QOLIBRI Overall Scale: A brief index of health-related quality of life after
traumatic brain injury
Nicole von Steinbuechel (1), Lindsay Wilson (2), Holger Muehlan (3), Holger Schmidt
(4), Henning Gibbons (1) and the QOLIBRI Task Force
1. Department of Medical Psychology and Medical Sociology, Georg-August-University,
2. Division of Psychology, University of Stirling, Stirling, UK
3. Department of Health and Prevention, University of Greifswald, Greifswald, Germany
4. Department of Neurology, University Medical Center, Göttingen, Germany
Members of the QOLIBRI Task Force: Nicole von Steinbuechel (Chair of Methodological Group,
Germany), Henning Gibbons (Germany), Silke Schmidt (Germany), Nadine Sasse (Germany), Sanna
Koskinen (Finland), Jaana Sarajuuri (Finland), Stefan Höfer (Austria), Monika Bullinger (Germany),
Andrew Maas (Belgium), Edmund Neugebauer (Germany), Jane Powell (UK), Klaus von Wild
(Germany), Lindsay Wilson (UK), George Zitnay (USA), Wilbert Bakx (Netherlands), Anne-Lise
Christensen (Denmark), Rita Formisano (Italy), Graeme Hawthorne (Australia), Jean-Luc Truelle
(Chair of Steering Committee, France).
NvS and LW are joint first authors.
Please address correspondence to:
Lindsay Wilson, Department of Psychology, University of Stirling, Stirling FK9 4LA, UK. Tel: +44 1786
467658; Fax: +44 1786 467641: Email: firstname.lastname@example.org
Nicole von Steinbuechel, Department of Medical Psychology and Medical Sociology
Georg-August-University, Waldweg 37, D- 37073 Göttingen, Germany.
Tel: +49 551 39 8192; Fax: +49 551 39 8194; Email: email@example.com
Nicole von Steinbuechel, Department of Medical Psychology and Medical Sociology
Georg-August-University, Waldweg 37, D- 37073 Göttingen, Germany.
Tel: +49 551 39 8192; Fax: +49 551 39 8194; Email: firstname.lastname@example.org
Lindsay Wilson, Department of Psychology, University of Stirling, Stirling FK9 4LA, UK. Tel: +44 1786
467658; Fax: +44 1786 467641: Email: email@example.com
Holger Muehlan, Department of Health and Prevention, University of Greifswald, Robert-Blum-Str. 13,
D-17487 Greifswald, Germany. Tel: +49 3834 863802; Fax: +49 3834 863801; Email:
Holger Schmidt, Department of Neurology & Department of Medical Psychology and Medical
Sociology University Medical Center Göttingen, Robert-Koch-Str. 40, D- 37075 Göttingen, Germany.
Tel: +49 551 39 22355; Fax: +49 551 39 8504; Email: firstname.lastname@example.org
Henning Gibbons, Department of Medical Psychology and Medical Sociology
Georg-August-University, Waldweg 37, D- 37073 Göttingen, Germany. Tel: +49 551 39 8198; Fax:
+49 551 39 8194; Email: Henning.Gibbons@med.uni-goettingen.de
Wilbert Bakx, Rehabilitation Foundation Limburg, Hoensbroeck Rehabilitation Centre, Hoensbroek and
Maastricht University, Faculty of Health Sciences, Maastricht, The Netherlands. Tel: : +31 45 52 82-34
0; Fax: ++ 31 45 52 82-34 7 Email: email@example.com
Monika Bullinger, Institut und Poliklinik für Medizinische Psychologie, Zentrum für Psychosoziale
Medizin, Universtitätsklinikum Hamburg-Eppendorf, Martinistr. 52, Haus S 35, 20246 Hamburg,
Germany.Tel: +49 (0) 40 / 42803-2863/ -6430; Fax: + 49(0) 40 / 42803-4940/-4965; Email:
Anne-Lise Christensen, Centre for Rehabilitation of Brain Injury and Centre for Cognition and Memory,
University of Copenhagen, 88 Njalsgade, Copenhagen, Denmark. Tel: +45 39 65 59 53; Fax : +45 39
65 09 80 ; Email: firstname.lastname@example.org
Rita Formisano, Primario Unità Post-Coma, Ospedale di Riabilitazione Fondazione Santa Lucia, Via
Ardeatina 306 – 00179, Roma (Italy). Tel.: +39-06 5150 1680; Fax: +39-06 5150 1752; Email:
Graeme Hawthorne, Department of Psychiatry, The University of Melbourne, Level 1 North, Royal
Melbourne Hospital, Grattan Street, Parkville, Victoria, AUSTRALIA, 3050. Tel: +61 3 8344 5467; Fax:
N/A; Email email@example.com
Stefan Höfer, Department of Medical Psychology, Innsbruck Medical University, Schoepfstr. 23a, A-
6020 Innsbruck, Austria. Tel: +43 512 504 26227; Fax: +43 512 504 26232; Email: Stefan.Hoefer@i-
Sanna Koskinen, Head of the Unit of Clinical Neuropsychology and Psychology
Käpylä Rehabilitation Centre, P.O. Box 103, FIN-00251 Helsinki, Finland. Tel:+358 (9) 777 071; Fax:
+358 (9) 777 071; E-mail: firstname.lastname@example.org; mail: Sanna.Koskinen@invalidiliitto.fi
Andrew Maas, Department of Neurosurgery, University Hospital Antwerp, Wilrijkstraat 10, 2650
Edegem (Belgium). Tel:. 00-32-3-821-4632; Fax:. 00-32-3-825-2428; Email email@example.com
Edmund Neugebauer, Institute for Research in Operative Medicine, University of Witten/Herdecke,
Ostmerheimer Straße 200, 51109 Cologne,Germany
Tel: +49 221 98957-0; Fax: +49 221 98957-30; Email: firstname.lastname@example.org
Jane Powell, Dept of Psychology, University of London, Lewisham Way, New Cross, London SE14
Tel : +44 (0) 207 919 7871; Fax : +44 (0) 207 919 7873; Email: email@example.com
Jaana Sarajuuri, Unit of Clinical Neuropsychology and Psychology, Käpylä Rehabilitation Centre, P.O.
