Canadian Neurological Scale: Training for Trainers Workshop
INSTRUCTIONS FOR SPEAKERS/FACILITATORS
Thank you for sharing your expertise at the Canadian Neurological Scale: Training for
Trainers Workshop. The Canadian Neurological Scale (CNS) is a validated and
recommended tool for assessing and monitoring the neurological status of stroke clients.
Background
Performing ongoing neurological assessment provides a standardized method to detect
subtle changes in neurological status that can lead to early intervention and improved
outcomes. In 1985, Dr. Robert Cote and associates developed the Canadian Neurological
Scale to provide a standardized neurological assessment to use with stroke patients who
were alert or drowsy. The Heart and Stroke Foundation of Ontario Best Practice
Guidelines for Stroke Care, 2003 and the Clinical Practice Guideline for Stroke (AHCPR,
1995) have recommended the Canadian Neurological Scale as a valid and reliable
standardized tool for the assessment of neurological deficits in the acute stroke patient.
Although the Canadian Neurological Scale was initially developed as an assessment tool,
the total initial CNS score was found to be a significant predictor of death, morbidity and
recovery of ADL even after adjustments were made for other covariates. For patients
whose initial CNS score was 11 or more, 2.1% had died within 6 months, and 2.1 % had
another vascular event within 6 months. In contrast, for those whose CNS score was less
than 9, 13.2% had died within 6 months, and 20.6% had had another vascular event
within six months. Patients with higher CNS scores tended to be more independent in
ADL at six months than those with lower CNS scores (Cote et al, 1989).
Canadian Neurological Scale Training for Trainers Workshop
The CNS Training for Trainers Workshop is a four-hour workshop that has been
developed to provide resources on training front line staff to perform the Canadian
Neurological Scale, to provide practice with simulated patients, and to use the
simulations on the training video to assess interrater reliability.
Canadian Neurological Scale Teaching Package
The CNS Teaching Package is meant to be adapted for regional use. Clinicians should
follow the procedures and protocols within their region and/or organization for
performing and documenting the Canadian Neurological Scale.
The PowerPoint presentation included on the CD can be adapted for regional practice and
presenter style. Please note that the Heart and Stroke Foundation and Coordinated Stroke
Strategy logos, style guides and branding must not be altered or removed. For example, it
is acceptable to add regional or hospital logos, but the Heart and Stroke logos cannot be
removed. References to the Ministry of Health and Long-Term Care or Ontario Stroke
System must not be removed. Any acknowledgements that are part of the package must
also stay in place.
The CNS Teaching Package consists of a coordinator and speaker package and is meant
to be adapted for regional practice. The teaching package consists of six key components:
 A PowerPoint presentation that outlines how to implement the CNS in an organization.
 A PowerPoint presentation that outlines the history and advantages of the CNS,
describes the components of the scale in detail, and reviews the scoring of the scale.
 A procedure for how to use the CNS Record. The procedure defines key terms and
outlines the steps that need to be followed to complete the record. The procedure is
presented in a generic format to allow organizations to adapt it according to
organization-specific requirements.
 Two documentation templates for recording the CNS in the patient care record that can
be adapted to meet the needs of the organization:
 One with the CNS scale and bar graph for trending the CNS results.
 One with the CNS scale, vital signs, and pupil size and reaction.
 A video that reviews how to perform the CNS, demonstrates motor weakness grading,
and provides five patient simulations for testing inter-rater reliability using the CNS.
 A Reference Sheet that can be used as a teaching aid or as a reference for staff to assist
to perform the CNS.
For more information about the history of the Canadian Neurological Scale and
corresponding reliability and validity studies, please see the following references:
Anemaet WK. Using standardized measures to meet the challenge of stroke assessment.
Topics in Geriatric Rehabilitation. 2002;18(2):47-62.
Bushnell CD, Johnston DC, Goldstein LB. Retrospective assessment of initial stroke
severity: Comparison of the NIH Stroke Scale and the Canadian Neurological Scale.
Stroke. 2001;32:656-60.
Cote R, Battista RN, Wolfson C, Boucher J, Adam J, Hachinski V. The Canadian
Neurological Scale: Validation and reliability assessment. Neurology. 1989;39:638-43.
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Cote R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C. The Canadian Neurological
Scale: A preliminary study in acute stroke. Stroke. 1986;17:731-7.
Cuspineda E, Machado C, Aubert E, Galan L, Llopis F, Avila Y. Predicting outcome in
acute stroke: A comparison between QEEG and the Canadian Neurological Scale. Clin
Electroencephalogr. 2003;34:1-4.
D'Olhaberriague L, Litvan I, Mitsias P, Mansbach HH. A reappraisal of reliability and
validity studies in stroke. Stroke. 1996;27:2331-6.
Goldstein LB, Chilukuri V. Retrospective assessment of initial stroke severity with the
Canadian Neurological Scale. Stroke. 1997;28:1181-4.
Muir KW, Weir CJ, Murray GD, Povey C, Lees KR. Comparison of neurological scales
and scoring systems for acute stroke prognosis. Stroke. 1996;27:1817-20.
Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke
severity with the NIH Stroke Scale. Stroke. 2000;31:358-862.
The Heart and Stroke Foundation of Ontario gratefully acknowledges the contribution of
the Regional Stroke Centre at Hamilton Health Sciences for the development of this
teaching package for the Canadian Neurological Scale. A team of professionals at the
Hamilton General site developed the content and worked with the Heart and Stroke
Foundation of Ontario to make this information available as a provincial resource for the
Ontario Stroke Strategy. The members of the team were:
Lisa Colizza, Regional Stroke Development Specialist
Linda Gould, Stroke Registry Data Analyst
Rhonda McNicoll, Education and Development Clinician
Kelly Waid, Regional Stroke Coordinator
In addition, Gina Tomaszewski, Southwestern Ontario Regional Stroke Educator,
London Health Sciences Centre, London was instrumental in the development of the
CNS Reference Sheet.
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