What is the National Institutes of Health (NIH) stroke scale score for best language for a patient who is unable to articulate but can follow two-step commands?

NIH Stroke Scale Score for Best Language in a Patient Unable to Articulate but Able to Follow Two-Step Commands

The appropriate NIH Stroke Scale score for item 9 (Best Language) in a patient who is unable to articulate but can follow two-step commands is 3, indicating mute or global aphasia. 1

Understanding the NIHSS Language Assessment (Item 9)

The NIH Stroke Scale evaluates language function in item 9 using the following scoring criteria:

• 0 = Normal language 2
• 1 = Mild to moderate aphasia 2
• 2 = Severe aphasia 2
• 3 = Mute or global aphasia 2, 1

Clinical Reasoning for Scoring

• A patient who cannot articulate at all but can follow commands is demonstrating a severe receptive-expressive language disconnect characteristic of global aphasia or mutism 1
• The ability to follow two-step commands indicates some preserved comprehension, but the complete inability to articulate words represents a severe language deficit 1
• This presentation differs from dysarthria (item 10 on NIHSS), which evaluates speech clarity rather than language function 3

Assessment Technique

• The language assessment involves asking the patient to:
  • Describe a standardized picture
  • Name objects
  • Read sentences 1
• When a patient cannot produce any meaningful language despite preserved comprehension (as evidenced by following commands), the appropriate score is 3 1
• This assessment must be distinguished from decreased level of consciousness, which would be scored separately in item 1A of the NIHSS 2

Clinical Significance

• The presence of severe aphasia contributes significantly to the overall NIHSS score 1
• Higher NIHSS scores correlate with poorer outcomes, with scores >20 indicating large strokes with only 4-16% chance of favorable outcomes at one year 1
• Early identification of language deficits is crucial for appropriate rehabilitation planning and prognosis 2

Common Pitfalls to Avoid

• Do not confuse inability to speak due to decreased consciousness with aphasia 1
• Distinguish between aphasia (language function) and dysarthria (speech clarity) 3
• Ensure the patient is not simply unable to follow commands due to hearing impairment or other non-language factors 1

Management Implications

• Patients with severe aphasia should be referred to a Speech-Language Pathologist for comprehensive assessment and therapy 1
• Early access to intensive language and communication therapy improves outcomes 1
• Treatment approaches may include language therapy, conversational treatment, constraint-induced language therapy, and assistive technology 1