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RehabMeasures Instrument

Glasgow Outcome Scale - Extended

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Purpose

The GOS-E classifies global outcomes in TBI survivors. It is primarily intended to describe outcome in groups of cases for research purposes. The utility for individual assessment is limited.

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Instrument Details

Acronym GOS-E

Area of Assessment

Communication
Activities of Daily Living
Life Participation
Social Relationships
Occupational Performance

Assessment Type

Performance Measure

Cost

Free

Diagnosis/Conditions

  • Brain Injury

Key Descriptions

  • 8 levels are in the scale:
    A) Minimum Score = 1
    B) Maximum Score = 8
  • Level 1 = Dead
  • Level 2 = Vegetative State:
    Condition of unawareness with only reflex responses but with periods of spontaneous eye opening.
  • Level 3 = Low Severe Disability; Level 4 = Upper Severe Disability:
    Patient who is dependent for daily support for mental or physical disability, usually a combination of both. If the patient can be left alone for more than 8 hours at home, it is upper level of SD. If patient cannot be left at home for more than 8 hours at home, it is lower level of SD.
  • Level 5 = Low Moderate Disability; Level 6 = Upper Moderate Disability:
    Patients have some disability such as aphasia, hemiparesis or epilepsy and/or deficits of memory or personality but are able to look after themselves. They are independent at home but dependent outside. If they are able to return to work even with special arrangement, it is upper level of MD. If they are not able to return to work, then it is lower level MD.
  • Level 7 = Low Good Recovery; Level 8 = Upper Good Recovery:
    Resumption of normal life within the capacity to work even if pre-injury status has not been achieved. Some patients have minor neurological or psychological deficits. If these deficits are not disabling, then it is upper level GR. If these deficits are disabling, then it is lower level GR.
  • Specific questions to determine upper or lower levels of disability are dictated by the structured interview.

Number of Items

19

Time to Administer

15 minutes

Required Training

No Training

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.

Updated by Bridget Hahn, OTD, OTR/L, Sam Souza, OTS; Morgan Haak, OTS; Jamie Heiney, OTS; Rush University in 2019

Body Part

Head

ICF Domain

Body Structure
Body Function
Activity
Participation

Measurement Domain

Cognition

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

NR

NR

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

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

 

Common Data Elements

Classification and Disease (Adult, unless otherwise specified)

Date Retrieved

Core: Traumatic Brain Injury (TBI)

Supplemental: Stroke and Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)

1/20/2020

Considerations

According to recommendations (Teasdale et al., 1998) the GOS-E should not be done too early in a person’s recovery because the degree of resumption of normal life cannot be assessed at this stage. 

Studies support the improved validity of the GOS-E when using the structured interview questions. 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Brain Injury

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Normative Data

Traumatic Brain Injury (Wilson, et al. 2000; n= 135; 36.74 (13.9) years (range 16-69 years old); admissions to regional neurosurgical unit with TBI, mean time post injury= 7.39 months (range 5-10 months post injury) ): assessed 5-10 months post injury and compared to the amount of time in PTA following injury. 

GOS-E 

<1 hour PTA 

1-24 hr PTA 

1-7 days 

> 7 days 

TOTAL 

GR UPPER 

18 

GR LOWER 

16 

34 

MD UPPER 

11 

10 

24 

MD LOWER 

11 

20 

SD UPPER 

   

13 

SD LOWER 

   

20 

26 

TOTAL 

13 

15 

46 

61 

135 

 

Test/Retest Reliability

Brain Injury (Wilson, et al. 2002; n=141, mean age of 44.8 (19.1) years, administered either two postal surveys or phone vs. mail) 

Mean interval between completion of first questionnaire and second questionnaire = 14.4 (8.8) days; mean interval between phone and mail survey 6.4 (5.0 days). 

  • Excellent test-retest reliability for postal surveys (weighted kappa coefficient = .98) 
  • Excellent test-retest reliability for phone vs. mail survey (K=.92) 

 

Brain Injury: (Pettigrew, et al. 2003; n=30 ; mean age=36.77 (12.11) years old, (range from 19-68 years old); mean time post injury= 214 days (range from 168- 270 days) ) 

  • Compared in-person versus telephone interview using the GOS-E 
  • Excellent test-retest reliability (weighted kappa coefficient = .92)

Mild to Moderate TBI (Hong, 2016; (n = 89); Mean Age = 38.7 (16.0); mean 2.7 years post TBI (5.2); mild-moderate TBI)

  • Excellent test-retest reliability: ( ICC = 0.92)

Interrater/Intrarater Reliability

Brain Injury (participants from 32 trauma centers): (Lu, et al. 2010; tested three methods to improve agreement of ratings on 6 pre- and post-injury narratives completed by medical staff.) 

