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The Wessex Head Injury Matrix (WHIM) main scale: a preliminary

report on a scale to assess and monitor patient recovery after severe
head injury

Article  in  Clinical Rehabilitation · September 2000

DOI: 10.1191/0269215500cr326oa · Source: PubMed

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 Clinical Rehabilitation
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The Wessex Head Injury Matrix (WHIM) main scale: a preliminary report on a scale to assess
and monitor patient recovery after severe head injury
A Shiel, S A Horn, B A Wilson, M J Watson, M J Campbell and D L Mclellan
Clin Rehabil 2000 14: 408
DOI: 10.1191/0269215500cr326oa

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Clinical Rehabilitation 2000; 14: 408–416

The Wessex Head Injury Matrix (WHIM) main

scale: a preliminary report on a scale to assess
and monitor patient recovery after severe head
injury
A Shiel University of Southampton Rehabilitation Research Unit, SA Horn Department of Psychology, University of
Southampton, Southampton, BA Wilson MRC-CBU, Addenbrookes Hospital, Cambridge, MJ Watson Occupational
Therapy and Physiotherapy, School of Health, University of East Anglia, Norwich, MJ Campbell ScHARR, Community
Sciences Centre, North General Hospital, Sheffield and DL McLellan University of Southampton Rehabilitation Research
Unit, Southampton General Hospital, Southampton, UK

Received 8th October 1998; returned for revisions 23rd March 1999; revised manuscript accepted 4th August 1999.

Objective: To develop a behavioural assessment based on observations of

patients recovering after severe head injury whereby data could be collected
by observation and by testing everyday tasks.
Design: A prospective observational study of a cohort of 88 consecutive
hospital admissions with severe head injury.
Setting: Two district general hospitals in the UK.
Patients: Eighty-eight consecutive admissions with severe traumatic head
injury. Ages ranged from 14 to 67 years, mean coma duration was 14 days
and mean duration of post traumatic amnesia (PTA) was 56 days.
Results: Fifty-eight items of behaviour were identified. Paired preference
analysis was used to identify a sequence of recovery of these behaviours.
The sequence began with arousal and led on to behaviours signalling recovery
of social interaction and communication. Subsequent behaviours indicated
increasing cognitive organization and return of orientation and memory. The
behaviours on the scale are hierarchical and range from coma to emergence
from PTA.
Conclusions: A scale to assess patients and monitor cognitive recovery after
severe head injury has been developed. While individual patients will show
some departures from the sequence identified, the scale helps to make
explicit the earliest stages of natural recovery patterns after head injury.

Introduction the UK 6–8 per 100 000 people sustain a moder-

ate or severe head injury with long-term conse-
Traumatic brain injury has been described by quences. Improvements from the initial stage of
Chamberlain1 as a ‘silent epidemic’. Each year in coma may be gradual and unless accurate assess-
ment takes place, small gains may go unnoticed.
Address for correspondence: A. Shiel, MRC-CBU, Box 58,
Addenbrookes Hospital, Hills Road, Cambridge CB2 2EF, When patients are slow to recover it is not
UK. e-mail: [email protected] unusual to be misled into believing that no recov-
© Arnold 2000 0269–2155(00)CR326OA
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 Wessex Head Injury Matrix 409

