Clinical measurement
Clinical measurement is an important component of treatment during recovery from brain injury. As a means of assessment, clinical measurement may involve the use of various screening tools, rating scales, or standardized tests. The use of these measures among interprofessional rehabilitation providers can facilitate efficient communication, the selection of targets for intervention, and tracking outcomes.
Some measures are better than others, and selecting an appropriate measure for use in practice or research requires familiarity with properties that characterize the utility of a measurement tool. Screening tools used in differential diagnosis may be characterized by their sensitivity to detect a condition and specificity to rule out another condition. The reliability of a rating scale can refer to how well the items work together to measure a construct, the agreement among different providers using the same scale, and the consistency of the scale’s performance over time. The validity of a measure describes how well a measure assesses the condition that it purports to measure, how logically the items of a measure relate to its target, and how relatable the measure is to the everyday lives of individuals with brain injury. A brief list of measurement terms and definitions may be found in Table 16.1.
| Measurement Term | Definition |
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| Diagnostic Likelihood | |
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| Reliability | |
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| Validity | |
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Evaluation of functional status depends on the properties of the measurement tool, appropriate use of the measure, and interpretation of the results. Standardized tests are developed under specific conditions that must be replicated or approximated when administered in clinical practice or research settings to ensure valid assessment. Normed measures are interpreted after comparing the results of a test to reference groups based on variables such as age, ethnicity, sex, or education level. In general, the results of any test should be interpreted in the context of potentially confounding situational factors such as fatigue, discomfort, emotional state, effects of medication, effort, and sensitivity to evaluation potential.
Domains of functional assessment
Global outcome
Disability rating scale
The Disability Rating Scale (DRS) is an eight-item measure that assesses general functional changes through recovery. It is commonly used in inpatient rehabilitation settings and can be used to track recovery over time into the community. Admission and discharge DRS scores from inpatient rehabilitation predictive of long-term employment outcomes.
The total scale score may range from 0 to 29, with higher scores indicating greater levels of disability. Item content includes:
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Three items modified from the Glasgow Coma Scale (GCS) (eye opening, communication ability, and motor control)
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Three items measuring cognitive ability relate to feeding, toileting, and grooming
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One global level of functioning item measuring degree of functional independence
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One employability item measuring degree of restrictions on work or school
Glasgow outcome scale
The Glasgow Outcome Scale (GOS) is considered the “gold standard” in outcome studies. The GOS categorizes a survivor’s function into one of five classifications of function:
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Dead
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Vegetative (unable to interact with the environment)
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Severe disability (able to follow commands but unable to live independently)
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Moderate disability (able to live independently but not return to work or school)
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Good recovery (able to return to work or school)
To allow for additional specificity regarding level of function, an extension of the GOS, the Glasgow Outcome Scale-Extended (GOS-E) split the good recovery, moderate disability, and severe disability categories (e.g., “upper” and “lower” moderate disability) to create a total of eight categories of functioning. The GOS-E is more sensitive to change among individuals with less severe injuries and is administered as a structured interview to increase reliability and consistency.
Adaptive and daily living skills
Functional independence measure
The Functional Independence Measure (FIM) is an 18-item instrument assessing level of independent functioning on various physical and cognitive tasks:
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Physical items relate to tasks such as ambulation, toileting, transfers, continence, and grooming.
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Cognitive items relate to problem solving, communication, memory, and social interaction.
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Performance on each item is rated at a level of 7 (complete independence), 6 (modified independence), 5 (supervision), 4 (minimum assistance), 3 (moderate assistance), 2 (maximum assistance), or 1 (total dependence).
The FIM is commonly used in inpatient or subacute rehabilitation centers to assess progress toward functional goals or to communicate to families or other treatment staff the level of care a survivor may require. Accrediting bodies and third-party payers review FIM scores to determine program effectiveness. Given the FIM’s focus on basic activities of daily living (ADLs), its usefulness often diminishes as individuals transition into the community and make further progress in recovery.
Continuity assessment record and evaluation tool
The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) required that facilities offering rehabilitation services collect and submit standardized data elements to the Centers for Medicare & Medicaid Services (CMS). The rationale for this standardization effort was to improve continuity, outcomes, affordability, and communication among long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs).
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The Continuity Assessment Record and Evaluation (CARE) Tool item set was developed through comparison of its performance to the FIM.
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Items are organized by self-care, functional mobility, and supplemental functional abilities.
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Items are scored as 6 (independent with or without a device), 5 (setup or cleanup with assistance), 4 (supervision or touching assistance), 3 (partial/moderate assistance), 2 (substantial/maximal assistance), and 1 (dependent).
Mayo-portland adaptability inventory–4th revision
The Mayo-Portland Adaptability Inventory–4th Revision (MPAI-4) is a 35-item instrument that assesses a broad range of brain injury sequelae across three domains of functioning, including an Ability Index, Adjustment Index, and Participation Index.
