J Neurol (1995) 242 : 587-592

© Springer-Verlag 1995

N. S. King The Rivermead Post Concussion

S. Crawford
F. J. Wenden Symptoms Questionnaire:
N. E. G. Moss
D. T. Wade a measure of symptoms commonly
experienced after head injury
and its reliability

Abstract After head injuries, partic- an RPQ administered by an investi-

Received: 28 July 1994
Received in revised form:
16 December 1994
Accepted: 14 January 1995
N. S. King (N~) • S. Crawford
F. J. Wenden • N. E. G. Moss - D. T. Wade
Oxford Head Injury Service,
Rivermead Rehabilitation Centre,
Abingdon Road, Oxford OX 1 4XD, UK
ularly mild or moderate ones, a range
of post-concussion symptoms (PCS)
are often reported by patients. Such
symptoms may significantly affect
patients' psychosocial functioning.
To date, no measure of the severity
of PCS has been developed. This
study presents the Rivermead Post
Concussion Symptoms Question-
naire (RPQ) as such a measure, de-
rived from published material, and
investigates its reliability. The RPQ's
reliability was investigated under
two experimental conditions. Study 1
examined its test-retest reliability
when used as a self-report question-
naire at 7-10 days after injury. Forty-
one head-injured patients completed
an RPQ at 7-10 days following their
head injury and again approximately
24 h later. Study 2 examined the
questionnaire's inter-rater reliability
when used as a measure adminis-
tered by two separate investigators.
Forty-six head-injured patients had
gator at 6 months after injury. A
second investigator readministered
the questionnaire approximately 7
days later. Spearman rank correlation
coefficients were calculated for rat-
ings on the total symptom scores,
and for individual items. High re-
liability was found for the total PCS
scores under both experimental con-
ditions (R s = +0.91 in study 1 and
R s = +0.87 in study 2). Good reliabil-
ity was also found for individual
PCS items generally, although with
some variation between different
symptoms. The results are discussed
in relation to the major difficulties
involved when looking for appropri-
ate experimental criteria against
which measures of PCS can be vali-
dated.
Key words Head injury • Post-
concussion symptoms • Rivermead
Post Concussion Symptoms
Questionnaire

