15 Neurorehabilitation

Neurological rehabilitation programs are designed for people with injury or disorders of the nervous system and aim to improve function, reduce symptoms, and improve the well-being of the patient. It has been shown that brain is a dynamic organ capable of undergoing considerable modifications after suffering injuries or environmental changes—a property known as neuroplasticity. Due to this, great importance is currently being given to provide effective rehabilitation in cases of acquired brain injury and adequate stimulation to slow cognitive deterioration characteristic of pathologies.

Some of the conditions that may benefit from neurorehabilitation may include:

Vascular disorders, such as ischemic and hemorrhagic strokes, and subdural hematomas
Infections, such as meningitis, encephalitis, and brain abscesses
Acquired trauma, such as brain and spinal cord injury
Structural or neuromuscular disorders, such as brain or spinal cord tumors, peripheral neuropathy, muscular dystrophy, myasthenia gravis
Neurodegenerative disorders, such as Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis, Alzheimer’s disease (AD), and Huntington’s chorea
Intellectual disability
Mental illness
Normal aging

15.1 Categories of Neurorehabilitation Scales

Acute assessment (e.g., for admission/screening)
- Consciousness/cognition (e.g., Glasgow Coma Scale, Mini-Mental State Examination (MMSE))
- Stroke deficit (e.g., National Institute of Health Stroke Scale, Canadian Neurological Scale)
- Global disability (e.g., Rankin Scale)
- Activities of daily living (ADL)/outcomes (e.g., Barthel, Functional Independence measure (FIM), Supports Intensity Scale (SIS)-see below)
- Health outcomes, physical and mental (e.g., Health Survey SF-36, on web)
- Screening for rehab adherence (cognition, motivation, depression)
Rehab admission/monitoring/outcomes
- General scales such as ADLs (Barthel, FIM) or various quality of life (QOL) scales
- Targeted functional assessment scales such as for balance, mobility, language/speech, dysphagia, hand function, cognition, depression, continence
Stroke assessment scales overview

