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Modified Rankin Scale (mRS)
Availability
Please visit this website for more information about the instrument Modified Rankin Scale
Classification
Supplemental - Highly Recommended: Unruptured Cerebral Aneurysm and Subarachnoid Hemorrhage (SAH) and Stroke (based on study type, disease stage and disease type)
 
Exploratory: Myasthenia Gravis (MG)
Short Description of Instrument
The van Swieten mRS scale is in the public domain.  A formal tool for clinician-rater assignment of an mRS score in the public domain is the Rankin Focused Assessment (RFA) (Saver et al., 2010). Formal tools for patient/family self-assignment of an mRS score in the public domain include: 1) the short mRS questionnaire (SmRSQ) (Bruno et al., 2013), and 2) the mRS-9Q (Patel et al., 2021).  
 
Purpose:
The modified Rankin Scale (mRS) is a scale commonly used for measuring the degree of disability or dependence in the daily activities of individuals who have suffered a stroke. It has become the most widely used clinical outcome measure for stroke clinical trials.
 
Overview:
The mRS was originally introduced in 1957 by Rankin, and first modified to its currently accepted form by Charles Warlow and others as part of the UK-TIA study in the 1980s. (Broderick et al., 2017; Farrell et al., 1991) In 1988, van Swieten et al., first published the current mRS as well as the first interobserver agreement analysis of the mRS. (van Sweiten et al., 1988)
 
Time:
The assessment requires 5 minutes to complete.
 
Prestroke Scoring:
Uses a scale from 0 to 5. For Score=1, symptoms may refer to those of a prior stroke in patients with a history of stroke.
 
Other Important Notes:
English and eleven different language translations are available. Consider employing a formal scoring system for the mRS such as the, the Structured Interview for the mRS, or a training program to determine the score that best describes the subject's current state. The mRS is highly reliable at pre-stroke, 30 and 90 days, and upon return to the community, but caution should be exercised when trying to apply it at hospital arrival or discharge. There are currently no published instructions on the use of the mRS to assess initial stroke disability. Raters using this at admission or discharge should develop a standard methodology and scoring instructions for use in hospital setting. The mRS is a widely used measure used 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.
Comments/Special Instructions
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 assessment may lead to increased reliability among those conducting assessments using the mRS.
Scoring and Psychometric Properties
Scoring:
The mRS defines 6 different levels of disability, from 0 for "no symptoms at all" to 6 indicating 'death'.
 
0 - No Symptoms
1 - No significant disability. Able to carry out all usual activities, despite some symptoms
2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
3 - Moderate disability. Requires some help, but able to walk unassisted.
4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
6 - Dead.
 
Psychometric Properties:
Multiple types of evidence attest to the validity and reliability of the mRS. The reported data support the view that the mRS is a valuable instrument for assessing the impact of new stroke treatments. Inter-observer reliability of the mRS can be improved by using a structured interview, by using structured assessment forms, and by having raters undergo a multimedia training process.
Rationale/Justification
Strengths:
The mRS "covers the entire range of functional outcomes from no symptoms to death, its categories are intuitive and easily grasped by both clinicians and patients, its concurrent validity is demonstrated by strong correlation with measures of stroke pathology (for example, infarct volumes) and agreement with other stroke scales, (Harrison et al., 2013) and its use has demarcated effective and ineffective acute stroke therapies in trials with appropriately powered sample sizes." (Broderick et al., 2017)
 
Weaknesses:
Even though a single-point change on the mRS is clinically relevant, with a limited number of levels the mRS may be less responsive to change than some other stroke scales. (Harrison et al., 2013) Another limitation of the mRS has been the subjective determination between categories and the reproducibility of the score by examiners and patients. (Harrison et al., 2013; Quinn et al., 2009) Reproducibility is improved with the use of formal rating systems.
References
Key References:
Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957;2(5):200-215.
 
van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604-607.
 
Additional References:
Banks 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.
 
Broderick JP, Adeoye O, Elm J. Evolution of the Modified Rankin Scale and Its Use in Future Stroke Trials. Stroke. 2017 Jul;48(7):2007-2012.
 
Bruno A, Akinwuntan AE, Lin C, Close B, Davis K, Baute V, Aryal T, Brooks D, Hess DC, Switzer JA, Nichols FT. Simplified modified rankin scale questionnaire: reproducibility over the telephone and validation with quality of life. Stroke. 2011;42(8):2276-2279.
 