symptoms has been classified by the World Health Orga-

Introduction
Uncomplicated head injuries resulting in post-traumatic
amnesia (PTA) of less than 24 h are usually described as
being of minor, mild or moderate severity [17, 23]. Com-
monly reported problems after such injuries include:
headaches, dizziness, fatigue, irritability, reduced concen-
tration, sleep disturbance, memory dysfunction, anxiety,
sensitivity to noise, double or blurred vision, sensitivity to
light and depression [1, 3, 8, 10, 24]. This cluster of
nization as the post-concussion syndrome [28] and it has
been noted that "the presentation of the post-concussion
syndrome cluster of symptoms across samples of patients
with head injuries is remarkably consistent" [20]. There is
still controversy regarding the causes and development of
such symptoms [3, 15]. Neuropsychological, neurophysi-
ological, neuropathological and psychological factors
have all been reported as being important [2, 26]. Simi-
larly there is still a debate as to whether or not they form
a distinct syndrome [2, 15]. This study will refer to the
588
s y m p t o m cluster as p o s t - c o n c u s s i o n s y m p t o m s (PCS) and
the v a l i d i t y o f the m e a s u r e s will be discussed.
Patients with m i l d or m o d e r a t e h e a d injuries u s u a l l y
report the resolution o f m o s t o f their s y m p t o m s within 3
months o f their injury [1, 6, 9, 10]. P r o s p e c t i v e studies in-
dicate, however, that a significant m i n o r i t y still report
s o m e s y m p t o m s at 3 m o n t h s after injury [1, 9], and a
small m i n o r i t y at 12 months after injury [1, 26]. PCS m a y
significantly i m p e d e return to w o r k and p s y c h o s o c i a l
functioning [7, 8, 29].
C o n v e n t i o n a l m e a s u r e s o f the severity o f h e a d injury,
such as PTA, h a v e q u e s t i o n a b l e utility w h e n c o n s i d e r i n g
m i l d and m o d e r a t e l y severe h e a d injuries [29]. W r i g h t s o n
and G r o n w a l l [29] c o n c l u d e d that P T A h a d m a j o r limita-
tions in p r e d i c t i n g p s y c h o s o c i a l o u t c o m e in patients
w h e r e P T A was less than 1 - 2 days. Other studies have
d e m o n s t r a t e d that P T A has, at best, only w e a k correlation
with PCS. F o r e x a m p l e , R u t h e r f o r d [24] and M i d d e l b o e et
al. [ 18] reported no significant relationship, Jakobsen et al.
[13] reported an inverse relationship and Minderhoud et al.
[19] r e p o r t e d a p o s i t i v e correlation. Thus this study does
not aim to c o m p a r e PCS m e a s u r e s with c o n v e n t i o n a l
m e a s u r e s o f h e a d injury severity or to clarify the causes,
d e v e l o p m e n t and m a i n t a i n i n g factors of P C S , but rather to
investigate w h e t h e r PCS can be consistently rated and
therefore r e l i a b l y m e a s u r e d .
To date, m o s t studies have m e a s u r e d PCS solely b y us-
ing a checklist for patients to report the p r e s e n c e or ab-
sence o f s y m p t o m s [1, 11, 22, 25, 26]. S o m e have ob-
tained self-reports o f the absolute or relative increase in
s y m p t o m s f o l l o w i n g t r a u m a [3-5], also using a checklist.
Others h a v e u s e d n u m e r i c a l self-report ratings corre-
s p o n d i n g to the d e g r e e to w h i c h the PCS i m p i n g e on
e v e r y d a y life [9, 11 ].
S i m p l e checklists do not a i m to assess the degree to
w h i c h PCS m a y i m p i n g e on p s y c h o s o c i a l functioning.
This reduces their usefulness. T h e p u b l i s h e d self-report
m e a s u r e s have no data on their reliability. It is therefore
unclear w h e t h e r they have the potential to be v a l i d m e a -
sures o f PCS.
This study presents the R i v e r m e a d Post C o n c u s s i o n
S y m p t o m s Q u e s t i o n n a i r e (RPQ; A p p e n d i x 1), d e v i s e d to
g a u g e the severity o f PCS. T h e patient is asked to rate the
d e g r e e to w h i c h 16 P C S are m o r e o f a p r o b l e m c o m p a r e d
with p r e m o r b i d levels, using values f r o m 0 to 4. This aims
to o v e r c o m e the difficulties inherent in the finding that
p o s t - c o n c u s s i o n - t y p e s y m p t o m s are r e p o r t e d b y a signifi-
