Reliability of structured modified rankin scale assessment.

Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at To the Editor: The modified Rankin Scale (mRS) is the most prevalent stroke outcome assessment in clinical trials, yet literature describing the properties of the scale remains limited, 1 so we were pleased to see 2 papers describing clinometric assessment of mRS in the May issue of the Journal. Saver and colleagues describe a Rankin Focused Assessment Tool (RFAT), 2 whereas Bruno's group describes a simplified mRS questionnaire. 3 The proposed use of structured assessment is in saving interviewers' time and decreasing interobserver variability; both of these points are worthy of further discussion. The issue of time spent conducting mRS assessment is interesting. Based on collected data from 100 video-recorded, paired mRS interviews, we performed multivariate analysis to explore if clinical, demographic, interview, or interviewer-specific features were associated with disagreement in mRS scoring. 4 The only factor significantly associated with variability in mRS scoring was interview length. Counterintuitively, it was longer, more detailed interviews that were associated with greatest interobserver variation. This could suggest that there is no value in lengthy discourses with the patient and that meaningful assessment can be made fairly promptly. Alternatively, it may suggest that there are some patients with more complex disability who, despite thorough assessment, are difficult to grade. However, with regard to actual time saved, simplified mRS questionnaire assessments last approximately 2 minutes and RFAT 3 to 5 minutes. In our studies, median duration of unstructured mRS was 4.1 minutes (SD 2.07); thus, benefits of any time-saving with these new structured assessments are debatable. Although attractive to the busy researcher, there are potential problems with a reductionist approach to mRS assessment. A strength of mRS as an outcome tool is the global approach to patient ability. Properly conducted, mRS interviews score patients based on perception of functioning within the context of their own lives and as such have potential to offer a more meaningful assessment than scales that focus solely on activities of daily living. In focusing the mRS interview to concrete ability, there is a …