A Spanish validation of the Coma Recovery Scale-Revised (CRS-R)

Reliability and validation of the Japanese version of the coma recovery scale-revised (CRS-R)

PRIMARY OBJECTIVE

This study aimed to verify the reliability and validity of the Japanese version of the Coma Recovery Scale-Revised (CRS-R).

METHODS

Subjects included 59 patients with disorders of consciousness (DOC) due to acquired brain injury. To validate test-retest reliability, Evaluator A assessed the CRS-R twice on the same day (A1, A2). To examine inter-rater reliability, Evaluators A (A2) and B (B) assessed the CRS-R without a time interval. To test concurrent validity, Evaluator A (A1) assessed the CRS-R, Japan Coma Scale (JCS), and the Glasgow Coma Scale (GCS) consecutively. To validate diagnostic accuracy, we evaluated the degree of agreement between A1 and A2 and between A2 and B in their diagnosis of DOC by CRS-R.

RESULTS

The test-retest (ρ = 0.92) and inter- (ρ = 0.98) reliability of CRS-R were excellent" and Concurrent validity of CRS-R with JCS (ρ =  -0.82) and GCS (ρ = 0.92) were high. Results of DOC diagnosis were consistent for 48/59 cases (κ = 0.82) for A1 and A2 and for 54/59 cases (κ = 0.92) for A2 and B.

CONLCUSION

The Japanese version of the CRS-R may be as reliable and valid as the original English and other language versions.

Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach

Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.

Coma Recovery Scale-Revised Predicts Disability Rating Scale in Acute Rehabilitation of Severe Traumatic Brain Injury

OBJECTIVE

To explore the prognostic value of the Coma Recovery Scale-Revised (CRS-R) in predicting disability outcomes in patients with severe traumatic brain injury using the Disability Rating Scale (DRS).

DESIGN

Secondary analysis including linear and logistic regressions were performed.

SETTING

Data were collected in a previous clinical trial.

PARTICIPANTS

One hundred eighty-four participants across 3 countries (N=184).

MAIN OUTCOME MEASURES

Disability Rating Scales.

RESULTS

Analyses showed an inverse relation between CRS-R scores obtained at baseline and change in DRS scores at 6 weeks. Similarly, changes in CRS-R scores between baseline and 4 weeks were also found to have an inverse relation to change in DRS scores at 6 weeks.

CONCLUSIONS

This study generates a tool that can be used to predict the probability that a patient with severe traumatic brain injury lands in 1 of 3 disability categories. The CRS-R may be useful in prognostication of disability in patients with severe traumatic brain injury.

Functional networks in prolonged disorders of consciousness

Prolonged disorders of consciousness (DoC) are characterized by extended disruptions of brain activities that sustain wakefulness and awareness and are caused by various etiologies. During the past decades, neuroimaging has been a practical method of investigation in basic and clinical research to identify how brain properties interact in different levels of consciousness. Resting-state functional connectivity within and between canonical cortical networks correlates with consciousness by a calculation of the associated temporal blood oxygen level-dependent (BOLD) signal process during functional MRI (fMRI) and reveals the brain function of patients with prolonged DoC. There are certain brain networks including the default mode, dorsal attention, executive control, salience, auditory, visual, and sensorimotor networks that have been reported to be altered in low-level states of consciousness under either pathological or physiological states. Analysis of brain network connections based on functional imaging contributes to more accurate judgments of consciousness level and prognosis at the brain level. In this review, neurobehavioral evaluation of prolonged DoC and the functional connectivity within brain networks based on resting-state fMRI were reviewed to provide reference values for clinical diagnosis and prognostic evaluation.

Classification of Level of Consciousness in a Neurological ICU Using Physiological Data

BACKGROUND

Impaired consciousness is common in intensive care unit (ICU) patients, and an individual's degree of consciousness is crucial to determining their care and prognosis. However, there are no methods that continuously monitor consciousness and alert clinicians to changes. We investigated the use of physiological signals collected in the ICU to classify levels of consciousness in critically ill patients.