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Ability Index measures motor functioning, dexterity, speech and communication, sensory issues, and cognitive abilities.
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Adjustment Index measures mood, anxiety, somatic concerns, self-awareness, social cognition, and social functioning.
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Participation Index measures social contacts, leisure and recreational activities, self-care abilities, productivity, and other instrumental ADLs.
The measure may be self-rated or rated by a significant other, a professional provider, or by team consensus. Response options range from 0 (no impairment or normal functioning) to 4 (moderate to severe impairment or interference with normal functioning). The measure may be used with children or adolescents, with the degree of impairment rated based on developmentally normative expectations for an individual’s abilities.
Behavioral functioning
Rancho level of cognitive function scale
The Rancho Level of Cognitive Function Scale (LCFS) scale is designed to measure cognitive and behavioral function as individuals with brain injury emerge from coma. An individual’s presentation is categorized as:
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Level I: nonresponsive (unresponsive to all stimuli)
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Level II: generalized responses (inconsistent, nonpurposeful responses)
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Level III: localized responses (inconsistent response directly related to stimulus)
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Level IV: confused and agitated
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Level V: confused, inappropriate, and nonagitated
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Level VI: confused, appropriate, with deficits in memory
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Level VII: automatic, appropriate, with deficits in judgment and insight
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Level VIII: purposeful and appropriate, although occasionally requiring supervision
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Level IX: purposeful and appropriate, standby assistance needed upon request
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Level X: purposeful and appropriate with modified independence
The Rancho scale is commonly used in inpatient or subacute rehabilitation centers to guide treatment and behavioral interventions for patients who may be confused, disruptive, or otherwise unable to participate effectively in care. As such, it is effective at communicating a general impression of presentation but may not capture subtle changes over time.
Agitated behavior scale
The Agitated Behavior Scale (ABS) is a 14-item measure that assesses behavioral symptoms of agitation after brain injury. Agitation is operationalized as an excess of behavior that occurs during an altered state of consciousness. Response options for each item range from 1 (not present) to 4 (present to an extreme degree). The items of the ABS span three subscales, including (1) disinhibition, (2) aggression, and (3) lability.
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Disinhibition assesses behaviors such as a short attention span, impulsivity, self-stimulation, restlessness, and pulling at tubes or restraints.
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Aggression assesses behaviors such as resistance to care, explosive anger, threatening behaviors, and self-abusiveness.
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Lability assesses behaviors such as excessive talking, sudden changes in mood, and easily initiated crying or laughing.
The ABS is a helpful, objective measure of agitation or behavioral dyscontrol that can be used across the continuum of recovery.
Neuropsychiatric and psychological status
Patient health questionnaire–9
The Patient Health Questionnaire–9 (PHQ-9) is a nine-item measure that assesses symptoms of depression. Item content is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for an episode of depressed mood:
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Items related to anhedonia, sadness, guilt, suicidal ideation, sleep, fatigue, appetite, concentration, and psychomotor agitation/retardation
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Respondents rate how much they have been bothered by each symptom over the past 2 weeks
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Response options include 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day)
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A total score is derived by summing the responses to each item
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Total scores of 15 or greater indicate treatment for depression is most likely warranted
The PHQ-9 has been validated for use among individuals with brain injury. The recommended criterion for a positive depression screen among individual with TBI is at least five items endorsed at the level of 2 (more than half the days), one of which should be anhedonia or depressed mood item.
Neurobehavioral symptom inventory
The Neurobehavioral Symptom Inventory (NSI) is a 22-item measure that assesses postconcussive symptoms.
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Respondents rate how much they have been disturbed by symptoms over the past 2 weeks.
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Response options include 0 (none/rarely present/not a problem), 1 (mild/occasionally present/not disruptive), 2 (moderate/often present/occasionally disruptive), 3 (severe/frequently present/frequently disruptive), and 4 (very severe/almost always present/cannot function without help).
Items content spans four domains, including physical, cognitive, affective, and sensory or vestibular symptoms. Raw scores are calculated for each of the four domains and to create a total score.
Recovery of consciousness/memory recovery
Orientation Log
The Orientation Log (O-Log) is a 10-item measure assessing temporal, spatial, and situation orientation. Responses to orientation prompts are scored based on whether:
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The spontaneous response is correct (3),
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The response is correct after providing a logical cue (2),
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The correct response is identified among three choices (1), or
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No correct/appropriate response is given (0).
A total score is derived by summing the 10 items for a possible range of 0 to 30. Serial administration of the O-Log is used to estimate emergence from posttraumatic amnesia (PTA), and administration is discontinued after obtaining two consecutive scores greater than or equal to 25/30, separated by at least 24 hours but not more than 72 hours. The day of the first score greater than or equal to 25/30 that satisfies the discontinuation criterion is used to denote the date of emergence from PTA. A modified O-Log can be used to assess orientation among individuals with barriers to communication by providing written multiple-choice options for each item. In this paradigm, items are scored dichotomously (correct or not), and a cut-off of 8 of 10 is used to satisfy the discontinuation criterion.
