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ClinicalNeurologyandNeurosurgery113(2011)435–441ContentslistsavailableatScienceDirectClinicalNeurologyandNeurosurgeryjournalhomepage:www.elsevier.com/locate/clineuroReviewOutcomDhavalSaDepartmentobDepartmentoarticlArticlehistory:Received6JunReceivedinreAccepted12FAvailableonlinKeywords:OutcomescaleTraumaticbraRehabilitationDisabilityNeuropsychologicalassessmenttainedattentionandGroovedPegboardforfinemotordexterity.AmoreholisticandcompleteoutcomemeasureisQualityofLife(QOL).DiseasespecificQOLmeasureforTBI,QualityofLifeafterBrainInjury(QOLIBRI)hasalsobeenrecentlyproposed.Theproblemswithoutcomemeasuresincludepooropera-tionaldefinitions,lackofsensitivityorlowceilingeffects,inabilitytoevaluatepatientswhocannotreport,lackofintegrationofmorbidityandmortalitycategories,andlimiteddomainsoffunctioningassessed.GOSE-EsatisfiesmostofthecriteriaofgoodoutcomescaleandincombinationwithneuropsychologicalContents1.Prope1.1.1.2.1.3.1.4.2.Classi3.Barth4.Funct5.Craig6.Comm7.Ranch8.Disab9.Funct10.Glas11.Neur12.Qual13.Outc14.ConcRefer∗CorresponE-mailadd0303-8467/$–doi:10.1016/j.testsisanearcompleteinstrumentforassessmentofoutcomeafterTBI.©2011ElsevierB.V.Allrightsreserved.rtiesofanoutcomescale......................................................................................................................436Validity.......................................................................................................................................436Reliability.....................................................................................................................................436Precision......................................................................................................................................436Applicability..................................................................................................................................436ficationandchoiceofoutcomemeasure......................................................................................................436elIndex(BI)....................................................................................................................................437ionalIndependenceMeasure(FIM)............................................................................................................437HandicapAssessmentandReportingTechnique(CHART)....................................................................................437unityIntegrationQuestionnaire(CIQ)........................................................................................................438oLevelofCognitiveFunctioningScale(LCFS).................................................................................................438ilityRatingScale(DRS).........................................................................................................................438ionalStatusExamination(FSE)................................................................................................................438gowOutcomeScale(GOS).....................................................................................................................439opsychologicaloutcomemeasures............................................................................................................439ityofLifeafterBrainInjury(QOLIBRI).........................................................................................................440omeaftermildTBI.............................................................................................................................440lusion..........................................................................................................................................440ences...........................................................................................................................................440dingauthor.Tel.:+917