ery is occurring, even though slow but subtle response, eye opening and verbal response. It has
progress is continuing over weeks or months. been shown to be sensitive to change in the early
Objective evidence of progress could perhaps stages of coma and is still considered to be the
enable more accurate long-term predictions to be best method of monitoring response in the acute
made for individuals. Failure to recognize such stage of coma. It is the only scale to be widely
changes could suggest a falsely poor prognosis used in routine clinical practice in the UK. In
and impair staff motivation and the quality of part, this is probably due to the fact that brain-
patient care. injured people are initially cared for in a wide
In the early stages of recovery, systematic mon- range of different hospital settings, including gen-
itoring of the recovery of functions such as motor eral orthopaedic and surgical wards which may
skills, cognitive abilities, social interaction and not be geared specifically for detailed neurologi-
the control of behaviour cannot be undertaken cal or cognitive assessment and monitoring.
because of the lack of appropriate instruments. Current scales for monitoring recovery and
Wilson2 argued that methods of assessment for classifying outcome after patients after severe
severely head-injured patients were inadequate head injury have been shown to have limited use.
because of the following factors. A comprehensive review of the most commonly
used scales can be found in Horn et al.5 Most are
1) They do not provide a clear relationship not used because of the following limitations.
between performance on tests and perfor-
mance in everyday life. 1) The categories are broad so it may not be
2) They cannot be employed at all stages fol- possible to detect subtle behavioural changes
lowing traumatic brain injury. For example, e.g. confused/nonagitated and confused/
most neuropsychological tests cannot be agitated on the Rancho Los Amigos Scale.3
employed on people as they are emerging 2) Items in the scales cross several behavioural
from coma. dimensions (e.g. cognitive functioning and
3) They cannot be used across a spectrum of social awareness) so it may be difficult to
varying degrees of severity. For example, identify improvement in a single area.
many tests cannot be used with people with 3) Patients recovering from head injury may
severe motor, sensory or cognitive impair- exhibit behaviour appropriate to more than
ments, although precise and objective one category. For example, Rancho Los Ami-
measures of these impairments might be gos level 3 is described as ‘confused agitated’
crucial. and level 4 as ‘confused nonagitated’.
4) They have very little (or only very crude) pre- Patients may exhibit both behaviours on dif-
dictive power regarding final outcome. ferent occasions or in different environments.
5) They provide inadequate information for 4) The scales are rating scales rather than obser-
designing and guiding treatment pro- vations or assessments and, as such, are open
grammes. to subjective interpretation which may not
reflect the true level of the behaviour accu-
Several scales have been developed to monitor rately.
recovery after emergence from coma. Examples 5) The scales do not specify the sequence of
include the Rancho Los Amigos Scale3 and the recovery in sufficient detail. For example,
Glasgow Coma Scale4 (GCS). The Rancho Los item 4 on the Glasgow Outcome Scale
Amigos Scale is an eight-item scale with broad (GOS)6 is defined as ‘can travel by public
categories. When assessed on this scale, patients transport and work in a sheltered environ-
may show behaviours which are appropriate to ment and can, therefore, be independent in
more than one category at the same time and can so far as daily life is concerned.’ The ques-
also change categories several times in the same tion remains as to whether ‘ability to travel
day, e.g. ‘confused and agitated’ and ‘confused on public transport’ precedes, follows on, or
and non-agitated’. The GCS is one of the most always goes along with ‘ability to work in a
widely used measures of level of consciousness. sheltered environment’.
It assesses three aspects of behaviour: motor 6) Most scales have ordinal scoring; that is, a
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410 A Shiel et al.

behavioural description (such as response to • it examines behaviours in the areas of motor

