1.a. Level of Consciousness

This global measure of responsiveness is assessed by the patient's interactions with the physician at the bedside when the patient is first examined. The physician should stimulate the patient (by patting or tapping the patient) to determine the best level of consciousness. On occasion, more noxious stimuli, such as pinching, may be required to check the level of consciousness.

0 = Alert - Patient is fully alert and keenly responsive

1 = Drowsy - Patient is drowsy but can be aroused with minor stimulation. The patient obeys, answers, and responds to commands

2 = Stuporous - Patient is lethargic but requires repeated stimulation to attend. The patient may need painful or strong stimuli to respond to or follow commands.

3 = Coma - Patient is comatose and responds only with reflexive motor or automatic responses. Otherwise, the patient is unresponsive.

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1.b. LOC - Questions

Level of Consciousness - Questions is checked by asking the patient to respond to two questions. The patient is asked the month of the year and his/her age. The answer must be correct - there is no partial credit for being close (for example, being off by one year in age). If the patient gives the wrong initial answer but then corrects it, the answer should still be scored as incorrect. Other measures of orientation such as time of day, location, etc. are not asked as part of this examination. If the patient has aphasia, the physician should judge the responses to questions in light of the language impairment.

0 = Answers BOTH correctly.

1 = Answers ONE correctly.

2 = BOTH incorrect.

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1.c. LOC - Commands

The Level of Consciousness - Commands is checked by asking the patient to follow two commands. The patient is asked to open and close his/her eyes and then is asked to make a grip (close and open his/her hand). Only the initial response is scored. If a patient is aphasic and unable to follow verbal commands, the patient may imitate these movements (pantomime). For a patient who has hemiparesis, the response in the unaffected limb should be measured. For example, if the patient has a left hemiparesis, making a fist with the right hand is a normal response to the command. If a paralyzed patient does try to move the limb in response to a command but is unable to form a fist, it is counted as a normal response.

0 = Obeys BOTH correctly

1 = Obeys ONE correctly

2 = BOTH incorrect

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2. Gaze

The position of the eyes at rest and movement of the eyes to command are tested. First look at the position of the eyes at rest. Spontaneous eye movements to the left are right should be noted. The patient is then asked to look to the left or right. Only horizontal eye movements are tested. Disorders of vertical gaze, nystagmus, or skew deviation are not measured. Reflexive eye movements (oculocephalic or oculovestibular) should be tested in patients who are unable to respond to commands. If a patient has ocular rotatory problems, such as a strabismus, but leaves the midline and attempts to look both right and left, he/she should be considered to have a normal response. If a patient has an isolated oculorotatory problem, such as an oculomotor (CN III) or abducens (CN IV) palsy, the score should be 1. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score should be 1. If there is a conjugate lateral deviation that is NOT overcome with reflexive movements, the score should be 2.

0 = Normal - The patient has normal lateral eye movements

1 = Partial Gaze Palsy - Patient is unable to move one or both eyes completely to both directions.

2 = Forced Deviation - The patient has conjugate deviation of the eyes to the right or left, even with reflexive movements.

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3. Visual Fields

Visual fields of both eyes are examined. In most cases, the physician asks the patient to count fingers in all four quadrants. Each eye is independently tested. If a patient is unable to respond verbally, the physician should check responses (attending) to visual stimuli in the quadrants or have the patient hold up the number of fingers seen. A quadrantic field cut should be scored 1. The entire half field (both upper and lower quadrants) should be involved with a dense field loss to be scored 2. If a patient has severe monocular visual loss due to intrinsic eye disease and the visual fields in the other eye are normal, the physician should score the visual fields are normal. If the patient has monocular blindness due to primary eye disease and the visual fields in the other, "normal" eye demonstrate a partial or dense visual field defect, the visual loss should be scored as 1, 2, or 3 as appropriate.

0 = No visual loss

1 = Partial hemianopia - There is a partial visual field defect in both eyes. Included is a quadrantic field defect or sector field defect.

2 = Complete hemianopia - There is dense visual field defect in both eyes. A homonymous hemianopia is included.

3 = Bilateral hemianopia - There are bilateral visual field defects in both eyes. Cortical blindness is included.

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4. Facial Movement (Facial Paresis)

The patient is examined by looking at the patient's face and noting any spontaneous facial movements. The facial movements in response to commands are also tested. Such commands may include asking the patient to grimace or smile, to puff out his/her cheeks, to pucker, and to close his/her eyes forcefully. If the patient is aphasic and is unable to follow commands, the physician should have the patient attempt imitative (pantomime) responses. The facial responses to painful stimuli (grimace) may substitute for responses to commands in a patient who has decreased levels of alertness.

0 = Normal facial movements No asymmetry.

