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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 40-44

Validation of the Hindi version of National Institute of Health Stroke Scale

Department of Neurology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Nov-2011
Date of Decision03-Dec-2011
Date of Acceptance31-Dec-2011
Date of Web Publication7-Mar-2012

Correspondence Address:
Kameshwar Prasad
Room No - 704, Department of Neurology, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.93587

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 » Abstract 

Aims: To determine the reliability and validity of the National Institute of Health Stroke Scale (NIHSS) with the Hindi and Indian adaptation of items 9 and 10. Materials and Methods: NIHSS items 9 and 10 were modified and culturally adapted at All India Institute of Medical Sciences (AIIMS) and the resulting version was termed as Hindi version (HV-NIHSS). HV-NIHSS was applied by two independent investigators on 107 patients with stroke. Inter-observer agreement and intra-class correlation coefficients were calculated. The predictive validity of the HV-NIHSS was calculated using functional outcome after three months in the form of modified Rankin Scale (mRS) and Barthel Index (BI). Results: The study included 107 patients of stroke recruited from a tertiary referral hospital at Delhi between November 1, 2009, and October 1, 2010; the mean age of these patients was 56.26±13.84 years and 65.4% of them had suffered ischemic stroke. Inter-rater reliability was high between the two examiners, with Pearson's r ranging from 0.72 to 0.99 for the 15 items on the Scale. Intra-class correlation coefficient for the total score was 0.995 (95% CI-0.993-0.997). Concurrent construct validity was established between HV-NIHSS and baseline Glasgow Coma Scale, with a high correlation (Spearman coefficient = -0.863, P<.001). Predictive validity was also established with BI at three months (Spearman's rho: -0.829, P<.001) and with mRS at three months (Spearman's rho: 0.851, P<0.001). Conclusions: This study shows that a Hindi language version of the NIHSS developed at AIIMS appears reliable and valid when applied to a Hindi-speaking population.

Keywords: Barthel index, Hindi version, modified Rankin Scale, National Institute of Health Stroke Scale

How to cite this article:
Prasad K, Dash D, Kumar A. Validation of the Hindi version of National Institute of Health Stroke Scale. Neurol India 2012;60:40-4

How to cite this URL:
Prasad K, Dash D, Kumar A. Validation of the Hindi version of National Institute of Health Stroke Scale. Neurol India [serial online] 2012 [cited 2023 Dec 1];60:40-4. Available from:

 » Introduction Top

Predictive short-term and long-term outcome is important for prognostic stratification and for discussing prognosis with patients or their caregivers. There is a strong correlation between baseline stroke severity and outcome after stroke. A tool for measurement of baseline severity of neurological impairments is, therefore, important. Routine use of such a tool can improve medical documentation and internal communication between healthcare providers. Many scales are used in clinical practice and trials to objectively measure the deficits due to stroke. The National Institute of Health Stroke Scale (NIHSS) is a quantitative measure of stroke-related neurological deficit that was developed for prospective clinical research. [1] The NIHSS is a non-linear ordinal scale. The scale has 15 items. The individual items have 3- or 4-point response scales scored from 0 to 4. The total possible score is from 0 to 42, with higher scores indicating greater deficits. It takes 5-8 minute to administer the scale. [1] The NIHSS has established validity and reliability for use in prospective clinical research and also predictive validity for long-term stroke outcome. [2] It can be administered by physicians, research workers, and nurses alike and has proven intra-rater and inter-rater reliability. [3],[4] It is strongly predictive of early functional recovery and long-term outcome. It includes key aspects of the neurological examination: Level of consciousness, speech and language function, neglect, visual fields, eye movements, facial symmetry, motor strength, sensation, and coordination. It is widely used, easy to learn, and can be performed rapidly on admission. The NIHSS is constructed differently, in that each test item is graded, but no significant weighting is given to limb function; further, many additional items such as ataxia, sensory loss, or visuospatial perception are also included.