pain) may be scored as 2 for extension and 3 ability, cognitive skills and social interaction.
for flexion. Inaccuracies are likely to be The operational basis for the development of
introduced when these scores are summed, the Wessex Head Injury Matrix came from the
often across dimensions, to produce a total clinical approach to the description of behaviours
score. As the numbers are not absolute num- commonly used in brain-injury rehabilitation.
bers and a variety of dimensions are grouped The intention was to establish which behaviours
together it is unclear whether all functions patients with head injury were observed to show
are changing at the same rate or in the same and construct this into a measure which met the
direction. specific needs of individual patients. In short, the
Current neuropsychological tests are also first aim of the study was to develop a behav-
unsuitable for people emerging from coma or for ioural assessment schedule that would help assess
those who have very severe deficits. Early testing and monitor recovery after severe head injury in
has poor power of prediction and thus can not be the clinical environments in which such patients
used to guide the design of rehabilitation pro- are actively treated. The second aim was to
grammes.7 Testing at later stages of recovery has develop an assessment free of the limitations
been shown to give useful information about the mentioned above, which could be used by a mul-
importance of some cognitive factors in rehabili- tidisciplinary team to assess patients and to set
tation. However, neuropsychological tests cannot goals for rehabilitation from the outset. The third
be used to specify sequences of recovery or fully aim was to bridge the gap between those scales
to account for behaviour problems. which are useful in the very acute stages after
Other forms of assessment that have been used head injury such as the Glasgow Coma Scale
with head-injured patients include developmen- (GCS), and standard tests of cognition, motor
skills and dependency which cannot be applied
tal assessments, for example, the Vineland Adap-
until the later stages of recovery after head
tive Behaviour Scale.8 Eson et al.9 advocated the
injury.
use of developmental scales with brain-injured
adults to monitor recovery. This was based on the
belief that with head-injured adults, some func-
Method
tions at least recover in their developmental
sequence. The results of their study suggested The development of the scales took place in four
that for the functions tested, recovery did occur main stages:
in a developmental sequence but the inventory
had used a developmental construct, so that other 1) Identification of the behaviours observed
significant behaviours may have been uninten- during recovery after head injury. This cor-
tionally excluded from it. responded to the three-step procedure
The aim of this study was to develop an assess- described by Goldfried and Linahan10:
ment technique in which data could be collected a) Sampling of situations where behav-
by observation and by testing tasks used in every- iours occurred
day life. The approach was based on Wilson’s b) Sampling of the range of responses
work in 1988 in assessing head-injured patients c) Judging responses.
using the Portage Scale.2 This approach was con- 2) Categorization of the behaviours into sub-
sidered to be appropriate for use with head- scales.
injured patients because: 3) Development of the operational definitions
for the scale.
• it covers a wide range of abilities of real life 4) Analysis of the data collected and reordering
skills; of the scale.
• it can be administered by observation and its
focus is on what the subject does or does not
do, rather than upon clinical diagnostic fea-
tures; and
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 Wessex Head Injury Matrix 411