  • Good to excellent interrater reliability (weighted kappa coefficient = .70-.95) improved by a method that encouraged the rating of the 5 level Glasgow Outcome Scale first, prior to determining GOS-E level, with central monitoring 

 

Brain Injury: (Mean age 39 (16) years, range 16-76) comparing psychologist and nurse, one in person and one by phone (Pettigrew, et al. 2003) 

  • Excellent Interrater reliability (weighted kappa coefficient = .84-.92) 
  • Minor Injury (weighted kappa coefficient = .89) and Severe Injury (weighted kappa coefficient = .92) 

 

Brain Injury : (Wilson, et al. 1998; n= 50; mean age = 39.4 (range 18-76 years old); post injury mean= 10.2 months(range 5-17 months post injury) ) 

  • Excellent inter rater reliability (weighted kappa coefficient = .85)

 

Mild to Moderate TBI (Hong, 2016)

  • Excellent interrater reliability: (Kappa =0.84) 
  • Instrument demonstrated low person reliability (0.63)

Internal Consistency

Mild to Moderate TBI (Hong, 2016)

  • Adequate Cronbach’s Alpha (a= 0.80)

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Evaluating whether the GOS-E is a better predictor of Neuropsychological Outcome Measures than the GOS- 3 months post injury

 

Mild to moderate Traumatic Brain Injury: (Levin, et al., 2001; n= 43; mean age= 34.3 (14.1) years; evaluated at 1 month post injury and followed at 3 months post injury; n=44, mean age 36.9 years, patients with general trauma) 

  • GOSE demonstrated stronger relationships with measures of functional outcome, affect and neuropsychological function, with greater sensitivity than GOS. However, scores for GOSE were not significantly different in the general trauma group than for those with mild to moderate TBI.

Construct Validity

Brain Injury (ages 16-69): (Wilson, et al., 2000) 

  • Excellent correlation with the DRS (r=-.89) and 
  • Excellent correlation with the Beck Depression (r=-.64) 
  • Adequate correlation with the length of PTA (r=-.52) and 
  • Adequate correlation with the Barthel Index (r=.46) and 
  • Adequate correlation with self-rated subscales of the NFI (r = ranges from .37-.63) 
  • Adequate to excellent correlation with subscales of the SF-36 (r= ranges from .47-.71) 
  • Adequate to excellent correlation with the subscales of the NFI-rated by relative/friend (r= ranges from .47-.69)

Construct Validity:

Moderate to Severe TBI (Dikmen et al., 2019; (n = 533); Mean Age = 36.25 (16.4); (mean 3,6 months post TBI; moderate-severe TBI)

  • Spearman’s correlation is -0.88 at three months post-injury

Floor/Ceiling Effects

Traumatic Brain Injury: (Hall, et al. 2001; n= 48; mean age= 37 years; mean time post injury= not documented, ranged from 2-9 years post injury) 

  • Ceiling Effect: 69% for GOS, supporting the need for the more detailed GOS-E measure

Mild to Moderate TBI (Hong, 2016)

  • authors interpretation: no quantitative information provided
    • Adequate slight ceiling effect (4.5%)
    • Excellent No floor effect

Responsiveness

Moderate to Severe TBI (Dikmen et al., 2019)

  • p^a < 0.001 paired Wilcoxon signed rank test comparing change from 3 to 6 months post-injury on the FSE.
  • p^b < 0.001 paired Wilcoxon signed rank test comparing change from 3 to 6 months post-injury on the GOSE.
  • p^c < 0.001 paired Wilcoxon signed rank test comparing whether there is more change on one measure compared with another.

 

Mean change 3-6 months post injury:

  • FSE 1.97^a
  • GOSE -0.42^b

Pediatric Disorders

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Criterion Validity (Predictive/Concurrent)

Predictive validity:

Mild to severe non-penetrating TBI (Beer, 2012; (n = 159); (mean 80.9 months (56.9 months SD); 3 and 6 months after injury; mild to severe non-penetrating TBI)

  • Excellent: GOS and VABS rs = - 0.687 ( p < 0.001);

 

Concurrent validity:

Mild to severe non-penetrating TBI (Beer, 2012, pg. 11)

  • Excellent-Poor: See table

Correlationa of GOS and GOS-E Peds at 3 Months with Outcome Measures at 6 Months

 

GOS (3 Months)


 

GOS-E Peds (3 Months)


 

Instruments (6 Months)

rs

95% CI

rs

95% CI

Vineland Scales of Adaptive Behavior

 Communication SS

−0.481*

−0.61, −0.28

−0.616*

−0.71, −0.43

 Daily Living Skills SS

−0.451*

−0.59, −0.25

−0.540*

−0.65, −0.34

 Socialization SS

−0.468*

−0.60, −0.27

−0.598*

−0.70, −0.42

 Motor Skills SS

−0.660*

−0.79, −0.38

−0.784*

−0.87, −0.58

 Adaptive Behavior Composite SS

−0.546*

−0.67, −0.37

−0.687*

−0.77, −0.53

Bayley Scales of Infant Development-2 (ages <2.5 years)