Box 103, FIN-00251 Helsinki, Finland. Tel: +358 (9) 77707 283; Fax: ++358 9 794 734; Email:
Nadine Sasse, Department of Medical Psychology and Medical Sociology
Georg-August-University, Waldweg 37, D- 37073 Göttingen, Germany. Tel: +49 551 39 8192; Fax:
+49 551 39 8194; Email: firstname.lastname@example.org
Silke Schmidt, Department of Health and Prevention, University of Greifswald, Robert-Blum-Str. 13, D-
17487 Greifswald, Germany. Tel: +49 3834 863800; Fax: +49 3834 863801; Email:
Jean-Luc Truelle Rehabilitation department University Hospital F 92380 Garches, France. Tel/Fax:
+331 42 08 67 88; Email: email@example.com
Klaus von Wild, Medical Faculty, Westfälische Wilhelms-University, Münster, NRW Frauenburgstrasse
32, D 48155 Germany. Tel: +49 251 39 777 50; Fax: +49 251 39 777 51 Email: firstname.lastname@example.org
George Zitnay, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. Tel: 001
804 96; Fax: +1 (804) 293204; Email: email@example.com
Contributors: NvS initiated the collaboration, planned the study, analysed the data and drafted the
paper. LW analysed the data and drafted the paper. They contributed equally to the paper and are
joint guarantors. HS was reponsible for data collection in Germany and drafting the paper. HM and HG
analysed the data and drafted the paper. All members of QOLIBRI task force revised the draft paper,
and approved the final version. In addition NS, SK ,JP, GZ, WB, RF, GH implemented the study in,
respectively, Germany, Finland, UK, USA, Netherlands, Italy, and Australia. JLT chaired the steering
committee, and implemented the study in France.
Background: The Quality of Life after Brain Injury (QOLIBRI) scale is a recently
developed instrument that provides a profile of health-related quality of life (HRQoL)
in domains typically affected by brain injury. However, for some purposes it is
desirable to have a brief summary measure. This study examined a six-item
QOLIBRI Overall Scale (QOLIBRI-OS), and considered whether it could provide an
index of HRQOL after traumatic brain injury.
Methods: The properties of the QOLIBRI-OS were studied in a sample of 792
participants with traumatic brain injury (TBI) recruited from centres in nine countries
covering six languages. An examination of construct validity was undertaken on a
sub-sample of 153 participants recruited in Germany who had been assessed on two
relevant brief quality of life measures: the Satisfaction With Life Scale and the Quality
of Life Visual Analogue Scale.
Results: The reliability of the QOLIBRI-OS was good (Cronbach‟s =0.86, test-
retest reliability=0.81), and similar in participants with higher and lower cognitive
performance. Factor analyses indicated that the scale is unidimensional. Rasch
analysis also showed a satisfactory fit with this model. The QOLIBRI-OS correlates
highly with the total score from the full QOLIBRI scale (r=0.87). Moderate to strong
relationships were found between the QOLIBRI-OS and the GOSE, SF-36, and
Hospital Anxiety and Depression scale (r=0.54 to - 0.76). The QOLIBRI-OS showed
good construct validity in the TBI group.
Conclusion: The QOLIBRI-OS assesses a similar construct to the QOLIBRI total
score and can be used as brief index of HRQoL for TBI.
Key words: Traumatic brain injury, outcome, health-related quality of life.
After traumatic brain injury (TBI) difficulties are commonly present in physical,
cognitive, emotional, psychosocial and daily life domains.1-3 Outcome assessment
after TBI has traditionally focused on functional status, but over recent years there
has been increasing awareness of the need to supplement assessment of functional
status by measures that capture the patient‟s own perspective on quality of life
(QoL).4 Patient reported outcome (PRO) instruments are being been advocated
generally for use in the evaluation of interventions,5 they are an emerging area in TBI
research,6 and they are used increasingly in the clinical context.