cant m i n o r i t y o f p e o p l e w h o have h a d no h e a d injury
w h a t s o e v e r [7, 16]. T h e s y m p t o m s listed on the R P Q are
those m o s t c o m m o n l y r e p o r t e d in the p u b l i s h e d literature
as PCS. This report assesses the R P Q ' s reliability in two
ways. T h e first study i n v e s t i g a t e d the R P Q ' s test-retest re-
liability w h e n u s e d as a self-report questionnaire adminis-
tered b y patients themselves. T h e s e c o n d study investi-
g a t e d its inter-rater reliability w h e n used as a question-
naire a d m i n i s t e r e d b y two different clinicians. T h e spe-
cific s y m p t o m s e x p e r i e n c e d often v a r y o v e r time in the
s a m e i n d i v i d u a l [15, 24], and b e t w e e n individuals, so this
study concentrates u p o n the total score.
Subjects and methods
Two studies were undertaken. In the first study, the subjects con-
sisted of 41 adults (22 males and 19 females) with a mean age of
31 years (SD 14.3; range 16-64). They were consecutive consent-
ing patients registered with the Oxford Head Injury Service (OX-
HIS) and randomly assigned to be seen by one investigator (N.K.).
The subjects had a median PTA of 1 h (range 0-18 ). The causes
of head injury were heterogeneous: 17 road traffic accidents,
6 falls, 5 horse-riding accidents, 4 assaults, 3 sports accidents and
6 others.
Subjects received a letter of introduction to the OXHIS ap-
proximately 7 days after injury. The letter invited them to com-
plete an enclosed RPQ as soon as they had read it and informed
them that they would be contacted in the near future to be seen as
part of the OXHIS follow-up service. Subjects were then seen in
their homes by the investigator at approximately 8 days after in-
jury. They were given another RPQ to complete at the beginning
of the visit. A brief structured interview was then conducted to es-
tablish basic epidemiological information, including the length of
PTA and the cause of the head injury. Subjects who had not com-
pleted the questionnaire on receipt of the introduction letter or had
received the letter on the same day as being visited, were invited to
complete the second RPQ 24 h afterwards and return it by post.
Thus all subjects completed the RPQ on two separate occasions
(once alone and once when the investigator was present), rating
their symptoms over the previous 24 h.
In the second study the subjects were 46 adults (31 male, 15 fe-
male), who were consecutively registered by the OXHIS and who
consented to interview at a routine 6-month follow-up. Their mean
age was 34 years (SD 13.2; range 17-64) with a median PTA of 8
h (range 0 to 21 days). Six subjects were unable to estimate the
length of their PTA. The causes of head injury varied: 27 road traf-
fic accidents, 5 assaults, 5 accidents at work, 3 horse-riding acci-
dents and 6 others.
Subjects were contacted approximately 6 months after injury
and asked whether they would be willing to take part in a follow-
up of head-injured patients offered to all those registered by
OXHIS. If they agreed, they were visited at their home by one of
the investigators (S.C. or F.W.). The investigator administered the
RPQ, recording the patient's ratings for each item during the pre-
vious week. It was decided that this would give a broader and more
accurate indication of the incidence of symptoms beyond the acute
stage. A brief structured interview was also conducted in order to
establish basic epidemiological information, including length of
PTA and cause of head injury. Approximately 10 days later a sec-
ond investigator visited each patient at home and repeated the pro-
cedure. The two investigators alternated between seeing patients
on the first or second visit.
Total PCS scores were taken as the sum of all symptom scores
excluding ratings of 1 because these indicated that the symptoms
were unchanged from before the injury. Pilot investigations re-
vealed that the "Additional Symptoms" section of the RPQ was
commonly used by subjects for problems relating to orthopaedic
injuries rather than to the head injury itself, This section was there-
fore not included in the total score.
Results
In the first study, the questionnaires were first c o m p l e t e d
at a m e a n o f 8 days (SD 2.1; range 5 - 1 5 ) after injury and
 589

