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Flora M. Hammond - One of the best experts on this subject based on the ideXlab platform.
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Global Outcome Trajectories After TBI Among Survivors and Nonsurvivors: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.
The Journal of head trauma rehabilitation, 2015Co-Authors: Kristen Dams-oʼconnor, Flora M. Hammond, Christopher R. Pretz, Tausif Billah, Cynthia Harrison-felixAbstract:OBJECTIVE To compare long-term functional outcome trajectories of individuals with traumatic brain injury (TBI) who survive with those who expire more than 5 years postinjury, using individual growth curve analysis. DESIGN Secondary analysis of data from a multicenter longitudinal cohort study. SETTING Acute inpatient rehabilitation facilities that are current or former TBI Model Systems. PARTICIPANTS Individuals 16 years and older with a primary diagnosis of TBI. MAIN OUTCOME MEASURES Glasgow Outcome Scale-Extended; Disability Rating Scale. RESULTS Individuals in the TBI Model Systems who expire several years after injury demonstrate worse functional status at baseline and a steeper rate of decline over time as measured by both the Glasgow Outcome Scale-Extended and the Disability Rating Scale. There was significant variability in each growth parameter (P < .05) for both instruments. A reduced model was built for each outcome, including all covariates that related significantly to the growth parameters. An interactive tool was created for each outcome to generate individual-level trajectories based on various combinations of covariate values. CONCLUSION Individuals with TBI who die several years after injury demonstrate functional trajectories that differ markedly from those of survivors. Opportunities should be sought for health management interventions to improve health and longevity after TBI.
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Longitudinal description of the Disability Rating Scale for individuals in the National Institute on Disability and Rehabilitation Research traumatic brain injury model systems national database.
Archives of physical medicine and rehabilitation, 2013Co-Authors: Christopher R. Pretz, James F Malec, Flora M. HammondAbstract:Abstract Objective To develop a detailed understanding of temporal change (ie, estimated trajectories) at the individual level as measured by the Disability Rating Scale (DRS). Design Individual growth curve (IGC) analysis of retrospective data obtained from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury (TBI) Model Systems National Database. Setting Multicenter longitudinal database study. Participants Individuals with TBI (N=8816) participating in the TBI Model Systems National Database project. Interventions Not applicable. Main Outcome Measure DRS. Results The negative exponential consisting of 3 growth parameters (pseudointercept, asymptote, rate) was successfully used to predict trajectory of recovery on the DRS qualified by the following covariates: race, sex, level of education and age at admission, rehabilitation length of stay, and cognitive and motor FIM scores at rehabilitation admission. Based on these results, an interactive tool was developed to allow prediction of the trajectory of recovery for individuals and subgroups with specified characteristics on the selected covariates. Conclusions With the use of IGC analysis, the longitudinal trajectory of recovery on the DRS for individuals sharing common characteristics and traits can be described. This methodology allows researchers and clinicians to predict numerous individual-level trajectories through use of a web-based computer automated interactive tool.
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Structured Interview to Improve the Reliability and Psychometric Integrity of the Disability Rating Scale
Archives of physical medicine and rehabilitation, 2012Co-Authors: James F Malec, Flora M. Hammond, Joseph T. Giacino, John Whyte, Jerry WrightAbstract:Abstract Malec JF, Hammond FM, Giacino JT, Whyte J, Wright J. Structured interview to improve the reliability and psychometric integrity of the Disability Rating Scale. Objectives To (1) develop a standardized interview for telephone administration, (2) assess the psychometric properties of this interview format (Disability Rating Scale–Postacute Interview [DRS-PI]), and (3) identify additional items to reduce skew. Design Prospective cohort assessment study. Setting Not applicable. Participants Participants (N=406; 287 individuals with traumatic brain injury [TBI], 119 caregivers) in the U.S. TBI Model Systems national database during 1- to 20-year telephone follow-up. Interventions Not applicable. Main Outcome Measures Original Disability Rating Scale (DRS) and DRS-PI variations. DRS-PI questions were developed by consensus of the study investigators; item scores were derived from responses to questions by algorithm. Unnecessary questions were pruned. Results The DRS-PI correlated highly with the original DRS (intraclass correlation, .91) and demonstrated satisfactory construct validity and internal consistency (person separation/reliability, 2.51/.86; item separation/reliability, 16.72/1.00; Cronbach α=.83). Both versions showed substantial skew. For the original DRS, 42% of scores were 0 or 1; for DRS-PI, 44%. Adding several items to the DRS-PI including actual employment status further improved its psychometric properties (person separation/reliability, 3.10/.91; item separation/reliability, 21.42/1.00; Cronbach α=.92) and reduced skew. For the Expanded DRS-PI, 18% of scores were 0 or 1. Conclusions The DRS-PI provides an efficient method to ensure standardized administration of, and correlates highly with, the original DRS. The addition of several new items including actual employment status mitigates skew in postacute samples.
