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Rehab Measures: Disability Rating Scale (for TBI)

Link to instrument

http://www.tbims.org/combi/drs/drsrat.html 

Title of Assessment

Disability Rating Scale (for TBI) 

Acronym

DRS

Instrument Reviewer(s)

Initially reviewed by Sue Saliga, PT, DHSc, CEEAA and the TBI EDGE task force of the Neurology Section of the APTA in 9/2012

Summary Date

12/13/2012 

Purpose

To track recovery of an individual from coma to community and to measure general functional changes over the course of recovery for individuals with moderate to severe TBI.

Description

  • Scale addresses various items in the all World Health Organization categories: impairment, disability and handicap thus is it can be used during various stages of recovery.
  • An observer-rated, 30-point continuous scale that provides quantitative information to document the progress of patients with severe head injury patients from coma to community reintegration.
  • Evaluates eight areas of functioning in four categories:
    • (1) consciousness (eye opening, verbal response, motor response)
    • (2) cognitive ability (feeding, toileting, grooming)
    • (3) dependence on others
    • (4) employability
  • Each area of functioning is rated on a scale of 0 to either 3 or 5 (maximum score=29-extreme vegetative state, minimum score=0-person without disability) with the highest scores representing the higher level of disability

Area of Assessment

 

Body Part

 

ICF Domain

Body Structure; Body Function; Activity; Participation 

Domain

 

Assessment Type

 

Length of Test

 

Time to Administer

1 minute to 30 minutes depending on experience; self-administered or through interview; 5-15 minutes (Zhang et al, 2010)

Number of Items

8 areas assessed 

Equipment Required

None

Training Required

No, however a video (cost:  $20.00) and power point are available for training use

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Free

Age Range

 

Administration Mode

 

Diagnosis

Acquired Brain Injury; Traumatic Brain Injury 

Populations Tested

  • Traumatic Brain Injury
  • Acquired Brain Injury

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Traumatic Brain Injury: (TBI Model Systems National Database data 2012; n=11,058; mean age at injury=40 years old; gender=74% male)

  • Average DRS Score:
    • Rehab Admission (n=10837) 12.38
    • Rehab Discharge (n=10832) 6.38
    • 1 year post-jury (n=8134) 2.86
    • 2 years post-injury (n=6875) 2.57

Test-retest Reliability

Traumatic Brain Injury: (Gouvier et al, 1987; n=40, gender=27 male, 13 female; setting: acute care; between ratings at one day intervals)

  • Excellent test-retest relaibilty (r=0.95)

Interrater/Intrarater Reliability

Traumatic Brain Injury: (Rappaport et al, 1982; n=88; tool administered at day one of admission and 12 months after injury)

  • Excellent inter-rater reliability (r=0.97-0.98) among 3 raters

Traumatic Brain Injury: (Novack et al, 1991; n=45 caregivers; n=33 male and 12 female with TBI; one member of the treatment team completed the DRS; mean age of patients with TBI=24.3 years; average days in in-patient rehab=40.1 days)

  • Comparison of family members to rehabilitation specialist: the correlation was excellent for both admission and discharge (r=.95 and r=.93 respectively)

Traumatic Brain Injury: (Gouvier et al, 1987; n=40, gender=27 male, 13 female; setting: acute care; between ratings at one day intervals)

  • Excellent intra-rater reliability (r=0.98) among three raters

Traumatic Brain Injury: (Malec et al, 2012; n=406 (287-TBI, 119-caregivers)

  • 1-20 year telephone follow up; used raw scores for all 406 subjects
  • ICC between the ODRS and the DRS-PI-Beta= .909
  • ICC between the ODRS and the DRS-PI=.911
  • ICC between the DRS-PI-Beta and DRS-PI= .997

Internal Consistency

Traumatic Brain Injury: (Malec et al, 2012; n=406 (287-TBI, 119-caregivers; 1-20 year telephone follow up; used raw scores for all 406 subjects)

  • Original DRS: Cronbach’s alpha (.84) indicating excellent internal consistency
  • DRS-Post Acute Interview-Beta: Cronbach alpha (.83) indicated excellent internal consistency
  • DRS-Post Acute Interview: Cronbach alpha (.83) indicated excellent internal consistency

Acquired Brain Injury: (stroke, traumatic brain injury): (Eliason and Topp, 1984; n=128; mean age=57.35 (20.46); gender=male, n=74; acute stroke=69%, traumatic brain injury=31%; assessment obtained within 72 hours of injury)

  • Significant correlations were obtained between initial Disability Rating scores and 1) length of acute care hospital stay (r = .50, p < .01), 2) Disability Rating scores at discharge (r = .66, p < .01), and 3) discharge status (r = .40, p < .01)

