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
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
NIH Stroke Scale3 | Brief, reliable, and can be administered by non-neurologists | |||
Canadian Neurological Scale4 | ||||
Walking is the only explicit assessment criterion, low sensitivity | ||||
Widely used for stroke, measures mobility, ADL, cognition, functional communication | ||||
Folstein Mini-Mental State Examination14 | Several functions with summed score. May misclassify patients with aphasia | |||
Neurobehavioral Cognition Status Exam (NCSE)15 | Does not distinguish right from left hemisphere, no reliability studies in stroke, no studies of factorial structure, correlates with education | |||
Fugl-Meyer16 | Extensively evaluated measure, good validity and reliability for assessing sensorimotor function and balance | |||
Reliability assessed only in stable patients. Sensitivity not tested | ||||
Simple, well established with stroke patients, sensitive to change | ||||
Boston Diagnostic Aphasia Examination25 | 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 | 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 | Time to administer long, “aphasia quotients” and “taxonomy” of aphasia not well validated | |||
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 | Brief, easily administered, useful in elderly, effective for screening in stroke population | |||
Geriatric Depression Scale (GDS)31 | Brief, easy to use with elderly, cognitively impaired, and those with visual or physical problems or low motivation | |||
Multiple differing versions compromise interobserver reliability | ||||
Good internal consistency, correlates significantly with clinician ratings of depression severity, and is sensitive to change | ||||
Philadelphia Geriatric Center Instrumental Activities of Daily Living34 | Measures broad base of information necessary for independent living. | |||
Frenchay Activities Index35 | Developed specifically for stroke patients, assesses broad array of activities | Sensitivity and interobserver reliability not tested, sensitivity probably limited | ||
Family Assessment Device (FAD)36 | Widely used in stroke, computer scoring available, excellent validity and reliability, available in multiple languages | Assessment subjective, sensitivity not tested, “ceiling” and “floor” effects | ||
Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey37 | 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 | ||
Sickness Impact Profile (SIP)38 | 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 | ||
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 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
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
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:
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.
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.
Source: Rappaport et al. Disability rating scale for severe head trauma patients: coma to community. Arch Phys Med Rehabil 1982;63:118–123. | |||
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