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long term recovery course after traumatic brain injury a comparison of the functional independence measure and Disability Rating Scale
Journal of Head Trauma Rehabilitation, 2001Co-Authors: Flora M. Hammond, Karyn D Grattan, Howell C Sasser, John D Corrigan, Tamara Bushnik, Ross ZafonteAbstract:Objectives:To study group changes over time after traumatic brain injury (TBI).Design:Prospective cohort.Setting and Participants:TBI Model System Database with 1160 subjects using cohort with complete data.Main Outcome Measures:Functional Independence Measure (FIM™) and Disability Rating Scale (DRS
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use of injury severity variables in determining Disability and community integration after traumatic brain injury
Journal of Trauma-injury Infection and Critical Care, 2000Co-Authors: Amy K Wagner, Flora M. Hammond, Howell C Sasser, David Wiercisiewski, Harry James NortonAbstract:BACKGROUND: Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes. METHODS: Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data. RESULTS: Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed. CONCLUSION: Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term Disability and community integration for individuals hospitalized with TBI.
Stephen R Mccauley - One of the best experts on this subject based on the ideXlab platform.
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neurological outcome Scale for traumatic brain injury iii criterion related validity and sensitivity to change in the nabis hypothermia ii clinical trial
Journal of Neurotrauma, 2013Co-Authors: Stephen R Mccauley, Elisabeth A Wilde, Paolo Moretti, Marianne Macleod, Claudia Pedroza, Pamala Drever, Sierra Fourwinds, Melisa L FrisbyAbstract:Abstract The Neurological Outcome Scale for Traumatic Brain Injury (NOS-TBI) is a measure assessing neurological functioning in patients with TBI. We hypothesized that the NOS-TBI would exhibit adequate concurrent and predictive validity and demonstrate more sensitivity to change, compared with other well-established outcome measures. We analyzed data from the National Acute Brain Injury Study: Hypothermia-II clinical trial. Participants were 16–45 years of age with severe TBI assessed at 1, 3, 6, and 12 months postinjury. For analysis of criterion-related validity (concurrent and predictive), Spearman's rank-order correlations were calculated between the NOS-TBI and the Glasgow Outcome Scale (GOS), GOS-Extended (GOS-E), Disability Rating Scale (DRS), and Neurobehavioral Rating Scale-Revised (NRS-R). Concurrent validity was demonstrated through significant correlations between the NOS-TBI and GOS, GOS-E, DRS, and NRS-R measured contemporaneously at 3, 6, and 12 months postinjury (all p<0.0013). For predic...
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Use of the Disability Rating Scale Recovery curve as a predictor of psychosocial outcome following closed-head injury.
Journal of the International Neuropsychological Society : JINS, 2001Co-Authors: Stephen R Mccauley, H. Julia Hannay, Paul R. SwankAbstract:Rapid rate of recovery has been associated with better outcome following closed-head injuries, but few studies have compellingly demonstrated this. This study used growth curve analyses of Disability Rating Scale (DRS) scores at acute hospitalization discharge, 1, 3, and 6 months post injury in a sample of 55 patients with a closed-head injury. Six month post-injury outcome measures were taken from significant other (SO) responses on the NYU Head Injury Family Interview (NYU-HIFI) including severity and burden Ratings of affective/neurobehavioral disturbance, cognitive deficits, and physical/dependency status. Rate of recovery (linear and curvilinear recovery curve components) was significantly related to the level of affective/neurobehavioral severity, and the severity and burden of SO-perceived cognitive deficits. Only the intercept of the DRS recovery curve was associated with the SO-perceived severity and burden of physical/dependency status. Growth curve modeling is a meaningful and powerful tool in predicting head injury outcome.
