Although individualized assessments are useful, behaviorally-based assessment instruments (BBAIs), either alone or in conjunction with individualized assessments, are used routinely for minimally responsive TBI patients. BBAIs expand on the Glasgow Coma Scale by measuring the direction, if not the magnitude, of functional disability change. Before a BBAI is used, interrater reliability should be determined among the team members. Little is known about their precision.

     BBAIs are important in the rehabilitation of the minimally responsive TBI patient, because they:

• Provide a structured approach that permits and/or facilitates
  • Monitoring and documentation of neurological and cognitive recovery
  • Monitoring of the efficacy of pharmacologic, environmental, and behavioral interventions
  • Communication among the rehab team, and a framework for team conferences
  • Multicenter research

• Identify the patient's sensory, physical, and cognitive strengths, enabling maximization of communication and consistency of responses

• Identify the patient's weaknesses, enabling further intervention

• May prove able to help elucidate prognosis and/or serve as an early marker for neuromedical changes

BBAIs in current use include:

1. Western Neuro Sensory Stimulation Profile (WNSSP)
   • Recommended for patients who are slow to recover
   • Contains 33 items in 6 areas, for a total score of 1-113, based on responses to sensory stimulations, particularly auditory and visual comprehension, visual tracking, object manipulation, arousal/attention, and tactile/olfactory response
   • Higher total scores at admission have been reported for patients at Rancho Levels II - III who progress to Rancho Level V

2. Sensory Stimulation Assessment Measure (SSAM)
   • Expansion of the Glasgow Coma Scale motor response, vocalization, and eye opening to standardized sensory stimuli, with ratings of 1-6 in each of these 3 GCS areas, for a total score of 15-90
   • SSAM has been reported to:
     • Detect differences in performance between phases of directed and nondirected sensory stimulation in 6 minimally responsive patients
     • Be superior to the WNSSP in detecting daily fluctuations

3. Coma Recovery Scale (CRS)
   • Theorizes generalized - cognitively mediated responses, of 0 (no response) to 4 or 6, for 25 items in 6 areas: auditory, visual, motor, oromotor/verbal, communication, and arousal
   • Scores of 0-14 are considered "minimally responsive"; scores of 15-25 or high indicate "emergent awareness".
   • Correlation with outcomes have been documented as stronger for changes in CRS scores than for initial, one-time scores
   • Change as a % of total score has been documented as greater for the CRS than for the GCS (Glasgow Coma Scale) or DRS (Disability Rating Score)

4. Coma/Near Coma Scale (CNC)
   • Expansion of the upper range of the Disability Rating Scale (DRS) - i.e. "vegetative state" and "extreme vegetative state" - by scoring responses to stimulation for 8 items and grouping patients into 1 of 5 categories: no coma, near coma, moderate coma, marked coma, and extreme coma
   • Correlation with or prediction of future changes in the DRS by changes in the CNC scores has been documented