Traumatic Brain Injury: (Evans et al, 2005; n=96; gender=female 27%; median age=32)

  • DRS scores at admission to rehabilitation made independent contributions to prediction of subjective well-being as assessed with the Satisfaction With Life Scale( SWLS) at rehabilitation discharge (r=-0.31, p<.01)

Criterion Validity (Predictive/Concurrent)

Traumatic Brain Injury: (Rao et al, 1992; n=57; mean age= 30.8 years (14.6); gender=male 72%; return to work or school up to 26 months was assessed)

  • Rehabilitation admission and discharge DRS scores predicted return to work with 86.8% accuracy

Traumatic Brain Injury: (Gouvier et al., 1987; n=40; gender=27 male, 13 female; setting: acute care; between ratings at one day intervals)

  • Predictive validity of the DRS at admission demonstrated excellent correlated with the Stover Zeiger Scale (r=0.65) at discharge.

Acquired Brain Injury: (Fryer and Haffey, 1987; training group n=18; mean age=29.8 years; training group diagnosis=TBI, anoxic brain intracranial hemorrhages; comparison group n=9; mean age=26.5 years; comparison group diagnosis: TBI)

  • The need for cognitive rehabilitation is also predicated by the DRS.
  • DRS at admission to a cognitive rehabilitation program is a strong predictor of disability at follow up (r=.77, p< .001).
  • It also discriminated between those outpatients who received Cognitive Rehabilitation/Community Re-adaptation training vs. those who did not.

Traumatic Brain Injury: (Fleming et al, 1999; n=209; mean age=35.8 (12.96); male gender=80.4%; assessed vocational outcome 2-5 years post-TBI)

  • Those who returned to work had a lower DRS total score (5.0 vs 6.2) compared to those who remained unemployed

Acquired Brain Injury (cerebral hemorrhage, TBI, intracranial tumors): (Leung et al, 2005; n=79; mean age=42.85 (11.56); male gender=73.4%)

  • The DRS was predictive in discriminating among the three groups of patients (those who returned to the same job, those who changed jobs, and those who were unemployed)

Traumatic Brain Injury: (Whyte et al., 2005; n=124; Patient with TBI in vegetative state or minimally conscious state; mean age of 122 participants=34.2 (13.3); assessment=DRS score at 16 weeks post injury, n=96) (assessed in all participants who had DRS score at 16 weeks post injury) and the time until first command following occurs (assessed in participants not following commands at enrollment, n=93)

  • Date of enrollment (T enroll), DRS score at enrollment (DRS enroll) and daily rate of DRS score (Rate DRS) over first 2 weeks of enrollment are predictive of time until commands are followed
  • T enroll: later admission, later command following
  • DRS enroll:worse enrollment score, later command following
  • Rate DRS: Faster DRS change, earlier command following

Traumatic Brain Injury: (Testa et al, 2005; n=TBI participants 195, orthopedic participants 82; mean age=young TBI (16-49 years, n=146), 29.1(10.6); older TBI (50-89 years, n=49), 65.8 (9.5); orthopedic injury younger (16-50 years, n=54), 31.1 (10.2); orthopedic injury older (50-89 years, n=28), 64.2 (11.3)

  • DRS was moderately predictive of long-term functional outcome, return to employment and independent living status post TBI

Traumatic Brain Injury: (Evans et al, 2005; n=96; female gender=26%)

  • DRS score at admission predicted Satisfaction with Life Score (SWLS) at rehabilitation discharge (r=-0.31, p<0.01)

Traumatic Brain Injury: (Malec et al; 2012; n=406 (287-TBI, 119-caregivers); 1-20 year telephone follow up)

Spearman's Correlations Between DRS and Concurrent GOSE, PART, and FIM Raw Scores
Comparison Scale
ODRS
DRS-PI-Beta
DRS-PI
Expanded DRS-PI
GOSE
-0.88
-0.78
-0.77
-0.81
PART
-0.66
-0.63
-0.62
-0.70
FIM Cog
-0.84
-0.80
-0.80
-0.83
FIM Motor
-0.77
-0.77
-0.76
-0.76

ODRS:  Original DRS; DRS-PI-Beta: DRS Post acute interview-Beta; DRS-PI: Disability Rating Scale–Postacute Interview; DRS-PI:  DRS Post-Acute Interview; Expanded DRS-PI:  Expanded Disability Rating Scale–Postacute Interview; GOSE:  Glasgow Outcome Scale–Extended; PART:  Participation Assessment with Recombined Tools; FIM:  Functional Impairment Measure

Traumatic Brain Injury: (Demakis et al, 2010; n=110; mean age=36.2 (17.2); male gender=73%)