Table 1 Reliability of individual post-concussion symptoms and 40

total symptom scores at 7-10 days after injury (self-administered)
and 6 months after injury (clinician-administered); (Rs Spearman ®
rank correlation coefficient; P < 0.001 for all correlation coeffi- ® @
cients) 30 ®
Time 7-10 Days 6 Months [][]
R~ Rs (~[] [] []
20 []
[]
Post-concussion symptoms
Headaches 0.79 0.84 B []
Feelings of dizziness 0.85 0.81 10
Nausea 0.72 0.58
Noise sensitivity 0.84 0.94
Sleep disturbance 0.80 0.68 0 i i i i 7
Fatigue 0.81 0.69 0 10 20 30 40 50
Being irritable 0.80 0.65 First PCS Score
Feeling depressed 0.57 0.60
Fig. 2 Scatterplot showing total PCS scores at 6 months after head
Feeling frustrated 0.50 0.66
injury (clinician-administered)
Forgetfulness 0.81 0.78
Poor concentration 0.81 0.78
Taking longer to think 0.70 0.56
range 3-34) later; 21 of the sample were first seen by in-
Blurred vision 0.74
vestigator 1 and 25 first seen by investigator 2.
Light sensitivity 0.91 0.70
Table 1 and Fig. 1 show that the total PCS score was
Double vision a 1.00
rated reliably at 7-10 days after injury; test-retest reliabil-
Restlessness 0.56 0.47
ity was high. Table 1 and Fig. 2 show that the total PCS
Total PCS score 0.90 0.87
score was also reliable when rated at 6 months by two dif-
a Too few patients to calculate the coefficients ferent investigators; inter-rater reliability was good.
In the first study (Fig. 1) the main outlying subject (cir-
cled) was one who first completed the questionnaire when
again at a mean of 1.6 days (SD 0.9; range 9 h to 4 days) convalescing at home and later when he had returned to
later. Twenty subjects had completed the questionnaire school. He was likely, therefore, to be under greater cog-
before being visited, and 21 returned a completed ques- nitive stress, which probably exacerbates PCS [21]. In the
tionnaire by post 24 h after being visited. In the second second study (Fig. 2) four of the six most prominent out-
study the questionnaires were first administered at a mean lying results (circled) were obtained in patients who ap-
of 6 months and 6 days (SD 10.6 days; range 5 months, 21 peared, at least clinically, to have been placed under in-
days to 7 months, 2 days) after injury. They were admin- creased stress between the two administrations of the
istered for a second time at a mean of 9 days (SD 5.3; questionnaire. This may also have exacerbated their
symptoms. For example, two of the subjects were con-
cerned about their job security, one having been demoted;
40 []
[] another subject's long-term relationship had ended and
one subject was concerned about forthcoming examina-
t..
tions and the loss of his job due to the sale of the family
[]
",,,,;, 30 []
business. However, no formal testing of stress was con-
[] ducted.
[]
Table 1 shows that in both studies individual symp-
20 o [] toms were reliably rated, although with some variation in
correlation coefficients; in general the strength of repro-
=e, °wa ducibility was similar in both studies. Significant coeffi-
10 [] [] cients exist for all the symptoms and were highest for
headaches, dizziness, noise sensitivity, forgetfulness and
[]m ~e poor concentration. The least consistently rated symptoms
0~ ,• . , I I I
were feeling depressed, feeling frustrated, taking longer to
0 10 20 30 40 50 think and restlessness.
Tables 2 and 3 show how many patients were still re-
First PCS Score
porting symptoms at second assessment, and whether
Fig. 1 Scatterplot showing total post-concussion symptoms (PCS) these had improved, worsened or stayed the same, for
scores at 7-10 days after head injury (self-administered) both the 7-10 day and 6-month follow-up. Also shown
590