METHODS

We studied 61 patients with subarachnoid hemorrhage (SAH) and 178 patients with intracerebral hemorrhage (ICH) from the neurological ICU at Columbia University Medical Center in a retrospective observational study of prospectively collected data. The level of consciousness was determined on the basis of neurological examination and mapped to comatose, vegetative state or unresponsive wakefulness syndrome (VS/UWS), minimally conscious minus state (MCS-), and command following. For each physiological signal, we extracted time-series features and performed classification using extreme gradient boosting on multiple clinically relevant tasks across subsets of physiological signals. We applied this approach independently on both SAH and ICH patient groups for three sets of variables: (1) a minimal set common to most hospital patients (e.g., heart rate), (2) variables available in most ICUs (e.g., body temperature), and (3) an extended set recorded mainly in neurological ICUs (absent for the ICH patient group; e.g., brain temperature).

RESULTS

On the commonly performed classification task of VS/UWS versus MCS-, we achieved an area under the receiver operating characteristic curve (AUROC) in the SAH patient group of 0.72 (sensitivity 82%, specificity 57%; 95% confidence interval [CI] 0.63-0.81) using the extended set, 0.69 (sensitivity 83%, specificity 51%; 95% CI 0.59-0.78) on the variable set available in most ICUs, and 0.69 (sensitivity 56%, specificity 78%; 95% CI 0.60-0.78) on the minimal set. In the ICH patient group, AUROC was 0.64 (sensitivity 56%, specificity 65%; 95% CI 0.55-0.74) using the minimal set and 0.61 (sensitivity 50%, specificity 80%; 95% CI 0.51-0.71) using the variables available in most ICUs.

CONCLUSIONS

We find that physiological signals can be used to classify states of consciousness for patients in the ICU. Building on this with intraday assessments and increasing sensitivity and specificity may enable alarm systems that alert physicians to changes in consciousness and frequent monitoring of consciousness throughout the day, both of which may improve patient care and outcomes.

Behavioral Assessment of Patients with Disorders of Consciousness

Severe brain injury is associated with a period of impaired level of consciousness that can last from days to months and results in chronic impairment. Systematic assessment of level of function in patients with disorders of consciousness (DoC) is critical for diagnosis, prognostication, and evaluation of treatment efficacy. Approximately 40% of patients who are thought to be unconscious based on clinical bedside behavioral assessment demonstrate some signs of consciousness on standardized behavioral assessment. This finding, in addition to a growing body of literature demonstrating the advantages of standardized behavioral assessment of DoC, has led multiple professional societies and clinical guidelines to recommend standardized assessment over routine clinical evaluation of consciousness. Nevertheless, even standardized assessment is susceptible to biases and misdiagnosis, and examiners should consider factors, such as fluctuating arousal and aphasia, that may confound evaluation. We review approaches to behavioral assessment of consciousness, recent clinical guideline recommendations for use of specific measures to evaluate patients with DoC, and strategies for mitigating common biases that may confound the examination.

The misdiagnosis of prolonged disorders of consciousness by a clinical consensus compared with repeated coma-recovery scale-revised assessment

BACKGROUND

Previous studies have shown that a single Coma-Recovery Scale-Revision (CRS-R) assessment can identify high rates of misdiagnosis by clinical consensus. The aim of this study was to investigate the proportion of misdiagnosis by clinical consensus compared to repeated behavior-scale assessments in patients with prolonged disorders of consciousness (DOC).

METHODS

Patients with prolonged DOC during hospitalization were screened by clinicians, and the clinicians formed a clinical-consensus diagnosis. Trained professionals used the CRS-R to evaluate the consciousness levels of the enrolled patients repeatedly (≥5 times) within a week. Based on the repeated evaluation results, the enrolled patients with prolonged DOC were divided into unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS (EMCS). Finally, the relationship between the results of the CRS-R and the clinical consensus were analyzed.

RESULTS

In this study, 137 patients with a clinical-consensus diagnosis of prolonged DOC were enrolled. It was found that 24.7% of patients with clinical UWS were actually in MCS after a single CRS-R behavior evaluation, while the repeated CRS-R evaluation results showed that the proportion of misdiagnosis of MCS was 38.2%. A total of 16.7% of EMCS patients were misdiagnosed with clinical MCS, and 1.1% of EMCS patients were misdiagnosed with clinical UWS.