The NIHSS was designed for the English-speaking population and has items that require reading English words and sentences [Figure 1]. In a country like ours, many people can neither read nor write English. It would be helpful to have a validated Hindi language version of the NIHSS to be used by Hindi-speaking patients. The scale also uses standardized Figures and phrases to test for aphasia and dysarthria, items particularly vulnerable to cultural influences. These Figures will require cross-cultural adaptation for our population. Hindi version-NIHSS (HV-NIHSS) [Figure 2] has been developed by Professor Prasad for use in clinical trials, but has not been validated as yet. Therefore, this study aims to validate the HV-NIHSS. It is hoped that this instrument will be of practical use for examining Hindi-speaking patients suffering with stroke as well as to researchers who study the effects of stroke on Hindi-speaking populations.
Figure 1: Pictorial diagram for testing item 9 (aphasia) and Item 10 (dysarthria) assessment of English version of NIHSS stroke scale

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Figure 2: Pictorial diagram for testing item 9 (aphasia) and item 10 (dysarthria) assessment of Hindi version of NIHSS stroke scale

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 » Materials and Methods Top

This study was conducted at All India Institute of Medical sciences (AIIMS)-a tertiary referral hospital located in New Delhi-and has been approved by the Institute's Ethics Committee. Informed consent was taken from all subjects who participated in the study. Adult patients (>18 year) of both sexes with a diagnosis of stroke within one month of onset were enrolled in this study after informed consent from November 1, 2009, to October 1, 2010, from the Emergency Department and Neurology wards of AIIMS. The definition of stroke used in the study is the one devised by World health Organization-a neurological deficit of cerebrovascular cause that persists beyond 24 hour or is interrupted by death within 24 hour. [5] An infraction or hemorrhagic type of stroke was identified by computed tomography (CT).

The HV-NIHSS was developed at AIIMS by one of the authors (KP) for a clinical trial. Sentences and words in English NIHSS items 9 and 10 were substituted with Hindi words and sentences [Figure 2]. The material used for evaluation of aphasia and dysarthria (figures and phrases) was culturally adapted. The picture of hammock, cactus, feather, and gloves were replaced by pictures of balloon, lock, ball, spoon, tiger, bus, telephone, tire, and rose. The cookie jar picture was replaced with a picture with lady cooking on a chullah [Figure 2]. Patients with score falling in different segments of the NIHSS score range were taken. The three score range were 0-7, 8-24, and >24.The range of 8-24 score was the eligibility criteria for inclusion in NINDS rt-PA trial. [6] We studied inter-observer reliability (107 patients in whom two observers, DD and AK, administered the scale in a random order, on the same day with a small time gap) of HV-NIHSS, correlation between HV-NIHSS and NIHSS administered by the same observer (in 38 patients who knew both English and Hindi), and predictive validity (n=96) where ability of baseline HV-NIHSS to predict BI and mRS was 90 Days. Study architecture is shown in [Table 1]. One of the administrators of NIHSS was a resident of neurology and another was a PhD student who had experience in administering the scale as part of his training. Each investigator was trained and certified for NIHSS application through the American Stroke Association's Online NIH Stroke Scale Training Program. The inter-observer variability was calculated by administration of the HV-NIHSS by two investigators on the same patient.
Table 1: Study architecture in a tabular format

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During hospitalization, other patient characteristics were recorded like Glasgow Coma Scale, socio-demographic characteristics, and stroke type. Lesion volume was calculated in hemorrhagic stroke using CT on the day when the stroke scales were administered. Three months after the onset of stroke, functional capacity of the surviving patients was evaluated with the modified Rankin Scale and the Barthel Index by using a telephone.