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Factor analysis of an Outcome Interview for use in clinical trials of traumatically brain-injured patients: A preliminary study
American Journal of Physical Medicine & Rehabilitation, 2001Co-Authors: Sharon A. Brown, Stephen R Mccauley, Peggy R. Goldfader, Steven D. Mccormick, Daniel Rockers, David A. Kareken, Corwin Boake, Harvey S Levin, Meryl A Butters, David GostnellAbstract:Objective: To study the factor structure, internal consistency, concurrent validity, and sensitivity to detect change in patient report of problems of a structured interview in relationship with accepted outcome measures. Design: Outcome status of patients with severe traumatic brain injury participating in a randomized, phase III, multicenter clinical trial was assessed at 6 mo postinjury using the Glasgow Outcome Scale, the Disability Rating Scale, and the Severe Traumatic Brain Injury Outcome Interview. Results: Exploratory factor analysis of the Severe Traumatic Brain Injury Outcome Interview produced a meaningful five-factor model: (1) activities of daily living; (2) cognitive; (3) affective; (4) behavioral; and (5) instrumental activities of daily living. The internal consistency of the factors ranged from moderate (0.61 instrumental activities of daily living) to high (0.94 activities of daily living); the interfactor correlations were moderate. The summed factor scores were significantly correlated with measures of global outcome: the Glasgow Outcome Scale (r = 0.66; P < 0.0001) and the Disability Rating Scale (r = 0.61; P < 0.0001). Patient report of cognitive problems correlated moderately with the neuropsychological tests. The summed factor scores were sensitive to change over time. Conclusions: Overall, the interview assessed the major important features of outcome pertinent to traumatic brain injury and demonstrated greater sensitivity to subtle changes over time than the unidimensional approaches, such as the Glasgow Outcome Scale and Disability Rating Scale.
Claudia S Robertson - One of the best experts on this subject based on the ideXlab platform.
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Disability Rating Scale in the First Few Weeks After a Severe Traumatic Brain Injury as a Predictor of 6-Month Functional Outcome.
Neurosurgery, 2020Co-Authors: Jose-miguel Yamal, H. Julia Hannay, Imoigele P Aisiku, Frances A Brito, Claudia S RobertsonAbstract:An early acute marker of long-term neurological outcome would be useful to help guide clinical decision making and therapeutic effectiveness after severe traumatic brain injury (TBI). We investigated the utility of the Disability Rating Scale (DRS) as early as 1 wk after TBI as a predictor of favorable 6-mo Glasgow Outcome Scale extended (GOS-E). To determine the predictability of a favorable 6-mo GOS-E using the DRS measured during weeks 1 to 4 of injury. The study is a sub analysis of patients enrolled in the Epo Severe TBI Trial (n = 200) to train and validate L1-regularized logistic regression models. DRS was collected at weeks 1 to 4 and GOS-E at 6 mo. The average area under the receiver opeRating characteristic curve was 0.82 for the model with baseline demographic and injury severity variables and week 1 DRS and increased to 0.88 when including weekly DRS until week 4. This study suggests that week 1 to 4 DRS may be predictors of favorable 6-mo outcome in severe TBI patients and thus useful both for clinical prognostication as well as surrogate endpoints for adaptive clinical trials. Copyright © 2020 by the Congress of Neurological Surgeons.
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Longitudinal Changes in Disability Rating Scale Scores: A Secondary Analysis Among Patients With Severe TBI Enrolled in the Epo Clinical Trial.