CONCLUSIONS

The rate of the misdiagnosis by clinical consensus is still relatively high. Therefore, clinicians should be aware of the importance of the bedside CRS-R behavior assessment and should apply the CRS-R tool in daily procedures.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04139239 ; Registered 24 October 2019 - Retrospectively registered.

[Intrathecal baclofen therapy in brain injury and recovery of persistent vegetative state. Apropos of a case]

Patients with brain injury and spasticity are candidates for intrathecal baclofen therapy (ITB) when maximal doses of oral antispastic drugs fail. Some authors have described an improvement in the level of consciousness in patients with brain injury and disorder of consciousness treated with ITB for spasticity. We present the case of a 43-year-old patient with brain injury, spasticity, and permanent vegetative state (PVS) who showed an improvement in the level of consciousness after ITB for spasticity. We performed an ITB infusion test, assessing the spasticity with the Modified Ashworth Scale (MAS) and level of consciousness with the Coma Recovery Scale-Revised (CRS-R) and observed an improvement in the spasticity and the level of consciousness. Consequently, the ITB pump was implanted and the patient recovered from PVS to minimal conscious state (MCS). We conclude that ITB is indicated in patients with brain injury and spasticity. We suggest the improvement in the level of consciousness as a possible additional benefit. There is a lack of evidence to recommend ITB in patients with altered level of consciousness.

European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness

BACKGROUND AND PURPOSE

Patients with acquired brain injury and acute or prolonged disorders of consciousness (DoC) are challenging. Evidence to support diagnostic decisions on coma and other DoC is limited but accumulating. This guideline provides the state-of-the-art evidence regarding the diagnosis of DoC, summarizing data from bedside examination techniques, functional neuroimaging and electroencephalography (EEG).

METHODS

Sixteen members of the European Academy of Neurology (EAN) Scientific Panel on Coma and Chronic Disorders of Consciousness, representing 10 European countries, reviewed the scientific evidence for the evaluation of coma and other DoC using standard bibliographic measures. Recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The guideline was endorsed by the EAN.

RESULTS

Besides a comprehensive neurological examination, the following suggestions are made: probe for voluntary eye movements using a mirror; repeat clinical assessments in the subacute and chronic setting, using the Coma Recovery Scale - Revised; use the Full Outline of Unresponsiveness score instead of the Glasgow Coma Scale in the acute setting; obtain clinical standard EEG; search for sleep patterns on EEG, particularly rapid eye movement sleep and slow-wave sleep; and, whenever feasible, consider positron emission tomography, resting state functional magnetic resonance imaging (fMRI), active fMRI or EEG paradigms and quantitative analysis of high-density EEG to complement behavioral assessment in patients without command following at the bedside.

CONCLUSIONS

Standardized clinical evaluation, EEG-based techniques and functional neuroimaging should be integrated for multimodal evaluation of patients with DoC. The state of consciousness should be classified according to the highest level revealed by any of these three approaches.

Validation of the Chinese version of the Coma Recovery Scale-Revised (CRS-R)

PRIMARY OBJECTIVE

This study aims to validate the Chinese version of the Coma Recovery Scale-Revised (CRS-R).

METHODS

One hundred sixty-nine patients were assessed with both the CRS-R and the Glasgow Coma Scale (GCS), diagnosed as being in unresponsive wakefulness syndrome (UWS, formerly known as vegetative state), minimally conscious state (MCS), or emergence from MCS (EMCS). A subgroup of 50 patients has been assessed twice by the same rater, within 24 h. Patient outcome was documented six months after assessment.

RESULTS

The internal consistency for the CRS-R total score was excellent (Cronbach's α = 0.84). Good test-retest reliability was obtained for CRS-R total score and subscale scores (intra-class correlation coefficient [ICC] = 0.87 and ICC = 0.66-0.84, respectively). Inter-rater reliability was high (ICC = 0.719; p < 0.01). Concurrent validity was good between CRS-R total scale and GCS total scale. Diagnostic validity was excellent compared with GCS (emerged from UWS: 24%; emerged from MCS: 28%). When considering patient outcome, diagnostic validity was good. In addition, false-positive rates have been detected for both diagnoses.