A desire to measure PROs has lead to growing use of tools to assess health-
related quality of life (HRQoL) in brain injury.7 8 HRQoL measures address the
consequences of health conditions for QoL, rather than assessing general QoL, and
they are particularly appropriate when the aim is to understand the effects of a
condition such as TBI. The Quality of Life after Brain Injury (QOLIBRI) assessment is
a recently developed descriptive system for HRQoL after TBI.9 10 The QOLIBRI was
created in response to the need for a comprehensive disease-specific measure for
TBI,11 and was constructed simultaneously in six languages by an international
multidisciplinary team. The process of development was guided by the WHO concept
of QoL,12 and a model proposed by von Steinbüchel et al.13 The final version of the
QOLIBRI is a 37-item scale with six subscales covering areas of well-being and
functioning that are typically affected by TBI. The areas include the domains
“cognition” and “self” that are not contained in generic health status measures such
as the SF-36.14 The QOLIBRI has satisfactory psychometric properties and provides
information about outcome additional to that given by the SF-36 or the GOSE.9 10 15
The QOLIBRI offers a profile of HRQoL after TBI, but for some purposes a
single overall score is all that is required. Short assessments are popular in research
studies and clinical work, and they are particularly useful in TBI because patient
fatigue is often a problem16 and cognitive impairment may interfere with attention and
Single-item measures of QoL have been used in TBI studies17 18, but there is
wide variation in question format and options for response. Diener19 criticized single
item measures, noting among other shortcomings that they are inherently unreliable
and that they leave the patient to integrate different aspects of QoL. In practice some
participants may simply choose to respond on the basis of their current emotional
state. Multiple-item questionnaires generally prove to have better psychometric
properties, and the most widely used in TBI is the Satisfaction With Life Scale
(SWLS).20 The SWLS is a 5-item scale which has been suggested as a potential
“gold standard” in the assessment of subjective QoL in disability,21 and was recently
identified as a core outcome measure for TBI.6 The SWLS has been shown to be
robust psychometrically in a variety of groups,22 but there is no formal validation in
the TBI population. In fact the SWLS may not be entirely appropriate for use after
TBI: the questions do not specifically refer to life after brain injury, but evaluate the
whole life course,23 and the last item (Item 5: “If I could live my life over, I would
change almost nothing”) might appear incongruous to someone who has suffered a
The QOLIBRI includes a total score from all 37-items, which provides a
summary of HRQoL. In parallel with the development of the 37-item QOLIBRI
questionnaire we included a 6-item QOLIBRI Overall Scale (QOLIBRI-OS). The
current study had three aims: (1) to determine whether the QOLIBRI-OS has
satisfactory psychometric properties; (2) to examine whether this brief 6-item HRQoL
scale is comparable with 37-item QOLIBRI total score; and (3) to study the construct
validity of the QOLIBRI-OS in comparison with other brief wellbeing instruments.
The psychometric properties of the QOLIBRI-OS were examined in an
international data set, involving 792 participants after TBI predominantly recruited as
convenience samples from centres in nine countries covering six languages (Dutch,
English, Finnish, French, German, and Italian) and described in detail elsewhere.10
The analysis of construct validity was undertaken on a sub-sample of 153
participants recruited in Germany who had been assessed on relevant brief QoL
measures. The characteristics of these samples are shown in Table 1.
< Insert Table 1 about here >
The questionnaires were administered by self-report (mail, or participant
present at the clinic), face-to-face interview, or administration over the telephone (see
Table 1). In the case of face-to-face contact the GOSE and interviewer checklist were
completed at the same time. If the questionnaires were mailed then the GOSE and
clinician checklist were completed by telephone interview. Test-retest reliability was
investigated in a subsample of 375 participants by repeat administration after an
interval of two weeks.
Inclusion criteria for the study were: aged 15 years or older at time of injury, 3
months to 15 years post-injury, diagnosis of TBI on ICD-10 criteria, and able to give
informed consent. Exclusion criteria were: GOSE 3, spinal cord injury, the presence
of a significant current or pre-injury psychiatric condition or ongoing severe addiction,
a diagnosed terminal illness, and inability to understand, cooperate and answer
questions. Participating centres obtained local ethics approval.
TBI-specific HRQoL was captured by the QOLIBRI.9 10 The scale provides a
profile of HRQoL in six areas: “Cognition”, “Self”, “Daily life and Autonomy”, “Social
Relationships”, “Emotions, and “Physical Problems”. Satisfaction or feeling bothered
with items in each of these domains is assessed on a five-point scale. Before
completing the QOLIBRI participants filled in the QOLIBRI-OS. Six items were used
to assess overall satisfaction with facets of life relevant to people with TBI (Appendix
Measures were included from three areas relevant to assessing scale validity:
self-rated health status was assessed by the SF-36 Health Survey (Version 114) and
summarized as Physical and Mental Component scores. Emotional distress and
symptoms were assessed with the Hospital Anxiety and Depression scale (HADS25).
