Ontario Neurotrauma Foundation

Clinical Practice Guideline

For the rehabilitation of Adults with Moderate to Severe TBI

Ontario Neurotrauma Foundation INESSS
SECTION 2: Assessment and Rehabilitation of Brain Injury Sequelae > H. Comprehensive Assessment of the Person with TBI

H. Comprehensive Assessment of the Person with TBI

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A comprehensive assessment of each person is necessary because brain injury results in a complex mix of physical, emotional and cognitive changes. It is essential to understand the person’s experience, skills and abilities prior to the brain injury to understand the impact of the brain injury. Early post brain injury, the Glasgow Coma Scale provides insights into the severity of the brain injury. During the period of post-traumatic amnesia (PTA), a comprehensive assessment of cognition is not recommended because of the poor attention and likelihood of rapid changes.  Standardized assessment of PTA can better quantify the duration of PTA and a number of tools exist. Musculoskeletal and other trauma is frequently associated with brain injury; therefore, it is important that those with severe musculoskeletal or spinal trauma be screened for concomitant cognitive and other sequelae of brain injury.

Health care professionals should be trained in using standardized tools to assess the person with brain injury including the Glasgow Coma Scale, Glasgow Outcome Scale, Activities of Daily Living and PTA Scales. The interprofessional team should include those with specialized skills and training in cognitive and behavioural assessment. These assessments may require the purchase of equipment and test materials.

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Individuals should be assessed for common impairments.  Clinical assessments and protocols based on the Glasgow Coma Scale Score can guide the initial management. In some instances, relatives are able to offer clinicians information regarding the patient’s level of awareness that is more accurate than a patient’s self-report measure (Sohlberg, Mateer, Penkman, Glang, & Todis, 1998; Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010). In an observational study, patients and relatives who completed functional assessment questionnaires focused on the patient following a rehabilitation program, both scored similarly (Svendsen, Teasdale, & Pinner, 2004).

The transition from post-traumatic coma to post-traumatic delirium (PTD) or PTA is characterized by impairments in selective and sustained attention (Arciniegas, 2010). During the period of PTA, impairments in executive functioning, language and declarative learning are prominent. When emerging from PTA, executive function deficits manifest in problem solving, abstract thinking and cognitive flexibility. Emotional lability is also present during PTA expressed as agitation and aggression (Ponsford & Sinclair, 2014). Neuropsychologists/psychiatrists have found the following outcome measures valuable in determining PTA duration and TBI severity: Glasgow Coma Scale and the Galveston orientation and amnesia test (Arciniegas, 2010).

When an individual emerges from PTA, cognitive function should be evaluated. Throughout this process, caregivers should receive information and education regarding the patient’s injury and care to reduce the burden of care (Calvete & de Arroyabe, 2012) and maintain their mental health (Doyle et al., 2013).
It is also important to assess individuals with other forms of poly trauma and particular spinal cord injury because the concomitant injuries have an impact on clinical recovery and costs of care. Individuals with traumatic SCI and TBI had worse cognitive function and higher rehabilitation costs compared to those without TBI (Bradbury et al., 2008). Sharma et al. (2014) found a 58.5% frequency of missed traumatic brain injuries in a sample of 92 individuals with traumatic spinal cord injury.

Arciniegas, D. B. (2010). Neuropsychiatric Assessment of Traumatic Brain Injury During Acute Neurorehabilitation* Neuropsychiatric disorders (pp. 123-146): Springer.

Bradbury, C. L., Wodchis, W. P., Mikulis, D. J., Pano, E. G., Hitzig, S. L., McGillivray, C. F., . . . Green, R. E. (2008). Traumatic brain injury in patients with traumatic spinal cord injury: clinical and economic consequences. Arch Phys Med Rehabil, 89(12 Suppl), S77-84.

Calvete, E., & de Arroyabe, E. L. (2012). Depression and grief in Spanish family caregivers of people with traumatic brain injury: The roles of social support and coping. Brain Injury, 26(6), 834-843.

Doyle, S. T., Perrin, P. B., Diaz Sosa, D. M., Espinosa Jove, I. G., Lee, G. K., & Arango-Lasprilla, J. C. (2013). Connecting family needs and TBI caregiver mental health in Mexico City, Mexico. Brain Injury, 27(12), 1441-1449.

