
Top
Introduction
Approach to Stroke Assessment
Components of the AHA...
Psychometric Properties of the...
Application of the AHA...
Conclusion
References
1.
1998 Heart and Stroke Statistical
Update. Dallas, Tex: American Heart Association; 1998.
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I-P. Hsueh, W.-C. Wang, C.-H. Wang, C.-F. Sheu, S.-K. Lo, J.-H. Lin, and C.-L. Hsieh A Simplified Stroke Rehabilitation Assessment of Movement Instrument Physical Therapy, July 1, 2006; 86(7): 936 - 943. [Abstract] [Full Text] [PDF]
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 A-C Jonsson, I Lindgren, B Hallstrom, B Norrving, and A Lindgren Prevalence and intensity of pain after stroke: a population based study focusing on patients' perspectives J. Neurol. Neurosurg. Psychiatry, May 1, 2006; 77(5): 590 - 595. [Abstract] [Full Text] [PDF]
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A.-C. Jonsson, I. Lindgren, B. Hallstrom, B. Norrving, and A. Lindgren Determinants of Quality of Life in Stroke Survivors and Their Informal Caregivers Stroke, April 1, 2005; 36(4): 803 - 808. [Abstract] [Full Text] [PDF]
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I-P. Hsueh, W.-C. Wang, C.-F. Sheu, and C.-L. Hsieh Rasch Analysis of Combining Two Indices to Assess Comprehensive ADL Function in Stroke Patients Stroke, March 1, 2004; 35(3): 721 - 726. [Abstract] [Full Text] [PDF]
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 M. D. Lindner, V. K. Gribkoff, N. A. Donlan, and T. A. Jones Long-Lasting Functional Disabilities in Middle-Aged Rats with Small Cerebral Infarcts J. Neurosci., November 26, 2003; 23(34): 10913 - 10922. [Abstract] [Full Text] [PDF]
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C.-L. Hsieh, C.-F. Sheu, I-P. Hsueh, and C.-H. Wang Trunk Control as an Early Predictor of Comprehensive Activities of Daily Living Function in Stroke Patients Stroke, November 1, 2002; 33(11): 2626 - 2630. [Abstract] [Full Text] [PDF]
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 A. L. Gordon, V. Ganesan, A. Towell, and F. J. Kirkham Functional Outcome Following Stroke in Children J Child Neurol, June 1, 2002; 17(6): 429 - 434. [Abstract] [PDF]
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A. G. Hamedani, C. K. Wells, L. M. Brass, W. N. Kernan, C. M. Viscoli, J. N. Maraire, I. A. Awad, and R. I. Horwitz A Quality-of-Life Instrument for Young Hemorrhagic Stroke Patients Stroke, March 1, 2001; 32(3): 687 - 695. [Abstract] [Full Text] [PDF]
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S.-M. Lai and P. W. Duncan Evaluation of the American Heart Association Stroke Outcome Classification Stroke, September 1, 1999; 30(9): 1840 - 1843. [Abstract] [Full Text] [PDF]
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