 Mental Development Index

−0.646*

−0.87, −0.51

−0.701*

−0.86, −0.47

 Psychomotor Development Index

−0.727*

−0.85, −0.46

−0.740*

−0.87, −0.51

Stanford-Binet Intelligence Scale-IV (ages ≥2.5 years)

 Stanford-Binet Composite Score

−0.523*

−0.65, −0.27

−0.635*

−0.74, −0.43

Conners' Parent Rating Scale

 Conduct Problem T

0.098

−0.14, 0.35

0.137

−0.09, 0.39

 Learning Problem T

0.390*

0.15, 0.59

0.459*

0.26, 0.65

 Psychosomatic T

0.047

−0.16, 0.33

0.059

−0.14, 0.35

 Impulsive Hyperactive T

0.215

−0.01, 0.47

0.320

0.11, 0.55

 Anxiety T

0.007

−0.26, 0.24

−0.009

−0.29, 0.20

 Hyperactive Index T

0.274

0.05, 0.52

0.361

0.17, 0.59

CVLT-C

Short Delay Free Recall (SDFR)

−0.449*

−0.64, −0.19

−0.421*

−0.62, −0.16

Long Delay Free Recall (LDFR)

−0.414*

−0.57, −0.09

−0.406*

−0.56, −0.07

WISC-III Processing Speed Index

−0.537*

−0.74, −0.35

−0.639*

−0.78, −0.42

aCorrelation by Spearman's rho (rs).

*p<0.001; p<0.01; p<0.05.

GOS, Glasgow Outcome Scale; GOS-E Peds, Glasgow Outcome Scale-Extended Pediatric; CVLT-C, California Verbal Learning Test-Child; WISC-III, Wechsler Intelligence Scale for Children, 3rd Edition; SS, Standard Score; T, T score.

.

 

Construct Validity

Discriminant validity:

Mild to severe non-penetrating TBI (Beer, 2012)

  • Moderate-Weak: premorbid VABS Adaptive Behavior Composite r= .47; CPRS scores r= .001

Bibliography

Beers, S. R., Wisniewski, S. R., Garcia-Filion, P., Tian, Y., Hahner, T., Berger, R. P., … Adelson, P. D. (2012). Validity of a pediatric version of the Glasgow Outcome Scale-Extended. Journal of neurotrauma, 29(6), 1126–1139. doi:10.1089/neu.2011.2272 Find on PubMed

Dikmen, S., Machamer, J., Manley, G. T., Yuh, E. L., Nelson, L. D., Temkin, N. R., . . . Zafonte, R. (2019). Functional Status Examination versus Glasgow Outcome Scale Extended as Outcome Measures in Traumatic Brain Injuries: How Do They Compare? Journal of Neurotrauma. doi:10.1089/neu.2018.6198 Link on PubMed

Hall, K. M., Bushnik, T., et al. (2001). "Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals." Arch Phys Med Rehabil 82(3): 367-374. Find it on PubMed

Hong, I., Li, C., & Velozo, C. A. (2016). Item-Level Psychometrics of the Glasgow Outcome Scale. OTJR: Occupation, Participation and Health, 36(2), 65-73. doi:10.1177/1539449216632449 Link on PubMed

Jennett, B., & Bond, M. (1975). Assessment of outcome after severe brain damage. The Lancet, 1, 480-484. doi:10.1016/ S0140-6736(75)92830-5

Levin, H. S., Boake, C., et al. (2001). "Validity and sensitivity to change of the extended Glasgow Outcome Scale in mild to moderate traumatic brain injury." J Neurotrauma 18(6): 575-584. Find it on PubMed

Lu, J., Marmarou, A., et al. (2010). "A method for reducing misclassification in the extended Glasgow Outcome Score." J Neurotrauma 27(5): 843-852. Find it on PubMed

Nichol, A. D., Higgins, A. M., et al. (2011). "Measuring functional and quality of life outcomes following major head injury: common scales and checklists." Injury 42(3): 281-287. Find it on PubMed

Pettigrew, L. E., Wilson, J. T., et al. (2003). "Reliability of ratings on the Glasgow Outcome Scales from in-person and telephone structured interviews." J Head Trauma Rehabil 18(3): 252-258. Find it on PubMed

Teasdale, G. M., Pettigrew, L. E., et al. (1998). "Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow Outcome Scale." J Neurotrauma 15(8): 587-597. Find it on PubMed

Wilson, J. T., Edwards, P., et al. (2002). "Reliability of postal questionnaires for the Glasgow Outcome Scale." J Neurotrauma 19(9): 999-1005. Find it on PubMed

Wilson, J. T., Pettigrew, L. E., et al. (1998). "Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use." J Neurotrauma 15(8): 573-585. Find it on PubMed

Wilson, J. T., Pettigrew, L. E., et al. (2000). "Emotional and cognitive consequences of head injury in relation to the glasgow outcome scale." J Neurol Neurosurg Psychiatry 69(2): 204-209. Find it on PubMed

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