  • For the Anxiety scale, DRS at discharge was the only significant predictor (p=.005); individuals with a higher score (i.e., poorer disability) had lower levels of anxiety
  • For the Anxiety-Related Disorders scale, sex and DRS at discharge were both significant predictors (p=.004 and p=.03, respectively)
  • DRS at discharge was significantly related to depression; Similar to the Anxiety scale, the relationship between DRS and Anxiety-Related Disorders and Depression was negative-- greater disability was associated with lower levels of anxiety and depression

Construct Validity (Convergent/Discriminant)

Traumatic Brain Injury: (Rappaport et al, 1982; n=88; tool administered at day one of admission and 12 months after injury)

Correlation Between Admissions DRS Ratings and Admission Brain Evoked Potental Abnormality Scores and Outcome Disability
r
Strenth
n
AEP, Brain Stem
0.35
Adequate
88
AEP, Cortex
0.62
Excellent
88
VEP, Cortex
0.52
Adequate
88
SEP, Sub and Early Cortex
0.64
Excellent
39
SEP, Cortex
0.55
Adequate
41
AEP, VEP, and SEP, Cortex
0.73
Excellent
41
ALL EP's
0.78
Excellent
39
DRo
0.53
Adequate
77

AEP:  Auditory evoked potential (EP), VEP: Visual EP, SEP:  somatosensory EP, DRo:  Outcome disability rating approximately 12 months after injury        

Traumatic Brain Injury: (Hall et al, 1985; n= 70; average age=27; years; average length of coma=32 days; average days form injury to admission to rehab unit=87)

  • Correlation of DRS and Glasgow Outcome Scale at two time intervals was adequate (r=0.50) at admission and excellent (r=0.67) at discharge

Traumatic Brain Injury: (Gouvier et al, 1987; n=40, gender=27 male, 13 female; setting: acute care; between ratings at one day intervals)

  • Rehabilitation admission DRS and Stover Zeiger (SZ) Scale Spearman rho correlation was excellent (r=0.92)
  • The rehabilitation discharge DRS and discharge SZ correlation was excellent (r=0.81)

Traumatic Brain Injury: (Hall et al, 2001; n=48 who had previously received in-patient rehabilitation 2-9 years previously; male gender=77%)

  • The Functional Assessment Measure (FAM) employment item correlated most highly with the DRS employability item (-.96)
  • The Neurobehavioral Functioning Inventory (NFI) motor subscale correlated most highly with DRS employment items (.83)

Traumatic Brain Injury: (Zhang et al., 2010; n=70; % age=18-30 years (71.4%), 31-60 years (27.2%), >61 years (1.4%); gender=male 69%)

  • Correlation coefficient of total ratings between the CHART and the DRS was .53 (P<.01); between the CIQ and DRS, was .43 (P<.01).
  • Subscales of the DRS correlated with each other

DRS Subscales
Level of Function
Employment
Arousability
Cognition
Level of Function
---
---
---
---
Employment
0.674
---
---
---
Arousability
0.214
0.221
---
---
Cognition
0.273
0.244
0.158
---
Total 0.843 0.782 0.470 0.682

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Traumatic Brain Injury: (Hall et al, 1996; n=133; time interval=admission, discharge, 1 and 2 years post-injury)
  • No ceiling effects reported at discharge, year 1 and year 2 after injury
  • Ceiling effects at discharge and at 1 year postinjury are lower for the DRS than the FIM (6% vs 49% and 47% vs 84% of cases are independent, respectively)

Responsiveness

Traumatic Brain Injury: (Hall et al, 1985; n= 70; average age=27; years; average length of coma=32 days; average days form injury to admission to rehab unit=87)

  • In comparing the DRS with the Glasgow Outcome Scale, 71% of individuals showed improvements on the DRS compared to 33% with GOS between rehabilitation admission and discharge.

Traumatic Brain Injury: (Rappaport et al, 1989; n=63; obtained DRS scrores at admission, discharge and up to 10 years post-injury)

  • DRS has been shown to detect changes over the recovery process with a greater change in those admitted earlier to rehabilitation

Traumatic Brain Injury: (Bowers et al, 1989; n=96; no other info available from abstract)

  • It is sensitive to patient improvement in inpatient TBI rehabilitation, although the FIM is more sensitive for patients with a DRS score above 25.

Traumatic Brain Injury: (Hall et al, 1996; n=133; time interval=admission, discharge, 1 and 2 years post-injury)

  • The DRS has poor sensitivity to evaluation of mild TBI (DRS <3) or very severe impairment (DRS>22).
  • Authors recommended the addition of half-unit increments on the rating scale, in addition to whole units, for items 4 through 8 to increase sensitivity; however, in 2010, the TBIMS National Database members voted to omit the 0.5 rating option. Use of the 0.5 rating option after April 1, 2010 is not recommended.

