The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility

doi:10.1016/j.apmr.2004.02.033

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 12, December 2004, Pages 2020-2029

https://doi.org/10.1016/j.apmr.2004.02.033 Get rights and content

Abstract

Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility.

Objective

To determine the measurement properties and diagnostic utility of the JFK Coma Recovery Scale-Revised (CRS-R).

Design

Analysis of interrater and test-retest reliability, internal consistency, concurrent validity, and diagnostic accuracy.

Setting

Acute inpatient brain injury rehabilitation hospital.

Participants

Convenience sample of 80 patients with severe acquired brain injury admitted to an inpatient Coma Intervention Program with a diagnosis of either vegetative state (VS) or minimally conscious state (MCS).

Interventions

Not applicable.

Main outcome measures

The CRS-R, the JFK Coma Recovery Scale (CRS), and the Disability Rating Scale (DRS).

Results

Interrater and test-retest reliability were high for CRS-R total scores. Subscale analysis showed moderate to high interrater and test-retest agreement although systematic differences in scoring were noted on the visual and oromotor/verbal subscales. CRS-R total scores correlated significantly with total scores on the CRS and DRS indicating acceptable concurrent validity. The CRS-R was able to distinguish 10 patients in an MCS who were otherwise misclassified as in a VS by the DRS.

Conclusions

The CRS-R can be administered reliably by trained examiners and repeated measurements yield stable estimates of patient status. CRS-R subscale scores demonstrated good agreement across raters and ratings but should be used cautiously because some scores were underrepresented in the current study. The CRS-R appears capable of differentiating patients in an MCS from those in a VS.

Section snippets

Description and purpose of the JFK Coma Recovery Scale

The JFK Coma Recovery Scale (CRS), initially described by Giacino et al in 1991,6 was developed to more fully characterize and monitor patients functioning at LCFS levels I through IV. The CRS consists of 25 hierarchically arranged items that comprise 6 subscales addressing auditory, visual, motor, oromotor, communication, and arousal processes. Scoring is based on the presence or absence of specific behavioral responses to sensory stimuli administered in a standardized manner. The lowest item

Clinical and research applications

The CRS has been used in clinical and research settings. Giacino and Kalmar14 used the CRS to estimate the incidence of selected neurobehavioral signs in patients admitted to rehabilitation with a diagnosis of either VS or MCS. Visual tracking and motor agitation were observed significantly more frequently in the MCS group. Among patients in the VS group, 73% (8/11) of those with tracking recovered consciousness within the first 12 months postinjury, as compared with 45% (20/44) of those

Rationale for revision of the CRS

Three factors motivated revision of the CRS: clinical experience, results of previous analyses concerning the scale’s psychometric characteristics, and recent changes in diagnostic parameters pertinent to patients with disorders of consciousness. Since publication of the CRS more than 12 years ago, we have accumulated a considerable amount of feedback from CRS users regarding the administration guidelines, scoring procedures, and clinical utility of specific items. A review of the CRS by O’Dell

Composition of the JFK Coma Recovery Scale-Revised

In view of developments described above, modifications were made to all 6 subscales of the CRS. The JFK Coma Recovery Scale-Revised (CRS-R) Response Profile is shown in appendix 1. A new item—consistent movement to command—was added to the auditory subscale to help identify patients functioning at the border of the MCS and the MCS+. The command menu was expanded to circumvent physical limitations that might otherwise impede execution of limb movement commands. In the visual subscale, object

Purpose of our study

In keeping with the Measurement Standards for Interdisciplinary Rehabilitation adopted by the American Congress of Rehabilitation Medicine in 1992,19 the primary aims of this study were (1) to determine whether the CRS-R can be administered reliably across examiners, (2) to assess the stability of CRS-R scores over repeated assessments, and (3) to establish the concurrent validity of the CRS-R. A secondary aim was to explore the diagnostic sensitivity of the CRS-R. We hypothesized that CRS-R

Participants

A convenience sample of 80 patients was assembled for this study. Participants were actively involved in a specialized Coma Intervention Program (CIP) embedded in a comprehensive inpatient brain injury rehabilitation center. Patients are typically admitted to the CIP when they are unable to follow commands or communicate reliably. All participants received multidisciplinary rehabilitative treatment, including physical, occupational, and speech therapies, during participation in the study.

