Outcome Rating Scales in Neuroinsensivism

94 Outcome Rating Scales in Neuroinsensivism

Gustavo Petroni ¹, Silvia Lujan ¹, Carlos Rondina ¹

¹ Intensive Care Unit. Hospital de Emergencias Dr Clemente Álvarez. Rosario, Argentina

94.1 Introduction

An important aspect as the classification and initial assessment of brain injury is the accurate evaluation of the results. The effectiveness of many interventions during the acute care will depend on the evaluation of the results.

When evaluating results we must consider not only physical but also cognitive, mental, and social disabilities. Many of the survivors have deficits (neurological and/or cognitive) that interfere with quality of life.

Rating scales are useful tools to attempt to quantify outcomes in a reliable and accurate way in patients who have suffered neurological injury.

Then we’ll describe the most used.

94.2 Outcome Rating Scales

94.2.1 GOS (Glasgow Outcome Scale)

It is still the most used outcome rating scale to evaluate neurological injuries (traumatic and non-traumatic). It assesses general social skills (or dependence) of the patients, taking into account the combined effect of mental and neurological deficit [1]. It determines the independency of a person in the society and the return to the previous life style. Different studies have shown that it is a reliable scale and easily used by different observers.

The GOS includes five categories:

Death.
Vegetative state(VS): patients can not interact with the environment, they do not respond.
Severe disability: patients are able to follow orders, they can not live independently.
Moderate disability: patients can live independently, they can not return to work or school.
Good recovery: patients are able to return to work or school.

For statistical purposes, the GOS can be dichotomized in Poor outcomes (Dead, VS, severe disability) and Good outcomes (mild disability and good recovery). The GOS allows comparing results of patients treated with different treatments protocols or in different sites. One of the main criticisms is that its simplicity makes it relatively insensitive to changes in recovery that are not enough to make a change in the category.

94.2.2 GOS-E (Glasgow Outcome Scale Extended)

The GOS-E was developed to address the limitations of the original GOS due to the lack of a structured interview.

Dead.
Vegetative state.
Lower severe disability.
Upper severe disability
Lower moderate disability.
Upper moderate disability.
Lower good recovery.
Upper good recovery.

The structured interview has improved the classification reliability. It has demonstrated to be more sensitive than GOS to changes in patients with mild and moderate Traumatic Brain Injury (TBI).

The interview can be administered to the patient, to a family member, or to any other person who can provide information. The GOS-E is not considered an instrument of self perception, evaluators must give a score to each item based on the most accurate information available, regardless the source.

94.2.3 DRS (Disability Rating Scale)

It is a scale that allows to measure with precision general functional changes (disabilities and impairments) in the recovery process. It was developed and proved in patients with severe and moderate TBI in the rehabilitation environment.

Scores range from 0 (without disability) to maximum score of 29 (vegetative state).

The DRS assesses 8 items: The first three items (“eye opening”, “communication” and “motor response”) are a modification of the Glasgow Coma Scale and reflects the worsening degree.

The cognitive capacity for self-care activities like “feeding”, “ hygiene” and “cleanliness” shows the level of disability.

The “ functioning level” and “ employability” reflect impairment degree and are based on the capacity and not in performance (dependency and social adaptation).

It is one of the best scales to evaluate outcomes in patients with moderate TBI.

Advantages: proved reliability and validity, useful in a great variety of patients, data can be obtained from patients or family, can be done by phone or either by medical records revision, and not requires a great experience of the evaluator.

The ease of administration and the brevity of the scale are the most important reasons for its popularity (15 minutes).

Disadvantages: One of its limitations is its relative insensitivity to minor injuries (mild TBI) and its inability to reflect subtle but often significant changes, within a specified window of recovery. It does not measure changes in a short period of time.

94.2.4 FIM (Functional Independence Measure)

It was developed to solve the generalized lack of data of outcome in rehabilitation [2].

It’s a basic indicator of the severity of the disability, it evaluates what the person does with the impairment whatever its diagnosis or disability is.

It is an ordinal scale of 18 items including: self care independence, sphincter control, transfers, locomotion, communication, and social-cognitive state.

Scores range from one to seven: a score of seven in a FIM item is categorized as “complete independence”, while a score of one means “total assistance” (performs less than 25% of the task). Scores under six require another person for supervision or assistance. By summing the scores for each item, the possible total scoring ranges go from 18 (lowest) to 126 (highest).

It is very useful for the evaluation of progress during rehabilitation. It is the most widely used functional evaluation measure in rehabilitation. Limitations are that their reliability depends on training and certification of assessors.

94.2.5 Rancho Los Amigos Scale (Level of Cognitive Functioning Scale)

It assesses cognitive function in patients after coma [3]. Allows planning the treatment and following up of recovery. Classifies patients into eight levels:

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