Traumatic Brain Injury Outcome Measures Overview

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Uchechukwu Chukwuemeka, Simisola Ajeyalemi, Rachael Lowe, Tarina van der Stockt and Nicole Hills  

Introduction

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. 

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.

• 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

Setting of Treatment based on International Classification of Functioning, Disability, and Health Component

Overall 14 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 chronic traumatic brain injury category, which had a total of 3 “Highly Recommended” Outcome Measures and 19 “Recommended” Outcome Measures. Limited research in acute traumatic injury meant fewer measures could be recommended during this phase of injury.

Phase	Body Structure & Function	Activities	Participation
Acute	Agitated Behavior Scale Coma Recovery Scale-Revised Moss Attention Rating Scale Rancho Levels of Cognitive Functioning
Inpatient	Agitated Behavior Scale Cognitive Log Coma Recovery Scale-Revised * Disorders of Consciousness Modified Ashworth Scale Moss Attention Rating Scale * Orientation Log Patient Health Questionnaire Rancho Levels of Cognitive Function	6 Minute Walk Test (6MWT) 10 Meter Walk Test (10MWT) Barthel Index Berg Balance Scale Community Balance and Mobility Scale Functional Assessment Measure Functional Independence Measure	Disability Rating Scale Quality of Life after Brain Injury
Outpatient	Apathy Evaluation Scale Coma Recovery Scale - Revised * Dizziness Handicap Inventory Global Fatigue Index Assessment Modified Ashworth Scale Patient Health Questionnaire Rancho Levels of Cognitive Function	6 Minute Walk Test (6MWT) 10 Meter Walk Test (10MWT) Action Research Arm Test Balance Error Scoring Scale Berg Balance Scale Community Balance and Mobility Scale Functional Assessment Measure High Level Mobility *	Community Integration Questionnaire I Disability Rating Scale Quality of Life after Brain Injury Sydney Psychosocial Re-integration Scale
Long Term Care Facility	Agitated Behavior Scale Coma Recover Scale - Revised * Modified Ashworth Scale Patient Health Questionnaire Ranchos Levels of Cognitive Function	Action Research Arm Test Community Balance and Mobility Scale
Home Health	Coma Recovery Scale - Revised * Dizziness Handicap Inventory Modified Ashworth Scale Patient Health Questionnaire Rancho Levels of Cognitive Function	Action Research Arm Test Community Balance and Mobility Scale Functional Assessment Measure High Level Mobility Assessment *	Community Integration Questionnaire I Quality of Life after Brain Injury Sydney Psychological Re-integration Scale

Ambulatory Level based on International Classification of Functioning, Disability, and Health Component

Phase	Activity
Independent in Ambulation	6 Minute Walk Test (6MWT) * 10 Meter Walk Test (10MWT) Balance Error Scoring System Community Mobility and Balance Scale Functional Assessment Measure High Level Mobility Assessment Test *
Mildly Dependent in Ambulation	6 Minute Walk Test (6MWT) Functional Assessment Measure Functional Independence Measure High Level Mobility Assessment Test *
Moderately Dependent in Ambulation	Functional Assessment Measure Functional Independence 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.

Summary

Resources

The Center for Outcome Measurement in Brain Injury (COMBI)

Shirley Ryan Ability Lab Rehabilitation Measures Database

References