CRS-R total scores

Interrater reliability for the CRS-R total score was high (ρ=.84, P<.001), indicating that the scale yields reproducible findings across examiners. Test-retest reliability for the total score was also high (ρ=.94, P<.001), demonstrating adequate stability in patient performance over a brief assessment interval (ie, 36h). The cross-correlation, representing the relationship between scores obtained by different raters on different days, was the lowest of the 3 pairs of ratings (ρ=.79, P<.001).

Discussion

Standardized assessment methods specifically designed for patients with disorders of consciousness are increasingly relied on in rehabilitation settings. The movement toward a more empirical approach to rehabilitation assessment and treatment has been driven by forces intrinsic and extrinsic to the field. Rehabilitation medicine’s recent commitment to adopt an evidence-based approach to clinical practice and the continued mandate from payers to objectively document treatment effectiveness

Conclusions

Standardized assessment instruments designed for patients with disorders of consciousness were introduced in rehabilitation settings more than 10 years ago. Despite widespread use, few have undergone thorough psychometric analysis. This study explores the measurement properties and diagnostic utility of a revised version of the JFK CRS. The CRS-R appears to meet minimal standards for measurement and evaluation tools designed for use in interdisciplinary medical rehabilitation. The scale can be

Acknowledgements

We thank the members of the Consciousness Consortium for their assistance in piloting and providing feedback on early versions of the CRS-R: Madeline DiPasquale, PhD, Monica Vaccaro, MS, Walt Mercer, PhD, Nancy Childs, MD, Douglas Katz, MD, Carol Moheban, MD, David Long, MD, Barbara Journey-Merges, RN, Daniel Keating, PhD, Paul Novak, MS, and Susan Van Wie, CRRN. We would also like to thank Marcia Polansky, ScD, for providing consultation on the selection of statistical analyses and Tasha Mott,

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This study recruited 8 DOC patients and applied 20-min sessions of 2 mA HD-tDCS (central anode electrode at Pz) for 14 consecutive days. We record DOC patients' EEG data and Coma Recovery Scale–Revised (CRS-R) values at four time point: baseline (T0), after 1 day's and 7,14 days' parietal HD-tDCS treatment (T1, T2, T3). Power spectral density (PSD), relative power (RP), spectral entropy and spectral exponent were calculated to evaluate the EEG dynamic changes of DOC patients during long-term parietal HD-tDCS. At last, we calculated the correlation between changes of EEG features and changes of CRS-R values.
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^☆: Supported in part by the Irving I. and Felicia F. Rubin Family Brain Injury Research Grant.

¹: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

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ArticlesThe JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility1☆,

Abstract

Objective

Design

Setting

Participants

Interventions

Main outcome measures

Results

Conclusions

Section snippets

Description and purpose of the JFK Coma Recovery Scale

Clinical and research applications

Rationale for revision of the CRS

Composition of the JFK Coma Recovery Scale-Revised

Purpose of our study

Participants

CRS-R total scores

Discussion

Conclusions

Acknowledgements

Arch Phys Med Rehabil

Lancet

Arch Phys Med Rehabil

Arch Clin Neuropsyhol

Arch Phys Med Rehabil

Arch Phys Med Rehabil

The diagnosis of stupor and coma

Medical aspects of the persistent vegetative state (1). Multi-Society Task Force Report on PVS [see comments]

N Engl J Med

The minimally conscious statedefinition and diagnostic criteria

Neurology

The Western Neuro Sensory Stimulation Profilea tool for assessing slow-to-recover head-injured patients

Arch Phys Med Rehabil

Sensory stimulation of severely brain-injured patients

Brain Inj

Evaluation of coma and vegetative states

Arch Phys Med Rehabil

Levels of cognitive function

Rehabilitation of the head injured adultcomprehensive physical management

Standardized assessment instruments for minimally-responsive, brain-injured patients

NeuroRehabil

Articles
The JFK Coma Recovery Scale-Revised: Measurement characteristics and diagnostic utility¹☆,