Disability was assessed by the GOSE.26
Two brief measures of quality of life and wellbeing were included in the
instruments administered to the German language sample. A Quality of Life Visual
Analogue Scale (QoL-VAS)27 was chosen as a representative single-item QoL
measure. Participants are asked to estimate their QoL over the past week by marking
a scale between “Worst imaginable QoL” and “Perfect QoL”. The position of the mark
is measured with a ruler to give a QoL score. The QoL-VAS has been shown have
satisfactory reliability and validity in cancer patients.27 The SWLS20 was included
because it is a popular multi-item wellbeing assessment. Given potential cognitive
issues among those with TBI we simplified its administration by using five response
options rather than seven. The internal consistency of this modified scale was high (
=0.89) and comparable with the original scale.22 However, we found that reliability in
a TBI sample was even greater ( =0.94) when the last item was deleted, suggesting
that this item does not fully fit the construct in our sample.24 In the analysis we
therefore examined the SWLS both with 5 items and with 4 items (item 5 excluded).
Demographic characteristics, current health conditions, and clinical data for
participants were collected at interview and from case notes. The information taken
from case notes included the date of injury, cause of injury, site of major head injury,
and the worst GCS score in the first 24 hours.
Cognitive status was measured in a subsample of participants using either the
Mini Mental State Examination (MMSE)28 or the Telephone Interview for Cognitive
Status (TICS) screening instruments.29 Cut offs on the TICS and MMSE of 32/33 and
27/28, respectively, were used to define groups with lower and higher cognitive
We used both classical psychometric and item response theory approaches for scale
construction. The steps are summarised below, and a detailed rationale is given
elsewhere.9 10 Unless otherwise noted, analyses were carried out using
(a) Item level.
An endorsement index12 was calculated (items are considered problematic if
they have less than 10% of responses in two adjacent categories for at least half the
language versions), and item frequencies were inspected for floor and/or ceiling
effects (>60% of cases at the maximum or the minimum of the scale). Means were
calculated for each item, and skewness examined; conventionally, items with
skewness >1 are considered for removal.
(b) Scale reliability & unidimensionality.
Internal consistency was assessed using Cronbach‟s . An of 0.70 is
regarded as acceptable for group comparisons,30 and over 0.90 is desirable for
individual clinical applications.31 The fit of items was examined using corrected item-
total correlations (CITCs). CITCs conventionally should be over 0.40.12
To test the assumption of unidimensionality of the QOLIBRI-OS we applied
both exploratory and confirmatory factor analysis (CFA). First, dimensionality was
examined using principal component analysis (PCA) with a forced single-factor
solution. Second, for the CFA we used structural equation modelling (SEM, maximum
likelihood method) to evaluate the fit of the data to a single-factor model.
Conventional criteria for SEM fit are that the comparative fit index (CFI) should be
above 0.95 and that the root mean square error of approximation (RMSEA) should be
close to or below 0.06.32
Rasch analysis was carried out using Winsteps 3.66. The analysis assessed
scale reliability (person separation index) and the fit of items to the Rasch model. For
large sample sizes the mean square is preferred to the Z statistic as a measure of fit,
and satisfactory fit is indicated by values between 0.70 and 1.30.33
Test-retest reliability was assessed using intra-class correlation (ICC). ICC values
of 0.40 to 0.75 are interpreted as fair to good, and values over 0.75 as excellent.34
Differences between groups were interpreted using Cohen‟s d effect size. 35
(c) Scale validity
The validity of the QOLIBRI-OS was examined through Spearman correlations with
the QOLIBRI and with other outcome measures. Steiger‟s test 36 was used to assess
whether correlations were significantly different.
There were very few missing responses on QOLIBRI-OS items (0% to 0.25%; no
more than one item per participant). All items met the endorsement criterion, and no
item showed ceiling or floor effects. All items showed some skewness, but this was
within acceptable limits (range -0.12 to -0.52). The skew indicated positive HRQoL.
CITCs ranged from 0.59 to 0.69.
< Insert Table 2 about here >
Cronbach‟s was 0.86 which was excellent for a six-item scale. Internal consistency
was also satisfactory to good in the six language versions (see Table 2). In a
subsample of 274 participants, either MMSE or TICS scores were available. Internal
consistency of the QOLIBRI-OS was similar in subgroups with lower cognitive
performance (N=103; TICS<33 or MMSE<28) and higher cognitive performance
(N=171; TICS>32 or MMSE>27) (see Table 2). Table 2 also indicates very good test-
retest reliability of the scale in the total sample. Test-retest reliability (ICCs) was
measured in five language groups and was satisfactory to good. Test-retest reliability
was also comparably good in the groups of participants with lower and higher
cognitive performance. The QOLIBRI-OS sum score significantly increased from first
to second assessment, but the effect size was very small (d=0.07).
A single-factor solution from the PCA had an Eigenvalue of 3.51 and
accounted for 59% of the variance. Loadings on the first component indicated that all
items had high loadings (0.71 - 0.80), and suggested unidimensionality for the
QOLIBRI-OS item set. CFA demonstrated that a model with one underlying factor
had a reasonable fit (CFI = 0.983; RMSEA = 0.066; χ2 = 39.624, df = 9, p[χ2]<0.001),
although, not unexpectedly with a large sample size, the p-value of chi-square
< Insert Table 3 about here >
On Rasch analysis the person separation index was 2.46 and reliability was
0.86, indicating a good ability to sort respondents into different levels of HRQoL. All
items had correctly ordered category and threshold measures. The values of infit and
outfit shown in Table 3 are well within criteria for fit to the Rasch model. Item location
measures ranged from -0.56 logits for the “Daily life item” (i.e. the easiest to endorse
positively) to 0.34 logits for Cognition (i.e. the hardest to endorse positively). The
relatively limited range of item locations indicates that distributions of responses to
different items were similar.