Traumatic Brain Injury: (Hammond et al, 2001; n=1160; male gender=879 (76%); age=16-24 years (n=337, 29%), 25-40 years (n=477, 41%), 41-60 years (n=245, 21%) and >60 years (n=101, 9%)

  • Statistically significant differences for DRS years 1 and 3 (P = .0007), DRS years 1 and 5 (P =.0006)
  • Statistical significance between years 1 and 5 for DRS Disability Categories (P = .001 and n = 150); by year 5, 42% of the subjects had attained the maximum DRS Disability Category
  • For those with lower functional baseline levels: statistical significance including only those with DRS >3.5 at year 1 (P = .001 for years 1 and 2 and years 1 and 5)
  • Item change: most change was accounted for by Level of Functioning (51% and 59% for the respective intervals) and Employability (51% and 65%), whereas each of the other six DRS items changed less than 11% at both intervals

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

VEDGE

LS

LS

LS

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

R

LS

R

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

LS

LS

LS

LS

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

Yes

Yes

Not reported

VEDGE

No

yes

No

Yes

Considerations

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Bowers, D. and Kofroth, L. (1989). "Comparison: Disability Rating Scale and Functional Independence Measure during recovery from traumatic brain injury." Arch Phys Med Rehabil 70: A58.

Demakis, G. J., Hammond, F. M., et al. (2010). "Prediction of depression and anxiety 1 year after moderate-severe traumatic brain injury." Appl Neuropsychol 17(3): 183-189. Find it on PubMed

Eliason, M. R. and Topp, B. W. (1984). "Predictive validity of Rappaport's Disability Rating Scale in subjects with acute brain dysfunction." Phys Ther 64(9): 1357-1360. Find it on PubMed

Evans, C. C., Sherer, M., et al. (2005). "Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury." J Head Trauma Rehabil 20(6): 488-500. Find it on PubMed

Fleming, J., Tooth, L., et al. (1999). "Prediction of community integration and vocational outcome 2-5 years after traumatic brain injury rehabilitation in Australia." Brain Inj 13(6): 417-431. Find it on PubMed

Fryer, L. J. and Haffey, W. J. (1987). "Cognitive rehabilitation and community readaptation: Outcomes from two program models." J Head Trauma Rehabil.

Gouvier, W., Blanton, P., et al. (1987). "Reliability and validity of the Disability Rating Scale and the Levels of Cognitive Functioning Scale in monitoring recovery from severe head injury." Archives of physical medicine and rehabilitation 68(2): 94.

Hall, K., Cope, D. N., et al. (1985). "Glasgow Outcome Scale and Disability Rating Scale: comparative usefulness in following recovery in traumatic head injury." Arch Phys Med Rehabil 66(1): 35-37. Find it on PubMed

Hall, K. M., Bushnik, T., et al. (2001). "Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals* 1." Archives of physical medicine and rehabilitation 82(3): 367-374.

Hall, K. M., Mann, N., et al. (1996). "Functional measures after traumatic brain injury: Ceiling effects of FIM, FIM+ FAM, DRS, and CIQ." J Head Trauma Rehabil.

Hammond, F. M., Grattan, K. D., et al. (2001). "Long-term recovery course after traumatic brain injury: a comparison of the functional independence measure and disability rating scale." J Head Trauma Rehabil 16(4): 318-329. Find it on PubMed

Leung, K. L. and Man, D. W. (2005). "Prediction of vocational outcome of people with brain injury after rehabilitation: a discriminant analysis." Work 25(4): 333-340. Find it on PubMed

Malec, J. F., Hammond, F. M., et al. (2012). "Structured interview to improve the reliability and psychometric integrity of the Disability Rating Scale." Arch Phys Med Rehabil 93(9): 1603-1608. Find it on PubMed

Novack, T. A., Bergquist, T. F., et al. (1991). "Primary caregiver distress following severe head injury." J Head Trauma Rehabil.

Rao, N. and Kilgore, K. (1992). "Predicting return to work in traumatic brain injury using assessment scales." Arch Phys Med Rehabil 73(10): 911.

Rappaport, M., Herrero-Backe, C., et al. (1989). "Head injury outcome up to ten years later." Arch Phys Med Rehabil 70(13): 885-892. Find it on PubMed

Testa, J. A., Malec, J. F., et al. (2005). "Outcome after traumatic brain injury: effects of aging on recovery." Arch Phys Med Rehabil 86(9): 1815-1823. Find it on PubMed

Whyte, J., Katz, D., et al. (2005). "Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: A multicenter study." Arch Phys Med Rehabil 86(3): 453-462. Find it on PubMed

Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 12/10/2012 4:15 PM  by Jason Raad 
Last modified at 9/3/2014 10:12 AM  by Jason Raad