Sensory Modality Assessment and Rehabilitation Technique

Last Updated

March 30, 2017

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Purpose

Designed to be both an assessment and treatment tool for patients in vegetative and minimally responsive states. Identifies potential awareness in adults with severe brain damage in a vegetative state and identifies the functional and communication abilities of patients in a minimally-conscious state. (Gill-Thwaites & Munday, 2004).

Acronym SMART

Area of Assessment

Cognition

Cost

Not Free

Actual Cost

$0.00

Cost Description

The SMART must be purchased however perquisites must be completed prior to purchasing. Prerequisites include submission of a portfolio and completion of a 5-day training course held in the United Kingdom. (Seel et al, 2010).

Brain Injury

Includes two formal assessments (SMART Behavioral Observation Assessment and the SMART Sensory Assessment) and an informal component (information gathered from family members and caregivers regarding observed behaviors and premorbid interests) (Tennant & Gill-Thwaites, 2016).
SMART Behavioral Assessment
• The assessor observes the patient’s reflexive, spontaneous and purposeful behavior during a 10-minute quiet period. Done prior to the SMART Sensory Assessment. (Gill-Thwaites & Munday, 2004).
SMART Sensory Assessment:
• Involves a graded assessment of the patient’s level of sensory, motor and communicative responses to a structured sensory program (Tennant & Thwaites, 2016).
• Conducted in 10 sessions within a 3-week period. Equal number of sessions in morning and afternoon.
• Eight modalities total, which include:
Sensory stimuli:
• Visual
• Tactile
• Auditory
• Olfactory
• Gustatory
Physical assessment:
• Wakefulness
• Functional motor ability
• Communicative ability
Literature states that the assessments are done utilizing 29 standardized techniques (Tennat & Gill-Thwaites, 2016) however no other details could be found.
Each modality is assessed using a 5-point hierarchal scale ranging from no response (level 1) to discriminating response (Level 5)
The values of each modality were not designed to be summed, but instead to look at independently in order to assess rate and significance of change. (Gill-Thwaites & Munday, 1999).
Frequency of responses are also recorded:
• Highest inconsistent (response occurring 1-4x)
• Frequent inconsistent (response occurring 5x but not consecutively)
• Consistent (5x in a row)
A consistent response at the highest level (SMART Level 5) in any sensory modality would indicate a minimal conscious state response. (Gill-Thwaites, 1997)

Number of Items

None

60 minutes

Required Training

Training Course

Instrument Reviewers

Suzanne O’Neal, PT, DPT, NCS

ICF Domain

Body Structure
Body Function

Measurement Domain

Cognition
Sensory

Professional Association Recommendation

There are four recognized levels of SMART accreditation ranging from Level 1 SMART Assessor to Level 4 SMART Master. (Gill-Thwaites and Elliott Consultants).

Requires a prolonged period of time to complete the full assessment (10 sessions within a 3 week period) therefore may need more than one accredited assessor on staff.

Considerations

Recent research has tested the validity of a summed score and established cut-off scores to determine emergence from a vegetative state for both anoxic brain injuries and traumatic brain injuries. (Tennant & Gill-Thwaites, 2017).
Details of utilization of tool as a treatment technique unavailable through literature however one article does state that treatment lasts 8 weeks following the formal assessment (Gill-Thwaites & Munday, 1999) and that a SMART manual describes the core components that are to be continued from the assessment process into the treatment process.

Cut-Off Scores

(Gill-Thwaites & Munday, 1999; n=30)

If a consistent response is demonstrated at a SMART Level 5 on >5 consecutive assessments in any modality, the patient is indicating evidence of awareness and emergence from a vegetative state.

(Tennant, 2017; n=60; mean age = 35; mean time post injury = 276 days; TBI = 21, anoxic brain injury = 30, non-TBI = 9)

Cut-off scores when using summed scores of all modalities:

Anoxic brain injury: cut off score of 85 points predicted emergence from vegetative state
Traumatic brain injury: cut off score of 68 points predicted emergence from vegetative state

Test/Retest Reliability

(Gill-Thwaite, 2004; n=60; mean age = 35; mean time post injury = 276 days; TBI = 21, anoxic brain injury = 30, non-TBI = 9)

Excellent test-retest reliability (ICC > 0.95)

Interrater/Intrarater Reliability

(Gill-Thwaites & Munday, 2004)

Excellent inter-rater reliability (ICC = 0.96)
Excellent intra-rater reliability (ICC = 0.97)

Criterion Validity (Predictive/Concurrent)

(Gill-Thwaites & Munday, 2004)

Concurrent Validity

Adequate correlation with physician’s Rancho ratings (r=0.474)
Excellent correlation with the Western Neuro Sensory Stimulation Profile (r =0.70)

(Tennant & Gill-Thwaites, 2017)

Using summed scores of all modalities:

Predictive Validity

Anoxic brain injury: High specificity of 100% for predicting those emerging from a vegetative state; sensitivity of 66.7%
Traumatic brain injury: High specificity of 100% for predicting those emerging from a vegetative state; sensitivity of 86.7%

Bibliography

Gill-Thwaites and Elliott Consultants. Levels of SMART Accreditation. Retrieved from: http://gteconsultants.com/accurate-assessment/

Gill-Thwaites H, Munday R. The Sensory Modality Assessment and Rehabilitation Technique (SMART): A comprehensive and integrated assessment and treatment protocol for the vegetative state and minimally responsive patient. Neuropsychol Rehabil. 1999;9 (3/4): 305-320.

Gill-Thwaites H, Munday R. The Sensory Modality Assessment and Rehabilitation Technique (SMART): A valid and reliable assessment for vegetative state and minimally conscious state patients. Brain Injury. 2004; 18(12): 1255-1269. Find it on PubMed

Seel RT, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM,…Zasler N. Assessment scales for disorders of consciousness: Evidence-based recommendations for clinical practice and research. Arch Phys Med Rehab. 2010; 91: 1795-1813. Find it on PubMed

Tennant A, Gill-Thwaites H. A study of the internal construct and predictive validity of the SMART assessment for emergence from vegetative state. Brain Injury. 2017; 31(2): 185-192. Find it on PubMed