For an overview of practical considerations regarding the use of global measures in clinical practice please refer to Table 2. Global outcome measures such as the Glasgow Outcome Scale (GOS) [21] are broad-based measures of outcome after TBI. As such, these measures play a very limited role in informing individualized treatment planning and may actually be best suited to describe outcomes in groups of cases recovering from severe TBI [22]. There is evidence, however, that ratings on global outcome measures in the first several months post injury are predictive of long-term psychosocial outcomes [23, 24]. These measures are characteristically rapid to administer, typically requiring the rater to briefly synthesize several indicators of impairment, activity, and participation before assigning a categorical rating to the person with TBI. The relative insensitivity to change in early global outcome measures, such as the five-category GOS, led to the development of global measures with a greater number of categories (i.e., Extended GOS) [25] and others that were summed across individual items to create an ordinal score (i.e., DRS; [6]). While the items on the DRS still measure a combination of impairment, activity, and participation factors with no attempt to assess the person’s perception of their own level of functioning, the breaking down of broadly described categorical outcomes into more plainly delineated items represented an important transition to more circumscribed measures of activity and participation.

Case Example—continued. Mr. Smith’s treatment teams in the acute rehabilitation setting and at the post–acute residential facility may have found ratings on global outcome measures, such as GOS and DRS ratings made at the time of discharge from the acute trauma center, helpful as prognostic indictors for long–term outcome. While precise predictions regarding specific long–term activity and participation restrictions would be unreasonable, the treatment staff at these facilities could have used results of initial injury severity characteristics and global outcome indicators to tentatively prepare the person with TBI and their family for the most likely scenarios regarding supervision needs or likelihood of returning to competitive employment [26]. Prognostic information of this sort could be essential in helping the family to prepare for the long–term consequences of a significant TBI (e.g., loss of income, need for supervision, etc.).

Measures of disability and activities of daily living provide specific information about a range of behaviors considered essential for self-care (See Table 3). Behaviors are typically rated in terms of the patient’s level of independence, or by how much assistance and supervision are necessary for the patient to safely and successfully complete common tasks. These basic self-care behaviors typically have been the focus of interventions during the acute and sub-acute recovery periods following a significant brain injury, thus making measures of activities of daily living ideally suited for tracking individual recovery during initial inpatient care. Of note, however, is that as inpatient, hospital-based rehabilitation lengths of stay have decreased, some of these goals are now frequently being addressed in the post-acute phase of recovery [27].

Since the raters must observe and evaluate many different behaviors, measures of disability and activities of daily living typically require longer administration times relative to global outcome measures. The design of these measures (i.e., many items rated individually on Likert-type scales with similar underlying anchors), however, allows for the application of powerful test development techniques such as Item Response Theory. The FIM [5] is one of the most widely used measures of activities of daily living. One important limitation of the FIM is its relative insensitivity to change in the post-acute stages of recovery as the focus of TBI rehabilitation transcends basic ADLS and transitions to maximizing functioning in the community [7]. It should be noted, however, that FIM scores measured during acute recovery are predictive of important psychosocial outcomes such as employment [23]. The relatively low ceiling of the FIM was addressed by the development of the FAM [28], an extension of the FIM which includes a greater focus on functioning in the community. While this attempt to raise the ceiling of the FIM by creating additional items relevant to community reintegration was conceptually sound, the FIM + FAM still suffers from significant limitations in monitoring long-term outcome from TBI [7].

The Mayo-Portland Adaptability Inventory-4 (MPAI-4) [29] offers an alternative to earlier measures of activity and was developed specifically to monitor outcome following TBI. Rather than rating the level of independence in completing various self-care behaviors, the first 21 items of the MPAI-4 require the rater to determine the extent to which various cognitive, emotional, and social problems interfere with activities. The MPAI-4 also includes 8-items comprising a Participation Index [30], on which the rater is asked to determine how much assistance is required for successful completion of various instrumental activities essential for community participation. The Participation Index ostensibly makes the MPAI-4 an ideal measure for tracking a patient’s recovery after discharge into the community. Another advantage of the MPAI-4 is the effort to allow for completion of the measure by the clinician, significant other, and the patient [15]. Allowing significant others to rate the survivor of brain injury seems ideal in cases where involvement of the treatment team may be limited after the injury, and the ability to compare self-ratings to clinician and significant other ratings provides the potential of exploring the extent of problems with awareness on self-reporting.

Case Example—continued: As with global outcome indicators, rehabilitation staff at the acute care hospital and residential treatment facility certainly found the FIM and FAM useful in making predictions regarding Mr. Smith’s long–term psychosocial outcomes, such as employability. The design of these measures of activities of daily living also makes them ideal for selecting specific intervention targets (i.e., treatment planning) and tracking progress in therapy. In the case of Mr. Smith, the results of the FIM and FAM indicated need for additional physical and cognitive rehabilitation. Furthermore, the rehabilitation staff collected MPAI–4 ratings from the Mr. Smith, his rehabilitation team members, and his wife. Results from the three raters were used to assess and redress issues with awareness.

Community participation, as defined by independent living, social and leisure activity, and productivity, is the ultimate goal of persons with a history of TBI and the most important indicator of long-term success for rehabilitation programs [31]. Widely used measures, such as the Craig Handicap Assessment and Reporting Technique (CHART) [32] and the CIQ [33], focus on observable indicators of outcome (e.g., frequency of behaviors) (See Table 4). While measurement of observable behavior should arguably result in a more psychometrically robust measure, it has been suggested that a limitation of these and other (e.g. MPAI-4) participation measures is the lack of method to address individual differences in priorities [31]. More recently developed measures of participation, such as the Participation Objective, Participation Subjective (POPS) [34], allow the person with TBI to share their subjective impressions regarding the importance of each activity (Participation Subjective), in addition to indicating the frequency with which they engage in that activity (Participation Objective). As intended by the design of this measure, the subjective scales are more highly related to measures of well-being than objective scales. The Participation Assessment with Recombined Tools—Objective (PART-0) [35] and Subjective (PART-S) [36] also separate the objective and subjective constructs of participation.