Journal of the International Neuropsychological Society : JINS, 2019Co-Authors: Julia S. Benoit, H. Julia Hannay, Jose-miguel Yamal, Imoigele P Aisiku, David J. Francis, Claudia S RobertsonAbstract:Objectives: Long-term neurological response to treatment after a severe traumatic brain injury (sTBI) is a dynamic process. Failure to capture individual heterogeneity in recovery may impact findings from single endpoint sTBI randomized controlled trials (RCT). The present study re-examined the efficacy of erythropoietin (Epo) and transfusion thresholds through longitudinal modeling of sTBI recovery as measured by the Disability Rating Scale (DRS). This study complements the report of primary outcomes in the Epo sTBI RCT, which failed to detect significant effects of acute treatment at 6 months post-injury. Methods: We implemented mixed effects models to characterize the recovery time-course and to examine treatment efficacy as a function of time post-injury and injury severity. Results: The inter-quartile range (25 th –75 th percentile) of DRS scores was 20–28 at week1; 8–24 at week 4; and 3–17 at 6 months. TBI severity group was found to significantly interact with Epo randomization group on mean DRS recovery curves. No significant differences in DRS recovery were found in transfusion threshold groups. Conclusions: This study demonstrated the value of taking a comprehensive view of recovery from sTBI in the Epo RCT as a temporally dynamic process that is shaped by both treatment and injury severity, and highlights the importance of the timing of primary outcome measurement. Effects of Epo treatment varied as a function of injury severity and time. Future studies are warranted to understand the possible modeRating influence of injury severity on treatment effects pertaining to sTBI recovery. ( JINS , 2019, 25 , 293–301)
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the relation between acute physiological variables and outcome on the glasgow outcome Scale and Disability Rating Scale following severe traumatic brain injury
Journal of Neurotrauma, 2001Co-Authors: Margaret A Struchen, Julia H Hannay, Charles F Contant, Claudia S RobertsonAbstract:The relation between outcome and duration of adverse physiological events was studied, using suggested critical physiological values. Subjects were 184 patients with severe traumatic brain injury who received continuous monitoring of intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and jugular venous oxygen satuation. Longer durations of adverse physiological events were significantly related to Glasgow Outcome Scale (GOS) scores and Disability Rating Scale (DRS) scores for all variables at all timepoints postinjury. When analyses excluded patients who died, the relation between adverse physiological events and GOS was non-significant; however, duration of ICP, MAP, and CPP still accounted for a significant portion of the variance in DRS scalres. The relative sensitivity of the GOS and DRS is discussed.
Stephanie A. Kolakowsky-hayner - One of the best experts on this subject based on the ideXlab platform.
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Disability Rating Scale.
The Journal of head trauma rehabilitation, 2012Co-Authors: Kimberly Bellon, Jerry Wright, Laura Jamison, Stephanie A. Kolakowsky-haynerAbstract:T Disability Rating Scale (DRS) is an 8-item outcome measure that is one of the more frequently used measures in traumatic brain injury (TBI) research.1 The Scale is sometimes referred to as the Rappaport DRS to discriminate the Disability Rating Scale from the Dementia Rating Scale (also abbreviated DRS). The popularity of the DRS is derived from its brief administration time, its usefulness in a large variety of settings or levels of care, its widespread acceptance and use in research, and its free availability in the public domain. The DRS was designed to measure changes in recovery in adults with TBI, where total scores are meant to reflect a level of Disability.2 It has been recommended as a useful outcome measure for clinical trials involving individuals with brain injury and is currently classified as a Supplemental Measure within the National Institute of Neurological Disorders and Stroke Common Data Elements Project (www.commondataelements.ninds.nih. gov). The DRS has also been used to validate other brain injury outcome Scales, including the Coma Recovery Scale, Mayo Portland Adaptability Inventory, Supervision Rating Scale, and the Community Integration Questionnaire.3 Because of the brief administration time, one important benefit of the DRS is the efficiency at which it can be administered and the ability for researchers to complete it over the phone. The DRS is also unusual in that it has the ability to describe Disability for individuals in a wide variety of settings, from acute care hospitals
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Traumatic brain injury with and without late posttraumatic seizures: what are the impacts in the post-acute phase: a NIDRR Traumatic Brain Injury Model Systems study.
