The Brain Injury Screening Tool (BIST): Tool development, factor structure and validity
Alice TheadomNatalie HardakerCharlotte BrayRichard J. SiegertKevin HenshallKatherine ForchKris FernandoDoug KingMark FulcherSam JewellNusratnaaz ShaikhRenata Bastos GottgtroyPatria A. Hume
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Abstract:
Currently health care pathways (the combination and order of services that a patient receives to manage their injury) following a mild traumatic brain injury vary considerably. Some clinicians lack confidence in injury recognition, management and knowing when to refer. A clinical expert group developed the Brain Injury Screening Tool (BIST) to provide guidance on health care pathways based on clinical indicators of poor recovery. The tool aims to facilitate access to specialist services (if required) to improve longer term prognosis. The tool was developed using a three-step process including: 1) domain mapping; 2) item development and 3) item testing and review. An online retrospective survey of 114 adults (>16 years) who had experienced a mild brain injury in the past 10 years was used to determine the initial psychometric properties of the 15-item symptom scale of the BIST. Participants were randomised to complete the BIST and one of two existing symptom scales; the Rivermead Post-concussion Symptom Questionnaire (RPQ) or the Sports Concussion Assessment Test (SCAT-5) symptom scale to determine concurrent validity. Participant responses to the BIST symptom scale items were used to determine scale reliability using Cronbach’s alpha. A principal components analysis explored the underlying factor structure. Spearman’s correlation coefficients determined concurrent validity with the RPQ and SCAT-5 symptom scales. The 15 items were found to require a reading age of 6–8 years old using readability statistics. High concurrent validity was shown against the RPQ ( r = 0.91) and SCAT-5 ( r = 0.90). The BIST total symptom scale (α = 0.94) and the three factors identified demonstrated excellent internal consistency: physical/emotional (α = 0.90), cognitive (α = 0.92) and vestibular-ocular (α = 0.80). This study provides evidence to support the utility, internal consistency, factor structure and concurrent validity of the BIST. Further research is warranted to determine the utility of the BIST scoring criteria and responsiveness to change in patients.Keywords:
Concurrent validity
Acquired brain injury
Concurrent validity
Inter-Rater Reliability
Validity
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In the acute stages following ABI, when people are functionally dependent, a specific scale for physiotherapists to monitor incremental changes in neuro-motor function is needed. This thesis represents the development of the acute brain injury physiotherapy assessment (ABIPA), an outcome measure to fill this gap. The first step in the development of the ABIPA was to identify items known to reflect acute neuro-motor impairments for inclusion in the measure and develop scoring criteria along with guidelines for the identified items (Study 1). The final items of the ABIPA were: upper limb and lower limb movement; overall muscle tone in each limb; head and trunk alignment in supine; head and trunk alignment in sitting; head and trunk control in sitting; and overall presentation. Once items were selected and scoring criteria established, the new outcome measure underwent psychometric testing. In Study 1 responsiveness and concurrent validity of the ABIPA were examined together with participants assessed at day 1, 3, 7 and at discharge through their acute hospital admission to capture clinical changes. Concurrent validity of the ABIPA was examined against other commonly used measures; specifically, the Glasgow Coma Scale (GCS), Clinical Outcomes Variable Scale (COVS) and Motor Assessment Scale (MAS). The ABIPA was found to be responsive to change demonstrating greater sensitivity to change (SRM = 0.83) when compared to other assessment measures (SRMs ≤ 0.77) during the early weeks following ABI. Additionally, the ABIPA demonstrated good concurrent validity with commonly used measures to assess acute brain injury, including the GCS (rho = 0.76, p ≤ 0.001, COVS (rho = 0.82, p ≤ 0.001) and MAS (rho = 0.66, p ≤ 0.001). Study 2 of this thesis investigated inter- and intra-tester reliability of physiotherapists using the ABIPA. An observational study using video-recorded ABIPA assessments of seven people with moderate or severe ABI was undertaken with two cohorts of physiotherapists; trained and untrained. Trained physiotherapists attended two one-hour training sessions; an initial instructional session and then a practice session. The untrained physiotherapists were provided with the ABIPA guidelines. Participating physiotherapists scored the video recorded package of ABIPA assessments with intra-tester reliability examined by repeat screenings of the video recorded assessments a minimum of