NIHSS LOC Questions and Commands Scoring for Awake Patients Unable to Answer Audibly
For a patient who is awake but unable to answer questions audibly, score item 1B (LOC Questions) as 2 (answers none correctly) and item 1C (LOC Commands) as 0,1, or 2 based solely on their ability to perform the two motor commands, regardless of verbal ability. 1
Understanding the NIHSS LOC Assessment Structure
The NIHSS evaluates level of consciousness through three distinct components that assess different neurological functions 1:
- Item 1A (LOC/Alertness): Scores the patient's arousal state from 0 (alert) to 3 (coma/unresponsive) 1
- Item 1B (LOC Questions/Orientation): Tests orientation by asking the patient's age and current month, scored 0-2 based on correct verbal responses 1
- Item 1C (LOC Commands): Tests the patient's ability to follow two motor commands (typically "open and close eyes" and "grip and release hand"), scored 0-2 based on correct performance 1
Scoring Item 1B (LOC Questions) When Patient Cannot Speak
Score item 1B as 2 (answers none correctly) when the patient cannot provide audible answers, even if they are fully awake and alert. 1 This scoring applies regardless of the reason for inability to speak, whether due to:
- Severe aphasia (inability to produce language) 2
- Severe dysarthria (inability to articulate speech clearly) 3
- Mechanical intubation or other physical barriers to speech 1
The key principle is that item 1B specifically requires verbal responses to orientation questions, and if these cannot be provided audibly, the item must be scored as 2 1.
Scoring Item 1C (LOC Commands) When Patient Cannot Speak
Item 1C should be scored based entirely on the patient's motor performance of the two commands, independent of their ability to speak. 1 The scoring is:
- Score 0: Performs both commands correctly 1
- Score 1: Performs one command correctly 1
- Score 2: Performs neither command correctly 1
This item tests motor responsiveness and command-following ability, not verbal communication 1. A patient who is awake but unable to speak can still score 0 on this item if they successfully perform both motor tasks 1.
Critical Distinction: Separating Speech from Motor Function
The NIHSS deliberately separates verbal and motor assessments to capture different neurological deficits 1:
- Do not penalize the patient twice for the same deficit—inability to speak affects item 1B scoring but should not influence item 1C scoring if motor commands are followed 1
- Item 1C specifically tests command-following, which demonstrates comprehension and motor execution, both of which can be intact despite inability to vocalize 1, 4
- Research demonstrates that some patients who appear nonresponsive can actually follow commands through motor responses even when unable to communicate verbally 4
Common Clinical Pitfalls to Avoid
Do not confuse inability to speak with inability to follow commands. 5, 2 Key distinctions include:
- A patient with severe aphasia or dysarthria may be fully alert (1A = 0), unable to answer questions verbally (1B = 2), but perfectly able to follow motor commands (1C = 0) 2, 3
- Do not assume altered consciousness based solely on lack of verbal response—assess arousal level independently for item 1A 5
- Distinguish between aphasia (language disorder affecting item 9) and dysarthria (articulation disorder affecting item 10), as both can prevent audible responses but represent different neurological deficits 2, 3
Clinical Significance
The ability to follow commands (item 1C) even without verbal responses has important prognostic implications 6, 7:
- Command-following ability is one of the key predictive components of the NIHSS for long-term functional outcome 6
- Level of consciousness items, including command-following, help predict large vessel occlusion in stroke patients 7
- These items show excellent interrater reliability (kappa 0.92 for LOC-C questions) when properly assessed 8