The Journal of head trauma rehabilitation, 2012Co-Authors: Tamara Bushnik, Jeffrey Englander, Jerry Wright, Stephanie A. Kolakowsky-haynerAbstract:OBJECTIVE: : To compare and contrast the levels of impairment, Disability, and community participation of individuals with traumatic brain injury (TBI) with or without late posttraumatic seizures (LPTS). DESIGN: : Prospective survey study. SETTING: : Community. PARTICIPANTS: : Two groups of 91 individuals with TBI, with and without LPTS, were enrolled in the TBI Model Systems National Database between 1989 and 2002 and interviewed at years 1, 2, and 5 postinjury. INTERVENTIONS: : Not applicable. MAIN OUTCOME MEASURES: : Demographic, injury severity, productivity, and psychosocial outcomes. RESULTS: : The majority of the demographic and productivity outcomes up to 5 years postinjury were similar between individuals in the LPTS and non-LPTS groups. Both the LPTS and non-LPTS groups showed an increasing percentage of individuals who began to live alone after the first year postinjury and a decreasing percentage of individuals who were living with family members at 5 years postinjury compared with the first year post-TBI. A higher percentage of individuals in the LPTS group reported using more dependent forms of transportation such as riding with others or using public transportation. Individuals in the LPTS group had higher Disability Rating Scale scores at all time points, denoting greater functional Disability, than individuals in the non-LPTS group, despite the 2 groups having similar Disability Rating Scale scores at discharge from rehabilitation. Satisfaction With Life Scale scores showed no changes over time but were significantly different between both groups at all time points, with individuals in the LPTS group reporting lower Satisfaction With Life Scale score than individuals in the non-LPTS group. CONCLUSIONS: : It does appear that the development of LPTS following a TBI is associated with poorer functional and psychosocial outcomes in the first 5 years after injury. It remains to be determined whether there are other factors that also may account for these differences and that may be amenable to intervention. Language: en
Joseph T. Giacino - One of the best experts on this subject based on the ideXlab platform.
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An Italian multicentre validation study of the coma recovery Scale-revised.
European journal of physical and rehabilitation medicine, 2014Co-Authors: Anna Estraneo, Joseph T. Giacino, Pasquale Moretta, De Tanti A, Gatta G, Luigi TrojanoAbstract:BACKGROUND Rate of misdiagnosis of disorders of consciousness (DoC) can be reduced by employing validated clinical diagnostic tools, such as the Coma Recovery Scale-Revised (CRS-R). An Italian version of the CRS-R has been recently developed, but its applicability across different clinical settings, and its concurrent validity and diagnostic sensitivity have not been estimated yet. AIM To perform a multicentre validation study of the Italian version of the Coma Recovery Scale-Revised (CRS-R). DESIGN Analysis of inter-rater reliability, concurrent validity and diagnostic sensitivity of the Scale. SETTING One Intensive Care Unit, 8 Post-acute rehabilitation centres and 2 Long-term facilities POPULATION Twenty-seven professionals (physicians, N.=11; psychologists, N.=5; physiotherapists, N.=3; speech therapists, N.=6; nurses, N.=2) from 11 Italian Centres. METHODS CRS-R and Disability Rating Scale (DRS) applied to 122 patients with clinical diagnosis of Vegetative State (VS) or Minimally Conscious State (MCS). RESULTS CRS-R has good-to-excellent inter-rater reliability for all subScales, particularly for the communication subScale. The Italian version of the CRS-R showed a high sensitivity and specificity in detecting MCS with reference to clinical consensus diagnosis. The CRS-R showed good concurrent validity with the Disability Rating Scale, which had very low specificity with reference to clinical consensus diagnosis. CONCLUSIONS The Italian version of the CRS-R is a valid Scale for use from the sub-acute to chronic stages of DoC. It can be administered reliably by all members of the rehabilitation team with different specialties, levels of experience and settings. CLINICAL REHABILITATION IMPACT The present study promote use of the Italian version of the CRS-R to improve diagnosis of DoC patients, and plan tailored rehabilitation treatment.