Table 2 Prevalence of post-concussion symptoms at second as- c h a n g e the s y m p t o m s were m o r e frequently rated as less
sessment, 7-10 days after injury (n = 41); "same score" means severe, with the e x c e p t i o n o f concentration, sensitivity to
scoring the same at both first and second assessment
noise and restlessness. A t 6 months after injury f e w e r than
Sympto- Im- Worse Same score h a l f o f all subjects reported at least one s y m p t o m . Be-
matic proved (2-4) (0-1) t w e e n the two a s s e s s m e n t s at 6 months, there was no bias
t o w a r d s i m p r o v e m e n t in those who rated s y m p t o m s dif-
Symptom
ferently.
Fatigue 21 12 2 14 13
Headaches 19 14 2 11 14
Sleep disturbance 17 9 2 9 21
Poor concentration 15 2 4 10 25 Discussion
Being irritable 14 4 3 4 30
Taking longer to think 13 6 3 6 26 T h e results d e m o n s t r a t e that the R P Q is reliable in rating
Forgetfulness 12 7 2 6 26 a total PCS score, w h e t h e r used as a s e l f - a d m i n i s t e r e d or
Feeling frustrated 11 8 4 5 24 as a c l i n i c i a n - a d m i n i s t e r e d measure, early or late after
Feelings of dizziness 11 3 3 7 28 h e a d injury. T h e y also d e m o n s t r a t e that i n d i v i d u a l s y m p -
Noise sensitivity 10 2 5 4 30 toms are rated in a reliable m a n n e r under both e x p e r i m e n -
Restlessness 10 1 6 4 30 tal conditions. T h e consistency o f i n d i v i d u a l s y m p t o m
Feeling depressed 9 8 3 5 25 ratings varied. This was m o s t e v i d e n t in the s e c o n d study
Light sensitivity 8 4 1 5 3l and m i g h t b e attributable to the d e l a y b e t w e e n assess-
Nausea 5 5 1 4 31 ments in the s e c o n d study. Alternatively, it is p o s s i b l e that
Blurred vision 5 3 0 4 34 the slightly h i g h e r m e d i a n P T A of subjects in study 2
Double vision 0 1 0 0 40 m e a n s that they had s o m e w h a t m o r e severe h e a d injuries
than those in study 1.
Table 3 Prevalence of post-concussion symptoms at second as- It is also p o s s i b l e that the contribution o f e n v i r o n m e n -
sessment, 6 months after injury (n = 46); "same score" means scor- tal stressors to P C S is greater 6 months after injury than at
ing the same at both first and second assessment
7 - 1 0 days [15]. Patients are likely to have returned to
Sympto- Im- Worse Same score w o r k and r e s u m e d other responsibilities within their fam-
matic proved (2-4) (0-1) ilies. In addition, further stressful life events m a y have oc-
curred, such as court p r o c e e d i n g s in relation to the injury,
Symptom
Fatigue 22 7 8 12 19 other accidents, illnesses or difficulties at h o m e or work.
Being irritable 19 4 10 6 26 The pattern o f s y m p t o m s supports this suggestion. Fa-
Feeling frustrated 17 8 7 6 25 tigue r e m a i n s the m o s t c o m m o n l y r e p o r t e d s y m p t o m , but
Forgetfulness 16 7 8 4 27 difficulties with headaches and sleep b e c o m e less c o m m o n
Poor concentration 15 5 5 6 29 a while irritability and frustration b e c o m e m o r e c o m m o n .
Taking longer to think 13 8 8 3 27 D i s t u r b a n c e s o f v i s i o n and n a u s e a r e m a i n less c o m m o n l y
Feeling depressed 13 3 8 4 31 r e p o r t e d s y m p t o m s , but their incidence decreased, sug-
Sleep disturbance 12 5 5 5 31 gesting that somatic complaints are less prevalent 6 months
Noise sensitivity 10 5 1 4 36 after injury.
Feelings of dizziness 10 3 3 6 34 It is interesting to note that s y m p t o m s with h i g h e r and
Restlessness 8 9 4 1 32 l o w e r correlation coefficients at 7 - 1 0 days after head in-
Headaches 8 3 2 4 37 j u r y are g e n e r a l l y those that have h i g h e r and l o w e r coeffi-
Light sensitivity 7 5 3 3 35 cients r e s p e c t i v e l y 6 m o n t h s after h e a d injury. T h e m o s t
Double vision 2 0 1 1 43 a r e l i a b l y rated PCS were headaches, dizziness, noise sensi-
Nausea 1 3 0 0 43 tivity, forgetfulness and p o o r concentration. These s y m p -
Blurred vision 0 5 0 0 40 a toms are p r o b a b l y the m o s t easily and u n a m b i g u o u s l y
identifiable b y patients, and/or are the m o s t consistently
a One missing value from the data
e x p e r i e n c e d s y m p t o m s over time. Conversely, the least
r e l i a b l y r e p o r t e d PCS in b o t h situations, such as feeling
frustrated, feeling depressed, taking l o n g e r to think and
are h o w m a n y subjects r e p o r t e d no s y m p t o m s at either restlessness, are p r o b a b l y those that are e x p e r i e n c e d in a
assessment (i.e., rated items as 0 or 1). Tables 2 and 3 show m o r e v a r i a b l e m a n n e r o v e r time, and/or are less easy to
fatigue as the m o s t p r e v a l e n t s y m p t o m b o t h early and late identify. F o r e x a m p l e , there m a y be a difficulty in distin-
after injury and visual disturbance and n a u s e a as the least guishing b e t w e e n feeling frustrated and feeling depressed.
prevalent. A t early f o l l o w - u p m o r e than h a l f o f all sub- T h e h i g h e r reliability of the total P C S score c o m p a r e d
jects r e p o r t e d at least one s y m p t o m . O v e r the 24 h be- with the v a r i a b i l i t y o f i n d i v i d u a l s y m p t o m scores m a y re-
t w e e n the assessments, in those patients w h o r e p o r t e d flect a c o n s t a n c y in the overall subjective e x p e r i e n c e o f
 591

