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QTBs are a resource for Academy members
that include existing tools which may be
useful in physiatric practice. Tools included
in the mild Traumatic Brain Injury QTB
were identified by subject matter experts
who treat patients with this condition,
and the Academy’s Performance Metrics
Committee has evaluated the tools for their
methodological quality.
Central Nervous System Rehabilitation Council
mild Traumatic
Brain Injury
Table of Contents
Review Articles, References and Other Resources
Evidence-Based Clinical Practice Guidelines
The Academy gratefully acknowledges the Central
Nervous System Rehabilitation Council and
Performance Metrics Committee for identifying and
compiling clinical tools to help Physiatrists treating
Assessment Instruments
Measurement Resources
Educational Resources
patients with mild Traumatic Brain Injury.
AAPM&R Resources
Central Nervous System Rehabilitation Council
Subject Matter Experts
External Resources
Amy L. Murphy, MD
Christian Shenouda, MD
Michael R. Yochelson, MD
(Council Lead for QTB Project)
Performance Metrics Committee
David Berbrayer, MD
Michael Hatzakis, MD
Kurtis M. Hoppe, MD
Amy Houtrow, MD
Elizabeth Sandel, MD
(PMC Chair and Lead for QTB Project)
Deepthi Saxena, MD
Michael Schaefer, MD
Felicia Skelton, MD (PMC Lead for QTB project)
Review Articles, References and Other Resources
1. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology
of concussive brain injury. Clinics in sports medicine.
2011 Jan;30(1):33-48, vii-iii.
2. Lee YK, Hou SW, Lee CC, Hsu CY, Huang YS, Su YC. Increased risk of
dementia in patients with mild traumatic brain injury: a nationwide
cohort study. PloS one. 2013;8(5):e62422.
3. Nygren-de Boussard C, Holm LW, Cancelliere C, Godbolt AK, Boyle
E, Stalnacke BM, et al. Nonsurgical interventions after mild traumatic
brain injury: a systematic review. Results of the International
Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of
physical medicine and rehabilitation. 2014 Mar;95(3 Suppl):S257-64.
4. Waljas M, Iverson GL, Lange RT, Liimatainen S, Hartikainen KM,
Dastidar P, et al. Return to work following mild traumatic brain injury.
The Journal of head trauma rehabilitation. 2014 Sep-Oct;29(5):443-50.
5. Marras C, Hincapie CA, Kristman VL, Cancelliere C, Soklaridis S, Li A,
et al. Systematic review of the risk of Parkinson’s disease after mild
traumatic brain injury: results of the International Collaboration on
Mild Traumatic Brain Injury Prognosis. Archives of physical medicine
and rehabilitation. 2014 Mar;95(3 Suppl):S238-44.
6. Boyle E, Cancelliere C, Hartvigsen J, Carroll LJ, Holm LW, Cassidy JD.
Systematic review of prognosis after mild traumatic brain injury in the
military: results of the International Collaboration on Mild Traumatic
Brain Injury Prognosis. Archives of physical medicine and rehabilitation.
2014 Mar;95(3 Suppl):S230-7.
7. Karr JE, Areshenkoff CN, Garcia-Barrera MA. The neuropsychological
outcomes of concussion: a systematic review of meta-analyses on the
cognitive sequelae of mild traumatic brain injury. Neuropsychology.
2014 May;28(3):321-36.
8. Ciuffreda KJ, Ludlam DP, Kapoor N. Clinical oculomotor training in
traumatic brain injury. Optom Vis Dev 2009;40(1):16-23.
9. Omalu B. Chronic traumatic encephalopathy. Progress in neurological
surgery. 2014; 28:38-49.
10. Yi J, Padalino DJ, Chin LS, Montenegro P, Cantu RC. Chronic
traumatic encephalopathy. Current sports medicine reports.
2013 Jan-Feb;12(1):28-32.
11. Lucas S. Headache Management in Concussion and Mild Traumatic
Brain Injury. October 2011 Volume 3, Issue 10, Supplement 2,
Pages S406–S412.
12. DVBIC Sleep Factsheet
Evidence-Based Clinical Practice Guidelines
• Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms
developed by the Ontario Neurotrauma Foundation
Assessment Instruments
• Neurobehavioral Symptom Inventory (NSI) — A questionnaire that can
be administered to someone who sustains a concussion or other form of
traumatic brain injury to measure the presence and severity of symptoms.