152287701;+917206423180(Mobile);fax:+917152287719.resses:dramitagrawal@gmail.com,dramitin@yahoo.com(A.Agrawal).seefrontmatter©2011ElsevierB.V.Allrightsreserved.clineuro.2011.02.013emeasuresfortraumaticbraininjuryhuklaa,B.IndiraDevia,AmitAgrawalb,∗fNeurosurgery,NationalInstituteofMentalHealthandNeurosciences,Bangalore,IndiafNeurosurgery,MMInstituteofMedicalSciences&Research,MaharishiMarkandeshwarUniversity,Mullana-Ambala,133203,Haryana,Indiaeinfoe2010visedform5January2011ebruary2011e26March2011sininjuryabstractTraumaticbraininjury(TBI)isamajorpublichealthproblemresultingindeathanddisabilitiesofyoungandproductivepeople.ThoughthemortalityofTBIhasdecreasedsubstantiallyinrecentyearsthedis-abilityduetoTBIhasnotappreciablyreduced.VariousoutcomescaleshavebeenproposedandusedtoassessdisabilityafterTBI.Afew,commonlyusedareGlasgowOutcomeScale(GOS)withorwithoutextendedscores,DisabilityRatingScale(DRS),FunctionalIndependenceMeasure(FIM),CommunityInte-grationQuestionnaire(CIQ),andtheFunctionalStatusExamination(FSE).Thesescalesassessdisabilityresultingfromphysicalandcognitiveimpairments.Forpatientswithgoodphysicalrecoveryacognitiveandneuropsychologicaloutcomemeasureisrequired.SuchmeasuresincludeNeurobehaviouralFunc-tionInventoryandspecificneuropsychologicaltestslikeReyComplexFigureforvisuoconstructionandmemory,ControlledOralWordAssociationforverbalfluency,SymbolDigitModalities(verbal)forsus-436D.Shuklaetal./ClinicalNeurologyandNeurosurgery113(2011)435–441Traumaticbraininjury(TBI)isamajorpublichealthproblemresultingindeathanddisabilities.InastudydoneatBangalore,theincidence,mortalityandcasefatalityratesofTBIwere150/100,000,20/100,000,and10%,respectively.InIndianearlytwomillionpeo-plesustainharerendereindailylifemortalityodisabilitydsurvivorsaneurologicaandhencerehabilitatetionalstaturoles,tasksWhetherittheresultsoformalscalofthepatiewhile”,“fulor“mentalminology,sGlasgowOu1975toasspoorprecisibeenpropoCommonlymodeofmedesignedtotomeasureintegrationchologicalptoolsmaytHowever,nareasofTBsarytoeffecoutcome.WereviTBI”and“oforTBI”froThearticlesity,andfeasrelevantan1.Propert1.1.Validity“Validitywhatitpurpisevaluatedmeasure,bubelabeled.ityoftheousocialvaluedevelopingcomponent“FacevaofvaliditydinstrumentexpecttoseofTBI,becaabstraction“Predictafuturestaisticbeingbeablepredictparameterslike,whichpatientwillbesuccess-fullydischargedhomeversustoanursinghome.TheproblemwithpredictivevalidityassessmentinTBIisthatthereisnodefinedthresholdscorebeyondwhichanaccuratepredictioncanbemade.scrimentwtrumnstruremeonstliabiliabilremeeoreasueralicatereseheandtdsfoappaeliabecisioientsprov[8].Teascalesibletothnstrursonasurblepplicapracy.Thutcocultlty,soressddemtervssificaffecorldoningity(asfollairmical,oabilitnt)orangeadinjuries,onefifthmilliondieandnearlyonemillionddisabled.ThesurvivorsofTBIhavevariousproblemsaffectingalmosteverysphereoflife[1].ThoughthefTBIhasdecreasedsubstantiallyinrecentyearstheuetoTBIhasnotappreciablyreduced.Mostofthesereyoungandproductive.TBIresultsinimpairmentoflandcognitivefunctionsleadingtoactivityrestrictionlackofparticipationinsociety.Thecurrentfocusistothemsothattheycanregaintheirpremorbidfunc-s,whichisdefinedasaperson’sabilitytoperformthose,oractivitiesuponwhichthesocietyplacesvalue[2].isanewdrug,traumacenterorsurgicalinterventionfallhavetobeassessedwithanoutcomescale.BeforeesforoutcomeafterTBIwereintroducedtheoutcomentsweredescribedintermslike“useful”or“worth-lyactive”,“abletoparticipate”,“persistentdementia”restitution”.Toovercomesuchdiscrepanciesintheter-oonaftertheintroductionofGlasgowComaScale(GCS),tcomeScale(GOS)wasproposedbythesamegroupinesstheoutcomeofcomatosepatientsafterTBI[3].TheonofGOSwasrealizedandvariousoutcomescaleshavesedsince1981toassessdisabilityfollowingTBI[4,5].utilizedTBIoutcomeassessmentsvaryinscopeandasurement.Someoutcomeassessmentsaregeneralandprovideaglobalindexofoutcome.Othersaremeantfunctionalabilitiesfordailyactivitiesorcommunity.Assessmentsmayalsospecificallyfocusonneuropsy-erformanceorpsychiatricdysfunction.Measurementargetspecificpopulations,suchasthosewithmildTBI.osinglemeasurementtoolcanencompassallrelevantIoutcome.Multimodalassessmentsareoftenneces-tivelyreflectthecomplexrangeoffactorsaffectingTBIewedtheliteraturebysearchingterms“outcomeafterutcomeassessmentforTBI”,and“outcomemeasuresmMedlineandtextbooksontraumaticbraininjury.describingtheoutcomemeasure;itsproperties,util-ibilityofapplicationinclinicalpracticewereconsidereddformedbasisofthisreview.iesofanoutcomescale”referstothequestion:isthisinstrumentmeasuringortstomeasure?Validityofanynewoutcomemeasurecomparedtotheexistingwidelyacceptedoutcometstilltheso-calledperfectoutcomemeasureisyettoManystudiesdonotreportthevalidityandreliabil-tcomemeasuresused.Variabledefinitions,associatedsandtargetpopulationcanbedifficulttoaddresswhenneworutilizingexistingTBIoutcomemeasure.Thesofvalidityare:lidity”is(intheeyesofmostauthorities)notaformetermination,butananswertothequestion:doesthe“onthefaceofit”measurewhatthosecompletingite.Facevalidityishardlyanissueforoutcomemeasureusetheconstructsquantified,haveafairlylowlevelof.ivevalidity”concernstheabilityofameasuretopredictteoreventthatisinherentlylinkedtothecharacter-measured.InTBIsettingsanoutcomemeasureshould“Dibetwetheins“Comeasuotherc1.2.Re“RemeasuthesamablemthesamberepThereascale,tmentamethoofthekmostr1.3.PrPat66%im1yearcomemidealsofposreferscomeiablepeestmemorea1.4.ApThecabilitofanocaldiffidifficumeasuavarietimein2.ClaTBITheWFunctidisabiltion)aImplogDismetheinativevalidity”isbasedondifferencesinscalescoresogroupsthatareknowntodifferinthecharacteristic,entaimstomeasure.ctvalidity”concernstherelationshipsbetweenthentdataofa(highlyabstract)constructanddataforructs[6,7].lityity”referstothequestion:howreproducibleisthisnt–ifwerepeatedthemeasurementoperation,withasimilar“ruler”,wouldwegetthesameresult?Areli-reshouldbescoredequallybyvariousratersandalsobyteratdifferentoccasion.Theoutcomemeasureshoulddintheoriginalsampleandinothersamplesaswell.veralmethodstoevaluatethereliabilityofanoutcomepplicabilityofwhichdependsonthelevelofmeasure-hekindofreliabilityaskedfor.Oneofthecommonestrordinalscalesandinter-rateragreementiscalculationcoefficient.Closerthecoefficientkappato1.0,indicatesleisoutcomemeasure[7].nafterTBIimproveovertime.AccordingtoGOS,nearlyeby3months,90%by6monthsandadditional5%byhisobservationmayserveasaguidance,andotherout-uresshouldbeabletodetectthischangeovertime.Anshouldbeabletodetectdifferencesatthewholerangeoutcomes(best,intermediate,orworst).Flooreffectelowestmeasurablelevelofperformanceonanout-mentbeinghigherthanwhatisthestatusoftheleasttobemeasuredandaceilingeffectmeansthatthehigh-ablelevelislowerthanthelevelofatleastsomeoftheatients/clients[7].bilityticalimplicationrelatedtoabovepropertiesisappli-efollowingarethepracticalconcernsonapplicabilitymemeasure:expertiserequiredtoadminister,techni-y,contentdifficulty,participantunderstanding,scoringundness,andtimetocompletion.Aneffectiveoutcomehouldbefeasibleinfollowingsettings:populationwithographicprofile,broadrangeofinjuryseverity,varyingals,proxies,andtelephoneormail[6,7].ationandchoiceofoutcomemeasuretsthebodysystemofapersonlivinginthesociety.HealthOrganization[9]InternationalClassificationof(ICF),disabilityandhealthhasdefinedimpairment,ctivitylimitation)andhandicap(participationrestric-owing:ent:anylossorabnormalityofpsychological,physio-ranatomicalstructureorfunction.y:anyrestrictionorlack(resultingfromanimpair-fabilitytoperformanactivityinthemannerorwithineconsiderednormalforahumanbeing.D.Shuklaetal./ClinicalNeurologyandNeurosurgery113(2011)435–441437Table1ClassificationofoutcomemeasuresforTBI.Impairment/functionallimitationmeasuresGlasgowComaScale(GCS)Activity/actiBarthelIndFunctionaParticipatioCraigHandCommuniMeasuresthRanchoLoDisabilityFunctionaGlasgowONeuropsycQualityofHandicaanimpamentofandcultTheoutcclassificatiosuresareclmeasurescsettingslikeafterdischasuresimpaiGCScanbeanyotheriseeimmediparingadmpredictorooutcomeinhadsuffereBeforecminingwhaaspectsofiwhataspecandconseqtestinginathepatientactualcontetrationandbyobservinturedintervshoulduseticularcatebeidentifietusandcurdependsonparedwithseverityofTtationofouphysician.Dmentduetomedicalco-3.BarthelTheBIismid20thceoutcomeasItwasimprdenceMeasisapopulaoutcomeafterTBIandhasbeenfoundinferiortoFIM[14].How-ever,cliniciansandresearchersintheUnitedKingdom,AustraliaandelsewherestillusetheBIandmodificationsofit.AlternativesandextensionsoftheBIhavebeencreatedthatadditems,makeringctioFIMuselscal.Itinpag-stdisaricaademtedondtrangas“nce”uireresiansfeingt8(lolitatibservtelyabyqinstrringsclieilinglyatlyinsitivlitatiFIMaftenalasintedtfactome,n.igHaT)CHAvitylimitationmeasuresexlIndependenceMeasuren/participationrestrictionmeasuresicapAssessmentandReportingTechnique(CHART)tyIntegrationQuestionnaire(CIQ)atcrossICFdomainssAmigosLevelofCognitiveFunctioningScale(RanchoorLCFS)RatingScale(DRS)lStatusExamination(FSE)utcomeScale(GOS)hologicalAssessmentLifeafterBrainInjury(QOLIBRI)p:adisadvantageforagivenindividual,resultingfromirmentoradisability,thatlimitsorpreventsthefulfill-arolethatisnormal(dependingonage,sex,andsocialuralfactors)forthatindividual.omemeasuresofTBIcanbeclassifiedaccordingtoICFn(Table1).Asdisabilityisacontinuum,outcomemea-assifiedaccordingICFdomainsinthisreview.Outcomeanalsobeclassifiedaccordingtotheirutilityinspecificacutestage,in-patientrehabilitation,andatfollowuprge.GCShasbeenincludedinclassificationasitmea-rmentbutitisnottrulyanoutcomemeasure.However,usedtoevaluateconditionofpatientaftersurgeryorntervention.Itcanbeusedasanoutcomemeasuretoateeffectoftherapyatthetimeofdischargebycom-issionGCStodischargeGCS.SincetheGCSisastrongfoutcomeitshouldbenotedbeforeadministeringthestrumenttoindicatetheseverityofinjurythepatientd[10].hoosinganoutcomemeasure,thefirststepisdeter-tonewantstomeasure:activity(limitation)only,ormpairmentandparticipation.Thesecondquestionis:toffunctioningisofinterest,capacityorperformance,uentlywhattypeofadministrationshouldbeselected:laboratoryorothersetting,observation,orreportbyoraproxy.Eachinstrumentshouldbereviewedforntandsyllabusandinstructionsrequiredforadminis-scoring.Theoutcomemeasureshouldbeadministeredgorevaluatingthepatientconditionandalsobystruc-iewwithpatientortheclosecaretaker.Theexaminerhis/herbestjudgmentwhileplacingthepatientinpar-goryofoutcome.Disabilityduetoheadinjuryshoulddbyachangefrompreinjurystatus.Onlypreinjurysta-rentstatusshouldbeconsidered.ThoughtheoutcomeseverityofTBI,thecurrentoutcomeshouldnotbecom-theworstconditionofthepatientafterinjury.However,BIshouldbekeptonthebackgroundforrealisticexpec-thesco4.FunThesureinordinaulationduringthelondataonofAmecanAcseparaitemsascoresgorizedassistasixreqmeasutrol,trByaddfrom1rehabiciansoaccuraisteredofthetionduFIMha[20].Cticularseverenotsenrehabibythebancesfunctio12itemsubjecasatistingsodomai5.Cra(CHARThetcomeforboththepatients’attendantsandthetreatingisabilitymustbearesultofmentalorphysicalimpair-TBIandnotduetootherfactorslikesystemicinjuries,morbiditiesandnonwillingnesstogobacktowork[11].Index(BI)crudebutsimpleinstrument.ItwasdevelopedinthenturybyMahoneyandBarthel[12]andwasthemajorsessmentinstrumentinuseinrehabilitationintheUSA.oveduponandsupplantedbytheFunctionalIndepen-ure(FIM),andnowmostlyhashistoricsignificance.Itrmeasureforstroke[13],andalsousedforassessingofthedegrecapsintheconsistsof3ofthesixdfillvariousscognitiveinandeconomteriaandhaconsistentiamaximumthedomainable-bodiedorhighersmoreprecise[7].nalIndependenceMeasure(FIM)isthemostwidelyacceptedfunctionalassessmentmea-intherehabilitationcommunity.TheFIMisan18-iteme,usedwithalldiagnoseswithinarehabilitationpop-isviewedasmostusefulforassessmentofprogresstientrehabilitation.TheFIMwasdevelopedtoresolveandingproblemoflackofuniformmeasurementandbilityandrehabilitationoutcomes.TheFIMisaproductnCongressofRehabilitationMedicineandtheAmeri-yofPhysicalMedicineandRehabilitation