Behavioral Recovery in Disorders of Consciousness: A Prospective Study With the Spanish Version of the Coma Recovery Scale–Revised

Published:January 27, 2012DOI:


      Noé E, Olaya J, Navarro MD, Noguera P, Colomer C, García-Panach J, Rivero S, Moliner B, Ferri J. Behavioral recovery in disorders of consciousness: a prospective study with the Spanish version of the Coma Recovery Scale–Revised.


      To describe the clinical characteristics and short-term pattern of evolution of a sample of patients within 1 year after acquiring a brain injury that led to a vegetative state (VS) or a minimally conscious state (MCS).


      Cohort study.


      Inpatient brain injury rehabilitation program.


      Patients with acquired brain injury (N=32; 47% traumatic, 37.5% hemorrhagic, 15.5% anoxic) who were in a VS or an MCS according to Coma Recovery Scale–Revised (CRS-R) scores.


      Integrative multisensory program comprising daily physical rehabilitation procedures and multimodal sensory stimulation.

      Main Outcome Measure

      All patients were assessed with a Spanish version of the CRS-R at admission and then monthly for at least 6 months or until emergence from MCS.


      At the time of admission, 12 patients were diagnosed as being in a VS and 20 as being in an MCS. Eight patients were able to emerge from their MCS during follow-up. Seven of these 8 patients were diagnosed as being in an MCS at inclusion, and only 1 was diagnosed as being in a VS. Emergence from an MCS was mostly associated with improvement in both the communication and motor function scales (n=4). Lesser chronicity (P=.01) and the presence of more than visual behavioral responses at admission (P=.05) were both significant predictors of emergence from an MCS.


      The CRS-R seems appropriate for establishing an immediate prognosis in this population. A quick referral of these patients for specialized assessment and rehabilitation facilities is recommended.

      Key Words

      List of Abbreviations:

      CRS (Coma Recovery Scale), CRS-R (Coma Recovery Scale–Revised), MCS (minimally conscious state), RLA-S (Rancho Los Amigos Scale of Cognitive Functioning), TBI (traumatic brain injury), VS (vegetative state)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jennett B.
        • Plum F.
        Persistent vegetative state after brain damage.
        Lancet. 1972; 1: 734-737
        • Giacino J.
        • Kalmar K.
        The vegetative and minimally conscious states: a comparison of clinical features and functional outcome.
        J Head Trauma Rehabil. 1997; 12: 36-51
        • Giacino J.
        • Whyte J.
        The vegetative and minimally conscious states: current knowledge and remaining questions.
        J Head Trauma Rehabil. 2005; 20: 30-50
        • Giacino J.
        • Zasler N.D.
        Outcome after severe brain injury: coma, vegetative state and the minimally responsive state.
        J Head Trauma Rehabil. 1995; 10: 44-61
        • Giacino J.T.
        The minimally conscious state: defining the borders of consciousness.
        Prog Brain Res. 2005; 150: 381-395
        • Giacino J.T.
        • Ashwal S.
        • Childs N.
        • et al.
        The minimally conscious state: definition and diagnostic criteria.
        Neurology. 2002; 58: 349-353
        • Giacino J.T.
        • Kezmarsky M.A.
        • DeLuca J.
        • Cicerone K.D.
        Monitoring rate of recovery to predict outcome in minimally responsive patients.
        Arch Phys Med Rehabil. 1991; 72: 897-901
        • Katz D.I.
        • Polyak M.
        • Coughlan D.
        • Nichols M.
        • Roche A.
        Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up.
        Prog Brain Res. 2009; 177: 73-88
        • Lammi M.H.
        • Smith V.H.
        • Tate R.L.
        • Taylor C.M.
        The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury.
        Arch Phys Med Rehabil. 2005; 86: 746-754
        • Luauté J.
        • Maucort-Boulch D.
        • Tell L.
        • et al.
        Long-term outcomes of chronic minimally conscious and vegetative states.
        Neurology. 2010; 75: 246-252
        • Whyte J.
        • Gosseries O.
        • Chervoneva I.
        • et al.
        Predictors of short-term outcome in brain-injured patients with disorders of consciousness.
        Prog Brain Res. 2009; 177: 63-72
        • American Congress of Rehabilitation Medicine
        Recommendations for use of uniform nomenclature pertinent to patients with severe alterations in consciousness.
        Arch Phys Med Rehabil. 1995; 76: 205-209
        • Giacino J.
        • Zasler N.D.
        • Katz D.I.
        • Kelly J.P.
        • Rosenberg J.H.
        • Filley C.M.
        Development of practice guidelines for assessment and management of the vegetative and minimally conscious states.
        J Head Trauma Rehabil. 1997; 12: 79-89
        • Andrews K.
        • Murphy L.
        • Munday R.
        • Littlewood C.
        Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit.
        BMJ. 1996; 313: 13-16
        • Schnakers C.
        • Vanhaudenhuyse A.
        • Giacino J.
        • et al.
        Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment.
        BMC Neurol. 2009; 9: 35
        • Giacino J.T.
        • Kalmar K.
        • Whyte J.
        The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility.
        Arch Phys Med Rehabil. 2004; 85: 2020-2029
        • Estraneo A.
        • Moretta P.
        • Loreto V.
        • Lanzillo B.
        • Santoro L.
        • Trojano L.
        Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state.
        Neurology. 2010; 75: 239-245
        • The Multi-Society Task Force on PVS
        Medical aspects of the persistent vegetative state (2).
        N Engl J Med. 1994; 330: 1572-1579
        • Whyte J.
        • Katz D.
        • Long D.
        • et al.
        Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: a multicenter study.
        Arch Phys Med Rehabil. 2005; 86: 453-462
        • Seel R.T.
        • Sherer M.
        • Whyte J.
        • et al.
        Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research.
        Arch Phys Med Rehabil. 2010; 91: 1795-1813
        • Taylor C.M.
        • Aird V.H.
        • Tate R.L.
        • Lammi M.H.
        Sequence of recovery during the course of emergence from the minimally conscious state.
        Arch Phys Med Rehabil. 2007; 88: 521-525
        • Childs N.L.
        • Mercer W.N.
        • Childs H.W.
        Accuracy of diagnosis of persistent vegetative state.
        Neurology. 1993; 43: 1465-1467
        • Dolce G.
        • Lucca L.F.
        • Candelieri A.
        • Rogano S.
        • Pignolo L.
        • Sannita W.G.
        Visual pursuit in the severe disorder of consciousness.
        J Neurotrauma. 2011; 28: 1149-1154
        • Dolce G.
        • Quintieri M.
        • Serra S.
        • Lagani V.
        • Pignolo L.
        Clinical signs and early prognosis in vegetative state: a decisional tree, data-mining study.
        Brain Inj. 2008; 22: 617-623
        • Laureys S.
        • Faymonville M.E.
        • Luxen A.
        • Lamy M.
        • Franck G.
        • Maquet P.
        Restoration of thalamocortical connectivity after recovery from persistent vegetative state.
        Lancet. 2000; 355: 1790-1791
        • Laureys S.
        • Owen A.M.
        • Schiff N.D.
        Brain function in coma, vegetative state, and related disorders.
        Lancet Neurol. 2004; 3: 537-546