< Insert Figure 1 about here >
The relationship of the QOLIBRI-OS to the QOLIBRI
The QOLIBRI-OS correlated strongly with the QOLIBRI total score (rho=0.87),
indicating that essentially the same construct was being measured. The QOLIBRI-OS
score was also strongly related to all QOLIBRI scales: the Self scale (rho=0.81,
p<.001), the Daily Life and Autonomy scale (rho=.75, p<.001), the Cognition scale
(rho=.74, p<.001) the Social Relationships scale (rho=.626, p<.001), Physical
Problems (rho=.597, p<.001) and the Emotions scale (rho=0.56 p<.001). All
QOLIBRI-OS items showed strong positive correlations with the QOLIBRI total score
(rho=0.64 to rho=0.70), suggesting that the QOLIBRI-OS items contributed equally to
assessment of the HRQoL construct.
The relationship between the QOLIBRI total score and the QOLIBRI-OS is
shown in Figure 1. The scatterplot indicates that scores obtained are strongly related,
but the measures are clearly not identical. The mean score for the QOLIBRI-OS was
58.0% (SD= 21.5) and the mean QOLIBRI total from the full instrument was 64.6%
(SD= 18.2). The mean score on the QOLIBRI-OS was significantly lower than the
QOLIBRI total score (t= 17.3, df= 791, p< 0.001), and the standard deviation on the
QOLIBRI-OS was significantly larger (F-test, p< 0.0001). The coefficient of variation
of the QOLIBRI-OS was larger than for the QOLIBRI total: 0.37 (95% CIs: 0.35-0.39)
versus 0.28 (95% CIs: 0.27-0.30). Thus, in keeping with the use of a smaller set of
items, variation was greater on the 6-item scale than the 37-item scale.
< Insert Tables 4 and 5 about here >
The relationship of QOLIBRI-OS with other outcome assessments
This analysis was conducted using the German language sample, and scale scores
for this group are given in Table 4. Table 5 shows the relationships of QOLIBRI-OS to
age, GCS injury severity, and three outcome assessments that are relevant to
construct validity (GOSE, SF-36, and HADS). For comparison the same relationships
are shown for the QOLIBRI total score and the SWLS and QoL-VAS. Since the
internal consistency of the SWLS was better with the last item removed we included
a 4-item version of the SWLS in the comparison.
Relationships between the QOLIBRI-OS and age and injury severity were
weak and not statistically significant (rho <0.20). In contrast the scale showed strong
relationships with outcome assessments (rho >0.50). The strongest relationships
were with HADS Depression and Anxiety scores, and the SF-36 Mental Component
score, confirming the importance of mood and mental health for HRQoL. However,
there were also strong relationships (rho >.50) with the GOSE and the SF-36
Physical Component score, indicating that disability and physical health were strongly
associated with responses on the QOLIBRI-OS. The QOLIBRI-OS and QOLIBRI total
score showed very similar relationships with age, GCS, GOSE, SF-36, and HADS
supporting the idea that the two are measuring the same HRQoL construct. The
SWLS shows a similar pattern of correlations, but if anything these are somewhat
less strong, particularly for the conventional 5-item version (Table 5): the correlations
for the 5-item SWLS are significantly lower than the QOLIBRI-OS with the GOSE
(z=2.29, p<.05), the PCS (z=3.09, p<.01), and the HADS Anxiety scale (z=3.03,
p<.01). Table 5 suggests that removing the last item could possibly improve the
validity of the SWLS for participants with TBI. In general the correlations of QoL-VAS
with the other outcome assessments are weaker than with the QOLIBRI measures,
and it has the weakest relationship with the GOSE (rho =0.32, z for the comparison
with QOLIBRI-OS=3.29, p<.01).
The study demonstrated that the QOLIBRI-OS has satisfactory psychometric
properties. The internal consistency and test-retest reliability of the scale are
acceptable and appear unaffected by cognitive status, at least in this sample. Indeed
the reliability is good for a short scale assessing six areas of HRQoL. Furthermore,
both, factor and Rasch analysis indicate that the scale is essentially unidimensional.
All of the items in the QOLIBRI-OS are presented as „satisfaction‟ judgements.
Satisfaction judgements are intended to encourage an element of self-reflection in
contrast to simply asking people to report feelings that they experience. We were
concerned that in places this construction might seem a bit strained: for example,
asking people to report satisfaction with their emotional state. However, the
psychometric tests indicated that all the items had a good fit with the construct.
Analysis showed that the scale was highly correlated with the total score from
the full QOLIBRI. It was noted that the coefficient of variation was higher with the
short scale than the full QOLIBRI, and the absolute values obtained on the short
scale were lower. Bearing these points in mind the QOLIBRI-OS can be considered
as a tool when a short index of HRQoL after TBI is needed. The full QOLIBRI is a
comprehensive HRQoL assessment, but the QOLIBRI-OS may be useful for
screening purposes or in situations where workload has to be minimal. The QOLIBRI-
OS scale was related particularly strongly to the first three QOLIBRI subscales
(Cognition, Self, Daily Life & Autonomy). As such it captures areas such as cognition
and changes in the self that are relevant to TBI and not well assessed by popular
measures of generic HRQoL or self-rated health status such as the SF-36.
