New Picture Stimuli for the NIH Stroke Scale: A Validation Study

Abstract

BACKGROUND: The National Institutes of Health Stroke Scale is a widely accepted tool for structured graded neurological examination of stroke or suspected stroke in the hyperacute setting. Concerns have arisen about the use of its picture stimuli in a contemporary and global health context. Here, we present new stimuli prepared to serve the needs of stroke providers worldwide: the precarious painter image description and updated objects for naming. METHODS: This was a validation study of 101 healthy fluent English speakers. Participants were reached by the Johns Hopkins Outpatient Center, the University of South Carolina, and Prisma Health from 2022 to 2023 and included residents of the United States, Germany, Canada, the United Kingdom, Australia, and Zambia. Participants were recorded in person or via video conferencing when asked to describe the new picture, while a subset named seven illustrations. Multivariate analyses of variance were used for primary analyses. In a complementary investigation, 299 attendees of the 2023 International Stroke Conference were asked about their preference for the existing or new stimuli and why. RESULTS: Each of the 44 content units from the picture description was included by at least 5% of respondents in the demographically representative subsample. Performance was similar across healthy participants irrespective of age, sex, race, ethnicity, or education. Typical descriptions were characterized by an average of 23 content units (SD=5) conveyed with 167 syllables (SD=79). The new naming stimuli were recognized by 100% of participants from many countries as being familiar and identifiable, and names provided in response to the task were highly convergent. The majority of stroke health care providers preferred both the precarious painter and naming stimuli. CONCLUSIONS: The description of the new National Institutes of Health Stroke Scale picture, the precarious painter, results in rich samples among healthy speakers that will provide an appropriate basis for the detection of language deficits.

President's Column

“…Lastly, the picture cards used for testing language fluency have been heavily criticized. 10 These pictures were initially developed exclusively for an English-speaking, Western population and therefore do not translate well across other cultures. Additionally, the picture of the woman in the kitchen washing the dishes has perpetuated former stereotypical gender roles.…”

“…Recently, these pictures were updated to include a more culturally appropriate scenario, along with updated objects to name. 10 The new picture cards have been validated and are available on the NINDS website (Figure 1). Literacy concerns are also tied to the NIHSS phrases, as not all patients can read these, including those without disabilities or stroke.…”

“…Literacy concerns are also tied to the NIHSS phrases, as not all patients can read these, including those without disabilities or stroke. 10 Several iterations of the NIHSS have been proposed through the years to address these pitfalls. Introduced in 2002, the modified NIHSS (mNIHSS) focused on reducing redundancy and eliminating items with poor reliability, 11 however the mNIHSS has not been widely adopted because of poor detection of posterior stroke symptoms.…”