To evaluate the inter-rater agreement Pearson's correlation coefficient r was used and interpreted as follows: 0 to 0.2=negligible, 0.2 to 0.4=low, 0.4 to 0.6=moderate, 0.6-0.8=substantial, and 0.8-1.0=high to very high. [7] To evaluate inter-rater reliability, the intra-class correlation coefficient between the scores of the two observers was calculated. ICC can be interpreted as follows: 0-0.2 indicates poor agreement: 0.3-0.4 indicates fair agreement; 0.5-0.6 indicates moderate agreement; 0.7-0.8 indicates strong agreement; and >0.8 indicates almost perfect agreement. [8]

Statistical analysis

Baseline population characteristics measured in numerical scales were reported using the median or mean±SD, according to their distribution. Categorical variables were reported in terms of their percent frequency. Pearson's correlation was used when scores had a normal distribution. When the distribution was non-normal, Spearman's rho was used. Spearman correlation co-efficient was examined between HV-NIHSS and baseline GCS to evaluate the concurrent construct validity, and that between HV-NIHSS and functional outcome at three months (as measured by mRS and BI) to evaluate the predictive validity. The entire statistical analysis was carried out using SPSS version 16 for windows.

 » Results Top

Demographic characteristics

A total of 107 patients with stroke were recruited in the study from November 1, 2009, to October 1, 2010. The demographic characteristics and risk factor profile of the study population have been tabulated in [Table 2]. There were 22 patients in the NIHSS score range of 0-7, 54 in the score range of 8-24, and 31 in the range of >24.
Table 2: Demographic and risk factor profile of study population (n=107)

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HV-NIHSS was administered on all 107 patients by personal interview. In the follow-up after 90 days to assess the functional outcome in terms of BI and mRS, 96 patients could be contacted through telephone. Out of 107 patients, 96 could be followed up after three months of administering the HV-NIHSS telephonically. BI and mRS values of 96 patients were calculated based on a telephonic interview of patients and/or his relative. Eleven patients could not be contacted and were lost to follow-up. Seventeen (17.7%) were found dead at three-month follow-up.

Inter-rater reliability of HV-NIHSS

The inter-rater reliability was substantial to high between the two examiners, with Pearson r ranging from 0.72 to 0.99 for the 15 items on the Scale [Table 3]. Intra-class correlation coefficient of the total score of HV-NIHSS was 0.995, (95% CI=0.993-0.997) and for the individual items is tabulated in [Table 3].
Table 3: Inter-rater agreement of HV-NIHSS between examiner DD and AK (n=107)

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Correlation between HV-NIHSS and English version of modified items of NIHSS

Correlation between HV-NIHSS and NIHSS administered by the same observer (in 38 patients who knew both English and Hindi) is tabulated in [Table 4].
Table 4: Comparison of modified items of HV-NIHSS and NIHSS in patients who had knowledge of English (n=38)

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Correlation of scores obtained from the HV-NIHSS, Baseline GCS with BI and mRS

The HV-NIHSS had a high correlation (Spearman's rho: -0.863, P<0.001) with the baseline Glasgow Coma Scale (GCS) but it was negative because the scores move in the opposite direction (patient with mild stroke has low NIHSS score but high GCS and vice versa). It also has a high negative correlation with the Barthel Index at three months (Spearman's rho: -0.829, P<0.001). HV-NIHSS correlation with mRS at three months is also of high magnitude (Spearman's rho: 0.851, P<0.001). [Figure 3] and [Figure 4] shows scatter plot between HV-NIHSS versus BI and mRS at 90 days, respectively. Baseline GCS correlation with Barthel Index and mRS at three months is also high (Spearman's rho: 0.778, P<0.001; and Spearman's rho: -0.794, P<0.001) respectively. [Figure 5] and [Figure 6] shows a scatter plot between Baseline GCS versus BI and mRS, respectively.
Figure 3: Correlation between HV-NIHSS and BI at 90 days

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Figure 4: Correlation between HV-NIHSS and mRS at 90 days

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Figure 5: Correlation between baseline GCS and BI at 90 days

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Figure 6: Correlation between baseline GCS and mRS at 90 days

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 » Discussion Top

The present study demonstrated good inter-observer agreement rates and high predictive validity for the HV-NIHSS in Hindi-speaking population. A test is reliable if the measurement error (variance) is minimal. [9] Reliability includes reproducibility among observers as well as consistency among scale items. Reliability is important because the error increases if there is poor reproducibility among separate observers. Inter-observer reliability measures the agreement among different people performing the assessment-it ranges from 0 (no reliability) to 1 (perfect reliability).

