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      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

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          Abstract

          Background: We aimed to validate three widely used scales in stroke research in a multiethnic Brazilian population. Methods: The National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) were translated, culturally adapted and applied by two independent investigators. The mRS was applied with or without a previously validated structured interview. Interobserver agreement (kappa statistics) and intraclass correlation coefficients were calculated. Results: 84 patients underwent mRS (56 with and 28 without a structured interview), 57 BI and 62 NIHSS scoring. Intraclass correlation coefficient was 0.902 for NIHSS and 0.967 for BI. For BI, interobserver agreement was good (kappa = 0.70). For mRS, the structured interview improved interobserver agreement (kappa = 0.34 without a structured interview; 0.75 with a structured interview). Conclusion: The NIHSS, BI and mRS show good validity when translated and culturally adapted. Using a structured interview for the mRS improves interobserver concordance rates.

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          Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview.

          The modified Rankin Scale (mRS) is widely used to assess global outcome after stroke. The aim of the study was to examine rater variability in assessing functional outcomes using the conventional mRS, and to investigate whether use of a structured interview (mRS-SI) reduced this variability. Inter-rater agreement was studied among raters from 3 stroke centers. Fifteen raters were recruited who were experienced in stroke care but came from a variety of professional backgrounds. Patients at least 6 months after stroke were first assessed using conventional mRS definitions. After completion of initial mRS assessments, raters underwent training in the use of a structured interview, and patients were re-assessed. In a separate component of the study, intrarater variability was studied using 2 raters who performed repeat assessments using the mRS and the mRS-SI. The design of the latter part of the study also allowed investigation of possible improvement in rater agreement caused by repetition of the assessments. Agreement was measured using the kappa statistic (unweighted and weighted using quadratic weights). Inter-rater reliability: Pairs of raters assessed a total of 113 patients on the mRS and mRS-SI. For the mRS, overall agreement between raters was 43% (kappa=0.25, kappa(w)=0.71), and for the structured interview overall agreement was 81% (kappa=0.74, kappa(w)=0.91). Agreement between raters was significantly greater on the mRS-SI than the mRS (P or =0.94). Although individual raters are consistent in their use of the mRS, inter-rater variability is nonetheless substantial. Rater variability on the mRS is thus particularly problematic for studies involving multiple raters. There was no evidence that improvement in inter-rater agreement occurred simply with repetition of the assessment. Use of a structured interview improves agreement between raters in the assessment of global outcome after stroke.
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            Initial experience of a digital training resource for modified Rankin scale assessment in clinical trials.

            The modified Rankin Scale (mRS) is the preferred measure of disability in cerebrovascular clinical trials, but its value is restricted by interobserver variability. Poor reliability reduces the statistical power of clinical trials and leads to underestimation of effect size. Strategies to improve mRS grading are required. Video training has previously improved application of the National Institutes of Health Stroke Scale in clinical research. We developed an mRS training resource in an attempt to minimize interobserver variability. We produced a complete training resource comprising an instructional DVD with accompanying written materials and assessment recordings of patient interviews. Formal assessment of training involved grading of real-life cases. Results of initial training and recertification were collected centrally and scored. Data from 1564 assessments are presented. The majority of assessors were participating in 2 large prospective clinical stroke trials. Assessors represented a mixed group of disciplines and nationalities. After training, most trainees (90%) achieved certification in mRS assessment. The majority (85%) of investigators who did not reach an acceptable score on initial testing achieved certification after further exposure to the package. Mass training in mRS assessment for clinical trials is possible. We outline the development of a video-based training package, including technical issues, patient selection procedures, and methods of scoring and assessment. Certification results suggest that use of the resource can improve mRS grading. Acceptability of the training has been demonstrated by its successful use in 2 international acute stroke trials, SAINT 1 and CHANT.
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              Is Open Access

              Confiabilidade de escalas de comprometimento neurológico em pacientes com acidente vascular cerebral

              Escalas de comprometimento neurológico são utilizadas na avaliação de novos tratamentos, no acompanhamento da evolução clínica e em decisões terapêuticas. Estudamos a confiabilidade de três escalas: a Escala de Rankin (ER), o Índice de Barthel (IB) e a National Institute of Health Stroke Scale (NIHSS) versadas em português, em 51 indivíduos com acidente vascular cerebral, estimando a concordância entre resultados de diferentes examinadores. Utilizamos os coeficientes de concordância Kappa e Coeficiente de Correlação Intraclasse. A ER teve coeficientes moderados, substanciais ou excelentes. No IB estes foram substanciais ou excelentes nos totais e nos itens, assim como quando foi estratificado em agrupamentos prognósticos e funcionais. A NIHSS apresentou coeficientes excelentes nos totais, substanciais nos itens e moderados e excelentes nas estratificações em grupos de pontos e de itens afins. Estes resultados indicam que as versões em português da ER, o IB e a NIHSS apresentam adequada confiabilidade.
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                Author and article information

                Journal
                CED
                Cerebrovasc Dis
                10.1159/issn.1015-9770
                Cerebrovascular Diseases
                S. Karger AG
                1015-9770
                1421-9786
                2009
                February 2009
                28 November 2008
                : 27
                : 2
                : 119-122
                Affiliations
                aStroke Clinic and bEpidemiology Unit of the Federal University of Bahia, Salvador, and cNeurology Service of Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
                Article
                177918 Cerebrovasc Dis 2009;27:119–122
                10.1159/000177918
                7065394
                19039215
                8c38b27d-4c4a-47af-bb0d-336fb69f7c04
                © 2008 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 11 February 2008
                : 19 August 2008
                Page count
                Figures: 3, Tables: 1, References: 10, Pages: 4
                Categories
                Original Paper

                Geriatric medicine,Neurology,Cardiovascular Medicine,Neurosciences,Clinical Psychology & Psychiatry,Public health
                Stroke,National Institutes of Health Stroke Scale,Stroke trials, Brazil,Modified Rankin Scale,Barthel Index

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