Traumatic Brain Injury Outcome Measures Overview
Original Editor - Naomi O'Reilly
An Outcome Measure is a test used to objectively determine baseline function of an individual at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. With the move towards Evidence Based Practice (EBP), objective measures of outcome are important to provide credible and reliable justification for treatment. The instrument should also be convenient to apply for the therapist and comfortable for the individual, and where possible contain options for patient reported outcomes. 
Measuring the effectiveness of interventions is accepted as being central to good practice. An integral part of evaluating clinical practice is to objectively assess the intervention and measure it against a set of outcomes to determine its efficacy. For results to be meaningful, it is imperative that any measures used to assess outcomes in any health care context cover domains (for example pain, physical function, perceived independence) that are relatively specific and appropriate to both the particular context and population that you are working with and have acceptable measurement properties, including: reliability, validity, responsiveness, acceptability and feasibility specific to that population. 
Prior to formal scales were developed for traumatic brain injury, patient outcomes were described in terms including“useful”, “fully active”, “able to participate”, “persistent cognitive dysfunction”. The introduction of the Glasgow Coma Scale was a key initiative in the development of relevant scales post traumatic brain injury and led to further development of a range of measures which vary in scope and mode of measurement. Some are designed to provide a global index of outcome, while others measure functional abilities for daily activities or community integration, or focus specifically on neuropsychological performance or psychiatric dysfunction. Other measurement tools target specific populations, such as those with mild traumatic brain injury or concussion. However, no single measurement tool can encompass all relevant areas of traumatic brain injury outcome, and as such multimodal assessments are necessary to effectively reflect the complex range of factors affecting traumatic brain injury outcomes. 
Evidence of intervention effectiveness depends on, among other things, common use of valid and reliable tests and measures, which reflect clinically important outcomes and are responsive to change. There has been an increased focus on outcome measurement in the field of traumatic brain injury, with creation of common definitions and data sets to ensure that information being collected is both valid and accurate with consistent recording of both clinical and research information. Despite increased use of validated outcome and more frequent assessment, there is still a broad range of outcome measures being used that limits the ability to compare findings from centre to centre or client to client, which has an impact on identification and implementation of best practice. This page presents the best available information on how outcome measures for traumatic brain injury might be classified and selected for use, based upon their measurement qualities incorporating the most recent consensus recommendations.
The global acceptance and utilization of the International Classification of Functioning, Disability, & Health allows for inter-professional collaboration where various medical professionals are able to categorize the health functioning of individuals they work with. The International Classification of Functioning, Disability, & Health domains provide a framework from which a clinician can assess, provide intervention, establish goals and gauge progress in the patients that they treat, and it has been suggested that in order for a comprehensive clinical picture of a patient to be obtained in treating individuals with traumatic brain injury that the TBI Brief Core Set should be used in conjunction with other standardized outcome measures. 
TBI EDGE Task Force Recommended Outcome Measures
The Academy of Neurologic Physical Therapy of the American Physical Therapy Association (APTA) began a process to develop recommendations for the identification of core sets of Outcome Measures in 2009, with further development of the Evaluation Database to Guide Effectiveness (EDGE), in order to make recommendations for OM utilization in PT practice. In 2011, the Academy of Neurologic Physical Therapy initiated a task forces to evaluate Outcome Measures specifically for use in traumatic brain injury, which was a challenge given that traumatic brain injury is a chronic health condition that affects physical, cognitive, and behavioral function, often in heterogenous ways, so there fore requiring outcome measures that could accommodate a large range of physical and cognitive strengths and limitations. 
The TBI EDGE Task Force reviewed 88 outcome measures covering the range of ICF Domains, including body structure and function (15), activities (21), participation (23) and some covering more than 1 ICF domain (29), evaluating each for psychometrics and clinical utility for individuals with moderate to severe traumatic brain injury. Through literature review, analysis, and a modified Delphi Procedure, recommendations were formulated for outcome measures that are highly recommended for use in individuals with Traumatic Injury during each phase of treatment, with a summary for each of these outcome measures updated or added to the Shirley Ryan Ability Lab Rehabilitation Measures Database.  Furthermore, they have linked these outcome measures directly to the International Classification of Functioning, Disability, & Health domains. 