The issue of the potential influence of cognitive impairment on QoL
judgements is important,37 but remains relatively unexplored in the TBI literature. In
this study we employed the MMSE or TICS as screening measures for cognitive
impairment, and this allowed us to divide patients into those performing at a lower
and higher level. However, the MMSE and TICS were not designed to give
differentiated diagnoses for different types of cognitive impairment after head injury.
In our study they showed ceiling effects consistent with lack of sensitivity to cognitive
impairment in TBI. Furthermore they do not assess all aspects of cognition that are
important in HRQoL judgements. Level of insight is commonly supposed to be of
particular importance, but it remains an aspect of cognition that is difficult to
operationalize. Concern about the influence of cognitive impairment is likely to be one
of the main reservations about the use of PROs in TBI. Within the constraints of the
present methodology we found that cognitive impairment did not influence the
reliability of the QOLIBRI-OS scale, and as a very short assessment it may lend itself
for use with patients with cognitive impairment.
In addition to issues already mentioned, the current study had a number of
other limitations. Responsiveness to change is an important characteristic that was
not possible to investigate in the current design. Most assessments were carried out
late after injury (3-15 years), at a time when acceptance and coping may have been
quite complete. Overall ratings, and the associations with functional scales may be
very different at earlier phases. These issues thus await further investigation. The
samples from different countries were not matched for clinical and demographic
characteristics, and this limited direct comparisons between different language
versions of the scale. The majority of the cases were recruited through brain injury
rehabilitation centres, and there are evidently substantial inter-country differences in
admission policies for rehabilitation making matching of samples particularly difficult.
A further shortcoming of this study is the lack of morphological information on the
extent and localization of brain injury as a factor possibly influencing HRQoL.
The QOLIBRI-OS showed expected patterns of relationships with other
measures, confirming the construct validity of the scale. There was a strong
relationship with the GOSE, indicating that the scale was sensitive to disability
caused by TBI. There were also strong relationships with the two component scores
on the SF-36, suggesting the importance of physical and mental health to HRQoL.
However, there is little value in adding another measure of HRQoL to an
already crowded and confusing field unless it is more useful than currently available
measures. We have argued elsewhere that the QOLIBRI covers areas not included in
generic measures such as the SF-36.9 In this study we compared the QOLBRI-OS
with two other brief assessments of QoL. The QoL-VAS showed a relatively weak
association with the GOSE, suggesting that it was relatively insensitive to TBI-related
disability. Single item measures are likely to be less reliable and this may also
contribute to the weaker relationships observed for the QoL-VAS. The SWLS is a
popular and well accepted measure of QoL after TBI.6 38 However, there are issues
with its use as a measure of HRQoL. Like others 24 we found that one of the SWLS
items did not fit the construct fully. The SWLS encourages survey of the whole life
course, rather than evaluating the specific effects of TBI, and is perhaps best
regarded as reflecting general wellbeing. In conclusion the QOLIBRI-OS fills a gap in
the brief assessments currently available to measure health-related quality of life
after traumatic brain injury.
This work was supported by research grant 2008014 from the ZNS – Hannelore Kohl
Foundation, Germany. The Australian data were collected under a grant from the
Victorian Accident Commission.
1. Dikmen SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to 5 years after
moderate to severe traumatic brain injury. Archives of Physical Medicine and
2. Ponsford JL, Olver JH, Curran C. A profile of outcome - 2 years after traumatic
brain injury. Brain Injury 1995;9(1):1-10.
3. Hoofien D, Gilboa A, Vakil E, Donovick PJ. Traumatic brain injury (TBI) 10-20
years later: a comprehensive outcome study of psychiatric symptomatology,
cognitive abilities and psychosocial functioning. Brain Injury 2001;15(3):189-
4. Dijkers MP. Quality of life after traumatic brain injury: A review of research
approaches and findings. Archives of Physical Medicine and Rehabilitation
5. US Food and Drug Administration. Guidance for Industry: Patient-Reported
Outcome Measures: Use in Medical Product Development to Support Labeling
6. Wilde EA, Whiteneck GG, Bogner J, Bushnik T, Cifu DX, Dikmen S, et al.
Recommendations for the use of common outcome measures in traumatic
brain injury research. Archives of Physical Medicine and Rehabilitation
7. von Steinbüchel N, Richter S, Morawetz C, Riemsma R. Assessment of subjective
health and health-related quality of life in persons with acquired or
degenerative brain injury. Current Opinion in Neurology 2005;18(6):681-691.
8. Nichol AD, Higgins AM, Gabbe BJ, Murray LJ, Cooper DJ, Cameron PA.
Measuring functional and quality of life outcomes following major head injury:
Common scales and checklists. Injury 2011;42 281-287.
9. von Steinbuechel N, Wilson L, Gibbons H, Hawthorne G, Höfer S, Schmidt S, et al.
