Page views on the RMD Web site (from January 1, 2013, to May 14, 2015) for TBI EDGE measures that were designed specifically for TBI and were rated at least 3 (Recommend or Highly Recommend) are summarized in Table 5. Dissemination of TBI EDGE recommendations can be tracked most directly from page views from the APTA Academy of Neurologic Physical Therapy web site (www.neuropt.org), created in March 2013, following Combined Sections Meeting. From its creation in March 2013 until May 20, 2015, the page views numbered 14 562, with 8190 unique views.
This project is an important initial step toward identifying priority measures for use in TBI intervention by physical therapists. Our group of 8 volunteers (eventually increased to 9) took on a significant workload in reviewing and recommending 88 measures. The process would not have been possible in the yearlong time frame without help from prior EDGE group leadership and the collaborative efforts of the RMD group.
We used ambulatory status (modified FAC categories) as a method to refine our OM selection; however, this factor was often “not applicable” for most impairment and participation measures, even though it proved reasonable for the activity measures that addressed standing, walking, and higher-level mobility (see Supplemental Digital Content Table, available at: http://links.lww.com/JNPT/A144). This is reflective of a challenge in TBI care, as there is no standard way to characterize the combination of cognitive and physical impairments that occurs following a brain injury.
Many of the OMs included in our review were developed by National Institute on Disability and Rehabilitation Research (NIDRR, now National Institute on Disability, Independent Living, and Rehabilitation Research) TBI Model Systems investigators for use in research projects. These measures are sometimes designed to characterize important issues such as injury severity (eg, Glasgow Coma Scale67), or to reflect global outcome (Glasgow Outcome Scale-Extended,68 Disability Rating Scale51) but may not measure specific PT-related outcomes at a level that is useful clinically. This underscores the importance of recognizing measures that do capture clinically relevant abilities, such as the Coma Recovery Scale–Revised, an OM that received a high-level recommendation for inpatient rehabilitation.
In the TBI literature, there are measures that were developed long ago, sometimes called legacy measures, and many variations on prior measures. This was most evident in the participation category, where we identified many participation measures that could be used with TBI, but it was difficult to strongly advocate for a single choice. In this case, the Community Integration Questionnaire (CIQ)46 was rated the highest as a legacy measure that has been used in many studies, yet the CIQ has known ceiling effects postinjury.114,115
Participation measures developed to improve upon legacy measures such as the CIQ may lack published support to warrant a stronger recommendation. For instance, the PART-O,85 based on TBI Model Systems researcher consensus, combined elements of 3 legacy participation measures (CIQ,46 Participation Objective, Participation Subjective,87 and the Craig Handicap Assessment and Reporting Technique48,49). Since information on the PART-O was first published in 2011, insufficient support was available during our review to rate it higher than a 2 on our rating scale, yet additional validation of the measure has been published since our review process was completed.116–118 In the participation area, there were 22 measures that were rated at the “2” level, with the CIQ being the one of a few participation measures (also QOLIBRI and Sydney Psychosocial Rating Scale) to rise to the “3” level in more than 1 setting. This limited endorsement occurred despite efforts to improve the CIQ or create better alternatives that have been sufficiently validated to provide a stronger recommendation. Therapists working with TBI should monitor ongoing evidence emerging from the TBI Model Systems, as this collaborative research effort often leads the way in the validation of new measures. Future EDGE groups will need to consider this area carefully as newer measures become preferred tools.
Most of the OM-specific information reviewed in the EDGE process comes from classical test theory, using traditional measures of reliability and validity as a basis for recommendations. The use of item-response theory is increasingly a focus in the development of measures, not only to develop a hierarchy of item relationships but as a precursor to the use of computer-assisted test (CAT) methods. This approach allows testing of abilities across a wide continuum to occur rapidly by calibrating items tested based on individual responses to prior test items. Given the diversity of possible impairments and a range of abilities following TBI, CAT is an ideal target for TBI functional assessment. In our review, we examined literature related to PROMIS119 and NeuroQOL,83 measures that were not well studied in TBI at the time of the review; therefore, we included only NeuroQOL for TBI EDGE review. Since then studies on the TBI-related items for the NeuroQOL, referred to as TBIQOL, have been published.120–122 The CAT approach is likely to be very useful for self-report instruments that cover a wide range of topics, such as quality-of-life and participation measures. These instruments are available to clinicians at no charge, although the clinical use of them requires the use of a computer for the patient to enter responses, which may challenge feasibility.