Ponsford, J., & Sinclair, K. (2014). Sleep and fatigue following traumatic brain injury. Psychiatr Clin North Am, 37(1), 77-89.

Sharma, B., Bradbury, C., Mikulis, D., & Green, R. (2014). Missed Diagnosis of Traumatic Brain Injury in Patients with Traumatic Spinal Cord Injury. Journal of Rehabilitation Medicine, 46(4), 370-373.

Sohlberg, M. M., Mateer, C. A., Penkman, L., Glang, A., & Todis, B. (1998). Awareness intervention: Who needs it? J Head Trauma Rehabil, 13(5), 62-78.

Spikman, J. M., Boelen, D. H., Lamberts, K. F., Brouwer, W. H., & Fasotti, L. (2010). Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life. Journal of the International Neuropsychological Society, 16(01), 118-129.

Svendsen, H., Teasdale, T., & Pinner, M. (2004). Subjective experience in patients with brain injury and their close relatives before and after a rehabilitation programme. Neuropsychological Rehabilitation, 14(5), 495-515.

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H1. Principles of Assessment

P Priority F Fundamental New Level of evidence A B C
H 1.1 F C

All individuals with traumatic brain injury who are conscious, including those in post-traumatic amnesia (PTA), should be assessed for common impairments including:

  • Motor impairments, such as weakness, altered tone, balance and incoordination

  • Possible missed injuries/fractures

  • Pain

  • Bulbar problems affecting speech and swallowing

  • Sensory dysfunctions that may impact on safety including hearing loss, numbness, visual problems (including reduced acuity, visual field loss, gaze palsies)

  • Reduced control over bowels and bladder

  • Cognitive dysfunctions such as impairments in attention, orientation and memory

  • Behavioural dysregulations including potential emotional/behavioural issues

(Adapted from INCOG, Assess 1, p. 296)

H 1.2 C

The initial management of individuals with traumatic brain injury should be guided by clinical assessments and protocols based on the Glasgow Coma Scale (GCS) score.

(Adapted from ABIKUS 2007, G6, p. 16)

H 1.3 P B

Assessment should include seeking information from family and individuals who may be caring for the person following the traumatic brain injury.

(Adapted from INCOG, Assess 5, p. 297)

H 1.4 C

All individuals with traumatic brain injury who have emerged from post-traumatic amnesia / post-traumatic delirium (PTA/PTD) should have their cognitive function evaluated by a:

  • Neuropsychologist: to conduct a formal cognitive assessment using validated neuropsychological tests including measures of effort, emotional status and behavioural problems

  • Occupational therapist: to assess the impact of cognitive impairments on performance of meaningful activities and participation

  • Speech-language pathologist: to assess the impact of cognitive impairments on communication (listening, speaking, reading, and writing)

Assessment should be collaborative, and all professionals involved should aim to integrate their assessment findings, and avoid overtesting or duplicating tests with each other.

(Adapted from INCOG 2014, Assess 10, p. 298)

H 1.5 P C

After emerging from post-traumatic amnesia / post-traumatic delirium (PTA/PTD), all individuals with traumatic brain injury should be assessed for the presence of cognitive impairments in the following areas:

  • Attention (including speed of processing)

  • Visuospatial function

  • Executive function

  • Language, social communication

  • Social cognition

  • Learning and memory

  • Awareness of impairments

  • Detection/expression of emotion

This assessment may be either standardized or non-standardized depending on a number of factors, such as apparent rate of recovery and need of data for future planning. A formal standardized evaluation should be completed before initiating a cognitive rehabilitation program.

(Adapted from INCOG 2014, Assess 3, p. 296)

H 1.6 C

At the end of an assessment, the person with traumatic brain injury and the primary caregiver should be informed and have a discussion of his/her diagnosis, his/her prognosis, the recovery process and the treatments that are available.

(INESSS-ONF, 2015)

H 1.7 C

Depending on the mechanism of injury, individuals with other injuries, such as spinal cord injury or severe musculoskeletal injuries, should be screened by healthcare professionals for evidence of traumatic brain injury.

(INESSS-ONF, 2015)


- Sharma et al. (2014)
- Bradbury et al. (2008)

H 1.8 C

Individuals with comorbidities, such as spinal cord injury or severe musculoskeletal injuries, should have timely access to interdisciplinary traumatic brain injury (TBI) services. TBI services should be concurrent with other therapies or should immediately follow former therapies.

(INESSS-ONF, 2015)

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