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Structured Interview to Improve the Reliability and Psychometric Integrity of the Disability Rating Scale
Archives of physical medicine and rehabilitation, 2012Co-Authors: James F Malec, Flora M. Hammond, Joseph T. Giacino, John Whyte, Jerry WrightAbstract:Abstract Malec JF, Hammond FM, Giacino JT, Whyte J, Wright J. Structured interview to improve the reliability and psychometric integrity of the Disability Rating Scale. Objectives To (1) develop a standardized interview for telephone administration, (2) assess the psychometric properties of this interview format (Disability Rating Scale–Postacute Interview [DRS-PI]), and (3) identify additional items to reduce skew. Design Prospective cohort assessment study. Setting Not applicable. Participants Participants (N=406; 287 individuals with traumatic brain injury [TBI], 119 caregivers) in the U.S. TBI Model Systems national database during 1- to 20-year telephone follow-up. Interventions Not applicable. Main Outcome Measures Original Disability Rating Scale (DRS) and DRS-PI variations. DRS-PI questions were developed by consensus of the study investigators; item scores were derived from responses to questions by algorithm. Unnecessary questions were pruned. Results The DRS-PI correlated highly with the original DRS (intraclass correlation, .91) and demonstrated satisfactory construct validity and internal consistency (person separation/reliability, 2.51/.86; item separation/reliability, 16.72/1.00; Cronbach α=.83). Both versions showed substantial skew. For the original DRS, 42% of scores were 0 or 1; for DRS-PI, 44%. Adding several items to the DRS-PI including actual employment status further improved its psychometric properties (person separation/reliability, 3.10/.91; item separation/reliability, 21.42/1.00; Cronbach α=.92) and reduced skew. For the Expanded DRS-PI, 18% of scores were 0 or 1. Conclusions The DRS-PI provides an efficient method to ensure standardized administration of, and correlates highly with, the original DRS. The addition of several new items including actual employment status mitigates skew in postacute samples.
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placebo controlled trial of amantadine for severe traumatic brain injury
The New England Journal of Medicine, 2012Co-Authors: Joseph T. Giacino, John Whyte, Emilia Bagiella, Kathleen Kalmar, Nancy L Childs, Allen Khademi, Bernd Eifert, David Long, Douglas I Katz, Stuart A YablonAbstract:Background Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery. Methods We enrolled 184 patients who were in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury and who were receiving inpatient rehabilitation. Patients were randomly assigned to receive amantadine or placebo for 4 weeks and were followed for 2 weeks after the treatment was discontinued. The rate of functional recovery on the Disability Rating Scale (DRS; range, 0 to 29, with higher scores indicating greater Disability) was compared over the 4 weeks of treatment (primary outcome) and during the 2-week washout period with the use of mixed-effects regression models. Results During the 4-week treatment period, recovery was significantly faster in the amantadine group than in the placebo group, as measured by the DRS score ...
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Reliability and diagnostic characteristics of the JFK coma recovery Scale-revised: exploring the influence of rater's level of experience.
The Journal of head trauma rehabilitation, 2010Co-Authors: Marianne Løvstad, Joseph T. Giacino, Kathrine Frey Frøslie, Toril Skandsen, Audny Anke, Anne-kristine SchankeAbstract:Objective: To confirm the reliability and diagnostic validity of the JFK Coma Recovery Scale–Revised (CRS-R) across raters with varying levels of experience. Methods: Thirty-one patients with disorders of consciousness were recruited from 6 Norwegian hospitals. Main outcome measures: CRS-R and the Disability Rating Scale. Results: Reliability measures were good for the CRS-R total scores and moderate to good for its subScales. Diagnostic agreement among examiners was good. Raters' experience with the CRS-R favorably influenced reliability. Sensitivity and specificity analyses demonstrated better detection of patients in minimally conscious state on the CRS-R relative to the Disability Rating Scale. Conclusions: The CRS-R is a reliable tool for diagnosing vegetative state and minimally conscious state. Raters' level of experience influences the reliability of the CRS-R scores.