Wright, Santa Clara Valley Medical Center at
Citation Wright, J. (2000). The
Disability Rating Scale. The Center for Outcome Measurement
in Brain Injury. http://www.tbims.org/
combi/drs ( accessed
This citation is for the COMBI web material. Mr. Wright is
not the scale author for the DRS.
eyes open with sleep/wake rhythms indicating active and arousal
mechanisms; does not assume awareness.
SPEECH AND/OR SENSORY STIMULATION: a response to any verbal
approach, whether spoken or shouted, not necessarily the command
to open the eyes. Also, response to touch, mild pressure.
PAIN: tested by a painful stimulus.( Standard painful stimulus
is the application of pressure across index fingernail of
best side with wood or a pencil; for quadriplegics pinch nose
tip and rate as 0, 1, 2 or 5.)
no eye opening even to painful stimulation.
communication ability (if patient cannot use voice because of
tracheostomy or is aphasic or dysarthric or has vocal cord paralysis
or voice dysfunction then estimate patient's best response and enter
note under comments.)
implies awareness of self and the environment. Patient able
to tell you a) who he is; b) where he is; c) why he is there;
d) year; e) season; f) month; g) day; h) time of day.
attention can be held and patient responds to questions but
responses are delayed and/or indicate varying degrees of disorientation
intelligible articulation but speech is used only in an exclamatory
or random way (such as shouting and swearing); no sustained
communication exchange is possible.
moaning, groaning or sounds without recognizable words; no
consistent communication signs.
no sounds or communication signs from patient.
obeying command to move finger on best side. If no response
or not suitable try another command such as "move lips," "blink
eyes," etc. Do not include grasp or other reflex responses.
a painful stimulus at more than one site causes a limb to
move (even slightly) in an attempt to remove it. It is a deliberate
motor act to move away from or remove the source of noxious
stimulation. If there is doubt as to whether withdrawal or
localization has occurred after 3 or 4 painful stimulations,
rate as localization.
any generalized movement away from a noxious stimulus that
is more than a simple reflex response.
painful stimulation results in either flexion at the elbow,
rapid withdrawal with abduction of the shoulder or a slow
withdrawal with adduction of the shoulder. If there is confusion
between flexing and withdrawing, then use pin prick on hands,
painful stimulation results in extension of the limb.
no response can be elicited. Usually associated with hypotonia.
Exclude spinal transection as an explanation of lack of response;
be satisfied that an adequate stimulus has been applied.
ability for feeding, toileting and grooming.
each of the three functions separately. For each function answer
the question, does the patient show awareness of how and when to
perform each specified activity. Ignore motor disabilities that
interfere with carrying out a function, this is rated under Level
of Functioning described below. Rate best response for toileting
based on bowel and bladder behavior. Grooming refers to bathing,
washing, brushing of teeth, shaving, combing or brushing of hair
continuously shows awareness that he knows how to feed,
toilet or groom self and can convey unambiguous information
that he knows when this activity should occur.
intermittently shows awareness that he knows how to
feed, toilet or groom self and/or can intermittently convey
reasonably clearly information he knows when the activity
shows questionable or infrequent awareness that he knows
in a primitive way how to feed, toilet or groom self and/or
shows infrequently by certain signs, sounds or activities
that he is vaguely aware when the activity should occur.
shows virtually no awareness at any time that he knows
how to feed, toilet or groom self and cannot convey
information by signs, sounds, or activity that he knows when
the activity should occur.
INDEPENDENT: able to live as he wishes, requiring no restriction
due to physical, mental, emotional or social problems.
IN SPECIAL ENVIRONMENT: capable of functioning independently
when needed requirements are met (mechanical aids).
DEPENDENT: able to care for most of own needs but requires
limited assistance due to physical, cognitive and/or emotional
problems (e.g. needs non-resident helper).
DEPENDENT: able to care for self partially but needs another
person at all times.
DEPENDENT: needs help with all major activities and the assistance
of another person at all times.
DEPENDENT: not able to assist in own care and requires 24-hour
psychosocial adaptability or "employability" item takes into account
overall cognitive and physical ability to be an employee, homemaker
or student. This determination should take into account considerations
such as the following:
Able to understand, remember and follow instructions; 2. Can plan
and carry out tasks at least at the level of an office clerk or
in simple routine, repetitive industrial situations or can do school
assignments; 3. Ability to remain oriented, relevant and appropriate
in work and other psychosocial situations; 4. Ability to get to
and from work or shopping centers using private or public transportation
effectively; 5. Ability to deal with number concepts; 6. Ability
to make purchases and handle simple money exchange problems; 7.
Ability to keep track of time schedules and appointments.
RESTRICTED: can compete in the open market for a relatively
wide range of jobs commensurate with existing skills; or can
initiate, plan, execute and assume responsibilities associated
with homemaking; or can understand and carry out most age
relevant school assignments.
JOBS, COMPETITIVE: can compete in a limited job market for
a relatively narrow range of jobs because of limitations of
the type described above and/or because of some physical limitations;
or can initiate, plan, execute and assume many but not all
responsibilities associated with homemaking; or can understand
and carry out many but not all school assignments.
WORKSHOP, NON-COMPETITIVE: cannot compete successfully in
job market because of limitations described above and/or because
of moderate or severe physical limitations; or cannot without
major assistance initiate, plan, execute and assume responsibilities
for homemaking; or cannot understand and carry out even relatively
simple school assignments without assistance.
EMPLOYABLE: completely unemployable because of extreme psychosocial
limitations of the type described above; or completely unable
to initiate, plan, execute and assume any responsibilities
associated with homemaking; or cannot understand or carry
out any school assignments.
eight ratings to obtain total DRS score.
in doubt, give the patient the benefit of the doubt.
that feeding, toileting and grooming items are rated on cognitive
ability to know how and when, not physical ability.
the FIM+FAM, a rating of 5 (totally dependent) on level of functioning
means totally dependent.
use two independent raters when possible, and compare ratings after
of .5 ratings:
1994, the Traumatic Brain Injury Model Systems (TBIMS) National
Database adopted a 0.5 rating option for the last 5 items of the
DRS. Although raters found the half point discrimination useful,
no validation study was ever completed on the use of the 0.5 rating
option. In 2010, the TBIMS National Database members voted to omit
the 0.5 rating option. Use of the 0.5 rating option after April
1, 2010 is not recommended.