Disability Rating Scale

The Disability Rating Scale (DRS) was developed as a way to track a traumatic brain injury (TBI) patient from ‘Coma to Community’. The scale was used to rate the effects of injury and decide how long recovery might take. The rating gives insight into the cognitive impairment of the individual who suffered from the TBI.^[1]

The idea of the DRS is similar to the Glasgow Outcome Scale (GOS). However, the point of the scale is to track the patient’s progress over time^[2] while the GOS is used to simply determine the extent of a brain injury.^[3] In many ways, the DRS addresses many of the shortcomings of the GOS.^[4]

Training is not required to be able to administer the DRS. However, there is an optional video and powerpoint presentation. The test itself takes anywhere from 1 minute to 30 minutes to administer. It can be self-administered or done through an interview.^[5]

History

M. Rappaport introduced the DRS in 1982 to overcome the poor precision of the Glasgow Outcome Scale.^[6] It was initially developed to assess individuals with TBI in the rehabilitation phase of recovery.^[2] Upon development it was tested with older juvenile and adult individuals who had suffered from severe TBI. All tests were performed in an inpatient rehabilitation setting. The intent of the scale was to measure the general functional changes of the patient throughout the course of recovery.^[5]

Uses and Effectiveness

The Disability Rating Scale (DRS) is primarily used to assess impairment, disability, and handicap of an individual. An impairment rating is based on the Glascow Outcome Scale, such as "Eye Opening," "Communication Ability," and "Motor Response." Disability assesses the cognitive ability of the individual. Handicap assesses the individual’s ability to function within society.

Based on single assessments, the DRS is "used to predict ability to return to employment based on admission and discharge." ^[4] Eliason and Topp have had success in using the DRS for its predictive capabilities on hospital length of stay and discharge for patients with acute brain dysfunctions.^[7]

The DRS’s major advantage comes from its ability to track a patient’s rehabilitation progress. First, its flexibility and ease in assessing a patient makes progress tracking very accommodating. The assessor requires little training for accurate completion and approximately fifteen minutes to score. The patient can perform the assessment retrospectively or it can be done using medical history. Secondly, the scale allows effective tracking of progress.^[4] The scale is strongest and most sensitive in scaling general behavioral disability. The DRS becomes more accurate when used in tandem with the Functional Independence Measure (FIM), a more detailed measurement of functionality.

The DRS has a few disadvantages. Some sources claim the inter-rater reliability to be well established,^[2] while others report a high variability.^[4] Implementation also requires more specialized training by the rater. Because of its strength in general assessment, the DRS has difficulty in specific functional assessment and consequently has difficulty in assessing mild to severe functional impairment; this flaw can easily be overcome by following the assessment up with the FIM, which measures functionality in more detail.^[4]

Rating Scale

In Rappaport's Article, "Disability Rating Scale for Severe Head Trauma Patients: Coma to Community," he discussed each of the diagnostic criteria and how they would be represented on the scale. The following represents what was discussed in the article.^[8]

Arousability Awareness and Responsivity

• Eye Opening
  • 0 – Spontaneous
    • When the patient’s eyes open up with the sleep/wake rhythms indicating active arousal mechanisms. This does not assume that the patient is aware.
  • 1 – To Speech and/or Sensory Stimulation
    • When the eyes move in response to any verbal stimulation, whether the patient is spoken to or shouted at. This is not necessarily a command to open the eyes. Eyes can also open in response to a mild touch or pressure.
  • 2 – To Pain
    • When the eyes open as a result of the patient feeling pain.
  • 3 – None
    • When the eyes will not open for anything - even painful stimulus.
• Communication Ability
  • 0 – Oriented
    • This is when the patient is aware their surroundings. In this state, the patient can tell you basic facts about his/her location and other details of his/her life.
  • 1 – Confused
    • This is when the patient’s attention can be held and he/she can answer questions. When answering questions, the answers may be delayed and/or indicate a level of disorientation or confusion.
  • 2 – Inappropriate
    • The patient is able to talk with intelligible articulation but nothing meaningful is said. Patient’s speech is typically random or exclamatory. Having sustainable conversations with the patient is not possible.
  • 3 – Incomprehensible
    • Patient is able to make sounds such as groaning or moaning but is not able to make recognizable words. Conversations with the patient are impossible.
  • 4 – None
    • The patient displays no signs of communication or sounds whatsoever.
• Motor Response
  • 0 – Obeying
    • The patient obeys commands such as "move your fingers". This also includes other commands such as "blink your eyes" or "move your lips". Grasping, reflexes, and other complicated movements should not be used.
  • 1 – Localizing
    • When the patient moves his/her limb (even a little bit) to move away from painful stimulus occurring on more than one point on that limb. There must be a deliberate motor act to move away from, or remove, the source of stimulation. This is very similar to withdrawing.
  • 2 – Withdrawing
    • When the patient moves away from a stimulus and exhibits more than a reflex response.
  • 3 – Flexing
    • When the patient flexes at the elbow and attempts to withdraw in a result of feeling a painful stimulus.
  • 4 – Extending
    • When the patient extends his/her limb after feeling a painful stimulus.
  • 5 – None
    • When the patient exhibits no response to stimulus whatsoever.