1 = Minor paresis Asymmetrical facial movements or facial asymmetry at rest. This response may be noted with a spontaneous smile but not with forced facial movements.

2 = Partial paresis Unilateral "central" facial paresis. Decreased spontaneous and forced facial movements with changes most prominent at the mouth. Orbital and forehead musculature movements are normal.

3 = Complete palsy Dysfunction involves forehead, orbital, and circumoral muscles (the entire distribution of the facial nerve). Deficits may be unilateral or bilateral (facial diplegia) complete facial paresis.

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5. Motor Function - Arms (Left and Right)

The patient is asked to extend his arm outstretched in front of the body at 90 degrees (if sitting) or at 45 degrees (if supine). The effort is for a full 10 seconds. the physician should count to ten aloud to encourage the patient to maintain the limb's position. If a limb is paralyzed, the physician may wish to test any "normal" limb first. If a patient is aphasic, directions may be achieved by non-verbal cues or pantomime. Patients may be "helped" by the physician by placing the limb in the desired position. If the patient has restricted limb function due to arthritis or non-stroke related limitations, the physician should attempt to judge the "best" motor response. If the patient has decreased level of consciousness, an estimate of response to noxious stimuli should be measured. Volitional motor responses that are performed well should be graded as 0. If the patient has reflexive responses, such as flexor or extensor posturing, the response should be scored as 4. The only indication for scoring this item as 9 - untestable, is if the limb is missing or amputated, or if the shoulder joint is fused. A patient with a partial limb amputation should be tested.

0 = No drift The patient is able to hold the outstretched limb for 10 seconds.

1 = Drift The patient is able to hold the outstretched limb for 10 seconds but there is some fluttering or drift of the limb. If the limb falls to an intermediate position, the score is 1.

2 = Some effort against gravity The patient is not able to hold the outstretched limb for 10 seconds but there is some effort against gravity.

3 = No effort against gravity The patient is not able to bring the limb off the bed but there is some effort against gravity. If the limb is raised in the correct position by the examiner, the patient is unable to sustain the position.

4 = No movement The patient is unable to move the limb. There is no effort against gravity.

9 = Untestable May be used only if the limb is missing or amputated, or if the shoulder joint is fused.

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6. Motor Function - Leg (Right and Left)

The supine patient is asked to hold the outstretched leg 30 degrees above the bed. The limb should be held in this position for 5 seconds. The physician should count to 5 aloud to encourage the patient to maintain the limb's position. If the right leg is paralyzed, the examiner may wish to examine the "normal" left leg first. If a patient is unable to follow verbal commands, nonverbal cues may be used, or the limb may be placed in the desired position. If the patient has a decreased level of consciousness, an estimate of response to noxious stimuli should be measured. Volitional motor responses that are performed well should be scored 0. If the patient has reflexive responses, such as flexor or extensor posturing, the response should be scored 4. The only indication for scoring this item as 9 - untestable is if the limb is missing or if the hip joint is fused. Patients with artificial joints or partial limb amputations should be tested.

0 = No drift The patient is able to hold the outstretched limb for 5 seconds.

1 = Drift The patient is able to hold the outstretched limb for 5 seconds but there is unsteadiness, fluttering, or drift of the limb.

2 = Some effort against gravity The patient is unable to hold the outstretched limb for 5 seconds but there is some effort against gravity.

3 = No effort against gravity The patient is not able to bring the limb off the bed but there is effort against gravity. If the limb is placed in the correct position, the patient is unable to sustain the position.

4 = No movement The patient is unable to move the limb. There is no effort against gravity.

9 = Untestable May be used only if limb is missing or hip joint is fused.

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7. Limb Ataxia

This item is aimed at examining the patient for evidence of a unilateral cerebellar lesion. It will also detect limb movement abnormalities related to sensory or motor dysfunction. Limb ataxia is checked by the finger-to-nose and heel-to-shin tests. The physician should test the "normal" side first. The movements should be well performed, smooth, accurate, and non-clumsy. There should not be any dysmetria or dyssynergia. Non-verbal cues may be given to the patient. If a patient has dysmetria or dyssynergia in one limb, the score should be 1. If a patient has dysmetria or dyssynergia in both the arm and leg on one side, or if there are bilateral signs, the score should be 2. If limb ataxia is present, the ataxia should be rated as present regardless of the possible etiology. This item may be scored 9 - untestable only if there is complete paralysis of the limbs (All Motor Function scores = 4), if the limb is missing, amputated, or fused, or if the patient is comatose (item 1.a., LOC = 3).

0 = Absent The patient is able to perform both the finger-to nose and heel-to-shin tasks well. The movements are smooth and accurate.

1 = Present unilaterally in either arm or leg The patient is able to perform one of the two required tasks well.

2 = Present unilaterally in both arm and leg or bilaterally The patient is unable to perform either task well. Movements are inaccurate, clumsy, or poorly done.

