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Coma Recovery Scale-Revised

Coma Recovery Scale - Revised

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Purpose

The CRS-R assists with differential diagnosis, prognostic assessment, and treatment planning in patients with disorders of consciousness.

Link to Instrument

Instrument Details

Acronym CRS-R

Cost

Free

Diagnosis/Conditions

  • Brain Injury

Populations

Key Descriptions

  • 23 items, 6 subscales addressing
    1) Auditory
    2) Visual
    3) Motor
    4) Oromotor
    5) Communication
    6) Arousal Functions
  • Minimum score: 0
    Maximum score: 23
  • CRS-R subscales are comprised of hierarchically arranged items associated with brain stem, subcortical and cortical processes. The lowest item on each subscale represents reflexive activity while the highest items represent cognitively-mediated behaviors.
  • Scoring is standardized and is based on the presence or absence of operationally-defined behavioral responses to specific sensory stimuli.
  • The Guidelines and Administration instructions are provided on the COMBI website: http://www.tbims.org/combi/crs/CRS%20Syllabus.pdf

Number of Items

23

Equipment Required

  • Instruction manual
  • Scoring sheet
  • 2 common objects (cup, comb, etc.)
  • An object that produces a loud noise
  • ADL objects (toothbrush, phone, etc)
  • Hand mirror
  • Brightly coloured object
  • Baseball sized ball
  • Pencil
  • Tongue depressor

Time to Administer

25 minutes

Required Training

Reading an Article/Manual

Instrument Reviewers

Initially reviewed by Erin Donnelly, PT, MSPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 6/2012.

ICF Domain

Body Structure
Body Function

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

R

HR

HR

HR

HR

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

Ratings performed by the same rater were slightly more stable than those performed by different raters, so a consistent tester may be advisable. According to the Recommendations by the American Congress of Rehabilitation of Medicine, extended or repeated assessment with a DOC scale is likely to improve diagnostic accuracy (Godbolt et al, 2012). Clinicians should have training and experience with the DOC population to facilitate diagnostic accuracy when using a DOC scale (Lovstad et al, 2010). The use of CRS-R may identify patients in MCS who were previously thought to be vegetative and those who have emerged from MCS where consensus medical diagnosis may miss these changes (Schnakers et al, 2009).

 

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Brain Injury

back to Populations

Cut-Off Scores

Disorder of Consciousness (TBI, CVA, hypoxic-ischemic BI, tumor): (Giacino J, Kalmar K, Whyte J, 2004; n= 80; mean age= 38.86 years(range 17-79 years old); mean time post injury= 58.43 days, range 21-249 days and Lovstad et al, 2010; n=31 with severe brain injury, median age 33 years, median days post injury 143).

 

CRS-R subscale

Vegetative State

Minimally Conscious State

Emergence from Minimally Conscious State (MCS+)

Auditory 

Less than or equal to 2 and

3-4 OR 

 

Visual 

Less than or equal to 1 and

2-5 OR 

 

Motor 

Less than or equal to 2 and

3-5 OR 

OR

Oromotor/verbal 

Less than or equal to 2 and

3 OR 

 

Communication 

2-3

 

In order to be designated in the vegetative state all of the scores in column 2 must be met, however minimally conscious state can be achieved by the demonstration of only one of the score ranges in column 3, likewise emergence from MCS occurs with higher scores in motor or communication subscales.

Test/Retest Reliability

Disorder of Consciousness Presentation (TBI, CVA, hypoxi-ischemic BI, tumor): (Giacino J, Kalmar K, Whyte J, 2004; n= 20; mean age= 36.70 years old(range 17-57 years old); mean time post injury= 57.15 days, range 22-169 days). 