- 5 measures were recommended or highly recommended for acute setting
- 17 measures were recommended or highly recommended for inpatient rehabilitation
- 18 measures were recommended or highly recommended for outpatient rehabilitation
- 6 measures were recommended for patients mildly dependent to independent in ambulation:
- 2 measures were recommended for patients moderately to severely dependent in ambulation
- 19 measures were recommended as important for use in physiotherapy education
- 52 measures were recommended for use in traumatic brain injury research
Individuals with traumatic brain injuries receive care in a range of treatment settings, and that the severity level of each patient and constraints of each setting varies and would influence the choice of Outcome Measures that would be useful. Overall 18 measures were recommended or highly recommended for at least 2 levels of acuity providing the ability to compare progress over a longer period of time and covering a number of domains of the International Classification of Functioning, Disability, and Health. The acute traumatic brain injury category had a total of 4 “Recommended” Outcome Measures in comparison with the inpatient / outpatient traumatic brain injury category, which had a total of 3 “Highly Recommended” Outcome Measures and 22 “Recommended” Outcome Measures. 
|Phase||Body Structure & Function||Activities||Participation|
|Acute||Agitated Behavior Scale|
|Inpatient||Agitated Behavior Scale||6 Minute Walk Test (6MWT)||Disability Rating Scale|
|Outpatient||Apathy Evaluation Scale||6 Minute Walk Test (6MWT)||Community Integration Questionnaire I|
|Long Term Care Facility||Agitated Behavior Scale||Action Research Arm Test|
|Home Health||Coma Recovery Scale-Revised *||Action Research Arm Test||Community Integration Questionnaire I|
As there is a wide range of disability in motor and cognitive function seen at all stages of traumatic brain injury recovery, the task force decided that a rating of physical and cognitive function would be useful; however, there is no standardized method to classify traumatic brain injury in this way. As physical function is a primary focus for physiotherapy, the task force modified Functional Ambulation Classification (FAC), developed for use in Stroke, as a guide to describe mobility level after traumatic brain injury. Overall 7 measures were recommended or highly recommended across the range of amulatatory status all falling within the realm of the activity domain of the International Classification of Functioning, Disability, and Health. The independent to mildly dependant in ambulation had a total of 7 “Highly Recommended or Recommended” Outcome Measures in comparison with the moderately to severely dependent in ambulation category, which only had a total of 2 “Recommended” Outcome Measures. 
|Independent in Ambulation||6 Minute Walk Test (6MWT) *|
|Mildly Dependent in Ambulation||6 Minute Walk Test (6MWT)|
|Moderately Dependent in Ambulation||Functional Assessment Measure|
|Severely Dependent in Ambulation||Functional Assessment Measure|
|Note: Recommendations based on ambulatory level were made without consideration of treatment settings, therefore therapists must use clinical judgment to determine appropriateness of recommendations for individual cases.|
Many of the outcome measures currently utilized for individuals with traumatic brain injury were developed for use in research projects by the National Institute on Disability and Rehabilitation Research (NIDRR, now National Institute on Disability, Independent Living, and Rehabilitation Research) TBI Model Systems investigators. While designed to characterize important issues such as injury severity (e.g. Glasgow Coma Scale), or to reflect global outcome (Glasgow Outcome Scale-Extended, Disability Rating Scale), many are not physiotherapy specific and as such may not measure specific physiotherapy related outcomes at a level that is useful clinically.
Traumatic brain injury is a medically complex and life-disrupting condition with a high likelihood that secondary health complications, such as pressure ulcers, or circulatory dysfunction, will develop. Clinicians who work with individuals with a spinal cord injury share a commitment toward providing the best interventions to produce successful outcomes for those that they work with. The most meaningful determinant of treatment efficacy from the perspective of the individual with a traumatic brain injury generally relates to improvements in their ability to function in everyday activities and must be forefront in our minds as health care professionals throughout all stages of treatment and rehabilitation. While there will never be a perfect questionnaire or measure of outcome, choosing the right measure to use involves identifying the most appropriate measure for the chosen population group, in this case traumatic brain injury, but also to the context and purpose, where evidence exists to show that the questionnaire has exhibited adequate measurement properties pertaining to that group and/or context. 
The International Classification of Functioning, Disability, & Health is a universally accepted tool that can be used to foster the inclusion of variables which impact a person with traumatic brain injury, and is clinically useful when the Traumatic Brain Injury Core Sets  are used in conjunction with International Classification of Functioning, Disability, & Health supportive standardized outcome measures as identified above, a holistic approach to care linking the physical, psychological and environmental domains. This allows development of an inclusive treatment plan for the individual with a traumatic brain injury where the functional profile is fully considered. 