CONCLUSION

The Chinese version of the CRS-R is a reliable and sensitive tool and can discriminate patients in UWS, MCS, and EMCS successfully.

Cervical Spinal Cord Stimulation for the Vegetative State: A Preliminary Result of 12 Cases

OBJECTIVES

Data on the treatment of the vegetative state (VS) with cervical spinal cord stimulation (cSCS) are limited and prognostic factors are inconclusive. In this study, we present our experience of treating 12 VS patients with cSCS and discuss the prognostic factors.

METHODS

Twelve VS patients were enrolled. Preoperative assessments included CT/MRI, PET, brainstem auditory evoked potentials (BAEPs), somatosensory evoked potentials (SEPs), and electroencephalogram (EEG). cSCS surgeries were performed at West China Hospital. The electrode was implanted in the epidural space of the C2-4 vertebrae. Levels of consciousness were evaluated based on the Coma Recovery Scale-Revised (CRS-R) at baseline and during follow-up.

RESULTS

The average follow-up was 11.1 months. The average CRS-R score at the last evaluation was 10.8, which was significantly improved compared with the baseline score (6.25). Five patients achieved responsive outcomes (three recovered and two evolved to a minimally conscious state) and seven achieved unresponsive outcomes (six remained in VS and one died). Age, preoperative CRS-R score, the interval between acute comatose injury and cSCS, and the Vth wave of BAEPs did not differ significantly between the responsive group and the unresponsive group. Appearance of the N20 of SEPs and multifocal abnormalities on CT/MRI and PET were significantly associated with a better outcome, while the etiology of ischemia and anoxia (IAA) was significantly associated with a poor outcome.

CONCLUSIONS

cSCS should be a glimmer of hope for VS patients. Patients whose N20 is elicited or whose CT/MRI or PET demonstrates multifocal abnormalities are more likely to benefit from cSCS, whereas those with an IAA etiology have a lower likelihood of recovery after cSCS.

A Russian validation study of the Coma Recovery Scale-Revised (CRS-R)

INTRODUCTION

The aim of the study was to develop and validate a Russian adaptation of the Coma Recovery Scale-Revised (CRS-R).

SUBJECTS AND METHODS

We evaluated 58 patients with chronic disorders of consciousness (> 4 weeks post-injury, DOC) of various etiology and two patients in a locked-in state at different stages after coma. We tested sensitivity for changes over 1 week, reliability, criterion validity and diagnostic sensitivity of the Russian adaptation of the CRS-R in comparison with the Russian adaptations of Full Outline of UnResponsiveness Score (FOUR), and Glasgow Coma Scale (GCS).

RESULTS

We obtained good sensitivity for changes in neurological status over week (p < 0.0001) and good test-retest reliability (r = 0.997, p < 0.0001) of the CRS-R. Inter-rater reliability was good (κ = 0.99, p < 0.001). We showed high internal consistency (α = 0.87) of the scale and good criterion validity between other scales (r = 0.597 for GCS, and r = 0.900 for FOUR). CRS-R also demonstrated a higher sensitivity in differential diagnosis of DOC, as compared to GCS, and FOUR Score (p < 0.001).

CONCLUSION

The results show that the Russian version of the CRS-R is a valid and sensitive tool for the evaluation of patients with chronic DOC, which can be used for differential diagnosis and for recovery assessment.

Validation of Korean Version of Coma Recovery Scale-Revised (K-CRSR)

Objective

To determine the validity and reliability of the Korean version of the Coma Recovery Scale-Revised (K-CRSR) for evaluation of patients with a severe brain lesion.

