CHAPTER 34: WESSEX HEAD INJURY MATRIX (WHIM)

Description

The Wessex Head Injury Matrix (WHIM), by Shiel et al. (2000) was developed to assess subjects in and emerging from coma as well as those in vegetative and minimally conscious states. It is a 62-item observational matrix that collects data by observation as well as the person’s reaction to specific stimuli with regard to his or her arousal level and concentration, visual consciousness (visual pursuit), communication, cognition (memory and spatiotemporal orientation), and social behaviors by observing those behaviors that occur spontaneously or in response to stimulation (Schnakers, 2012). Use of the WHIM can give the clinician an opportunity to (1) monitor all of the stages of recovery from TBI, starting from coma to emerging post-traumatic amnesia; (2) monitor subtle changes in slow to recover persons; (3) reflect performance in activities of daily living; (4) help identify short-term objectives and realistic goals for those with TBI; and lastly, (5) specify a sequence of recovery (Majerus, Van der Linden, & Shiel, 2000). WHIM employs a unique scoring system in which the 62 items are categorized into 6 subscales (communication, attention, social behavior, concentration, visual awareness, and cognition) and are ordered in a hierarchical ascending scale reflecting a statistically derived order of recovery from coma such that the person’s ability to achieve item 1 should appear before item 2, item 2 before item 3, etc.; thus the WHIM score represents the rank order of the most advanced ability or item observed (rather than adding the different items observed) (Laureys, 2007a). Administration times can vary from less than 40 minutes to several hours.

Psychometrics

Original research by Shiel et al. (2000) concluded that correlation between the WHIM and Glasgow Coma Scale (GCS) was highly significant at r = 0.94, whereas inter-rater agreement was also excellent at 0.98. Validation of a French version of the WHIM scales showed good inter-rater agreement for 93% of the items and very good test-retest reliability at r = 0.98 (Laureys, 2007a). A final study explored the extent to which outcomes following sudden onset of a vegetative state or minimally conscious state could be predicted from baseline data of age, time since onset, length of observation period, or admission WHIM ratings and it was determined that only WHIM ratings had significant correlations for most advanced behavior at 0.49, while correlations for the most advanced behavior excluding 2 items was 0.58 and for total number of different behavior items 0.46, respectively (Turner-Stokes, Bassett, Rose, Stephen Ashford, & Thu, 2015).

Advantages

The WHIM is a relatively simple assessment to administer and has shown to have greater sensitivity than the GCS upon an individual’s exit from coma, the post-coma period, and the vegetative state; although, the GCS was more sensitive than the WHIM for the deep coma period, suggesting a greater sensitivity in detecting changes across the minimally conscious state not captured by other assessments (Majerus et al., 2000). Also, most standardized assessments have ordinal scoring, which is a behavioral description of a phenomenon where scores are summed across several dimensions that may not necessarily correlate with each other, whereas the hierarchical approach used by the WHIM allows for the more exact identification and assessment of a person’s abilities observed during recovery from one of the many TBI states (Shiel et al., 2000).

Disadvantages

There is a limited amount of supporting research outside of that involving its creators and the subtle gradations between each item of the scale can also be difficult to discern at times. Administration time is not standardized and may vary from a few minutes to several hours; however, Turner-Stokes et al. (2015) found that it was typically 20 to 40 minutes. Their research also noted that items 26 (frowning and grimacing) and 43 (smiles for any reason) may potentially be out of order where a stepwise regression analysis, excluding those two items, was able to account for 68% of the variance and along with total numbers of behaviors charted accounted for a further 5% of the variance, suggesting that at least some of the items are out of order.

Administration

WHIM is an interactive observational tool where the clinician discerns the presence or absence of the operational defined abilities of an individual outlined in an ascending hierarchical scale in the form of a checklist. WHIM has 62 items divided into 6 subtests where the final score is representative of the most advanced ability observed in the subject. The clinician can also study the most advanced behavior observed as well as the total number of different behaviors to gain further insight into functional performance. The following are example items of the matrix.

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