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Rehab Measures: Coma Recovery Scale-Revised

Link to instrument

Link to the CRS-R 

Title of Assessment

Coma Recovery Scale-Revised 

Acronym

CRS-R

Instrument Reviewer(s)

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

Summary Date

1/19/2013 

Purpose

The purpose of the scale is to assist with differential diagnosis, prognostic assessment, and treatment planning in patients with disorders of consciousness.

Description

  • 23 items, 6 subscales addressing Auditory, Visual, Motor, Oromotor, Communication and 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

Area of Assessment

 

Body Part

 

ICF Domain

Body Structure; Body Function 

Domain

 

Assessment Type

 

Length of Test

06 to 30 Minutes 

Time to Administer

Estimated at 25 minutes (varies dependent on expertise of the clinician and the level of the patient)

Number of Items

23 items 

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 colored object
  • Baseball sized ball
  • Pencil
  • Tongue depressor

Training Required

Instructions and guidelines are available on the COMBI website. No specific training is required.

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Free

Age Range

 

Administration Mode

 

Diagnosis

Acquired Brain Injury; Stroke; Traumatic Brain Injury 

Populations Tested

  • TBI
  • Brain Tumor
  • TBI with CVA
  • Hypoxic ischemic 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

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

6 OR

Oromotor/verbal

Less than or equal to 2 and

3 OR

Communication

0

1

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.

Normative Data

Not Established

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 (Convergent/Discriminant)

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.

Content Validity

Not Established

Face Validity

Not Established

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.

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

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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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.

Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 8/12/2011 11:31 AM  by Jason Raad 
Last modified at 9/3/2014 10:00 AM  by Jason Raad