The NBSI takes approximately 10 minutes to administer.
Core Constructs
• The Rivermead Post Concussion Symptoms Questionnaire —
Questionnaire to measure severity of symptoms.
Core Constructs were identified
to help guide the selection
of Assessment Instruments.
Core Constructs are based on
the International Classification
of Functioning, Disability
and Health (ICF) framework.
More information on the ICF
Framework can be found here.
The Core Constructs for this
QTB related to mTBI are:
• Dizziness Handicap Inventory (DHI) — A 25-item self-assessment inventory
•Cognitive status
•Behavioral health
•Life Satisfaction
•Participation/Social roles
• Screening for TBI Exposure— Ohio State University TBI Screening Form—
Assesses the patient’s prior history of TBI. It takes approximately 5–35
minutes to administer depending on the patient’s medical history.
• The Migraine Disability Assessment Test (MIDAS) — Measure of migraine
disability (only if needed from NSI/Rivermead).
designed to evaluate the self-perceived handicapping effects imposed by
• Balance Error Scoring System (BESS) — A measure of assessing static
postural stability (only if needed from NSI/Rivermead).
• Insomnia Severity Index — 7-item questionnaire that asks respondents
to rate the nature and symptoms of their sleep problems using Likert-type
• Morningness-Eveningness Questionnaire — A 19-item scale developed
to assess differences in the degree to which respondents are active and alert
at certain times of the day.
• Fatigue Visual Analog Scale — An 18-item scale that assesses subject
experience of fatigue.
• Epworth Sleepiness Scale — Evaluates overall daytime sleepiness based on
how likely they are to fall asleep in eight different situations (only if needed
from NSI/Rivermead)
Cognitive Status
• Montreal Cognitive Assessment (MOCA) — Rapid screen of cognitive
abilities designed to detect mild cognitive dysfunction.
• Moss attention rating scale — The MARS is an observational tool used
to measure attention-related behaviors after TBI.
continued on next page
Assessment Instruments
Behavioral Health
• Patient Health Questionnaire (PHQ-9) — Assesses the presence and
intensity of depressive symptoms
• CAGE Questionnaire — A 4-item questionnaire for screening for
alcohol abuse
• Primary Care – Post Traumatic Stress Disorder Screen (PC-PTSD) —
A 4-item screen used to screen for PTSD
• Generalized Anxiety Disorder (GAD-7) — A self-reported questionnaire
for screening and severity measuring of generalized anxiety disorder (GAD)
Participation/Social Roles
• Community Integration Questionnaire (CIQ) — Used to assess the social
role limitations and community interaction of people with acquired brain
• Glasgow Outcome Scale Extended (GOS-E) — Used to classify global
outcome in TBI survivors.
Life Satisfaction
• Quality of Life After Brain Injury (QOLIBRI) — 37 items questionnaire
covering six dimensions of health related quality of life.
Measurement Resources
• The Center for Outcome Measurement in Brain Injury
• National Institute of Neurological Disorders and Stroke (NINDS)
Common Data Elements for TBI
Educational Resources
• Brain Injury Association
• Centers for Disease Control
• U.S. Department of Veterans Affairs
Other Resources
AAPM&R Resources
• Evidence-Based Resources
• Vetted PQRS Measures
• Performance Measure Resources
• Endorsed Clinical Practice Guidelines
• Quality Glossary
External Resources
• Cochrane Library
An online collection of databases that brings together in one place
rigorous and up-to-date research on the effectiveness of healthcare
treatments and interventions, as well as methodology and diagnostic tests
• Oxford Centre for Evidence-Based Medicine 2011 Levels
of Evidence
Defines a process of finding appropriate evidence feasible and
its results explicit
Clinical Practice Guidelines:
• National Guidelines Clearinghouse
A public resource for evidence-based clinical practice guidelines
Assessment Instruments/Performance Measures:
• National Quality Measure Clearinghouse
A public resource for evidence-based quality measures and measure sets.
• National Quality Forum (NQF) Quality Positioning System
NQF’s measure search tool that helps you find the endorsed measures you
need quickly and easily. • Rehabilitation Measures Database
The Rehabilitation Clinician’s Place to Find the Best Instruments to
Screen Patients and Monitor Their Progress.