Careful choice of treatment goals and aims are essential in individuals with a traumatic brain injury in order to identify and determine the most appropriate outcome measures to use prior to determining any intervention, which means the physiotherapist can ensure they are providing the most appropriate intervention that meets the treatment goals and expectations of the individual with a traumatic brain injury. Use of an outcome measures, specifically validated for traumatic brain injury, should lead to improved identification of best practice and enable clinicians to more effectively monitor client progress.
The Center for Outcome Measurement in Brain Injury (COMBI) is an online resource for those needing detailed information and support in regards to outcome measures for brain injuries. The measures included in the COMBI are commonly used in the field of brain injury rehabilitation and assessment. The COMBI is a collaborative project of 16 brain injury facilities or centers, most of them Traumatic Brain Injury Model Systems, through grants funded by the National Institute on Disability and Rehabilitation Research. Each center contributes information on one or more measures.
The Rehabilitation Measures Database was developed to help clinicians and researchers identify reliable and valid instruments used to assess patient outcomes during all phases of rehabilitation. The database provides evidence-based summaries that include concise descriptions of each instrument’s psychometric properties, instructions for administering and scoring each assessment as well as a representative bibliography with citations linked to PubMed abstracts. Whenever possible, we have also included a copy of the instrument for the users to download or information about obtaining the instrument.”
In the fall of 2011, the Academy of Neurologic Physical Therapy initiated a task forces to evaluate Outcome Measure use in traumatic brain injury. An 8-member task force used a modified Delphi process to develop recommendations on the selection of Outcome Measures for individuals with Traumatic Brain Injury. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.
- Complete List all Reviewed Outcome Measures
- Summary Recommendations Inpatient and Outpatient Rehabilitation
- Summary Recommendations Acute Care
- Summary Recommendations ICF Domains
- Kyte DG, Calvert M, Van der Wees PJ, Ten Hove R, Tolan S, Hill JC. An introduction to patient-reported outcome measures (PROMs) in physiotherapy. Physiotherapy. 2015 Jun 1;101(2):119-25.
- Lennon S, Ramdharry G, Verheyden G, editors. Physical Management for Neurological Conditions E-Book. Elsevier Health Sciences; 2018 Jul 28.
- Shukla D, Devi BI, Agrawal A. Outcome measures for traumatic brain injury. Clinical neurology and neurosurgery. 2011 Jul 1;113(6):435-41.
- Laxe, S. (2015) Rehabilitation of traumatic brain injury in the light of the ICF. NeuroRehabilitation 36(1), 37-43
- Pavel P. (2012). Use of the International Classification of Functioning, Disability and Health in Brain Injury Rehabilitation, Brain Injury – Functional Aspects, Rehabilitation and Prevention, Prof. Amit Agrawal (Ed.), InTech, pp. 75-94. Retrieved from URL http://www.intechopen.com/ books/brain-injury-functional-aspects-rehabilitation-and-prevention/ use-of-the-international-classification-of-functioning-disability-andhealth-icf-in-rehabilitation-a
- Brainline. The Challenges of Measuring Outcome in Brain Injury. Available from: https://youtu.be/wRlVx6mMVBM[last accessed 30/08/19]
- McCulloch KL, De Joya AL, Hays K, Donnelly E, Johnson TK, Nirider CD, Roth H, Saliga S, Ward I. Outcome measures for persons with moderate to severe traumatic brain injury: recommendations from the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force. Journal of Neurologic Physical Therapy. 2016 Oct 1;40(4):269-80.
- World Health Organization ( 2012). ICF Core Sets Manual for Clinical Practice. Retrieved from URL http://www.icf-core-sets.org/
- Rotar, A (2013). The use of brief core sets for traumatic brain injury in occupational therapy to measure outcome of rehabilitation-presentation case [powerpoint slides]. Retrieved from URL http://tbi-challenge. eu/2013/download/presentations/TBI2013-Rotar.pdf
- Laxe, S. (2012) What domains of the International Classification of Functioning Disability and Health are covered by the most commonly used measurement instruments in traumatic brain injury research? Clinical Neurology and Neurosurgery 114(6), 645-650.