9 = Untestable May be used only if all Motor Function Scores = 4, limb is missing, amputated, or fused, or if item 1.a., LOC = 3.

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8. Sensory

The patient is examined with a pin in the proximal portions of all four limbs and asked how the stimulus feels. The patient's eyes do not need to be closed. The patient is asked if the stimulus is sharp or dull and if there is any asymmetry between the right and left sides. Only sensory loss that can be attributed to stroke should be counted as abnormal - usually this will be a hemisensory loss. Sensory loss due to a non-stroke related condition, such as a neuropathy, should not be graded as abnormal. If a patient has depressed level of consciousness, neglect, aphasia or is unable to describe the sensory perception, the patient's non-verbal responses, such as a grimace or withdrawal, should be graded. If the patient responds to the stimulus, it should be scored 0. The response to the stimulus on the right and left sides should be compared. If the patient does not respond to a noxious stimulus on one side, the score should be 2. Patients with severe depression of consciousness should be examined.

0 = Normal No sensory loss to pin is detected.

1 = Partial loss Mild to moderate diminution in perception to pin stimulation is recognized. This may involve more than one limb.

2 = Dense loss Severe sensory loss so that the patient is not aware of being touched. Patient does not respond to noxious stimuli applied to that side of the body.

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9. Best Language

The patient's language will be tested by having the patient identify standard groups of objects and by reading a series of sentences. Comprehension of language should be judged as the physician performs the entire neurologic examination. The physician should give the patient adequate time to identify the objects on the sheet of paper. Only the first response is measured. If the patient misidentifies the object and later corrects himself, the response is still considered abnormal. The physician should then give the patient a sheet of paper with the series of sentences. The examiner should ask the patient to read at least three sentences. The first attempt to read the sentence is measured. If the patient misreads the sentence and later corrects himself, the response is still considered abnormal. If the patient's visual loss precludes visual identification of objects or reading, the examiner should ask the patient to identify objects placed in his/her hand and the examiner should judge the patient's spontaneous speech and ability to repeat sentences. If the examiner judges these responses as normal, the score should be 0. If the patient is intubated or is unable to speak, the examiner should check the patient's writing.

0 = No aphasia The patient is able to read the sentences well and is able to correctly name the objects on the sheet of paper.

1 = Mild to moderate aphasia The patient has mild to moderate naming errors, word finding errors, paraphasias, or mild impairment in comprehension or expression.

2 = Severe aphasia The patient has severe aphasia with difficulty in reading as well as naming objects. Patient with either Broca's or Wernicke's aphasia is included here.

3 = Mute

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10. Dysarthria

The primary method of examination is to ask the patient to read and pronounce a standard list of words from a sheet of paper. If the patient is unable to read the words because of visual loss, the physician may say the word and ask the patient to repeat it. If the patient has severe aphasia, the clarity of articulation of spontaneous speech should be rated. If the patient is mute or comatose (item 9, Best Language = 3 ) or has an endotracheal tube, this item can be rated as 9 - untestable.

0 = Normal articulation Patient is able to pronounce the words clearly and without any problem in articulation.

1 = Mild to moderate dysarthria Patient has problems in articulation. Mild to moderate slurring of words is noted. The patient can be understood but with some difficulty.

2 = Near unintelligible or worse Patient's speech is so slurred that it is unintelligible

9 = Untestable May be used only if item 9, Best Language = 3, or if the patient has an endotracheal tube.

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11. Neglect (Extinction and Inattention)

The presence of neglect is examined by the patient's ability to recognize simultaneous cutaneous sensory and visual stimuli from the right and left sides. The visual stimulus is a standard picture. The picture is shown to the patient and s/he is asked to describe it. The physician should encourage the patient to scan the picture and identify features on both the right and left sides of the picture. The physician should encourage the patient to compensate for any visual loss. If the patient does not identify parts of the picture on one side, the result should be considered abnormal. The physician then assesses the ability to recognize bilateral simultaneous touch to upper or lower limbs. The test is done by touching the patient with the patient's eyes closed. The test should be considered abnormal if the patient ignores sensory stimuli from one side of the body. If the patient has a severe visual loss and the cutaneous stimuli are normal, the score should be 0. If the patient has aphasia and is unable to describe the picture, but does attend to both sides, the score should be 0.

0 = No neglect The patient is able to recognize bilateral simultaneous cutaneous stimuli on the right and left sides of the body and is able to identify images on the right and left sides of the picture.

1 = Partial neglect The patient is able to recognize either cutaneous or visual stimuli on both the left and right, but is unable to do both successfully (unless severe visual loss or aphasia is present).

2 = Complete neglect The patient is unable to recognize either bilateral cutaneous sensory or visual stimuli.

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