Type	Name and source	Approximate time to administer	Strengths	Weaknesses
Level-of-consciousness scale	Glasgow Coma Scale¹^,²	2 minutes	Simple, valid, and reliable	None observed
Stroke deficit scales	NIH Stroke Scale³	2 minutes	Brief, reliable, and can be administered by non-neurologists	Low sensitivity
Stroke deficit scales	Canadian Neurological Scale⁴	5 minutes	Brief, valid, and reliable	Some useful measures omitted
Global disability scale	Rankin Scale⁵^,⁶^,⁷	5 minutes	Good for overall assessment of disability	Walking is the only explicit assessment criterion, low sensitivity
Measures of disability/activities of daily living (ADL)	Barthel Index⁸^,⁹	5–10 minutes	Widely used for stroke, excellent validity and reliability	Low sensitivity for high-level functioning
Measures of disability/activities of daily living (ADL)	Functional Independence Measure (FIM)¹⁰^,¹¹^,¹²^,¹³	40 minutes	Widely used for stroke, measures mobility, ADL, cognition, functional communication	“Ceiling” and “floor” effects
Mental status screening	Folstein Mini-Mental State Examination¹⁴	10 minutes	Widely used for screening	Several functions with summed score. May misclassify patients with aphasia
Mental status screening	Neurobehavioral Cognition Status Exam (NCSE)¹⁵	10 minutes	Predicts gain in Barthel Index scores, unrelated to age	Does not distinguish right from left hemisphere, no reliability studies in stroke, no studies of factorial structure, correlates with education
Assessment of motor function	Fugl-Meyer¹⁶	30–40 minutes	Extensively evaluated measure, good validity and reliability for assessing sensorimotor function and balance	Considered too complex and time-consuming by many
	Motor Assessment Scale¹⁷^,¹⁸	15 minutes	Good, brief assessment of movement and physical mobility	Reliability assessed only in stable patients. Sensitivity not tested
	Motricity Index¹⁹^,²⁰	5 minutes	Brief assessment of motor function of arm, leg, and trunk	Sensitivity not tested
Balance assessment	Berg Balance Assessment²¹^,²²	10 minutes	Simple, well established with stroke patients, sensitive to change	None observed
Mobility assessment	Rivermead Mobility Index²³^,²⁴	5 minutes	Valid, brief, reliable test of physical mobility	Sensitivity not tested
Assessment of speech and language functions	Boston Diagnostic Aphasia Examination²⁵	1–4 hours	Widely used, comprehensive, good standardization data, sound theoretical rationale	Time to administer long; half of patients cannot be classified
	Porch Index of Communicative Ability (PICA)²⁶	1/2–2 hours	Widely used, comprehensive, careful test development and standardization	Time to administer long, special training required to administer, inadequate sampling of language other than one word and single sentences
	Western Aphasia Battery²⁷	1–4 hours	Widely used, comprehensive	Time to administer long, “aphasia quotients” and “taxonomy” of aphasia not well validated
Depression scales	Beck Depression Inventory (BDI)²⁸^,²⁹	10 minutes	Widely used, easily administered, norms available, good with somatic symptoms	Less useful in elderly and in patients with aphasia or neglect, high rate of false positives, somatic items may not be due to depression
	Center for Epidemiologic Studies Depression (CES-D)³⁰	< 15 minutes	Brief, easily administered, useful in elderly, effective for screening in stroke population	Not appropriate for aphasic patients
	Geriatric Depression Scale (GDS)³¹	10 minutes	Brief, easy to use with elderly, cognitively impaired, and those with visual or physical problems or low motivation	High false negative rates in minor depression
	Hamilton Depression Scale³²^,³³	< 30 minutes	Observer rated; frequently used in stroke patients	Multiple differing versions compromise interobserver reliability
	Quick Inventory of Depressive Symptomatology (QIDS)	5–10 minutes	Good internal consistency, correlates significantly with clinician ratings of depression severity, and is sensitive to change
Measures of instrumental ADL	Philadelphia Geriatric Center Instrumental Activities of Daily Living³⁴	5–10 minutes	Measures broad base of information necessary for independent living.	Has not been tested in stroke patients.
Measures of instrumental ADL	Frenchay Activities Index³⁵	10–15minutes	Developed specifically for stroke patients, assesses broad array of activities	Sensitivity and interobserver reliability not tested, sensitivity probably limited
Family assessment	Family Assessment Device (FAD)³⁶	30 minutes	Widely used in stroke, computer scoring available, excellent validity and reliability, available in multiple languages	Assessment subjective, sensitivity not tested, “ceiling” and “floor” effects
Health status/quality of life measures	Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey³⁷	10–15minutes	Generic health status scale SF36 is improved version of SF20. Brief, can be self-administered or administered by phone or interview. Widely used in the United States	Possible “floor” effect in seriously ill patients (especially for physical functioning), it is suggested that it should be supplemented by an ADL scale in stroke patients
Health status/quality of life measures	Sickness Impact Profile (SIP)³⁸	20–30minutes	Comprehensive and well-evaluated, broad range of items reduces “floor” or “ceiling” effects	Time to administer somewhat long, evaluates behavior rather than subjective health; needs questions on well-being, happiness, and satisfaction
Sources: 1 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81–84 2 Teasdale G, Murray G, Parker L, Jennett B. Adding up the Glasgow Coma Score. Acta Neurochir (Wien) 1979(Suppl 28):\|13–16 3 Brott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20(7):864–870 4 Côté R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C. The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke 1986;17(4):731–737 5 Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957;2(5):200–215 6 Bonita R, Beaglehole R. Modification of Rankin Scale. Recovery of motor function after stroke. Stroke 1988;19(12):1497–1500 7 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 8 Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1965;14:61–65 9 Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 1988;10(2):64–67 10 Guide for the uniform data set for medical rehabilitation (Adult FIM), version 4.0 Buffalo, NY 14214: State University of New York at Buffalo; 1993 11 Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwin FS. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1(3):59–74 12 Granger CV, Hamilton BB, Sherwin FS. Guide for the use of the uniform data set for medical rehabilitation. Uniform Data System for Medical Rehabilitation Project Office, Buffalo General Hospital, NY; 1986 13 Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence measure: a new tool for rehabilitation. In: Eisenberg MG, Grzesiak RC, ed. Advances in clinical rehabilitation. Vol. 1. New York: Springer-Verlag; 1987:6–18 14 Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189–198 15 Kiernan RJ, Mueller J, Langston JW, Van Dyke C. The Neurobehavioral Cognitive Status Examination: a brief but quantitative approach to cognitive assessment. Ann Intern Med 1987;107(4):481–485 16 Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975;7(1):13–31 17 Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985;65(2):175–180 18 Poole JL, Whitney SL. Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys Med Rehabil 1988;69(3 Pt 1):195–197 19 Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry 1990;53(7):576–579 20 Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol 1980;19(6):382–389 21 Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil 1992;73(11):1073–1080 22 Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989;41(6):304–311 23 Collen FM, Wade DT, Robb GF, Bradshaw CM. The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. Int Disabil Stud 1991;13(2):50–54 24 Wade DT, Collen FM, Robb GF, Warlow CP. Physiotherapy intervention late after stroke and mobility. BMJ 1992;304(6827):609–613 25 Goodglass H, Kaplan E. The assessment of aphasia and related disorders. Philadelphia: Lea and Febiger; 1972. Chapter 4, Test procedures and rationale. Manual for the BDAE. Goodglass H, Kaplan E. Boston Diagnostic Aphasia Examination (BDAE). Philadelphia: Lea and Febiger; 1983 26 Porch B. Porch Index of Communicative Ability (PICA). Palo Alto: Consulting Psychologists Press; 1981 27 Kertesz A. Western Aphasia Battery. New York: Grune & Stratton; 1982 28 Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961 June;4:561–571 29 Beck AT, Steer RA. Beck Depression Inventory: manual (revised edition). NY Psychological Corporation; 1987 30 Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. J Appl Psychol Meas 1977;1:385–401 31 Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982–1983–83;17(1):37–49 32 Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62 33 Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967;6(4):278–296 34 Lawton MP. Assessing the competence of older people. In: Kent D, Kastenbaum R, Sherwood S, eds. Research Planning and Action for the Elderly. New York: Behavioral Publications; 1972 35 Holbrook M, Skilbeck CE. An activities index for use with stroke patients. Age Ageing 1983;12(2):166–170 36 Epstein NB, Baldwin LM, Bishop DS. The McMaster Family Assessment Device. J Marital Fam Ther 1983;9(2):171–180 37 Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473–483 38 Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care 1981;19(8):787–805 Note: Instrument is available from the Health Services Research and Development Center, The Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, Baltimore, MD 21205. Taken from “Post-Stroke Rehabilitation: Assessment, Referral, and Patient Management Quick Reference Guide Number 16” and published by the US Agency for Health Care Policy and Research.