There are many benefits to using the TBI EDGE and RMD summary forms in clinical practice. These recommendations include a wide variety of practice settings and levels of physical independence and allow for efficient identification of recommended and appropriate outcomes based on specific patient needs and practice settings. Many of the measures (n = 61) received no higher than “2” rating in multiple practice settings, including gait and balance measures that are in common use such as the Activities Specific Balance Confidence Scale, Balance Evaluation Systems Test, Clinical Test of Sensory Integration in Balance, Dynamic Gait Index, Fullerton Advanced Balance Scale, Functional Gait Assessment, Functional Reach, Sensory Organization Test, and Timed Up and Go (including cognitive version). These measures are reasonable to use, but there is not enough information on psychometric properties in the TBI population specifically to provide a higher-level recommendation. Measures rated at a “2” are ideal candidates for validation research for use in moderate to severe TBI.
There were 9 measures that were rated a “1” for all criteria, although only the Mini-Mental Status Exam was inadvisable to use with TBI based on study of the measure. For cognitive screening, the Montreal Cognitive Assessment appears better suited for TBI. Other measures that were rated “1” for all criteria had not been studied sufficiently in TBI to warrant a higher-level rating. Overall, the information from TBI EDGE provides an excellent starting point for a clinician or researcher looking for appropriate OMs for a specific patient or research study.
The effort summarized in this article is consistent with an ongoing Academy of Neurologic Physical Therapy priority on knowledge translation. The “knowledge to action framework” highlights steps in an inverse pyramid of knowledge creation that starts with knowledge inquiry—exemplified by the EDGE literature search process; knowledge synthesis—consistent with the process of rating each measure by setting type based on clinical perspectives and synthesized evidence; and knowledge tools that are created on the basis of the synthesis of information123 described in the Figure. Basic knowledge tools that are disseminated via the Academy of Neurologic Physical Therapy and RMD Web sites are listed in Table 4 and in the 1-page summaries described in the Figure. It is not possible for an organization such as the Academy of Neurologic Physical Therapy to accomplish all of the steps of the knowledge to action process. Therapists and administrators in clinical practice have the greater challenge of implementing recommendations put forth in knowledge tools or products. End users of these OM tools must analyze their clinical context including possible barriers to OM use, choose the OM that are best for implementation, then monitor, evaluate, and sustain the use of recommendations based on “real-world” experience. Clinical research that documents the use of these knowledge tools will be valuable in providing updated information to revise future OM recommendations.
The Academy of Neurologic Physical Therapy has sponsored the work of multiple EDGE groups across diagnostic groups, resulting in many tools that are recommended for use, but few that have the highest-level rating for multiple groups. The spread of ratings across hundreds of OMs may add to clinician difficulty in selecting the most appropriate OM for a patient. While EDGE documents are organized by condition, many clinicians work with multiple populations. Clinical practice guidelines are statements that include recommendations that synthesize the current literature. Since the EDGE groups have provided their recommendations, members of the Academy of Neurologic Physical Therapy of APTA are developing a CPG using EDGE recommendations to synthesize OM guidance across diagnostic groups. The leaders of this CPG group are former chairs of the Stroke and MSEDGE groups and the physical therapist liaison to the RMD, ideal players to facilitate a consensus. The process of continuing to integrate new literature into such recommendations also presents a challenge, but the likelihood of OM recommendations becoming more refined increases with collaborative processes such as the process used for TBI EDGE.
The TBI EDGE group thanks Jane Sullivan, Kirsten Potter, and Genevieve Pinto-Zipp for the advise and assistance they provided to our process. We are also grateful to the individuals who were part of the Rehabilitation Measures Database team who worked directly with us to facilitate reviews and to disseminate this information, especially Jennifer Moore and Jason Raad.
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