  • Excellent test-retest reliability (Spearman rho=.94) in patient performance over 1 day interval

Interrater/Intrarater Reliability

Disorder of Consciousness Presentation (TBI, CVA with TBI, Brain Tumor, Hypoxic-ischemic BI): (Giacino et al., 2004) 

  • Excellent reliability for total score (Spearman rho= .84) 
  • Subscale reliability scores: 
  • Excellent : 
    • Visual (k = .90)
    • Motor (k = 1.00)
    • Communication (k = .89) 
  • Adequate: 
    • Auditory (k= .63) 
  • Poor :
    • Oromotor/verbal (K=.23) 
  • Adequate to excellent reliability for experienced and less experienced raters (Spearman rho ranges .66-.83) (Lovstad et al, 2010) 

 

Disorders of Consciousness Presentation (variety of Neurological diagnoses including TBI(Schnakers, 2008; n= 77; age range 19-86 years old; 43 participants: 1-27 days post injury, 34 participants: 27 days-24 years post injury). 

  • Excellent reliability for total score (k= .80) 
  • Excellent reliability for Subscales: 
    • Auditory (k = .82) 
    • Visual (k = .85) 
    • Motor (k = .93)
    • Oromotor (k = .92) 
    • Communication (k =. 98) 
    • Arousal (k = .74)

Internal Consistency

Disorder of Consciousness Presentation (TBI, CVA with TBI, Brain Tumor, Hypoxic-ischemic BI): ( Giacino et al., 2004)

  • Excellent internal consistency (Cronbach’s alpha= .83)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

Disorder of Consciousness Presentation (TBI, CVA, hypoxi-ischemic BI, tumor): (Giacino J, Kalmar K, Whyte J, 2004) n= 80; mean age= 38.86 years(range 17-79 years old); mean time post injury= 58.43 days, range 21-249 days). 

  • Excellent concurrent validity with original Coma Recovery Scale (Spearman rho = .97) and Disability Rating Scale (Spearman rho=-.90) 
  • Use of CRS-R scores to diagnose vegetative state, minimally conscious state or minimally conscious plus state had adequate correlation between two raters (k=.60, p=.03), and better correlation for a single rater on two occasions (k=.82, p<.004). Overall rate of agreement of two raters was 87.5%. 

 

Post-comatose patients (Traumatic TBI, post-anoxia, Stroke, encephalitis, hemorrhagic, metabolic, status epilepticus): (Schnakers, et al. 2008) 

  • Excellent concurrent validity between the CRS-R and the other 3 scales in the acute phase 
  • Excellent concurrent validity between the CRS-R and the FOUR and WHIM in the chronic stage

 

CRS-R 

GCS 

FOUR 

WHIM 

Both Stages 

.59 

.63 

.76 

Acute Stage 

.72 

.61 

.68 

Chronic Stage 

.46 

.69 

.87

Construct Validity

Variety of Diagnoses affecting consciousness: (Schnakers et al., 2009, n=103 prospective patients with variety of diagnoses affecting consciousness, 55 (19) years, Belgian sample. Consensus medical diagnoses for vegetative, minimally conscious or “uncertain” were compared with diagnostic categories derived from CRS-R testing. ) 

Of 44 patients diagnosed in VS, 18 were in MCS; of 41 in MCS, 4 had emerged from MCS, and majority of “uncertain” diagnoses were in MCS (89%). The use of the CRS-R standardizes assessment and identified misclassified patients who have greater levels of consciousness than recognized by medical consensus.

Floor/Ceiling Effects

The measure was designed to assess patients at Rancho Levels of Cognitive Functioning I-IV, so patients who are beyond these levels are not appropriate for its use.

Bibliography

Giacino, J. T., Kalmar, K., et al. (2004). "The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility." Archives of physical medicine and rehabilitation 85(12): 2020-2029.

Godbolt, A. K., Stenson, S., et al. (2012). "Disorders of consciousness: Preliminary data supports added value of extended behavioural assessment." Brain Injury 26(2): 188-193. 

Løvstad, M., Frøslie, K. F., et al. (2010). "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 25(5): 349-356. 

Schnakers, C., Majerus, S., et al. (2008). "A French validation study of the Coma Recovery Scale-Revised (CRS-R)." Brain Injury 22(10): 786-792. 

Schnakers, C., Vanhaudenhuyse, A., et al. (2009). "Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment." BMC neurology 9(1): 35.

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