Other useful instruments for measuring disability/ADL include the following:
- Katz Index of ADL
  
  Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185:914–919
- Kenny Self-Care Evaluation
  
  Schoening HA, Iversen IA. Numerical scoring of self-care status: a study of the Kenny self-care evaluation. Arch Phys Med Rehabil 1968;49(4):221–229
- LORS/LAD
  
  Carey RG, Posavac EJ. Program evaluation of a physical medicine and rehabilitation unit: a new approach. Arch Phys Med Rehabil 1978;59(7):330–337
- Picture Exchange Communication System (PECS)
  
  Harvey RF, Jellinek HM. Functional performance assessment: a program approach. Arch Phys Med Rehabil 1981;62(9):456–460
Another useful instrument for assessing mental status is motor impersistence. Ben-Yishay Y, Diller L, Gerstman L, Haas A. The relationship between impersistence, intellectual function and outcome of rehabilitation in patients with left hemiplegia. Neurology 1968;18(9):852–861
Instrument for assessing depression is the Zung Scale.

Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63–70
Useful instruments for measuring IADL include:
- OARS-Instrumental ADL
  
  Duke University Center for the Study of Aging and Human Development. Multidimensional Functional Assessment: The OARS Methodology. Durham, NC: Duke University; 1978
- Functional Health Status
  
  Rosow I, Breslau N. A Guttman health scale for the aged. J Gerontol 1966;21(4):556–559

15.2 Measures (Scales) of Disability

15.2.1 Glasgow outcome scale

The Glasgow Outcome Scale (GOS) has provided a high inter-rater reliability and has proved its usefulness in multicenter clinical studies of head injury.

Score	Outcome
1	Death
2	Vegetative state: unresponsive and speechless
3	Severe disability: depends on others for all or part of care or supervision because of mental or physical disability
4	Moderate disability: disabled, but independent in ADLs and in the community
5	Good recovery: resumes normal life; may have minor neurologic or psychologic deficits
Source: Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1(7905):480–484

15.2.2 Disability rating scale (DRS)

Developed as an alternative to GOS which was thought to be insensitive. It was tested with older juveniles and adults with moderate and severe brain injuries in an inpatient rehabilitation setting.

It is an 8-item outcome measure; scoring is reversed from many scales. The scale is intended to measure accurately general changes over the course of recovery. It is widely used in brain injury research.

Category	Item	Instructions	Score
Arousability	Eye opening	0 = spontaneous
		1 = to speech
		2 = to pain
		3 = none
Awareness and responsivity	Communication ability	0 = oriented
		1 =confused
		2 = inappropriate
		3 = incomprehensible
		4= none
	Motor response	0 = obeying
		1 = localizing
		2 = withdrawing
		3 = flexing
		4 = extending
		5 = none
Cognitive ability for sef-care activities	Feeding	0 = complete
		1 = partial
		2 = minimal
		3 = none
	Toileting	0 = complete
		1 = partial
		2 = minimal
		3 = none
	Grooming	0 = complete
		1 = partial
		2 = minimal
		3 = none
Dependence on others	Level of functioning	0 = completely independent
		1 = independent in special environment
		2 = mildly dependent
		3 = moderately dependent
		4 = markedly dependent
		5 = totally dependent
Psychosocial adaptability	Employability	0 = not restricted
		1 = selected jobs
		2 = sheltered workshop
		(noncompetitive)
		3 = not employable
Total DR score
Source: Rappaport et al. Disability rating scale for severe head trauma patients: coma to community. Arch Phys Med Rehabil 1982;63:118–123.