Subjects research, we tried to avoid making any assump-

Subjects were accepted for inclusion in the tions as to how recovery might occur, or which
study according to the following criteria: behaviours might be important.
In the early stages of the study, it became evi-
1) Traumatic brain injury (TBI) causing loss of
dent that periods of observation when frequent
consciousness (defined as a score of 8 or less
behaviours occurred were often interspersed with
on the Glasgow Coma Scale).
long periods of observation when no behaviours
2) The duration of coma was 6 hours or longer
were detectable. Because of the possibility that
(score of 8 or less on the GCS) or the dura-
these periods could be masking developments in
tion of post traumatic amnesia (PTA)
the capacity to respond to stimuli, a series of sim-
measured prospectively on a modified ver-
ple stimuli were compiled in an attempt to elicit
sion of the Westmead PTA11 test was 24
behavioural responses. These were chosen on the
hours or longer (severe injury as defined by
basis of being easy for clinical staff of any disci-
the Medical Disability Society 1988).12
pline to use, and likely to have face validity for
3) Aged between 14 and 70 years at the time of
those wishing to establish the state of arousal or
injury.
to communicate with the subject. They were pre-
4) No premorbid neurological or learning dis-
sented to the subjects daily. All such stimuli were
abilities or serious mental illness (i.e. docu-
recorded and the responses or lack of responses
mented illness requiring inpatient psychiatric
were noted. Any behaviour occurring within 30
admission).
seconds of the stimulus was counted as a
5) Inpatient in Southampton General Hospital
response. This period of time was used to take
(SGH) or Poole General Hospital (PGH).
account of the response latency and has been
6) The subject’s relatives gave consent to the
used previously in other studies.13
study.
Thus, three types of behavioural event were
recorded:
Identification of behaviours observed during
recovery after severe head injury 1) Spontaneous behaviours (for example, open-
Data were collected by observing and record- ing eyes or attempting to remove an naso-
ing behavioural events. Naturalistic or simple gastric tube).
observation, that is observation of behaviour as 2) Responses to naturally occurring stimuli
it occurs in natural settings, observed by an which were presented incidentally (for exam-
observer who is not participating in the care of ple, turning the head briefly towards a noise
the patient, was employed in this study. Simple arising from activity in another part of the
observation was used as this is particularly appro- ward).
priate for gathering of clinical data which can be 3) Responses to a standard set of stimuli (for
used to set realistic goals. All behaviour could be example, calling the patient’s name, or
recorded, thus avoiding any floor and ceiling sounding a buzzer).
effects. This was a particularly appropriate tech-
nique for assessing severely compromised indi- Categorization of behaviours into subscales
viduals or those whose behavioural repertoire This was an iterative process using ‘action’
was severely restricted. Data collection began research. Records of the observations and struc-
when patients were no longer sedated and venti- tured stimuli resulted in a list of 145 behaviours.
lated and continued until discharge from the Initially, these were categorized into 10 proposed
study hospital. Patients in Southampton General subscales: visual awareness, social, communica-
Hospital were observed daily at the outset and tion, cognition, feeding, washing, dressing, conti-
periods of observation ranged from 15 minutes to nence, upper limb and gross motor. This division
several hours. Video recordings of periods of up was arbitrary and was decided upon in discussion
to 24 hours were made to facilitate sampling of on the basis of the domain in which the behav-
‘round the clock’ behaviours. It was decided to iour best seemed to fit. There was duplication of
develop the scales by observing recovery after early behaviours in some scales. For example, eye
head injury in detail and, in contrast to previous contact could be considered to be either an early
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412 A Shiel et al.

cognitive social or communicative behaviour and which the behaviour was first observed to occur.
was included in all three scales initially. Where subjects were seen daily, this allowed cal-
Examination of the behaviours in each scale culation of the number of days between the
showed that overlaps occurred across four sub- injury and the first observed occurrence of the
scales : cognition, communication, social behav- behaviour. These data were used to calculate the
iour and visual awareness. Furthermore rank order of recovery of items of behaviour.
recording the assessment became more compli- Where the subjects were seen less frequently, it
cated when behaviours were divided into sub- could not be assumed that the date of an obser-
scales as patients tended to recover early items vation of a new behaviour was the date on which
in several domains simultaneously so that all rel- it would first have been observed. In such cases,
evant subscales had to be administered concur- ‘first observations’ of behaviour tended to clus-
rently. In order to avoid these difficulties, the ter. This created disparities in accuracy of timing
subscales were amalgamated to form a single cog- between subjects and the large amount of ‘miss-
nitive scale. Duplicated behaviours were ing data’ presented a challenge for analysis.
removed and the result was a 58-item scale of Traditional analysis requires complete or
cognitive behaviours. mainly complete data sets. However, Allen and
The gross motor and upper limb scales have Yen15 described a technique of developing ordi-
undergone no further development to date and nal scales whereby rather than examining scaling
the feeding, washing, dressing and continence properties, a categorical analysis between pairs of
scales were abandoned. There were two reasons variables is carried out. For each pair of vari-
for this: very few data on these behaviours had ables, it is determined whether one is likely to
been collected and it was not possible to record recover sooner than the other in more than 50%
a sequence of recovery of these items as they of the observed cases. With the data collected in
were so strongly affected by environmental fac- this study, each ‘first observed on’ date was used
tors. When patients were looked after on general to identify a rank order of emergence of behav-
wards, nursing staff tended to wash, dress and iours and a matrix of paired comparisons was
feed patients rather than allow them to attempt generated. The procedure is described fully else-
to carry out these tasks themselves. where.16 The advantage of using this technique
was that all data, including that which was incom-
Development of operational definitions plete could be used. This allowed analysis of
Each behaviour included in the scale was oper- incomplete data and the data could be used
ationally defined.14 Operational definitions need to identify a potential sequence or trend of
to be concise and concrete and, for some com- recovery.
plex behaviours, salient and more easily identi-
fied components of the behaviour were Reliability
described. Although the fine definitions do not The reliability of the scale was evaluated with
therefore encompass all aspects of the behaviour a different set of subjects and raters. Two
of which these elements were a part, it was clear researchers, unfamiliar with the scale, underwent
that without definitions there was little chance of training in administration of the scale using video
developing a useable tool. There were three recordings of subjects and behaviours were
stages in the development of these operational recorded on the WHIM. As reliability between
definitions. First, draft definitions were devel- raters at this stage was found to be unacceptably
oped by the research observers. Second, they poor, further training was provided. Subse-
were discussed and revised by the whole project quently, a further group of subjects were
team. Third, they were tested prospectively using recruited using the same recruitment criteria as
subjects and finally, further revised as necessary. for the scale development. These subjects were
observed daily for times ranging from 15 minutes
Analysis of data to 21/2 hours. Two types of reliability were exam-
All behavioural observations were recorded ined: inter-rater reliability and test–retest relia-
and particular attention was paid to the date on bility. Inter-rater reliability referred to the degree
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 Wessex Head Injury Matrix 413