Coma Recovery Scale–Revised
The Coma Recovery Scale–Revised (CRS-R) is a bedside assessment tool for differentiating levels of consciousness.
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Composed of six subscales: auditory, visual, motor, oromotor/verbal, communication, and arousal
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23 dichotomously scored items
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Items summed to create total score identifying ascending levels of conscious behavior or ability
Combination of items can be used to differentiate vegetative state, minimally conscious state, and emergence from coma based on Multi-Society Task Force and Aspen Workgroup criteria. An American Congress of Rehabilitation Medicine practice parameter recommends use of the CRS-R based on its standardized administration and scoring procedures, item content, and interrater and test–retest reliability.
Social role participation and social competence
Participation Assessment with Recombined Tools–Objective–17
The Participation Assessment with Recombined Tools–Objective–17 (PART-O-17) is a 17-item measure used to assess social participation. The items assess functioning across three domains, including:
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Productivity (e.g., participation in work, school, or homemaking)
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Social relations (e.g., interactions with friends, family, supportive others, and partners)
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Going out and about (e.g., dining out, shopping, entertainment, religious activities)
Each item is scored on a scale of 0 to 5, with each response option corresponding to time spent engaged in each activity, either based on frequency of occurrence or duration of time throughout the week or month. The items can be combined to create domain scores and total scores (either averaged or balanced). Standard scores are calculated based on reference groups.
Craig Hospital Inventory of Environmental Factors
The Craig Hospital Inventory of Environmental Factors (CHIEF) is a 25-item measure used to assess environmental barriers to social role fulfilment encountered by people with disabilities. The environmental barriers described by the items span five domains, including:
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Policies (e.g., barriers related to government, business, or education/employment policies)
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Physical/structural (e.g., barriers related to the natural or designed environment)
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Work/school (e.g., barriers related to attitudes, help, and support in education or employment settings)
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Attitudes/support (e.g., barriers related to discrimination, community values or beliefs)
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Services/assistance (e.g., access to transportation, medical care, information, community services, or equipment)
For each item, respondents are asked to reflect over the past year and rate how frequently the barrier was encountered and the degree to which each barrier was a problem.
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Frequency is rated on a 0 to 4 scale (0, never; 1, less than monthly; 2, monthly; 3, weekly; and 4, daily)
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Degree of problems is rated from 0 to 2 (0, no problem or never encountered; 1 a little problem, and 2, a big problem)
Neuropsychological tests
Compared with the screening measures or rating scales described earlier, neuropsychological evaluations represent a more comprehensive assessment of brain-based behavior or performance across domains of cognitive, emotional, and personality functioning. Clinical neuropsychology is a specialty area of professional psychology that focuses on understanding brain-based relationships and the normal and abnormal functioning of the CNS. Clinical neuropsychologists apply principles of assessment and intervention to measure functional abilities and make recommendations to maximize recovery and rehabilitation. “Although neurological diagnoses can validly be established using many other techniques and methods (e.g., computed tomography [CT] and magnetic resonance imaging [MRI]) the psychological consequences of cerebral damage are uniquely represented by neuropsychological evaluation .”
Neuropsychological evaluations integrate information from a variety of sources, including medical records, clinical interviews, behavioral observations, collateral informants, and the results of neuropsychological tests administered as part of a flexible or fixed battery of assessment tools. Most referral questions for neuropsychological evaluation after brain injury will involve characterizing (1) whether an individual’s performance is different from the estimated or known baseline pattern, (2) whether performance is at variance with what would be expected based on known injuries, (3) what an individual’s pattern of functioning means for treatment and recovery, (4) the real-word implications of performance for social participation, and (5) what accommodations or interventions would help maximize performance.
Neuropsychological tests are developed through a rigorous process of standardization, and these tests are administered under strictly controlled conditions designed to replicate the protocol for routine administration. The results of neuropsychological tests are interpreted by comparing an individual’s performance to that of a normative or reference group. As such, it is important to select a test with adequate normative data, often based on factors such as age, sex, education level, ethnic background, or diagnostic group. Finally, neuropsychological tests are selected based on the quality of their measurement properties (e.g., sensitivity/specificity, reliability, validity, measurement error) and their suitability for measuring the domain of functioning of relevance to the referral question. Tests may assess performance across multiple domains of functioning, including processing speed, attention and concentration, language ability, visuospatial functioning, psychomotor skill, learning and memory, reasoning, and executive functioning. Commonly used neuropsychological tests categorized by domain of functioning are included in Table 16.2 .
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