[15,16].Twomainsofitemsare:themotordomainconsistingof13hecognitivedomainconsistingof5items[17,18].FIMefromonetoseven:aFIMitemscoreofseveniscate-completeindependence,”whileascoreofoneis“total(performslessthan25%oftask).Scoresfallingbelowanotherpersonforsupervisionorassistance.TheFIMndependentperformanceinself-care,sphinctercon-rs,locomotion,communication,andsocialcognition.hepointsforeachitem,thepossibletotalscorerangeswest)to126(highest)levelofindependence.Duringon,admissionanddischargescoresareratedbyclini-ingpatientfunction.Functioningpost-dischargecanbessessedusingatelephoneversionofFIMwhenadmin-ualifiedandtrainedinterviewers.Precision(theabilityumenttodetectmeaningfulchangeinleveloffunc-rehabilitation)hasbeenobservedtobehigh[19].Thenicallyappropriatevalidityandinter-rateragreementeffectsoftheFIMatrehabilitationdischarge,andpar-1yearpostinjurywereobservedinthemoderateandjuredTBIpopulation[21].Inotherwords,theFIMisetomoresubtlechangesexpectedafteracuteinpatientondischarge.Dissatisfactionwiththelimitedcoverageofcommunicative,cognitive,andbehavioraldistur-rbraininjuryleadtothecreationofa“FIM-annex”,thessessmentmeasure(FAM),whichoffersanadditionalthesedomain[22].The30-itemFIM+FAMhasbeenolimitedtestingofpsychometricqualities,butappearsrymeasure[23].ItmaintainedalltheBIitems,split-andaddedtasksreflectingstatusinthesocio-cognitivendicapAssessmentandReportingTechniqueRTwasdesignedtoprovideasimple,objectivemeasureetowhichimpairmentsanddisabilitiesresultinhandi-yearsafterinitialrehabilitation[24].TherevisedCHART2questionsandemploysuptosevenquestionsineachomainstoquantifytheextenttowhichindividualsful-ocialroles.Thesedomainsare:physicalindependence,dependence,mobility,socialintegration,occupation,icself-sufficiency.Theitemsfocusonobservablecri-vebeenwordedtominimizeambiguityandpromoteanterpretation.EachofthesubscalesoftheCHARThasscoreof100points,whichindicatesthatroleswithinarefulfilledatalevelequivalenttothatofthenorm:anperson.Highsubscalescoresindicatelesshandicap,ocialandcommunityparticipation.TheCHARTcanbe438D.Shuklaetal./ClinicalNeurologyandNeurosurgery113(2011)435–441administeredbyinterview,eitherinpersonorbytelephone,andtakesapproximately15min.Participant-proxyagreementacrossdisabilitygroupshasprovidedevidenceinsupportoftheuseofproxydataforpersonswithvarioustypesofdisabilities.TheCHARThasbeenfobeusedwiimpairmenCHART(CHrelatedstatastocreateCHART-SFtTheshortfoandequival6.CommuCommunstreamoffaanddisabiltermsfortliving,normofhandicapBarryWilletraumaticbabilityforuwiththepefocusonbedetectchanTheCIQsocialintegtoprovideintegrationperformingcompleted,15min.NoCIQ.TheCIalswithTBinjury[28,3significantldifferencesgrationsubwithrespecbutions;an(knownasC7.RanchoTheLCFcognitivefuofasingle8toincreasinposefulappwideusebyhaveamodrelateswithscoreonadoutcomes.recoveryan8.DisabiliTheDRStrackanindducedtoov(GOS)[5].MsiblebecausevariousitemsinthisscaleaddressallthreeWHOcategories:impairment,disabilityandhandicap.ThefirstthreeitemsoftheDRS(“EyeOpening,”“CommunicationAbility”and“MotorResponse”)areaslightmodificationoftheGCS,andreflectmeningyabtelygfthetheematdisthroscorpoputhouglrecagepletefamrateationreisdbeterelieturn[39].ssacnalrvalieitsnalcabiliteveresmeuseffunaybe3].malizedaterecodGOereleciseomesefunvolvctionyoupasssingttowaftheres.Tluaterainpatioresoajorandanciundtobeanappropriatemeasureofhandicapthatcanthindividualshavingarangeofphysicalorcognitivets,includingindividualswithTBI.AshortformoftheART-SF)wasdevelopedusingregressionanalysisandisticalmethodstoselectitems,followedbyrescoringsothesame0–100rangesastheoriginalCHARTdisplays.akeslesstimetoadministerthantheoriginalCHART.rmhas19items(insteadof32);itsmetricpropertiesencetotheCHARThavenotyetbeenevaluated[25–30].nityIntegrationQuestionnaire(CIQ)ity(re)integrationreferstoreturningtothemain-milyandcommunitylife,bypersonswithimpairmentsitiesduetoinjury,chronicillness,oroldage.Otherhesameorsimilarphenomenainclude:independentalization,deinstituti