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?

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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

References

1
Guideline

NIH Stroke Scale Score for Patients with Severe Aphasia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

NIH Stroke Scale Score for Dysarthria in Patients Unable to Communicate

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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