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;41(5):1048-1050.
 
Bruno A, Close B, Switzer JA, Hess DC, Gross H, Nichols FT 3rd, Akinwuntan AE. Simplified modified Rankin Scale questionnaire correlates with stroke severity. Clin Rehabil. 2013 Aug;27(8):724-7.
 
Cheng B, Forkert ND, Zavglia M, Hilgetag CC, Golsari A, Siemonsen S, Fiehler J, Pedraza S, Puig J, Cho T, Alawneh J, Baron J, Ostergaard L, Gerloff C, Thomalla G. Influence of Stroke Infarct Location on Functional Outcome Measured by the Modified Rankin Scale. Stroke;45(6):1695-1702.
 
D'Olhaberriague L, Litvan I, Mitsias P, Mansbach HH. A reappraisal of reliability and validity studies in stroke. Stroke. 1996;27: 2331-2336.
 
de Haan R, Limburg M, Bossuyt P, van der Meulen J, Aaronson N. The clinical meaning of Rankin "handicap" grades after stroke. Stroke. 1995; 26: 2027-2030.
 
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;54(12):1044-1054.
 
Fearon P, McArthur KS, Garrity K, Graham LJ, McGroarty G, Vincent S, Quinn TJ. Prestroke modified rankin stroke scale has moderate interobserver reliability and validity in an acute stroke setting. Stroke. 2012 Dec;43(12):3184-8.
 
Harrison JK, McArthur KS, Quinn TJ. Assessment scales in stroke: clinimetric and clinical considerations. Clin Interv Aging. 2013;8:201-11.
 
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975 Mar 1;1(7905):480-484.
 
Lansberg M, Schrooten M, Bluhmki E, Thijs VN, Saver JL. Treatment Time-Specific Number Needed to Treat Estimates for Tissue Plasminogen Activator Therapy in Acute Stroke Based on Shifts Over the Entire Range of the Modified Rankin Scale. Stroke. 2009; 40(6):2079-2084.
 
López-Cancio E, Salvat M, Cerdà N, Jiménez M, Codas J, Llull L, Boned S, Cano LM, Lara B, Molina C, Cobo E, Dávalos A, Jovin TG, Serena J; REVASCAT investigators. Phone and Video-Based Modalities of Central Blinded Adjudication of Modified Rankin Scores in an Endovascular Stroke Trial. Stroke. 2015 Dec;46(12):3405-10.
 
Patel N, Rao VA, Heilman-Espinoza ER, Lai R, Quesada RA, Flint AC. Simple and reliable determination of the modified rankin scale score in neurosurgical and neurological patients: the mRS-9Q. Neurosurgery. 2012 Nov;71(5):971-5; discussion 975.
 
Patel RD, Starkman S, Hamilton S, Craig S, Grace A, Conwit R, Saver JL. The Rankin Focused Assessment-Ambulation: A Method to Score the Modified Rankin Scale with Emphasis on Walking Ability. J Stroke Cerebrovasc Dis. 2016 Sep;25(9):2172-6.
 
Quinn TJ, Dawson J, Walters MR, Lees KR. Exploring the reliability of the modified rankin scale. Stroke. 2009 Mar;40(3):762-6.
 
Saver JL, Chaisinanunkul N, Campbell BCV, Grotta JC, Hill MD, Khatri P, Landen J, Lansberg MG, Venkatasubramanian C, Albers GW; XIth Stroke Treatment Academic Industry Roundtable. Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI. Stroke. 2021 Aug;52(9):3054-3062.
 
Saver JL, Filip B, Hamilton S, Yanes A, Craig S, Cho M, Conwit R, Starkman S; FAST-MAG Investigators and Coordinators. Improving the reliability of stroke disability grading in clinical trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke. 2010 May;41(5):992-5.
 
Uyttenboogaart M, Stewart RE, Vroomen CAJ, De Keyser J, Luijckx G. Optimizing Cutoff Scores for the Barthel Index and Modified Ranking Scale for Defining Outcome in Acute Stroke Trials. Stroke. 2005;36:1984-1987.
 
Wilson 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;36(4):777-781.
 
Document last updated October 2024