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Rehab Measures: Disorders of Consciousness Scale

Link to instrument

http://www.queri.research.va.gov/ptbri/docs_training/manual_2011.pdf 

Title of Assessment

Disorders of Consciousness Scale 

Acronym

DOCS

Instrument Reviewer(s)

Initially reviewed by Erin Donnelly, PT, NCS and Karen McCulloch, PT, PhD, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 7/2012

Summary Date

12/7/2012 

Purpose

The DOCS is a bedside test measuring neurobehavioral functioning during coma recovery. It was developed to detect subtle changes in observable indicators of neurobehavioral functioning.

Description

  • 23 items
  • Minimum score = 0; Maximum score = 100. Raw scores are converted to interval level data (logits) and rescaled on a 0 to 100 point scale.
  • The rating scale describes levels of neurobehavioral integrity and a level is assigned to responses to test stimuli. The rating scale points are as follows:
    • 0=No Response
    • 1=Generalized Response
    • 2=Localized Response
  • The rating scale defines transitions from low to middle to high neurobehavioral functioning within the continuum of altered consciousness.
  • Neuroanatomic structures important for function of each item are indicated in the manual (above link).

Area of Assessment

 

Body Part

 

ICF Domain

Body Structure; Body Function 

Domain

 

Assessment Type

 

Length of Test

31 to 60 Minutes 

Time to Administer

45 mintues

Number of Items

23 items in the scale; 8 subscales: auditory, visual, tactile, olfactory, proprioceptive/vestibular, taste/swallowing, test readiness 

Equipment Required

  • One mini vibrator
  • Flavor extracts (vanilla, mint, orange)
  • One penlight
  • One red block
  • One small/hand held school bell
  • One can of pressurized air
  • Feathers
  • Kitchen scrubs
  • Alcohol prep swabs
  • Metal spoon
  • One 'do not disturb' sign
  • Cotton tipped applicators
  • Photographs of people familiar to the patient (familiar means that the patient knew the person for at least 1 year prior to the date of injury)
  • Yellow tennis ball
  • A hand-held mirror: 4 inches by 6 inches
  • One coaches whistle
  • Ice chips  
  • Small amounts of juice, soda and/or a familiar taste
  • Towels and/or a washcloth
  • Latex and/or non-latex gloves
  • Pulse oximeter

Training Required

Clinical setting: review instruction manual and 2 hour training DVD.

Research purposes: Training for clinical testing plus observation of an experienced DOCS examiner administering the exam, scoring of the DOCS in tandem with an experienced rater.

Type of training required

Reading an Article/Manual; Training Course 

Cost

Free 

Actual Cost

No cost

Age Range

 

Administration Mode

 

Diagnosis

Acquired Brain Injury; Traumatic Brain Injury 

Populations Tested

  • Traumatic Brain Injury
  • Non-traumatic Brain Injury

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Not Established

Test-retest Reliability

Not Established

Interrater/Intrarater Reliability

Brain Injury (CHI, anoxia, aneurysm, open-head injury, AV malformation, hemorrhage): ( Pape et al, 2005a; n= 95; mean age at injury= 36 years old; mean time post injury= not documented)

  • Interrater reliability is based on ratings done by 44 clinicians (speech pathologists, PT, OT, RN, neuropsych doctoral candidates and respiratory therapists) where exact agreement on ratings was 54.4% (Pape et al, 2005a) A consensus process by American Congress of Rehabilitation Medicine, found fault with this method of reporting IRR (Seel et al., 2010). Pape et al.(2011) reported that the reliability is analogous to K=.95.

Internal Consistency

Brain Injury (CHI, anoxia, aneurysm, open-head injury, AV malformation, hemorrhage): (Pape et al, 2005a)

  • Excellent internal consistency (Cronbach’s alpha .85 for closed head injury, .77 for other head injury)

Criterion Validity (Predictive/Concurrent)

Predictive validity (Brain Injury (CHI, anoxia, aneurysm, open-head injury, AV malformation, hemorrhage): (Pape et al, 2005a)

  • True positive and negative rates for the baseline DOCS <48 or ≥ 48 indicate that the baseline DOCS detects recovery and lack of recovery of consciousness 71% and 68% of the time.
  • The AUC = .73 when comparing predicted recovery according to the baseline DOCS with actual recovery of consciousness indicates that the baseline DOCS accurately discriminates between these outcomes 73% of the time.

Brain Injury, unconscious >28 days (closed head injury, anoxia, hemorrhage, aneurysm, blast injury): (Pape, et al., 2009; n= 113; mean age= 38 years old (TBI= 36 years old, OBI= 44.0 years old); mean days post injury= 48.3(TBI=45.93 days, OBI= 55.10 days))

  • Excellent predictive validity at 4 months post injury (Area Under Receiver Operating Characteristic Curve - AUC = .87)
  • Excellent predictive validity at 8 months post injury (AUC= .88)
  • Excellent predictive validity at 12 months post injury (AUC= .89 )

Construct Validity (Convergent/Discriminant)

Brain Injury (CHI, anoxia, aneurysm, open-head injury, AV malformation, hemorrhage): (Pape, et al., 2005a)

  • The DOCS possibly has unidimensional hierarchic interval characteristics when used with persons with closed head injury.
  • The unidimensional hierarchic structure in Other Brain Injury has not been adequately established.

Content Validity

The DOCS has acceptable content validity but only for differentiating persons in MCS from those in VS based on Aspen Workgroup criteria, the ability to detect emergence from MCS has not been studied.

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

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 (VEDGE) 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

NR

R

LS

LS

LS

 

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

No

Yes

Yes

Not reported

Considerations

DOCS testing procedures allow for various response modes (gestures, verbal, eye gaze) to respond to stimuli at a localized or generalized level. For those with severe injuries, this flexibility may allow for therapists to detect small changes in responsiveness where dichotomous scoring does not.
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Kelly, J. P., Hurder, A. G., et al. (2005). "A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of the Disorders of Consciousness Scale." Journal of Rehabilitation Research & Development 42(1): 1-18.

Pape, T., Senno, R., et al. (2005). "A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation." Journal of Rehabilitation Research and Development 42(1): 19.

Pape, T. L. B., Tang, C., et al. (2009). "Predictive Value of the Disorders of Consciousness Scale (DOCS)." PM&R 1(2): 152-161.

Seel, R. T., Sherer, M., et al. (2010). "Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research." Archives of physical medicine and rehabilitation 91(12): 1795-1813.

Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 12/7/2012 2:57 PM  by Jason Raad 
Last modified at 9/3/2014 10:15 AM  by Jason Raad