Modified Rankin Scale for Neurologic Disability
The mRS can help users determine the degree of disability in patients who have suffered a stroke.
The Modified Rankin Scale (mRS) assesses disability in patients who have suffered a stroke and is compared over time to check for recovery and degree of continued disability. A score of 0 is no disability, 5 is disability requiring constant care for all needs; 6 is death.
- The mRS has been used in clinical research for over 30 years and is a common standard for assessing functional outcomes in patients with stroke.
- Multiple studies have shown that the mRS correlates with physiological indicators such as stroke type, lesion size and neurological impairment as assessed by other stroke evaluation scales.
Points to keep in mind:
- There is criticism that the mRS contains subject components that results in variability and bias that lowers the score’s reliability.
- The use of structured interviews when assessing the mRS appears to result in improved interrater reliability though this effect is not completely consistent.
There are nearly 800,000 cases of acute stroke in the United States every year, with 130,000 associated deaths (4th leading cause of death in Americans).
The mRS is a widely used measure to assess the functional outcomes for patients who have suffered a stroke. It can also provide a common language for describing the degree of disability.
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Decisions about further medical management, the need for PT/OT therapy and the degree of care that a patient requires can be partially informed by the mRS, but final determinations should be made on an individual basis.
The mRS is used to evaluate the degree of disability in patients who have suffered a stroke, but individual quality of life and independence are influenced by a wide variety of factors including the presence of comorbidities and socioeconomic status.
The use of a structured interview may lead to increased reliability among those conducting assessments using the mRS.
Assignation of points based on severity of disability.
Facts & Figures
Standardized Interview for the mRS:
Ask these Yes/No Questions:
- Do you have any symptoms that are bothering you?
- Are you able to do the same work as before?
- Are you able to keep up with your hobbies?
- Have you maintained your ties to friends and family?
- Do you need help making a simple meal, doing household chores, or balancing a checkbook?
- Do you need help with shopping or traveling close to home?
- Do you need another person to help you walk?
- Do you need help with eating, going to the toilet, or bathing?
- Do you stay in bed most of the day and need constant nursing care?
- The original scale was introduced in 1957 by Dr. John Rankin and was actually changed to its current modified Rankin Scale Form for use in the UK-TIA Study. (van Swieten JC 1988)
- The interrater reliability of the mRS was first assessed in a trial of 100 stroke patients who each participated in two separate interviews that were conducted by pairs of raters drawn from a group of 10 staff neurologists and 24 neurology residents.
- Overall kappa was 0.56, with a weighted kappa of 0.91.
- A 2002 trial of 63 stroke patients evaluated by two observers found that using structured interviews to conduct the mRS improved reliability and decreased variability and bias. (Wilson JT 2002)
- A similar trial in 2005 of 113 patients assessed by a pair of trained raters found that without using a structured interview the observers agreed only 43% of the time (kappa = 0.25), but that agreement improved markedly (kappa = 0.74) when a structured interview was used. (Wilson JT 2005)
- A 2007 literature review and systematic analysis of 50 trials found an overall moderate interrater reliability for the mRS (kappa = 0.56) that improved when structured interviews were used (kappa = 0.78). (Banks 2007)
- Among 50 patients assessed using a simplified mRS had good agreement between raters (kappa = 0.72) and that the average time to complete an assessment was 1 minute and 40 seconds as opposed to 5 minutes for the regular mRS. (Bruno 2010)
- A 2009 systematic review that included 10 trials found wide variability in the interrater reliability (kappa = 0.25-0.95) and an overall only moderate reliability (kappa = 0.46). (Quinn TJ 2009)
- Among 74 stroke patients interviewed by 2 interviewers, a 2012 study found reliability for a standard mRS interview was 56% agreement, kw=0.55 (95% CI 0.39-0.71) and 70%, kw=0.70 (95% CI, 0.53-0.87), for prestroke assessment, raising concerns of poor correlation of prestroke mRS with certain markers of function, and that "relying on mRS alone may be a suboptimal measure of prestroke function and could potentially bias trial samples" (Fearon 2012).
- A 2015 trial comparing the mRS assessments of local evaluators compared to central evaluators who used phone or video interviews found that video assessment was superior to phone assessment (kw 0.92, 95% CI 0.88-0.96) versus 0.77, 95% CI 0.72-0.83) and demonstrated the potential utility of video interview mRS assessments (López-Cancio 2015).
Original/Primary Referencevan Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988 May;19(5):604-7.
ValidationBanks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke. 2007 Mar;38(3):1091-6. Epub 2007 Feb 1.Fearon P, McArthur KS, Garrity K, et al. Prestroke modified Rankin stroke scale has moderate interobserver reliability and validity in an acute stroke setting. Stroke. 2012;43(12):3184-8.López-Cancio E, Salvat M, Cerdà N, et al. Phone and Video-Based Modalities of Central Blinded Adjudication of Modified Rankin Scores in an Endovascular Stroke Trial. Stroke. 2015;46(12):3405-10.
Other ReferencesWilson JT, Hareendran A, Grant M, Baird T, Schulz UG, Muir KW, Bone I. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke. 2002 Sep;33(9):2243-6.Wilson JT, Hareendran A, Hendry A, Potter J, Bone I, Muir KW. Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview. Stroke. 2005 Apr;36(4):777-81. Epub 2005 Feb 17.Bruno A, Shah N, Lin C, Close B, Hess DC, Davis K, Baute V, Switzer JA, Waller JL, Nichols FT. Improving modified Rankin Scale assessment with a simplified questionnaire. Stroke. 2010 May;41(5):1048-50. doi: 10.1161/STROKEAHA.109.571562. Epub 2010 Mar 11.Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry. 1991 Dec;54(12):1044-54. PubMed PMID: 1783914.Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale: a systematic review. Stroke. 2009 Oct;40(10):3393-5. doi: 10.1161/STROKEAHA.109.557256. Epub 2009 Aug 13. Review. PubMed PMID: 19679846.
About the Creator
John van Swieten, MD, PhD, is a professor in the Department of Neurology at Erasmus University Medical Center in Rotterdam. His research has focused on several aspects of dementia, especially frontotemporal dementia (FTD), and he has studied clinical, genetic and pathological aspects of FTD in a large nation-wide cohort over the last 15 years.
To view Dr. John van Swieten's publications, visit PubMed