Neurological Outcome Scale for Traumatic Brain Injury

Last Updated

December 07, 2012

Purpose

Assess common neurological sequelae of TBI by physicians and non-MDs, serving as a tool to stratify injury severity and as an outcome measure in randomized clinical trials. Based on the National Institutes of Health Stroke Scale, with modifications to allow for scoring of patients in coma/vegetative state or agitated, and to assign items to a “supplemental” category that are problematic after TBI and not stroke (e.g. limb ataxia).

Link to Instrument

instrument details

Acronym NOS-TBI

Cost

Free

Diagnosis/Conditions

Brain Injury Recovery

Brain Injury

15-item scale (some having sub-items for a total of 23 items) addressing clinical neurologic exam elements of orientation, cranial nerve function, strength, sensation, language and coordination.
Items added specifically for TBI include: olfactory sensation, pupillary response, hearing, and lateralization.
Two supplemental items, limb ataxia and tandem gait are administered if orthopedic restrictions don’t prevent their attempt.
Items are rated on 3-, 4-, or 5-level scales.
The total score for the NOS-TBI is the sum of the scores for items 1-13 except those scored as “UN” (untestable and is not included in the total score), range from 0-58 for require items, 4 points for supplemental items (14 and 15). Supplementary items do not factor into the total score but could be assessed if a patient demonstrated ataxia.
Higher scores reflect greater neurological impairments.

Number of Items

Incandescent penlight for pupillary testing
Laminated stimulus cards from the Boston Diagnostic Aphasia Examination for the “Cookie Theft” picture and object naming
Stimulus cards of the words and sentences for aphasia and dysarthria testing
Disposable safety pins for sensory testing
Essential oils for olfactory testing

15 minutes

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Erin Donnelly, PT, MSPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 6/2012

ICF Domain

Body Structure
Body Function

Professional Association Recommendation

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 (Vestibular EDGE) 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 based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	NR	N/A	N/A	N/A

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

Considerations

Developers noted that there was difficulty with administration of the test with the severely injured and those presenting with agitation. They suggested that this may be more of a challenge for in-experienced raters.

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Test/Retest Reliability

Traumatic Brain Injury: (McCauley et al., 2010; n= 50 with moderate to servere TBI; mean age= 33.3 (12.9); tested <18 months post injury, mean time post-injury= 2.9 months)

Excellent test-retest reliability with testing a mean of 1.6 days apart, range 0 -6 days (Spearman rank order correlation = .97)

Interrater/Intrarater Reliability

Traumatic Brain Injury: (McCauley et al., 2010)

Excellent inter-rater reliability (Kendall’s coefficient of concordance = .995 for total score)

Internal Consistency

Traumatic Brain Injury: (McCauley et al., 2010)

Excellent internal consistency for total score ( Cronbach’s alpha = .942)
Item-to- item internal consistency ranged from excellent to poor (Cronbach’s alpha ranging from .34-.84)
The deletion of any single item did not improve the coefficient alpha, so all items were retained.

Criterion Validity (Predictive/Concurrent)

Traumatic Brain Injury: (Wilder et al., 2010b, same sample as McCauley et al., 2010, n=50 individuals with moderate to severe TBI, tested <18 months post injury, mean age 33.3 (12.9) years, majority with + CT scans and + LOC)

Excellent construct validity between the total NOS-TBI score and the neurologist performed clinical Neurological Exam Scores (Spearman correlation =0.76)

Construct Validity

Construct Validity:

Traumatic Brain Injury : (Wilde et al, 2010b)

Item-to-item: Excellent correlations between items (ranging from .60 to .99)

Convergent Validity:

Traumatic Brain Injury: (McCauley et al., 2010)

Excellent convergent validity of the NOS-TBI when compared to the DRS (Spearman Correlations = .75)
Excellent convergent validity of the NOS-TBI when compared to the FIM (Spearman Correlations = -.68)
Excellent convergent validity of the NOS-TBI when compared to the Rancho Los Amigos Levels of Cognitive Function (Spearman Correlations = -.60)
Adequate convergent validity of the NOS-TBI when compared to the Supervision Rating Scale (Spearman Correlations = .59)

Content Validity

The Content Validity of the NOS-TBI was evaluated by a panel of recognized experts from a wide range of relevant backgrounds (drawn from two Level 1 trauma centers in a large metropolitan area) who regularly treated patients with TBI. Panelists included two neurologists, 2 neurosurgeons, and 4 neuropsychologists specializing in TBI. Panelists advised on items that should be retained from the NIHSS because they are sufficiently problematic in TBI. They were also asked to recommend items that should be removed from the scale and to suggest items that were missing that are problems post-TBI but not in stroke. (Wilde et al., 2010a)

Face Validity

The measure closely parallels the items included in a typical neurological exam, but provides standardized testing and scoring for each item

Floor/Ceiling Effects

A floor effect is predicted for those with minor/less severe TBIs.

Bibliography

Maas, A. I. R., Menon, D. K., et al. (2012). "Re-orientation of clinical research in traumatic brain injury: report of an international workshop on comparative effectiveness research." Journal of Neurotrauma 29(1): 32-46.

McCauley, S. R., Wilde, E. A., et al. (2010). "The Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI): II. Reliability and convergent validity." J Neurotrauma 27(6): 991-997. Find it on PubMed

Wilde, E. A., McCauley, S. R., et al. (2010). "Feasibility of the Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI) in adults." J Neurotrauma 27(6): 975-981. Find it on PubMed

Wilde, E. A., McCauley, S. R., et al. (2010). "The Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI): I. Construct validity." J Neurotrauma 27(6): 983-989. Find it on PubMed