Methods

With permission from Giacino, the developer of the Coma Recovery Scale Revised (CRSR), the scale was translated into Korean and back-translated into English by a Korean physiatrist highly proficient in English, and then verified by the original developer. Adult patients with a severe brain lesion following traumatic brain injury, stroke, or hypoxic brain injury were examined. To assess the inter-rater reliability, all patients were tested with K-CRSR by two physiatrists individually. To determine intra-rater reliability, the same test was re-administered by the same physiatrists after three days.

Results

Inter-rater reliability (k=0.929, p<0.01) and intra-rater reliability (k=0.938, p<0.01) were both high for total K-CRSR scores. Inter- and intra-rater agreement rates were very high (94.9% and 97.4%, respectively). The total K-CRSR score was significantly correlated with K-GCS (r=0.894, p<0.01), demonstrating sufficient concurrent validity.

Conclusion

K-CRSR is a reliable and valid instrument for the assessment of patients with brain injury by trained physiatrists. This scale is useful in differentiating patients in minimally conscious state from those in vegetative state.

Early rehabilitation of Disorders of Consciousness (DOC): management, neuropsychological evaluation and treatment

In order to ensure the best possible rehabilitation plan and best outcome for patients with Disorders of Consciousness (DOC), optimal management of the early phase of rehabilitation is fundamental. This includes a correct diagnosis, accurate assessment of the patient's state of alertness and the main comorbidities, appropriate neurophysiological and neuroradiology examinations, and education of the caregiver and family so that they can provide the best assistance. Thirty years ago, specialists first began applying a systematic approach to the rehabilitation of patients with DOC, but still today many problems remain unsolved: the rate of misdiagnosis is still high, and recommendations about the most appropriate mode of rehabilitation are lacking, both as regards the timing of interventions and what the best techniques to use are. In a medical sector where nosography has changed over the last decade and where the documented evidence, though increasing, still remains insufficient, we discuss in this brief review the main assessment tools and disability scales to use and the key issues that need to be considered when a patient with DOC is admitted to the rehabilitation unit and decisions about the early rehabilitation plan are made.

Functional Networks in Disorders of Consciousness

Severe brain injury may cause disruption of neural networks that sustain arousal and awareness, the two essential components of consciousness. Despite the potentially devastating immediate and long-term consequences, disorders of consciousness (DoC) are poorly understood in terms of their underlying neurobiology, the relationship between pathophysiology and recovery, and the predictors of treatment efficacy. Recent advances in neuroimaging techniques have enabled the study of network connectivity, providing great potential to improve the clinical care of patients with DoC. Initial discoveries in this field were made using positron emission tomography (PET). More recently, functional magnetic resonance (fMRI) techniques have added to our understanding of functional network dynamics in this population. Both methods have shown that whether at rest or performing a goal-oriented task, functional networks essential for processing intrinsic thoughts and extrinsic stimuli are disrupted in patients with DoC compared with healthy subjects. Atypical connectivity has been well established in the default mode network as well as in other cortical and subcortical networks that may be required for consciousness. Moreover, the degree of altered connectivity may be related to the severity of impaired consciousness, and recovery of consciousness has been shown to be associated with restoration of connectivity. In this review, we discuss PET and fMRI studies of functional and effective connectivity in patients with DoC and suggest how this field can move toward clinical application of functional network mapping in the future.

Chinese translation of the Coma Recovery Scale-Revised

BACKGROUND

Misdiagnosis rate is high in patients with disorders of consciousness, potentially leading to an inappropriate clinical management of these patients. Sensitive standardised rating scales offer some protections from these diagnostic errors. In this context, the use of the Coma Recovery Scale-Revised (CRS-R) has strongly been recommended by the American Congress of Rehabilitation Medicine.

OBJECTIVE

Here, we present the work that has been performed to translate this important diagnostic tool in Chinese.

METHODS

The scale has been translated from its original English version to Chinese by a team of native Chinese speakers in agreement with an expert highly trained in the use of the original version of the CRS-R and, then, back-translated to English by four independent translators blinded to the original version. The resulting translation has been sent to the original author for final approval.

RESULTS AND CONCLUSION

The Chinese version of the CRS-R is now available for use in clinical practise. Further investigations will nevertheless be needed in order to show that its psychometric properties are identical to the original English version.