two weeks after the initial session. A high level of inter-tester reliability (α ≥ 0.9) was demonstrated for both trained and untrained physiotherapists. Trained physiotherapists showed good to excellent internal consistency for total ABIPA score and for all individual items except for alignment of the trunk in supine (α = 0.4). Similarly, untrained physiotherapists showed good to excellent internal consistency on the total ABIPA score and all individual items except for alignment of the trunk in supine (α = 0.09) and alignment of the head in supine (α = 0.60). For intra-tester reliability, substantial or perfect agreement was achieved for eight items (Weighted kappa Kw ≥ 0.6), with moderate agreement reached for a further four items (Kw = 0.4 - 0.6), leaving three items (representing 20% of the scale) achieving fair agreement. Items with the lowest agreement were alignment of the head in supine (Kw = 0.289); alignment of the trunk in supine (Kw = 0.387) and tone left upper limb (Kw = 0.366). This was similar for both the trained and untrained physiotherapists. Study 3 of the thesis investigated the underlying factor structure of the ABIPA using an exploratory factor analysis with principal axis factor extraction and varimax rotation. A four-factor solution with a simple structure (factor loadings ≥.30) that explained 69.6% of total variance was suggested. Factor one (alignment and posture) accounted for 36.6% of the variance while factor two (tone) explained 15.8%, factor three (left side movement) explained 9.6% and factor four (right side movement) accounted for 7.5%. Two items were identified with the lowest loading with the four-factor solution, alignment of the head in supine loading to factor three at 0.358 and alignment of the trunk in supine loading to factor two at 0.405. The final study of this thesis examined the association of the ABIPA with long term recovery following ABI by evaluating ABIPA scores at acute hospital admission and ABIPA scores at admission to rehabilitation against: length of stay in the acute hospital setting, length of stay in rehabilitation, discharge destination and secondary measures including the GCS, Mental Status Questionnaire, COVS, Coma Recovery Scale-Revised (CRS-R), Functional Independence Measure (FIM), Disability Rating Scale (DRS) and Carer Strain Index (CSI). ABIPA at acute hospital admission and rehabilitation were inversely related to acute, rehabilitation and total hospital length of stay (rho ≥ -.508; p ≤ 0.044). ABIPA at acute hospital admission demonstrated moderate to good correlations with ABIPA, FIM (motor) and COVS (rho ≥ 0.563, p ≤ 0.023) at long term follow up. ABIPA scores at rehabilitation admission demonstrated moderate to good correlations with GCS and MSQ (rho ≥ 0.564, p ≤ 0.023) and excellent correlations with ABIPA, FIM (motor) and COVS (rho ≥ 0.799, p ≤ 0.001). Overall the ABIPA showed moderate to good relationships with length of stay and long-term neuro-motor recovery from severe ABI. This thesis demonstrates that a new outcome measure with strong psychometric properties has been developed for measurement of acute neuro-motor impairments following severe ABI. Further investigation is required to continue the development paradigm by removing outlying items, establishing a minimal clinically important difference and expanding participant numbers.
Acquired brain injury
Concurrent validity
Sitting
Supine position
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The aim of this study was to determine whether robotic-assisted locomotor training, a new clinical service introduced at the Tan Tock Seng Hospital (TTSH) Rehabilitation Centre, Singapore is effective at improving the ability to transfer and the ambulatory status of patients with an acquired brain injury.This was a retrospective review of data collected from patients with an acquired brain injury, before and after robotic-assisted locomotor training from September 2008 to May 2009. The primary outcome measures used were the functional independence measure (FIM) for transfer and ambulation, and the Rivermead Motor Assessment (RMA) gross function subscale. The secondary outcome measures used were the Motricity Index (MI) and Modified Ashworth Scale of the lower limb. Statistical analysis was performed on this data to evaluate whether robotic-assisted locomotor training was effective at improving the functional mobility of these patients.Significant improvement was observed in the scores of FIM transfer (p is less than 0.05), FIM ambulation (p is less than 0.05) and RMA (p is less than 0.05) after robotic-assisted locomotor training. Significant improvements in the MI of hip flexion (p is less than 0.05), knee extension (p is less than 0.05) and ankle dorsiflexion (p is less than 0.05) post training have also been noted.Robotic-assisted locomotor training was found to be effective at improving the transfer, ambulation and functional mobility of patients with an acquired brain injury.