Cognitive Ability for Self Care Activities

• Feeding
  • 0 – Complete
    • When the patient continuously shows awareness about how to feed and the patient can convey the information that be/she knows when feeding should occur.
  • 1 – Partial
    • When the patient can sometimes show awareness that he/she knows how to feed and/or convey information that he/she knows when feeding should occur.
  • 2 – Minimal
    • When the patient rarely shows awareness about how to feed and/or rarely shows that he/she knows when this is to occur. The patient can communicate desire to feed with certain signs, sounds, or activities.
  • 3 – None
    • Shows no awareness of how to feed or when to feed. The patient cannot convey any information by signs, sounds, or activity.
• Toileting
  • 0 – Complete
    • When the patient continuously shows awareness that he/she knows how to use the toilet and convey information that he/she knows when this should occur.
  • 1 – Partial
    • When the patient can sometimes show awareness that he/she knows how to use the toilet and/or can convey information that he/she knows when the act should occur.
  • 2 – Minimal
    • When the patient rarely shows awareness that he/she knows how to use the toilet and/or rarely show that he/she knows when this is to occur.
  • 3 – None
    • Shows no awareness of how to use the toilet or when he/she should go. The patient cannot convey any information by signs, sounds, or activity.
• Grooming
  • 0 – Complete
    • When the patient continuously shows awareness that he/she knows how and when to groom.
  • 1 – Partial
    • When the patient can sometimes show awareness that he/she knows how to groom and/or convey information that he/she knows when grooming should occur.
  • 2 – Minimal
    • When the patient rarely shows awareness about how to groom and/or rarely shows that he/she knows when this is to occur based on certain signs, sounds, or activities
  • 3 – None
    • Shows no awareness of how to groom or when to groom. The patient cannot convey any information by signs, sounds, or activity.

Dependence on Others

• Level of Functioning
  • 0 – Completely Independent
    • The patient is able to live as he/she wishes without any restrictions regarding physical, mental, emotional, or social situations.
  • 1 – Independent in Special Environment
    • The patient is capable of living as he/she wishes, as long as certain requirements are met (such as mechanical aids).
  • 2 – Mildly Dependent
    • The patient is able to care for most of her/his own needs but s/he needs a little help due to physical, mental, emotional, or social problems.
  • 3 – Moderately Dependent
    • The patient can partially take care of himself/herself. In some cases, the patient may need another person there at times.
  • 4 – Markedly Dependent
    • The patient needs help with all major activities and the help of another person at all times.
  • 5 – Totally Dependent
    • The patient is not able to care for anything by himself/herself and requires 24-hour nursing care.

Psychosocial Adaptability

• Employability
  • 0 – Not Restricted
    • The patient can compete with others in a large variety of jobs that incorporate existing skills. The patient can also initiate, plan, execute, and assume responsibilities associated with homemaking. In addition he/she can also carry out and complete most age relevant school assignments.
  • 1 – Selective Jobs, Competitive
    • The patient can compete with others in a limited variety of jobs that incorporate existing skills because of some type of limitations. He/she can also initiate, plan, execute, and assume responsibilities of some homemaking tasks. It is also possible for her/him to carry out and complete some, but not all age relevant school assignments.
  • 2 – Sheltered Workshop, Non-Competitive
    • The patient cannot compete with others in any variety of jobs that incorporate existing skills because of moderate or severe limitation. He/she cannot, without major assistance, initiate, plan, execute, and assume responsibilities associated with homemaking. In addition, the patient cannot carry out and complete age relevant school assignments without assistance.
  • 3 – Not Employable
    • The patient is completely unemployable because of extreme limitations. He/she is completely unable to initiate, plan, execute, and assume responsibilities associated with homemaking. In addition, the patient cannot carry out and complete any age relevant school assignments.

• Score 0 - Normal
• Score 1 - Mild
• Score 2 to 3.5 – Partial
• Score 4 to 6 – Moderate
• Score 7 to 11 – Moderately Severe
• Score 12 to 16 – Severe
• Score 17 to 21 – Extremely Severe
• Score 22 to 24 – Vegetative State
• Score 25 to 29 – Extreme Vegetative State (or, if the person has a score of 29, possible death)

Notes

1. Rappaport, et al. (1982) 119
2. Nichol, et al. (2011), 283
3. Nichol, et al (2011), 282
4. Shulka, Devi, & Agrawal (2010), 438
5. Wright (2000)
6. Rappaport, et al. (1982), 119
7. Eliason & Topp (1984), 1357
8. Rappaport, et al. (1982) 118-123

References

• Eliason & Topp (1984) Predictive Validity of Rappaport's Disability Rating Scale in Subjects with Acute Brain Dysfunction. Journal of the American Physical Therapy Association,64:1357-1360
• Nichol, et al. (2011) Measuring Functional and Quality of Life Outcomes Following Major Head Injury: Common Scales and Checklists. Injury, Int J. 42:281-287
• Rappaport, et al. (1982) Disability Rating Scale for Severe Head Trauma Patients: Coma to Community. Archives of Physical Medicine and Rehabilitation, 63:118-123.
• Shulka, Devi, & Agrawal (2011) Outcome Measures for Traumatic Brain Injury. Clinical Neurology and Neurosurgery, 113:435-441
• Wright (2000) The Disability Rating Scale. The Center for Outcome Measurement in Brain Injury. http://www.tbims.org/cmbi/drs.