P C S b y a patient regardless o f variation in specific s y m p - In conclusion, the R P Q is d e m o n s t r a b l y reliable both

toms. In other words, i n d i v i d u a l s y m p t o m s m a y substitute when s e l f - a d m i n i s t e r e d and c l i n i c i a n - a d m i n i s t e r e d . There
for each other o v e r time but leave the g e n e r a l level o f sub- are s o m e differences in the r e l i a b i l i t y o f i n d i v i d u a l s y m p -
j e c t i v e e x p e r i e n c e unchanged. It is clear that the total tom ratings, but these are b y no m e a n s significant enough
R P Q score is sufficiently reliable to be useful for both to detract from the q u e s t i o n n a i r e ' s overall robustness. It is
clinical and research p u r p o s e s as a general i n d i c a t i o n o f h o p e d that the instrument will p r o v i d e a m e a n s o f m e a -
severity. W e do not b e l i e v e that the differences in reliabil- suring PCS in a m o r e systematic and uniform m a n n e r than
ity in s o m e o f the i n d i v i d u a l s y m p t o m s are significant has been p o s s i b l e previously. A s such, its use b y clini-
e n o u g h to u n d e r m i n e the overall robustness o f the ques- cians and researchers is strongly encouraged.
tionnaire. H o w e v e r , it is p o s s i b l e that under certain cir-
c u m s t a n c e s (e.g. w h e n using rigorous research protocols) Acknowledgements We thank Mrs. Ann White for her secretarial
and administrative contribution to the paper, and the Department
s o m e researchers m a y be cautious w h e n using the R P Q to
of Health for funding the Oxford Head Injury Service as part of its
m e a s u r e the severity o f i n d i v i d u a l s y m p t o m s w h i c h h a v e Brain Injury initiative.
l o w e r reliability coefficients.
A n e x p e r i m e n t a l a s s e s s m e n t o f the q u e s t i o n n a i r e ' s va-
lidity is e x t r e m e l y difficult as there are few, if any, b e h a v -
ioural, p h y s i o l o g i c a l or n e u r o l o g i c a l correlates for the Appendix 1
s u b j e c t i v e l y e x p e r i e n c e d p h e n o m e n a o f PCS to be c o m -
p a r e d with. A c o m m o n v a l i d a t i o n criterion for h e a d injury After a head injury or accident some people experience symptoms
which can cause worry or nuisance. We would like to know if you
m e a s u r e s is PTA. A s p r e v i o u s l y m e n t i o n e d , h o w e v e r , this now suffer any of the symptoms given below. As many of these
is not a useful m e a s u r e once an injury has b e e n estab- symptoms occur normally, we would like you to compare yourself
lished as being o f m i l d or m o d e r a t e severity [29]. S o m e now with before the accident. For each one please circle the num-
neuropsychological measures of information processing ber closest to your answer.
and d i v i d e d attention, such as the P a c e d A u d i t o r y Serial 0 = Not experienced at all
A d d i t i o n Task [12] and the Stroop test [27], have s h o w n 1 = no more of a problem
2 = a mild problem
s o m e correlation with PCS [4, 5, l 1]. T h e r e f o r e one future
3 = a moderate problem
investigation of the R P Q ' s v a l i d i t y m a y b e its c o m p a r i s o n 4 = a severe problem
with such measures. Its v a l i d i t y should also be a s s e s s e d in
Compared with before the accident,
terms of the p s y c h o s o c i a l predictions that can b e m a d e do you now (i.e. over the last 24 hours) suffer from:
from the measure; does it p r e d i c t o u t c o m e ? To study this Headaches 0 1 2 3 4
firstly requires a sensitive and e c o l o g i c a l l y relevant m e a - Feelings of dizziness 0 1 2 3 4
sure o f p s y c h o s o c i a l functioning. M o s t m e a s u r e s u s e d to Nausea and/or vomiting 0 1 2 3 4
assess p s y c h o s o c i a l o u t c o m e following head injury have Noise sensitivity,
easily upset by loud noise 0 1 2 3 4
been d e s i g n e d for severe injuries. T h e y usually m e a s u r e Sleep disturbance 0 1 2 3 4
d i m e n s i o n s such as mobility, activities o f daily living, Fatigue, tiring more easily 0 1 2 3 4
w o r k level, social relationships and future prospects [14]. Being irritable, easily angered 0 1 2 3 4
Few, if any, are sensitive enough to gauge the m o r e subtle Feeling depressed or tearful 0 1 2 3 4
Feeling frustrated or impatient 0 1 2 3 4
difficulties e x p e r i e n c e d as a result o f m i l d and m o d e r a t e
Forgetfulness, poor memory 0 1 2 3 4
h e a d injury. S e c o n d l y a m e a n s o f controlling for extra- Poor concentration 0 1 2 3 4
neous variables likely to influence the scoring on such a Taking longer to think 0 1 2 3 4
measure is required. Both these criteria are likely to be dif- Blurred vision 0 1 2 3 4
ficult to meet. P r o b a b l y the most feasible m e t h o d of vali- Light sensitivity,
easily upset by bright light 0 1 2 3 4
dation will be heuristic reports of its utility b y clinicians in Double vision 0 1 2 3 4
the assessment and follow-up o f head injury. Its use in the Restlessness 0 1 2 3 4
systematic f o l l o w up o f head-injured patients b y the O X - Are you experiencing any other difficulties?
HIS certainly so far supports its clinical validity [21]. Its Please specify, and rate as above:
further use is therefore r e c o m m e n d e d in order that its clin- 1. 0 1 2 3 4
ical validity can be assessed m o r e extensively. 2. 0 1 2 3 4

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