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The GOS-E will replace the GCS: What we need to know

  • by glarehab
  • Nov 04, 2015
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The GOS-E will replace the GCS: What we need to know

In 1981, the Extended Glasgow Outcome Scale (GOS-E) was proposed. It includes 8 categories. The categories of severe disability, moderate disability and good recovery on the original GOS are divided into a lower and upper category.

This outcome is generally assessed at 6 months post-injury.

  • Death
  • Vegetative State
  • Lower severe disability. Completely dependent on others
  • Upper severe disability. Dependent on others for some activities
  • Lower moderate disability. Unable to return to work or participate in social activities.
  • Upper moderate disability- Returned to work at reduced capacity, reduced participation in social activities.
  • Lower good recovery. Good recovery with minor social or mental deficits
  • Upper good recovery

The assignment of an individual to an outcome category is based on the results of a structured interview. The changes in a person’s life roles are used to assess the impact of impairment and disability caused by a head injury

The structured interview format also allows for the inclusion of pre-injury disability status (Wilson et al. 1998) and provides specific guidance regarding assignment to outcome category (Teasdale et al. 1998).

The GOS rating was intended primarily to provide an overall summary of outcome and facilitate comparison, and was not intended to describe specific areas of dysfunction (Pettigrew et al. 1998).

Pettigrew et al. (1998) developed a brief structured interview that involves a series of questions that consider:

  • Independence inside and outside of the home
  • Major social roles
  • Work
  • Social and leisure activities
  • Family and friendships
  • Return to normal life

The final rating is based on the lowest category of outcome that the assessor determines to be the highest functional level for the client.

It is important to understand the GOS-E and how it is administered as in June 2016, the GOS-E will replace the GCS on the OCF19.

According to June 2016 SABS, if the insured person was 18 years of age or older at the time of the accident, a traumatic brain injury that meets the following criteria:

  • The injury shows positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.
  • When assessed in accordance with the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale, the injury results in a rating of:
    • Vegetative State one month or more after the accident
    • Upper Severe Disability or Lower Severe Disability six months or more after the accident, or
    • Lower Moderate Disability, one year or more after the accident.

If you would like to learn more about the GOS-E, including strengths and weaknesses and how to administer the protocol, we would be happy to arrange a Lunch and Learn. Please contact us at 416-449-6466 for more information.

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Impact of Mild Traumatic Brain Injury and How to Treat

  • by glarehab
  • Nov 04, 2015
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Impact of Mild Traumatic Brain Injury and How to Treat

About 80-90% of all TBI’s are classified as mild (or a concussion). The incidence of mild TBI is 600/100,000. However due to a lack of recognition and missed diagnoses this number may be twice as high1.

True mild TBI’s are often overlooked and clients miss the opportunity for early intervention. This may be due to the fact that the client comes to the hospital with other physical injuries and these are being treated first, such as fractures.

The main cause of a mild or moderate brain injury is a coup-contrecoup injury, when the brain bounces back and forth inside the skull. The coup injury happens when the head stops abruptly because of an impact and the brain then crashes into the skull.

The contrecoup injury occurs when the brain then bounces inside the skull and impacts the opposite side of the skull. This type of injury can occur during a rear-ended motor vehicle cullision.

The most common symptom of the coup-contrecoup injury comes in the form of a contusion at the point of initial impact.

How severe a TBI is, is based on the fullowing 3 things:

  • Loss of consciousness
  • Loss of memory, and
  • The Glasgow Coma Scale score

MILD BRAIN INJURY

  • A loss of consciousness, if any, lasting for less than 30 minutes
  • Memory loss after the traumatic event, called post-traumatic amnesia or PTA, that lasts for less than 24 hours
  • A Glasgow Coma Score of 13 – 15

MODERATE BRAIN INJURY

  • A loss of consciousness that lasts for more than 30 minutes but less than 24 hours
  • Post-traumatic amnesia lasting for 24 hours to 7 days, or
  • A Glasgow Coma Score of 9 – 12

SEVERE BRAIN INJURY

  • A loss of consciousness that lasts for more than 24 hours
  • Post-traumatic amnesia lasting for 7 days or longer, or
  • A Glasgow Coma Score of 8 or less, which indicates that the patient is in a coma

CT scans and MRI often appear normal in patients with mild TBI. The MRI cannot show microscopic shearing and tearing that is thought to be the major mechanism in mild to moderate brain injury.