Functional Independence Measure
Acquired brain injury
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The Rivermead Mobility Index is used to measure mobility in patients with head injury or stroke. The purpose of the study was to examine construct validity, predictive validity, and the responsiveness of the Rivermead Mobility Index in stroke patients. Thirty-eight stroke inpatients participated in the study. The Rivermead Mobility Index, the Barthel Index, and the Berg Balance Scale were administered at admission to the rehabilitation ward and at discharge. The results showed that the Rivermead Mobility Index fulfilled the Guttman scaling criteria (coefficients of reproducibility > 0.9, coefficients of scalability > 0.7). The Rivermead Mobility Index scores were highly correlated with the Barthel Index scores (Spearman rs > 0.6) and the Berg Balance Scale scores (Spearman rs > = 0.8, all ps < 0.001). The Rivermead Mobility Index score at admission was closely correlated with the Barthel Index score at discharge (Spearman r = 0.77, p < 0.001). About 76% (29) of the subjects improved by more than 3 Rivermead Mobility Index points (median = 5) during their stay. The relationship between the change in score of the Rivermead Mobility Index and the Barthel Index was fair (Spearman r = 0.6, p < 0.001). These results indicate that the Rivermead Mobility Index is valid and sensitive to change over time. It is therefore a useful scale for the assessment of mobility in stroke patients.
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Barthel index
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The Inventory of Interpersonal Problems 32 (IIP-32; Horowitz, Aiden, Wiggins, & Pincus, 2000) is a brief, 32-item, self-report questionnaire used to screen for interpersonal problems. While studies of the IIP-32's psychometric properties have been conducted in other nations, and studies have examined the psychometric properties of the IIP-32's circumplex structure, no studies have examined the factor-analytic structure in the United States since the original standardization sample. The aim of this study was to examine the psychometric properties of the IIP-32 in American college women for the first time and explore its structural validity as a circumplex measure and its concurrent validity with measures of attachment. The current study found that internal consistency estimates and interscale correlations were generally high and confirmed the proposed circumplex structure. In addition, concurrent validity was evidenced by confirming theorized relations between attachment and the IIP-32 subscales. However, IIP-32 subscales were limited with regard to divergent validity.
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Abstract In this article distinctions are made among some of the different conceptualizations of, and formulas for, Cronbach's coefficient alpha as it is applied to dichotomous or nondi‐chotomous, standardized or unstandardized, and weighted or unweighted data. Issues regarding the statistical significance of alpha and the occasionally encountered anomalies of artificially high alpha and negative values of alpha are given particular attention.
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Post-concussion syndrome
Blast injury
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Prospective memory (PM) has been shown to be impaired in children with acquired brain injuries (ABI) and is a major concern for parents. Few studies have addressed this issue and most used tasks that are not ecologically valid. The aims of this study were (1) to explore if children who have sustained an ABI suffer PM impairment, measured both by the Children’s Cooking task (CCT) PM score and using the 2 PM subtests of the Rivermead Behavioral Memory Test (RBMT), and (2) to explore if the CCT PM score is sensitive to developmental changes in PM in typically developing children and in children with ABI. Fifty-four children with ABI and 33 typically developing controls participated in the study. Children with ABI had significantly lower PM scores and poorer performance in the CCT than their typically developing peers. PM scores increased significantly with age, indicating developmental progress of PM performance.
Acquired brain injury
Prospective Memory
Typically developing
Ecological validity
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