to which trained raters agree and test–retest reli- apparently ‘random eye movement’. Others
ability referred to the stability of measures over appear to be purposeful in nature, for example
at least two observational sessions. To test inter- looking at a person briefly, looking at the person
rater reliability, researchers observed the subject who is talking or following with the eyes a per-
and recorded the behaviours observed during the son moving in the line of vision. All of these
same session; test–retest reliability was evaluated behaviours have been noted to occur prior to
by assessing the subject twice on the same day at obeying a command.
least two hours apart. Reliability was tested using The sequence of behaviours between obeying
kappa statistics which gave an agreement mea- a command and the first spoken utterance is
sure for both the occurrence and nonoccurrence dominated by visual behaviours (Table 2). We
of behaviour corrected for chance agreement can then see the emergence of behaviours
between raters.17 required for social interaction and communica-
tion, for example ‘vocalizing’, showing selective
responses to preferred people and frowning to
Results show dislike. These behaviours were observed
both in patients who had no mechanical barrier
Eighty-eight subjects were recruited to the study. to speech and those with a tracheostomy and they
They ranged in age from 14 to 67 years. Median appeared to emerge prior to return of spoken
age was 26 years (mean = 30 years, SD =14). communication.
Median coma duration was six days (mean = 14 The next segment of the scale (Table 3)
days, SD = 21). Median duration of PTA was 30 includes behaviours which imply an increasing
days (mean = 56 days, SD = 65). recovery of attention and cognitive organization
including such items as looking at TV or books,
Main scale being distracted by any external stimulus and
Paired comparisons between each pair of items then continuing to being distracted but becoming
were calculated to identify an order of recovery. able to return to the task. Smiling spontaneously
The procedure has been described in detail else- typically returns at this stage.
where.16 The main scale of the matrix contained The final segment of the sequence demon-
58 items of behaviour. These are described in strates the recovery of orientation and continu-
four sections. ous memory and signals emergence from PTA
The first part of the scale includes basic behav- which was assessed prospectively using a modi-
iours (Table 1), some of which may be partly fied version of the Westmead PTA test (Table
reflexive in origin for example, ‘eye opening’ and 4).12 As can be seen from the behaviours, the ini-
tial recovery of orientation and memory func-
Table 1 Items of behaviour 1–15
Table 2 Items of behaviour 16–29
1) Eyes open briefly
2) Eyes open for extended period 16) Turns head/eyes to look when someone is talking
3) Eyes open and move but do not focus on 17) Watches person moving in line of vision
object/person 18) Tracks for 3–5 seconds
4) Attention held momentarily by dominant stimulus 19) Vocalizes to express mood or needs
5) Looks at person briefly 20) Tracks a source of sound
6) Volitional vocalization, to express feelings 21) Shows selective response to preferred people
7) Distressed when cloth put on face 22) Maintains eye contact over 5 seconds
8) Makes eye contact 23) Removes cloth from face by headshake, hand grasp,
9) Looks at person talking etc. × 3
10) Expletive utterance (‘Get off!’, etc.) 24) Silent mouthing
11) Eyes follow person moving in line of vision 25) Frowns, grimaces, etc. to show dislike
12) Looks at person giving attention 26) Is able to ignore distraction
13) Closes eyes and becomes quiescent when cloth 27) Looks at object when requested
put on face 28) Imitates gesture (blink x 2, thumb up, etc.)
14) Mechanical vocalization (with yawn, sigh, etc.) 29) Indicates understanding by headshake, nod,
15) Performs physical movement on verbal request gesture, etc.