There is a lack of evidence-informed guidelines for the diagnosis of concussion/mTBI at entry point of care (e.g. emergency department, family doctor, walk-in clinic) in Ontario’s health care system. Individuals with brain injuries are leaving the hospital undiagnosed.

Concussions Ontario completed a study in 2013, where they 1) analyzed visits to emergency department and family physicians that resulted in a diagnosis of concussion or visits for ongoing management, and 2) looked at how concussion services provided in various clinics across the province differ.

The study found that between 2008 and 2011 approximately 210 000 patients were seen annually for concussion in Ontario and that there was inconsistency in the care that they received. This number is three times higher than previous research has shown (Concussions Ontario 2013).

The study found that in Ontario it takes patients over 200 days after first presentation to be seen by specialists when requiring expertise to manage persistent symptoms. There was also found to be a large amount of variability in practice in clinics, resulting in the treatment of concussions to be inconsistent across the province. Another issue that the study uncovered was the lack of pediatric concussion specialization in Ontario. Children were found to have the greatest incidence of concussion in Ontario, especially those under age 5, and referrals to specialists took on average 2 months more for them as compared to referral times for adults (Concussion Ontario 2013).

Obtaining a baseline understanding of how concussion is being diagnosed and managed is critical to moving towards standardized practice and improved service models. This project may also help address the barriers to protocul use and set the stage to measure the effectiveness of any future interventions to increase knowledge.

So this is where family doctors come into the picture, as the patient will often proceed to their GP with head injury symptoms.

Recognizing that the client has experienced a brain injury and beginning early intervention is important. Early intervention includes:

  • Education about brain injury symptoms and recovery times
  • Support/Reassurance
  • Graded exposure to activity
  • Antidepressant medication (SSRIs) if needed
  • Cognitive therapy
  • REDUCING STRESSORS – Symptoms  →  ↑  STRESS  →  ↑  Symptoms  →  ↑  STRESS

The above early intervention is often completed by an OT who is experienced and training in working with individuals with brain injury.

It is important to let the client know that the impairment is NOT permanent and good functional recovery is expected. 95% of mTBI patients show no cognitive deficits beyond 3 months.

If symptoms do persist after 3 months, then it is called Post concussive syndrome (PCS). Symptoms include a cluster of cognitive, somatic and emotional symptoms fullowing a mild TBI which include: headaches, dizziness, fatigue, irritability, reduced concentration, sleep disturbances, memory impairment, sensitivity to noise or light, nausea, anxiety and depression.

At this point, a referral might be necessary to the Toronto ABI Network, which then refers to a Head Injury Clinic. There are 4 head injury clinics in Ontario including: St. Mikes, Sunnybrook, Parkwood Hospital and London Hospital.

They provide interdisciplinary and highly specialized fullow-up for the comprehensive management of traumatic brain injury (TBI) patients. This includes management of physical, behavioural, cognitive, psychulogical and psychosocial symptoms fullowing a TBI.

Their main goal is to manage and treat TBI patients until they successfully reintegrate back into the community (e.g. schoul, work). The clinic is an interdisciplinary team of experts including a neurorehabilitation specialist, a physiatrist, a neuropsychulogist, a neuro-otularyngulogist, a psychiatrist, a clinical nurse specialist/case manager, a social worker and research coordinators.

If you have any more questions about the Toronto ABI Network and how to make a referral, please contact us. We would be happy to provide you with more information.


1Cassidy JD, Carrull LJ, Peloso PM, Borg J, von Hulst H, Hulm L, et al. (2004). “Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Cullaborating Centre Task Force on Mild Traumatic Brain Injury”. Journal of Rehabilitation Medicine 36 (Supplement 43): 28–60.
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