Quality of Life after Brain Injury (QOLIBRI): Scale validity and correlates of
quality of life. Journal of Neurotrauma 2010.
10. von Steinbuechel N, Wilson L, Gibbons H, Hawthorne G, Höfer S, Schmidt S, et
al. Quality of Life after Brain Injury (QOLIBRI): Scale development and metric
properties. Journal of Neurotrauma 2010.
11. Berger E, Leven F, Pirente N, Bouillon B, Neugebauer E. Quality of life after
traumatic brain injury: A systematic review of the literature. Restorative
Neurology and Neuroscience 1999;14(2-3):93-102.
12. Power M, Kuyken W, Orley J, Herrman H, Schofield H, Murphy B, et al. The
World Health Organization Quality of Life assessment (WHOQOL):
Development and general psychometric properties. Social Science & Medicine
13. von Steinbüchel N, Petersen C, Bullinger M, the QOLIBRI Group. Assessment of
health-related quality of life in persons after traumatic brain injury –
development of the Qolibri, a specific measure Acta Neurochirurgica
14. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and
Interpretation Guide. Boston: New England Medical Center, The Health
15. Truelle JL, Koskinen S, Hawthorne G, Sarajuuri J, Formisano R, Von Wild K, et
al. Quality of life after traumatic brain injury: the clinical use of the QOLIBRI, a
novel disease-specific instrument. Brain Injury 2010;24(11):1272-1291.
16. Olver J, Ponsford J, Curran C. Outcome following traumatic brain injury: A
comparison between 2 and 5 years after injury Brain Injury. 1996;10:841–848.
17. Heinemann AW, Whiteneck GG. Relationships among impairment, disability,
handicap, and life satisfaction in persons with traumatic brain injury. Journal of
Head Trauma Rehabilitation 1995;10(4):54-63.
18. Steadman-Pare D, Colantonio A, Ratcliff G, Chase S, Vernich L. Factors
associated with perceived quality of life many years after traumatic brain
injury. Journal of Head Trauma Rehabilitation 2001;16(4):330-342.
19. Diener E. Subjective wellbeing. Psychological Bulletin 1984;95(3):542–75.
20. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale.
Journal of Personality Assessment 1985;49:71-75.
21. Brown M, Gordon WA. Empowerment in measurement: "Muscle," "Voice," and
subjective quality of life as a gold standard. Archives of Physical Medicine and
22. Pavot W, Diener E. Review of the Satisfaction With Life Scale. Psychological
23. Johnston MV, Goverover Y, Dijkers M. Community activities and individuals'
satisfaction with them: Quality of life in the first year after traumatic brain
injury. Archives of Physical Medicine and Rehabilitation 2005;86(4):735-745.
24. Heinemann AW, Corrigan JD, Moore D. Case management for traumatic brain
injury survivors with alcohol problems. Rehabilitation Psychology
25. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta
Psychiatrica Scandinavica 1983;67(6):361-370.
26. Wilson JTL, Pettigrew LEL, Teasdale GM. Structured interviews for the Glasgow
Outcome Scale and Extended Glasgow Outcome Scale: Guidelines for their
use. Journal of Neurotrauma 1998;15:573-585.
27. de Boer A, van Lanschot JJB, Stalmeier PFM, van Sandick JW, Hulscher JBF, de
Haes J, et al. Is a single-item visual analogue scale as valid, reliable and
responsive as multi-item scales in measuring quality of life? Quality of Life
28. Folstein MF, Folstein SE, McHugh PR. "Mini-mental State": A practical method of
grading the cognitive state of patients for the clinician. Journal of Psychiatric
29. Brandt J, Spencer M, Folstein M. The Telephone Interview for Cognitive Status.
Neuropsychiatry Neuropsychology and Behavioral Neurology 1988;1(2):111-
30. Moosbrugger H, Kaleva A, editors. Testtheorie und Fragebogenkonstruktion.
Heidelberg: Springer, 2007.
31. Bland JM, Altman DG. Cronbach's alpha. British Medical Journal
32. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis:
Conventional criteria versus new alternatives Structural Equation Modeling,
33. Smith AB, Rush R, Fallowfield LJ, Velikova G, Sharpe M. Rasch fit statistics and
sample size considerations for polytomous data. BMC Medical Research
34. Fleiss JL. The Design and Analysis of Clinical Experiments. New York: Wiley,
35. Cohen J. Statistical power analysis for the behavioural sciences. Hillsdale:
Lawrence Erlbaum, 1988.
36. Steiger JH. Tests for comparing elements of a correlation matrix. Psychological
37. Riemsma RP, Forbes CA, Glanville JM, Eastwood AJ, Kleijnen J. General health
status measures for people with cognitive impairment: learning disability and
acquired brain injury. Health Technol Assess 2001;5(6):1-100.
38. Dijkers MP, Harrison-Felix C, Marwitz JH. The Traumatic Brain Injury Model
Systems: History and Contributions to Clinical Service and Research. Journal
of Head Trauma Rehabilitation 2010;25(2):81-91.