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414 A Shiel et al.

tions (for example, the ability to say what part of communication aid. There is increasing evidence
the day it is) may predate first ‘day-to-day’ mem- of social interaction including initiation of con-
ory item – knowing the name of a member of versation and the ability voluntarily to attract
staff. This segment also introduces evidence of attention of others.
learning new information such as the name of a
staff member, or a new skill such as the use of a Reliability of the scale
Reliability was evaluated using 25 subjects
recruited to a second study over a nine-month
Table 3 Items of behaviour 30–46 period. The inclusion criteria were the same as in
30) Seeks eye contact
the first study. The median age of the reliability
31) Monosyllabic or single words in response to sample was 36 years (mean = 42, SD 21 years)
questions and median duration of coma was seven days
32) Looks at, and apparently explores, pictures, (mean = 13, SD = 20 days). There were no sig-
magazine, TV etc. nificant differences between the study sample and
33) Switches gaze from one person to another,
spontaneously this group on either of these parameters.
34) Speech is fluent but rambling. Lots of words but Initial data showed that neither inter-rater nor
meaning hard to discern test–retest reliability reached acceptable levels
35) Looks for object that has been shown and then when the scale was employed by previously
removed from line of vision
36) Can attend to task, TV etc., but concentration is
untrained observers immediately after a brief
vulnerable training session. (κ = 025 to 0.84 for inter-rater
37) Monosyllabic or single words to express mood or reliability and – 0.66 to 0.12 for test–retest relia-
need bility). Following this, more extensive training
38) Is momentarily distracted by external stimulus but was provided and an amended data collection
can return to task
39) Can find a specific playing card from a selection of procedure introduced. The training procedure
four comprised practice using the scales with video
40) Smiles demonstrations of the behaviours. Training took
41) Uses writing, typing or other communication aid, approximately two hours. The data-collection
but is hard to understand
42) Can say what part of day it is
procedure was amended so that instead of
43) Brief phrases recording new behaviours only, raters recorded
44) Points with eyes all the behaviours observed in a session. Follow-
45) Initiates conversation ing such training and using the amended record-
46) Vocalizes to attract attention ing system the level of reliability reached was
acceptable for both inter-rater and test–retest
reliability. Mean kappa scores were 0.86 for inter-
Table 4 Items of behaviour 47–58 rater reliability and 0.74 for test–retest reliability.
The range of scores for test retest reliability
47) Conventional speech usage but with very few words
48) Uses one or two gestures (scores ranged from 0.62 to 1 for inter-rater reli-
49) 1 or 2 orientation items correct (day of week, month, ability and 0.22 to 1 for test–retest reliability) was
year, age, place) considerably greater than for inter-rater reliabil-
50) Knows the price of three common objects ity. The lower scores were due to the fact that
51) Recognizes coins (eye-point or touch named coin)
52) Knows the name of one member of staff
two subjects changed significantly between the
53) Names or indicates left and right on self two assessments (carried out 4 hours and 8 hours
54) Uses writing, typing or other communication aid apart respectively) but all other kappa scores
fluently were high as confirmed by the mean kappa score
55) 3–5 orientation items correct (0.74).
56) Remembers something from the day before
(e.g. show a coin, key, watch, etc. from your
pocket and say you will ask them to remember it
tomorrow)
57) Remembers something from earlier in the day
(e.g. ‘Have you been to physio yet?’)
58) Completes PTA test