We found that the inter-rater agreement was between 0.72 and 0.99 for the 15 items in the scale using the Pearson correlation coefficient. Agreement was the highest for items evaluating motor power of arm and leg. The lowest agreement was for the item of dysarthria (Pearson's r: 0.721, P<0.001), visual field (Pearson's r: 0.798, P<0.001) and item of extinction (Pearson's r: 0.813, P<0.001). Examination of ataxia and visual field requires the skills of neurological examination, which might explain the disparity from other studies where both the examiners were clinicians, [10],[11] whereas in our study, one of the examiners was a research fellow and not a neurologist.

The original authors of NIHSS evaluated the scale reliability and found that the items for dysarthria and consciousness, rated fair to poor, whereas in our study, dysarthria item had substantial inter-rater agreement and item assessing consciousness had high inter-rater agreement .

When the scores of two modified items of HV-NIHSS was compared with scores of original NIHSS, Pearson's correlation was 0.843, P<0.001. When the study group was divided into three groups based on their NIHSS scores, group A with scores ranging from 0-7, group B: 8-24, and group C: >24, the Pearson's correlation decreased to 0.40 and 0.79 for item 9 and 10, respectively, for group A. For group B, Pearson's correlation was 0.63 and 0.85 for items 9 and 10, respectively, and for group C, Pearson correlation was 1.00 for both items. This was because most of the patients in group C were drowsy to comatose and unable to read or interpret pictures given in these items scoring. The scores of item 9 of NIHSS has low agreement with item 9 of HV-NIHSS in group A and moderate agreement in group B. The patients in these groups were able to read and interpret the pictures used in these items' scoring, and thus the agreement of scores was poor in these groups.

Validity is the extent to which an instrument or scale successfully measures the true state of the phenomenon being studied. In our study, we have also tested the predictive validity, which is how well a measure predicts a future event. In our case, we assessed how well HV-NIHSS scores predict functional outcome in the form of BI and mRS at three-month follow-up. We found significantly high correlation (rho: 0.851, P<0.001) of HV-NIHSS with mRS after 90 days of administering the scale. HV-NIHSS also had high magnitude of negative correlation (rho: -0.829, P<0.001) with BI at three-month follow-up and the baseline Glasgow Coma Scale (rho: -0.863, P<0.001), the latter supporting concurrent construct validity. Thus, higher baseline score of HV-NIHSS predicts poorer functional outcome at three months, thus proving the predictive validity of the HV-NIHSS scale.

 » References Top

1.Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20:864-70.  Back to cited text no. 1
2.Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999;53:126-31.  Back to cited text no. 2
3.Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH Stroke Scale. Arch Neuro 1989;46:660-2.  Back to cited text no. 3
4.Lyden P, Lu M, Jackson C, Marler J, Kothari R, Brott T, et al. Underlying structure of the National Institutes of Health Stroke Scale: Results of a factor analysis. Stroke 1999;30:2347-54.  Back to cited text no. 4
5.World Health Organization.International Classification of Impairments, Disabilities and Handicaps. Geneva, Switzerland: World Health Organization; 1980 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. 1995  Back to cited text no. 5
6.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group N Engl J Med. 1995 Dec 14;333(24):1581-7.  Back to cited text no. 6
7.Best JW, Khan JV. Research in Education. N J, New York: Prentice Hall; 1989. p. 205-52.  Back to cited text no. 7
8.Available from: [cited in 2011].  Back to cited text no. 8
9.Nunnally JC. Psychometric Theory. New York: McGraw-Hill Book Co; 1978.  Back to cited text no. 9
10.Domínguez R, Vila JF, Augustovski F, Irazola V, Castillo PR, Rotta Escalante R, et al. Spanish cross-cultural adaptation and validation of the National Institutes of Health Stroke Scale. Mayo Clin Proc 2006;81:476-80.  Back to cited text no. 10
11.Cincura C, Pontes-Neto OM, Neville IS, Mendes HF, Menezes DF, Mariano DC, et al. 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. Cerebrovasc Dis 2009;27:119-22.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4]

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