Table 1. Characteristics of the samples of patients with TBI
N 792 153
Male 570 (72%) 103 (67%)
Female 222 (28%) 50 (33%)
17-30 270 (34%) 33 (22%)
31-44 247 (31%) 28 (18%)
45-68 275 (35%) 92 (60%)
Highest educational qualification
Diploma or degree 260 (35%) 49 (32%)
Technical or trade certificate 216 (29%) 55 (36%)
School / other 260 (35%) 48 (33%)
GCS (24 h worst)
Severe: 3-8 463 (58%) 40 (26%)
Moderate: 9-12 75 (10%) 17 (11%)
Mild: 13-15 254 (32%) 96 (63%)
None 116 (15%) 36 (24%)
Focal 416 (53%) 108 (73%)
Diffuse 250 (32%) 4 (3%)
Years since injury
<1 yr 93 (12%) 19 (12%)
1 - <2 yrs 102 (13%) 23 (15%)
2 - <4 yrs 202 (26%) 50 (33%)
4 - 18 yrs 392 (50%) 61 (40%)
Current 255(33%) 6(4%)
Previous 394(51%) 79(52%)
No rehab 128(16%) 68(44%)
Employed full-time 168 (23%) 60 (39%)
Single 301 (41%) 27 (18%)
Partnered 349 (47%) 111 (73%)
Past partnered 90 (12%) 14 (9%)
Independent 418 (57%) 111 (73%)
Supported 319 (43%) 42 (27%)
Number of comorbid health conditions
0-3 314 (41%) 63 (41%)
4-6 225 (29%) 39 (26%)
7 and more 234 (30%) 51 (33%)
Self-reported health status
Healthy 528 (72%) 96 (64%)
Unhealthy 202 (28%) 55 (36%)
GOSE at follow-up
Severe disability (3-4) 143 (18%) 13 (8%)
Moderate disability (5-6) 432 (54%) 53 (34%)
Good recovery (7-8) 217 (28%) 87 (57%)
Self-completed, face-to-face 240 (30%) 4 (3%)
Self-completed, mail 323 (41%) 149 (97%)
Interview, face-to-face 215 (27%) 0
Interview, telephone 13 (2%) 0
Table 2. Cronbach‟s and test-retest reliability (ICC) of the QOLIBRI-OS for the total sample, separately for language versions and
subgroups with low and high MMSE/TICS scores.
Dutch English Finnish French German Italian Low
Table 3: Rasch analysis: Item location measure (logits) and Rasch fit statistics.
QOLIBRI-OS Items Item
Infit Infit Z Outfit Outfit Z
Physical condition 0.04 1.02 0.33 1.01 0.17
Cognition 0.29 1.15 2.86 1.14 2.74
Emotions -0.05 1.02 0.33 0.99 -0.18
Daily Life -0.56 0.86 -2.81 0.86 -2.72
Personal/Social 0.0 0.92 -1.56 0.91 -1.77
Current situation/ Future
0.28 0.98 -0.37 0.99 -0.18
Table 4. Means and standard deviations of scales in the German language sample
(N=153). The scores on the SWLS have been adjusted to match the standard version
which is scored on a 5 to 35-point scale.
Scale Mean SD
QOLIBRI total (0-100) 71.82 17.24
QOLIBRI-OS (0-100) 64.73 20.80
SWLS (4-item) (5-35) 24.26 7.01
SWLS (5-item) (5-35) 24.03 6.76
QoL-VAS (0-100) 60.26 23.41
GOSE 6.54 1.28
SF36-Physical Component Score (T-score) 47.75 11.08
SF36-Mental Component Score (T-score) 46.51 11.18
HADS Anxiety (0-21) 5.88 4.11
HADS Depression (0-21) 5.41 4.16
Table 5. Spearman correlations in the German sample (N=153) of quality of life assessments with age, GCS, and outcome measures
relevant for construct validity.
QOLIBRI-OS -0.06 0.10 0.56** 0.53** 0.61** -0.65** -0.75**
SWLS (4 items) -0.05 0.06 0.49** 0.40**†† 0.56** -0.52**†† -0.74**
SWLS (5 items) 0.08 0.05 0.45**† 0.38**†† 0.54** -0.51**†† -0.70**
** p<0.001. Steiger‟s t-test (two-tailed) for a difference with the QOLIBRI-OS correlation:† p<.05, †† p<.01
0.07 0.01 0.32**†† 0.43** 0.49** -0.41**†† -0.54**††
Figure 1. Scatterplot of QOLIBRI-OS scores against QOLIBRI total scores. The fit
line is from linear regression and has R2=.76
29 Download full-text
QUALITY OF LIFE AFTER BRAIN INJURY – Overall Scale
We would like to know how satisfied you are with different aspects of your life since your brain injury.
For each question please choose the answer which is closest to how you feel now (including the past
week) and mark the box with an “X”. If you have problems filling out the questionnaire, please ask for
These questions are about how you feel overall now (including the
1. Overall, how satisfied are you with your physical condition?
2. Overall, how satisfied are you with how your brain is working, in terms
of your concentration, memory, thinking?
3. Overall, how satisfied are you with your feelings and emotions?
4. Overall, how satisfied are you with your ability to carry out day to day
5. Overall, how satisfied are you with your personal and social life?
6. Overall, how satisfied are you with your current situation and future
Not at all
Not at all