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 Wessex Head Injury Matrix 415

Discussion head injury. The behaviours recorded and the

stimuli used to elicit them have been selected for
It is important to recognize that although a their practical utility and their relevance to cur-
sequence of behavioural recovery has been estab- rent inpatient rehabilitation practice. The WHIM
lished, the order of individual items is not has, of course, the potential to signal regression
absolute. This is to say that although the behav- (loss of elements of behaviour) as well as the
iours are statistically most likely to occur in the expected sequence of recovery.
sequence identified there will be differences with Not all patients will exhibit every behaviour on
individuals. For example, a patient whose speech the scale. For example, it is inappropriate to
and language function is not impaired may not assess the ability to use a communication aid with
eye point or use communication aids. The gen- a patient who can speak without difficulty, or to
eral sequence of recovery of these cognitive items monitor wheelchair mobility for a patient who
follows the hierarchy suggested by Adamovich,18 can walk.
beginning with arousal and alerting, continuing The scale has both strengths and weaknesses.
with selective attention and proceeding to diver- A major strength is that the behaviours are
gent thinking and reasoning. merely observed and recorded – it is not neces-
This scale effectively divides clinical recovery sary to make decisions regarding the purposeful-
from the time of injury into small steps, which ness of the behaviour. A further strength is that
can be used to evaluate progress from the point it can detect subtle deterioration (loss of previ-
of admission to emergence from PTA. It includes ously observed behaviours) in addition to
items of communication, social behaviour, cogni- improvement.19
tion, attention and communication. All the items We cannot comment, at present, on the rela-
require the ability to make some kind of response tive intervals between the various behaviours.
but do not require any assumption to be made Although it is probable that the intervals are
about purpose or awareness. The items on the uneven and that some parts of the scale are thus
scale are assessed by observation and by docu- more fine grained than others, the data collected
menting the patient’s response to a set of stan-
so far do not allow exploration of this question
dard stimuli and items are fine grained enough to
further. Further, some individual behaviours may
show small increments. The items on the scale
have a more direct clinical significance than oth-
could also be used to formulate short-term goals
ers in signalling change. These issues need to be
for rehabilitation.
addressed in a future prospective study.
An important advantage of the Wessex Head
The WHIM is an objective tool. Operational
Injury Matrix is that it can register behaviours
used in daily activities, and specifically in com- definitions for each behaviour state clearly the
munication, which is directly relevant to the care criteria by which a behaviour is judged to occur.
and rehabilitation of people recovering from The disadvantage of the definitions is that they
may be perceived as rigid and preclude record-
ing of significant behaviours which do not reach
Clinical messages these criteria. However, the behavioural nature
of the scale makes it user-friendly for description
• The development of a new assessment to and communication. With regard to monitoring
assess patients and monitor progress after treatment efficacy, the situation is less clear. The
severe head injury is described. WHIM does record change, but whether this is a
• The scale is administered by observation. result of treatment or of natural recovery is likely
The scale is sensitive to subtle changes in to depend on the individual patient concerned.
behaviour and is appropriate for assess- Given that the order of recovery is not absolute,
ment of both slow and rapid recovery of the WHIM should be used with caution in
function. attempting to differentiate between natural
• A sequence of behavioural recovery after recovery and change that has occurred as a result
head injury is proposed. of intervention. Neither should it be assumed that
precisely the same sequence of behaviours is
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