Rethinking How We Assess Traumatic Brain Injury: A New Framework for Better Care

As someone trained in the assessment and intervention of acute brain injury, I’ve seen firsthand how complex and varied recovery can be from one patient to the next. Traditionally, the medical community has relied on a few key tools to determine the severity of a brain injury, and while these tools have been helpful, they also have limitations—especially as our understanding of the brain continues to evolve.

Here’s a look at the core methods we’ve been using, and why the field is now moving toward a more complete and nuanced approach.

Traditional Tools for Assessing Brain Injury

There are four main ways we assess how serious a traumatic brain injury (TBI) is:

1. Length of Unconsciousness

How long a person remains unconscious after the injury is often the first clue about the severity of the damage.

2. Post-Traumatic Amnesia (PTA)

This is a temporary period of confusion and memory loss following a TBI. The person may be awake but unable to form new memories and may not remember where they are, what happened, or even basic information like the date or time. The longer the PTA, the more severe the injury is considered to be.

3. Rancho Los Amigos Scale (RLA)

This scale is used throughout rehab to track how a person is recovering cognitively and behaviorally. It ranges from no response (Level I) to purposeful and independent behavior (Level X) and helps guide care teams and families in understanding the recovery process.

4. Glasgow Coma Scale (GCS)

Since the 1970s, the GCS has been a go-to tool for paramedics and emergency teams. It rates patients based on their eye opening, verbal response, and motor response, assigning a score from 3 to 15:

• 13–15 = Mild TBI
  
  

• 9–12 = Moderate TBI
  
  

• 3–8 = Severe TBI
  

While GCS is incredibly useful in the early stages, it doesn’t capture the full complexity of brain injuries. Some people diagnosed with a “mild” concussion may go on to live with debilitating, long-term symptoms, while others with “severe” injuries may recover remarkably well. Clearly, a more personalized and thorough system is needed.

A New Era: The CBI-M Framework

In 2022, the U.S. National Institutes of Health–National Institute of Neurological Disorders and Stroke recognized this gap and launched an international initiative to improve how we classify brain injuries—especially in the early stages.

That’s where the CBI-M framework comes in. Developed by Dr. Geoffrey Manley from UCSF and a team of scientists, experts and TBI survivors, this new system expands our approach by looking at TBI from four critical angles:

🧠 Clinical

Still includes traditional GCS scores and pupillary reactivity—important basics for initial assessment.

🧪 Biomarkers

Measures specific proteins (like GFAP and UCH-L1) in the blood that are released after brain injury. These may be especially helpful in identifying “invisible” injuries.

🖥️ Imaging

CT and MRI scans give a deeper view of structural brain damage that might not be obvious through symptoms alone.

🧬 Modifiers

Takes into account other health conditions, the context of the injury, and even psychosocial factors that can affect recovery.

Why It Matters

This new approach could lead to:

• More accurate diagnoses
  

• Better-tailored treatments
  

• Fewer premature decisions, such as withdrawing life support
  

• Improved long-term outcomes, even for those with so-called "mild" injuries
  

While the CBI-M system still needs further research and testing before it becomes a clinical standard, it’s a huge step forward in making brain injury care more comprehensive and personalized.

Final Thoughts

Brain injuries are incredibly complex—and every person’s path to recovery is different. Our current tools like GCS and RLA have helped lay the foundation, but the future lies in embracing a multi-faceted, evidence-based approach like CBI-M. With continued research, we can move toward more accurate, compassionate, and effective care for everyone affected by TBI.

If you or a loved one is navigating brain injury recovery, stay hopeful. The science is evolving, and so is the support.

Have questions about TBI recovery or new diagnostic tools? Leave a comment or connect with us—we're here to help.

Reference: A new characterisation of acute traumatic brain injury: the NIH-NINDS TBI Classification and Nomenclature Initiative

Manley, Geoffrey TAdams, Rachel Syako et al.

The Lancet Neurology, Volume 24, Issue 6, 512 - 523